Pages 1--24 from (1) Pages

For changes
in benefits 4
see page

Serving The Philadelphia area
Enrollment in this plan is limited see page 5 for requirements
Enrollment code
ED1 Self Only AL COMMITT EE I ON A C C R E D I T E D B Y
ED2 Self and Family NAT FOR QUAL

I TY ASSURANCE

This plan is accredited by NCQA
See the FEHB Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States
Office of Personnel Federal Employees

Management Health Benefits Program

RI 73 483

1 1
1 Page 2 3
Keystone Health Plan East 2000
Table of Contents

Introduction 3
Plain Language 3
How To Use This Brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How We Change For 2000 4
Section 3 How To Get Benefits 5
Section 4 What To Do If We Deny Your Claim Or Request For Service 8
Section 5 Benefits 10
Section 6 General Exclusions Things We Don t Cover 18
Section 7 Limitations Rules That Affect Your Benefits 18
Section 8 FEHB FACTS 19
Inspector General Advisory Stop Healthcare Fraud 22
Summary of Benefits Inside Back Cover
Premiums Back Cover

2 2
2 Page 3 4
Keystone Health Plan East 2000
Introduction
Keystone Health Plan East Inc
1901 Market Street
Philadephia Pennsylvania 19101

This brochure describes the benefits you can receive from Keystone Health Plan East Inc under its contract CS2339 with the Office
of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page
4 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government s communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Keystone Health Plan East Inc as this Plan throughout this brochure even though in other legal documents you will see
a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan s benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don t cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

3 3
3 Page 4 5
Keystone Health Plan East 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventive
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan s benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician or group of physicians hospital or other
provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when
prescribing any course of treatment

Section 2 How We Change For 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care changes office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until
the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you
may add a brief statement to it If they do not provide you your records call us and we will assist
you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Your share of Keystone Health Plan East s non postal premium will increase by 3.1 for Self Only Plan

and decrease by 10.5 for Self and Family
The copay for doctor s office visits is now 10 per visit for primary care physician PCP 15 per
visit for specialists 15 for home visits by a PCP 15 for after hours visits to a PCP and 15 for the
first maternity care visit Previously the copay was 5 for visits to both PCPs and specialists 10 for
home visits by a PCP and after hours visits to a PCP and 5 for the first maternity visit

Diabetic self management training and education may be provided by a Plan provider who is a
licensed health care professional approved by the Plan The Plan also covers services provided by a
community based program that is approved by the Plan in accordance with criteria based on the
certification programs developed by the American Diabetes Association ADA and the Pennsylvania
Department of Health or at a participating Hospital on an outpatient basis through American
Diabetes Association approved community based programs a licensed health care professional or at
a hospital

Foot orthotics are covered when associated with the diagnosis of diabetes

4 4
4 Page 5 6
Keystone Health Plan East 2000
The Mental Conditions Substance Abuse Benefit has been enhanced to provide services for serious
mental illnesses Serious mental illnesses are any of the following biologically based mental illnesses
as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual DSM
schizophrenia bipolar disorder obsessive compulsive disorder major depressive disorder panic
disorder anorexia nervosa bulimia nervosa schizo affective disorder and delusional disorder
Outpatient care is limited to 60 days visits in a calendar year You pay a copay of 25 for each
covered outpatient visit or partial hospitalization stay Inpatient care is limited to 35 days of
hospitalization each calendar year You pay nothing Up to 30 inpatient days may be exchanged
on a 1 for 2 basis for up to 60 additional serious mental illness days visits

The Catastrophic Limit for out of pocket expenses is now 1,000 per individual or 2,000 per family
per calendar year Previously the limit was 650 per person per calendar year

Section 3 How To Get Benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our Plan s service service area is Pennsylvania counties of Bucks Chester Montgomery Delaware and Philadelphia
area Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care
services however as a Keystone Health Plan East member you have access to physician care through
a nationwide network of Blue Cross and Blue Shield HMOs This is one of the largest HMO
networks in the country offering coverage in more than 200 U S cities If you become ill while
visiting one of these cities contact the network at 1 800 446 6872 This number is also found on the
back of your I D card The network referral coordinator will schedule an appointment with a network
physician in the area from which you are calling No office visit copayment will be required and you
will not need to file a claim

If you or a covered family member move outside of our service area you can enroll in another plan
If your dependents live out of the area for example if your child goes to college in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates
in other areas Through the network s guest membership benefit dependents who are away from
home for at least 90 days may temporarily enroll in another network HMO Members are also eligible
for guest membership for up to six months if for example they are assigned out of area temporarily
Guest memberships enable members to receive the full range of HMO benefits and services offered
by the hosting HMO s To enroll members simply contact their Away From Home Care Coordinator
in advance The coordinator will make all the necessary arrangements for guest memberships and
take care of all the billing details Also your prescription drug card works in more than 52,000
pharmacies in the United States If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office

How much do I pafor You must share the cost of some services This is called a copayment a set dollar amount or services coinsurance a set percentage of charges Please remember you must pay this amount when you

receive services except for either of the following
the emergency room visit results in admission to a hospital or
you are referred to the emergency room by your primary care doctor and services could have been
provided by your doctor

After you pay 1,000.00 in copayments for one family member or 2,000 for two or more family
members you do not have to make any further payments for that person for certain services for the
rest of the year This is called a catastrophic limit However copayments for your prescription drugs
and dental services do not count toward these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments since you are responsible for informing us when
you reach the limits

5 5
5 Page 6 7
Keystone Health Plan East 2000
Do I have to submit You normally won t have to submit claims to us unless you receive emergency services from a claims provider who doesn t contract with us If you file a claim please send us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year
you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides mhealth Keystone Health Plan East a wholly owned subsidiary of Independence Blue Cross is an individual care practice plan IPP that provides access to care throughout the greater Philadelphia area Members

and their family members may select their own primary care doctor from among the 2,611 who
practice within the Plan s service area There are approximately 9,700 specialty care doctors who
participate with the Plan Your primary care doctor will arrange for the necessary specialty and
hospital care you need at one of the Plan s participating specialist office or a participating Plan
hospital throughout the Plan s service area

The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services
particularly those of a specialist are obtained It is the responsibility of your primary care doctor to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other providers are covered only when there has been a
referral by the members primary care doctor except for dental care vision care and visits to the
OB GYN for preventive care routine maternity care or problems related to gynecological conditions
when medically necessary Non routine care provided by Reproductive Endocrinologist Infertility
Specialists and Gynecologic Oncologists continues to require a referral from the primary care
physician Treatment for mental conditions and substance abuse may be obtained directly from
Magellan Behavioral Health formerly Green Spring Health Services Magellan Behavioral Health
or any other mental health administrator for Keystone Health Plan East manages all care related to
mental health and substance abuse services and will determine what specialty care is appropriate and
which specialists will be utilized Questions about related benefits and precertifications should be
directed to Magellan Behavioral Health at 1 800 688 1911

If you enroll you will be asked to complete a primary care doctor selection form and send it directly
to the Plan indicating the name of the primary care doctor selected for you and each member of your
family You are required to select a personal doctor from among participating plan primary care
doctors located within the Plan s service area Please note that if you reside in New Jersey and work
in Pennsylvania within our service area you must select a primary care doctor whose practice is in
Pennsylvania within our service area Your dependents may select a personal doctor from among
participating plan primary care doctors in Pennsylvania or New Jersey You and your dependents may
have only one dentist who must be selected from a list of participating plan dentists located within the
Plan s service area

What do I do if Call us We will help you select a new one my primary care

physician leaves the Plan

What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist to go into the hospital will make the necessary hospital arrangements and supervise your care

6 6
6 Page 7 8
Keystone Health Plan East 2000
What do I do if I m First call our customer service department at 1 800 227 3114 If you are new to the FEHB Program in the hospital when we will arrange for you to receive care If you are currently in the FEHB Program and are switching
I join this Plan to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will arrange your referral to a specialist at the primary care doctor s specialty care discretion if non Plan specialists or consultants are required the primary care doctor will arrange

appropriate referrals When you receive a referral from your primary care doctor you must return to
the primary care doctor after the consultation All follow up care must be provided or arranged by
the primary care doctor On referrals the primary care doctor will give specific instructions to the
consultant as to what services are authorized If the consultant suggests additional services or visits
you must first check with your primary care doctor Do not go to the specialist unless your primary
care doctor has arranged for and we have issued an authorization for the referral in advance

If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan

What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a I am seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate

when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do Call your primary care physician who will arrange for you to see another specialist You may receive if my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the Program
Please contact us if you believe your condition is chronic or disabling You may be able to continue
seeing your provider for up to 90 days after we notify you that we are terminating our contract with
the provider unless the termination is for cause If you are in the second or third trimester of
pregnancy you may continue to see your OB GYN until the end of your postpartum care

You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If
you are in your second or third trimester your new plan will pay for the OB GYN care you receive
from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist medical services or recommending follow up care Before giving approval we consider if the service is medically

necessary and if it follows generally accepted medical practice
How do you decide if a To establish if a biological medical device drug or procedure is experimental investigational or service is experimental not a technology assessment is performed The results of the assessment provide the basis for the

or investigational determination of the service s status e g medically effective experimental etc Technology assessment is the review and evaluation of available data from multiple sources using industry
standard criteria to assess the medical effectiveness of the service Sources of data used in technology
assessment include but are not limited to clinical trials position papers articles published by local
and or nationally accepted medical organizations or peer reviewed journals information supplied by
government agencies as well as regional and national experts and or panels and if applicable
literature supplied by the manufacturer

7 7
7 Page 8 9
Keystone Health Plan East 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or won t pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review a denial
OPM will determine if we correctly applied the terms of our contract when we denied your claim or
request for service

What if I have a serious Call us at 800 227 3114 and we will expedite our review or life threatening

condition and you haven t responded
to my request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM s
care and my condition health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern Time is serious or life Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or
threatening death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information

8 8
8 Page 9 10
Keystone Health Plan East 2000
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person s representative They must send a copy of the person s specific written consent with the
review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim Contract Division III P O Box 436 Washington D C 20044

to OPM
What if OPM upholds OPM s decision is final There are no other administrative appeals If OPM agrees with our decision the Plan s denial your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and Chapter 89 of Title 5 United States Code allows OPM to use the information it collects from you and the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the

review process becomes a permanent part of your disputed claims file and is subject to the provisions
of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the
court record

9 9
9 Page 10 11
Keystone Health Plan East 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered Plan doctors and other Plan providers provide a comprehensive range of preventive diagnostic and treatment services This includes all necessary office visits you pay a 10 copay per visit for visits to

your primary care doctor or a 15 copay per visit for visits to specialists but no additional copay for
laboratory tests and X rays You pay a 15 copay per visit for after hours visits to your primary care
doctor Within the service area house calls will be provided if in the judgment of the Plan doctor
such care is necessary and appropriate you pay a 15 copay for a doctor s house call nothing for
home visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care periodic check ups and routine gynecological care
Hearing exams are covered only when referred by a Plan primary care doctor
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 and above one mammogram every year In addition
to routine screening mammograms are covered when prescribed by the doctor as medically
necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor The 15 office visit copay for specialists applies only to the first
visit for obstetrical care The mother at her option may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after caesarean delivery Inpatient stays will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not
be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child
during the covered portion of the mother s hospital confinement for maternity will be covered
under either a Self Only or Self and Family enrollment other care of an infant who requires
definitive treatment will be covered only if the infant is covered under a Self and Family
enrollment
Voluntary sterilization and family planning service
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints breast
prosthesis and surgical bras as well as their replacement
Cornea heart heart lung kidney liver lung single or double and pancreas transplants
allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic
or non lymphocytic leukemia advanced Hodgkin s lymphoma advanced non Hodgkin s
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer
and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical
and hospital expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo masectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Foot orthotics with a diagnosis of diabetes

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

10 10
10 Page 11 12
Keystone Health Plan East 2000
Diabetic self management training and education through community based programs certified by
the American Diabetes Association or Pennsylvania Department of Health Covered services may
also be provided by these contracted providers a licensed health care professional or at a hospital
on an outpatient basis
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers is provided at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for
congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures
removal of teeth partially or totally covered by bone and excision of tumors and cysts All other
procedures involving the teeth or intra oral areas surrounding the teeth are not covered including any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member s appearance and if the
condition can reasonably be expected to be corrected by such surgery

A patient and her attending physician may decide whether to have breast reconstruction surgery
following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient
or outpatient basis for up to 60 consecutive days per condition if significant improvement can be
expected within two months you pay nothing Speech therapy is limited to treatment of certain
speech impairments of organic origin Occupational therapy is limited to services that assist the
member to achieve and maintain self care and improved functioning in other activities of daily living

Chiropractic services will be provided for up to 60 consecutive days per condition if significant
improvement can be expected in the two month period

Diagnosis and treatment of infertility the following types of artificial insemination are covered
intracervical insemination ICI and intrauterine insemination IUI you pay a 15 copay per visit
cost of donor sperm is not covered Non injectable fertility drugs are covered under the Prescription
Drug Benefit Other assisted reproductive technology ART procedures such as in vitro fertilization
and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided for up to 12 weeks You pay nothing

Orthopedic devices such as braces are covered but are limited to the initial device only
Prosthetic devices such as artificial limbs and lenses following cataract surgery are covered but are
limited to the initial device only

Standard Durable Medical Equipment such as wheelchairs and hospital beds are covered but are
limited to the initial device only

What is not Physical examinations that are not necessary for medical reasons such as those required for covered obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives not replaced by the member
Hearing aids

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

11 11
11 Page 12 13
Keystone Health Plan East 2000
Long term rehabilitation services
Homemaker services
Foot orthotics unless for treatment of diabetes
Charges for missed appointments or for completing insurance forms
Appetite suppressants
Radial keratotomy
Customized durable medical equipment
Dental prosthetics

Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
Hospital care hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for up to 180 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically

appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary
services are covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided

under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness
with a life expectancy of approximately six months or less

Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor service

Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is
procedures a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute

detoxification if the Plan doctor determines that outpatient management is not medically appropriate
See page 15 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member

Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

12 12
12 Page 13 14
Keystone Health Plan East 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or

surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if the service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone

system or go to the nearest hospital emergency room
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a
Plan hospital you will be transferred when medically feasible with any ambulance charges covered in
full

Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this plan any follow up care recommended by non plan providers must be
approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay 35 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital or you are referred to
the emergency room by your primary care doctor and services could have been provided by your
doctor the emergency care copay is waived

Emergencies outside Benefits are available for any medically necessary health service that is immediately required because the service area of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If
a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non plan providers must be
approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 35 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care
copay is waived
What is covered Emergency care at a doctor s office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctor s services

Ambulance service approved by the Plan
What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen

before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service
area

13 13
13 Page 14 15
Keystone Health Plan East 2000
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
you are required to pay for the services submit itemized bills and your receipts to the Plan along with
an explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied
If it is denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan s decision you
may request reconsideration in accordance with the disputed claims procedure described on page 8

Mental Conditions Substance Abuse Benefits
Treatment for mental conditions including various mental illnesses and substance abuse is coordinated directly by Magellan
Behavioral Health formerly known as Green Spring Health Services or any other behavioral health administrator we designate
Magellan Behavioral Health acting as our mental health administrator manages all care related to mental health and substance abuse
services including referrals to mental health and substance abuse specialists Questions about related benefits and precertifications
should be directed to Magellan Behavioral Health at 1 800 688 1911

Mental conditions What is a serious A serious mental illness is any of the following biologically based mental illnesses as defined by the

mental illness American Psychiatric Association in the most recent edition of the Diagnostic and Statistical Manual DSM as follows schizophrenia bipolar disorder obsessive compulsive disorder major depressive
disorder panic disorder anorexia nervosa bulimia nervosa schizo affective disorder and delusional
disorder and any other mental illness that is considered to be Serious Mental Illness by law

To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness or disorders

What is covered Diagnostic evaluation Psychological testing

Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care Outpatient visits or partial hospitalization treatment with Plan providers is covered each calendar year for up to 60 days visits for serious mental illness and 20 visits for all other mental conditions You

pay a 25 copay for each visit all charges thereafter Based on medical necessity up to 60
additional days visits for outpatient serious mental illness services and other mental conditions are
available per calendar year on a 2 for 1 exchange with available inpatient days

Inpatient care Up to 35 days of hospitalization are available for a non serious mental illness each calendar year you pay nothing for the first 35 days all charges thereafter Up to 30 days are available for serious

mental illness each calendar year you pay nothing for the first 30 days all charges thereafter Up
to 30 inpatient days for both serious and non serious mental illness may be exchanged on a 1 for 2
basis for additional outpatient mental health days visits

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

14 14
14 Page 15 16
Keystone Health Plan East 2000
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the

same as for any other illness or condition and to the extent shown below the services necessary for
diagnosis and treatment

Outpatient care Up to 60 visits per calendar year subject to a lifetime maximum of 120 visits you pay a 15 copay for each visit

Residential Up to 30 days per calendar year in a residential alcohol and or drug treatment rehabilitation center rehabilitation approved by the Plan subject to a lifetime maximum of 90 days Based on medical necessity
members may receive up to 15 additional substance abuse days per calendar year by exchanging any
two available outpatient substance abuse visits for one inpatient treatment facility day You pa
nothing during the benefit period all charges thereafter

Detoxification Outpatient and inpatient treatment is provided for up to seven days per episode subject to a lifetime services benefit maximum of four episodes

What is not covered Treatment that is not authorized by the mental health and substance abuse vendor

Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply or 120 unit supply or maximum allowed dosage as prescribed by
law whichever is less You pay a 5 copay per prescription unit or refill Maintenance drugs may be
obtained at a Plan pharmacy for up to a 90 day supply you pay a 15 copay per prescription unit
or refill

DRUG FORMULARY Drugs are dispensed in accordance with the Plan s drug formulary Non
formulary drugs will be covered when prescribed by a Plan doctor

MAIL ORDER OPTION A Mail Order program is available for obtaining up to a 90 day supply of
maintenance medications You pay a 5 copay per 90 day supply

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs up to a three cycle supply may be obtained for a single
copay charge
Contraceptive diaphragms and IUDs you pay a 5 copay for the device and a 15 copay for the
office visit
Implanted time release medications such as Norplant You pay a 5 copay for the implant and a
15 copay for the office visit There is no charge when the device is implanted during a covered
hospitalization Removal of the implanted time release medication before the end of the expected
life is not covered unless medically necessary and approved by the Plan
Insulin with a copay charge applied to each vial
Diabetic supplies including syringes needles glucose test tablets and test tape Benedict s
solution or equivalent and acetone test tablets and glucometers Copay applies to each diabetic
supply except Glucometers and lancets
Disposable needles and syringes needed to inject covered prescribed medication
Prenatal and Pediatric Vitamins
Non injectable fertility drugs

Intravenous fluids and medication for home use provided under home health services at no charge
and some covered injectable drugs are covered under Medical and Surgical Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

15 15
15 Page 16 17
Keystone Health Plan East 2000
Limited benefits Drugs to treat sexual dysfunction may be subject to dosage limitations Contact the Plan for dose limits

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Contraceptive devices except diaphragms and IUDs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation
Injectable fertility drugs

Other Benefits
Dental care

What is covered The following dental services are covered when provided by participating Plan general dentists You pay a 5 copay per office visit

Preventive services Oral examination and diagnosis limited to once in 6 months prophylaxis teeth cleaning to include scaling and polishing limited to once in six months topical fluoride includes child and adult oral
hygiene instruction
Diagnostic services Complete series x rays intraoral occlusal film bitewings limited to once in 6 months emergency examination panoramic film cephalometric film

Restorative Amalgam silver restoration to primary and permanent teeth anterior and posterior composite services restoration to primary and permanent teeth pin restoration sedative restoration per tooth
emergency treatment palliative
Other services We cover the following services at a discount Endodontic Orthodontic Oral Surgery Single Unconnected crowns and Prosthodontics What you pay may change periodically Call us for the

amounts you pay for these dental services
Out of area dental The program will provide coverage for members for dental services in connection with dental services emergencies for palliative treatment relieve pain up to a maximum of 25 for each occurrence To

receive payment for Out of Area Dental Services the member must submit a receipt to Keystone
Health Plan East Member Services The receipt must itemize charges and dental services performed

Accidental injurbenefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth while enrolled in this Plan and if services are initiated within 6 months or as other medical

conditions permit after the accident are covered when provided by participating Plan dentists
The need for these services must result from an accidental injury You pay a 15 copay per visit

What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the Medical and Surgical Benefits provided for diagnosis and treatment of diseases of the eye one eye refraction every two calendar years to provide a written lens prescription may be

obtained from Plan providers You pay a 15 copay per visit
What is not Up to a 35 allowance for frames and corrective lenses every two calendar years
covered Eye exercises

Contact lens fittings

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

16 16
16 Page 17 18
Keystone Health Plan East 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB
premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure

Keystone Health Plan East also offers members these Distinct Health Enhancement Opportunities
Weight Management Program Keystone and Weight Watchers have a special offer for those who want to lose weight and keep it off Keystone Members receive 100 reimbursement up to 200 on Weight Watchers 1

New Fitness Reimbursement Program To give members added incentive to maintain an active lifestyle we will reimburse members up to 150 of their annual fitness club fees Members can now enjoy the flexibility of joining any fitness
club and working out at multiple fitness clubs Visits can be recorded by swipe card computer printout telephone or logbook

Smoking Cessation Program If you smoke quitting is one of the best things you can do for your health Better yet when you kick the habit we ll help foot the bill You can get up to 200 back when you complete your choice of a variety of
proven smoking cessation programs And to give you more incentive we now will reimburse you the costs of nicotine replacement
products If you choose a smoking cessation program that costs less than 200 you use the difference toward the purchase of
nicotine replacement products such as the patch or chewing gum

Red Cross CPR and First Aid Course Discounts Keystone Health Plan East members will receive a 30 discount off any course offered by the American Red Cross

Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 18 certain annuitants and former spouses who are covered by both Medicare Parts A and B
and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB Contact your retirement system for information on
changing your FEHB enrollment Contact us at 1 800 43KEY65 for information on Plan benefits under the Medicare plan and the
cost of that enrollment

Poison Prevention Program Keystone Health Plan East members can receive warning stickers to place on poisonous substances and a coupon for a free bottle of Syrup of Ipecac

Child Safety Program Keystone Health Plan East offers its members a child identification record fingerprint kit and a poster listing My Eight Rules of Safety
For more information Call the Health Resource Center 1 800 ASK BLUE or if calling within the Philadelphia area 215 241 3367

1 Registered mark Weight Watchers International Inc

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
17 17
17 Page 18 19
Keystone Health Plan East 2000
Section 6 General Exclusions Things We Don t Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you
later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan
offered by this Plan see page 17

Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents

about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan
is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer
we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage

18 18
18 Page 19 20
Keystone Health Plan East 2000
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the

primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits

Medicaid We pay first if both Medicaid and this Plan cover you

Other government We do not cover services and supplies that a local State or Federal Government agency directly or agencies indirectly pays for

If you have If you have a malpractice claim because of services you did or did not receive from a Plan provider a malpractice claim it must go to binding arbitration Contact us about how to begin our binding arbitration process

Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right information about to information about your health plan its networks providers and facilities You can also find out
your HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM s website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 227 3114 or write to 1901 Market Street
Attention General Correspondence Philadelphia PA 19101 7979

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information Employees Health Benefits Plans brochures for other plans and other materials you need to make an

about enrolling informed decision about in the FEHB
When you may change your enrollment Program
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment

We don t determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office

19 19
19 Page 20 21
Keystone Health Plan East 2000
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled I retire in the FEHB Program for the last five years of your Federal service If you do not meet this

requirement you may be eligible for other forms of coverage such as Temporary Continuation of
Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are available unmarried dependent children under age 22 including any foster or step children your employing or

for my family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support which is also authorized by
your employing or retirement office
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce No new enrollment form is
necessary

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled
in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access claims records to it

confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use

an Employee Express confirmation letter
What if I paid a Your old plan s deductible continues until our coverage begins deductible under

my old plan

20 20
20 Page 21 22
Keystone Health Plan East 2000
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if menrollment You will receive an additional 31 days of coverage for no additional premium when in this
Your enrollment ends unless you cancel your enrollment or Plan ends
You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits under coverage
your former spouse s enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse s
employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you

can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not
elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

Key points about TCC You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in TCC
You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within
60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling
in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later

21 21
21 Page 22 23
Keystone Health Plan East 2000
How can I convert to Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your individual coverage employing or retirement office within the 60 day deadline

You may convert to an individual policy if
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have
How can I get a to answer questions about your health and we will not impose a waiting period or limit your Certificate of Group coverage due to pre existing conditions

Health Plan If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Coverage
indicates how long you have been enrolled with us You can use this certificate when getting health
insurance or other health care coverage You must arrange for the other coverage within 63 days of
leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 215 241 2273 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

22 22
22 Page 23 24
Keystone Health Plan East 2000
Summary of Benefits for Keystone Health Plan East 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of
this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day Care limit Includes in hospital doctor care room and board general nursing
care private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 12
Extended Care All necessary services up to 180 days per calendar year You pay nothing 12

Mental Condition Diagnosis and treatment of acute psychiatric conditions for up to 35 days of inpatient care and serious mental illnesses for up to 30 days of inpatient care per year
You pay nothing 14
Substance Abuse Up to 30 days per calendar year in a residential alcohol drug treatment rehabilitation center subject to a lifetime maximum of 90 days You pa

nothing 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness care or injury including specialist s care preventive care including well baby

care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay for primary care and
a 15 copay for specialty care per office visit 15 per house call by a doctor 10
Diabetes Foot orthotics and diabetic self management training and education prescribed by a Plan doctor 10 11

Home Health Care All necessary visits by nurses and health aides You pay nothing 11
Mental Up to 60 outpatient days visits for serious mental illnesses and 20 outpatient Condition visits for all other mental conditions per year You pay a 25 copay for each

visit 14
Substance Abuse Up to 60 full visits per calendar year for rehabilitation lifetime maximum of 120 visits You pay a 15 copay per visit 15

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 35 copay to the hospital for each
emergency room visit and any charges for services that are not covered by this Plan 13

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill A Mail Order program is
available for up to a 90 day supply of maintenance medications You pa a 5 copay per 90 day supply 15

Dental care Accidental injury benefit you pay a 15 copay per visit Preventive Diagnostic and Restorative dental care you pay a 5 copay per visit 16
Vision care One refraction every two years You pay a 15 copay per visit 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per person or 2,000

per family per calendar year covered benefits will be provided at 100 This copay maximum does not include prescription drugs or
dental services 5

23 23
23 Page 24
Keystone Health Plan East 2000
2000 Rate Information for
Keystone Health Plan East

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but not a member of a special postal employment class refer to the category definitions in The
Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to
determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment
classes or associate members of any postal employee organization Such persons not subject to postal rates must
refer to the applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Self Only ED1 69.87 23.29 151.39 50.46 82.68 10.48 82.68 10.48
Self and Family ED2 175.97 69.75 381.27 151.12 207.74 37.98 201.02 44.70

24 24

Page Navigation Panel