QualMed Plans for Health
of Ohio and West Virginia Inc 2000
A Health Maintenance Organization For changes
in beneftis see page 4
Serving Northeastern and Eastern Ohio and the Panhandle
North Central and Charleston areas in West Virginia
Enrollment in this Plan is limited see page 8 for requirements
Enrollment Code QJ1 Self only
QJ2 Self and Family
Service area In Ohio counties of Belmont Harrison Jefferson Monroe and Washington
In West Virginia counties of Brooke Doddidge Hancock Harrison Kanawha Lewis
Marion Marshall Monongalia Ohio Pleasants Putman Tyler Wetzel and Wood
Visit the OPM website at http www opm gov insure
And
our website at http www qualmed com pa
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service
Table of Contents
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 12
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB facts 23
Inspector General Advisory Stop Healthcare Fraud 28
Summary of Benefits Inside back cover
Premiums Back cover
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Introduction
QualMed Plans for Health of Ohio West Virginia Inc 121 Seventh Street Pittsburgh PA 15222
This brochure describes the benefits you can receive from QualMed Plans for Health of Western PA under its contract CS2500 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 QualMed Plans for Health of Ohio West Virginia 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
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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
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QualMed Plans for Health of Ohio West Virginia Inc 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 preventative 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 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
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Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copayment of 10 for all changes physician 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
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 the non postal premium will increase by 8.7 for Self Only or 7.1 Self and Plan Family
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Section 3 How to get benefits
What is this To enroll with us you must reside or work in our service area This is where our providers practice Plan's service Our service area is
area Northeastern Ohio area Counties of Columbiana Mahoning and Trumbull as well as the following
zip codes in Stark county 44601 Alliance and 44657 Minerva
Eastern Ohio and West Virginia Panhandle North Central Charleston area In Ohio counties of Belmont Harrison Jefferson Monroe and Washington In West Virginia counties of Brooke
Doddridge Hancock Harrison Kanawha Lewis Marion Marshall Monongalia Ohio Putman Tyler Wetzel and Wood
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
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 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 You must share the cost of some services This is called either a copayment a set dollar amount or pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or more family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs or 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 and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit who doesn't contract with us If you file a claim please send us all of the documents for your claim as
claims 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 QualMed Health Plan is a mixed model prepayment plan which means you can choose a doctor from my health either a medical group or individual physicians practicing out of their own offices The Plan services
care certain metropolitan and rural regions in Ohio and West Virginia
What do I do if Call our member service department at 1 800 333 3930 We will help you select a new one my primary
care physician leaves the
Plan
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Section 3 How to get benefits cont
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist I need to go will make the necessary hospital arrangements and supervise your care
into the hospital
What do I do if First call our customer service department at 1 800 333 3930 If you are new to the FEHB Program I'm in the we will arrange for you to receive care If you are currently in the FEHB Program and are switching to
hospital when us your former plan will pay for the hospital stay until I join this
You are discharged not merely moved to an alternative care center or Plan 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 participating specialist specialty care
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
However a woman may see her Plan Gynecologist without a referral
What do I do if A new member may continue an ongoing course of treatment with a nonparticipating health care I am seeing a provider for a transitional period of up to sixty 60 days from the effective date of enrollment in the
specialist Plan In the case of a new member in the second or third trimester of pregnancy on the effective date of when enrollment the transitional period shall extend through postpartum care related to the delivery Any
I enroll health care provided under this section shall be covered by the Plan under the same terms and conditions as applicable for participating health care providers
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
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Section 3 How to get benefits cont
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or You may also be able to continue seeing your provider if your plan drops out of the FEHB Program this Plan
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or leaves the chronic condition or are in your second or third trimester Your new plan will pay for or provide your
Program 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 Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize recommending follow up care Before giving approval we consider if the service is medically
medical necessary and if it follows generally accepted medical practice services
How do you The Plan's Medical Director and Technology Assessment Committee determine what procedures and decide if a services are experimental investigational using FDA guidelines and outside experts such as Quality
service is First and Code Review experimental
Plan providers will follow generally accepted medical practice in prescribing any course of treatment or Before you enroll in this Plan you should determine whether you will be able to accept treatment or
investigational procedures that may be recommended by Plan providers
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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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service
What if I have a Call us at 1 800 333 3930 and we will expedite the review serious or life
threatening condition and you
haven't responded to my request for
service If we expedite your review due to a serious medical condition and deny you claim we will
What if you have inform OPM so that they can give your claim expedited treatment too Alternatively you can denied my request call OPM's health benefits Contracts Division IC at 202 606 0737 between 8 a m and 5 p m
for care and my Serious or life threatening conditions are ones that may cause permanent loss of bodily condition is serious functions or death if they are not treated as soon as possible
or life threatening
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Section 4 What to do if we deny your claim or request for service cont
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time limits our 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
What do I send to Your request must be complete or OPM will return it to you You must send the following 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
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Section 4 What to do if we deny your claim or request for service cont
Who can make the Those who have a legal right to file a disputed claim with OPM are 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 Send your request for review to Office of Personnel Management Office of Insurance mail my disputed Programs Contracts Division IV P O Box 436 Washington D C 20044
claim to OPM
OPM's decision is final There are no other administrative appeals If OPM agrees with our
What if OPM decision your only recourse is to sue upholds the Plan's
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the denial third year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will I file a lawsuit base its 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 the Privacy Act you and 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
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Section 5 BENEFITS
Medical and Surgical Benefits What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan
doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no additional copay for laboratory tests and x rays Within the service
area house calls will be provided if in the judgement of the Plan doctor such care is necessary and appropriate you pay nothing
Plan doctors also provide all necessary medical or surgical care in a hospital or extended care facility at no additional cost to you
The following services are included
Preventive care including well baby care and periodic check up Mammograms are covered as follows for women age 35 through 39 one mammogram
during these five years for women age 40 and over 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 you pay nothing
Consultations by specialists you pay a 10 copay per office visit 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 mother at her option may remain in the hospital up
to 48 hours after a regular delivery and 96 hours after a cesarean 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 Midwife services and childbirth classes
Voluntary sterilization you pay a 35 copay and family planning services Diagnosis and treatment of diseases of the eye
Growth hormones you pay 20 of charges 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
Cornea heart kidney and liver 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 Transplants are covered when approved by the Medical
Director Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this process 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 Home health services of nurses and health aids including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
Breast prostheses and surgical bras as well as their replacement following a mastectomy CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Medical and Surgical Benefits cont
Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical
procedures occurring within adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts and extraction of impacted wisdom
teeth when partially or totally covered by bone All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered including any dental care involved in the
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 occupational and respiratory is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within two months you pay a 10 copay per outpatient session Speech therapy is limited to services that assist the member to achieve and maintain self care
and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered and you pay 10 of charges The following types of artificial insemination are covered Intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI you pay 10 of charges cost of donor sperm is not covered 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 myocardial infarction is provided for up to two months you pay nothing
Orthopedic devices such as braces and prosthetic devices such as artificial limbs are limited to the initial device unless a replacement is required due to a change in a medical condition
you pay 10 of charges
Durable medical equipment such as wheelchairs and hospital beds are covered for the initial rental or purchase only The Plan determines whether the equipment will be rented or
purchased
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Homemaker services Transplants not listed as covered
Hearing aids Long term rehabilitative therapy
Chiropractic services Blood and blood derivatives not replaced by the member
Radial keratotomy Biofeedback
Acupuncture Foot orthotics
Refractions including lens prescriptions Corrective eyeglasses frames contact lenses including fitting of lenses
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are 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 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 60 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 the terminally ill member is covered in the home or a 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 a Procedures 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 Detoxification diagnosis 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 16 for non medical 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
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Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe 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 or 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 the service area emergencies if you are unable to contact your doctor contact the local emergency system or go
to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member must notify the Plan
within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility 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 you are hospitalized in non Plan facilities and 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
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 hospital the copay is
waived
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the service because of injury or unforeseen illness
area 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 services to the extent the service would have been covered if received from Plan providers
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Emergency Benefits cont 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 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 non emergency 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
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers care 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 Mental conditions
What is covered 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 Diagnostic evaluation
Psychological testing Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 40 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay nothing for each covered visit all charges thereafter
Inpatient care All medically necessary days each calendar year you pay nothing
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Mental Conditions Substance Abuse Benefits cont What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not
covered 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
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 below the services necessary for diagnosis and treatment
Outpatient care Up to 30 outpatient visits to Plan providers for treatment each calendar year you pay a 10 copay per visit during the benefit period all charges thereafter
The substance abuse benefit may be combined with the outpatient mental conditions benefit shown above provided such treatment is necessary and approved by the Plan to permit
additional outpatient visits per calendar year
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the
benefit period all charges thereafter There is a lifetime maximum of 60 days for inpatient rehabilitation
What is not Treatment that is not authorized by a Plan doctor covered
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 You pay a 10 copay per prescription unit or refill for up to a 34 day supply or 100 unit supply whichever is greater Mail order prescription service
is available for maintenance medications up to a 90 day supply you pay a 20 copay
Drugs must be prescribed by Plan doctors and dispensed in accordance with the Plan's Select Drug Formulary The Select Drug Formulary is a list of commonly prescribed medications that
have been chosen by the Pharmacy and Therapeutics Committee based on a drug's effectiveness and cost The Pharmacy and Therapeutics Committee will evaluate any needed additions or
deletions to the formulary Upon your primary care doctor's request specific medications can be evaluated on a case by case basis to be added to the formulary
Non formulary drugs will be covered when prescribed by a Plan doctor It is the prescribing doctor's responsibility to obtain authorization for non formulary drugs before they are
dispensed
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prescription Drug Benefits cont Covered medications and accessories applicable to copayment include
Drugs for which a prescription is required by law Oral contraceptive drugs
Contraceptive devices including diaphragms and IUDs Injectable contraceptive drugs such as Depo Provera
Implantable contraceptive drugs such as Norplant Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medications Diabetic supplies including insulin syringes needles glucose test tablets and test tapes
Benedict's solution or equivalent and acetone test tablets injection aids insulin infusion devices and orthotics Glucose monitors and supplies are covered for insulin dependent
diabetics and gestation diabetes Intravenous fluids and medication for home use implantable drugs and some injectable drugs
are covered under Medical and Surgical Benefits
Fertility drugs
Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan at 1 800 333 3930 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 Drugs for cosmetic purposes
Drugs to enhance athletic performance Smoking cessation drugs and medications including nicotine patches
Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural benefit teeth The need for these services must result from an accidental injury and services must be
obtained within 6 months of the date of injury You pay nothing
What is not Other dental services not shown as covered covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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QualMed Plans for Health of Ohio West Virginia Inc 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 all 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 ofpocket maximums These benefits are not subject to the FEHB disputed claims procedure
Health Care Information and Assistance QualMed Through QualMed's toll free HealthLine registered nurses are available to provide health care
HealthLine answers for members 24 hours a day every day of the year These skilled professionals use their years of clinical experience and the extensive computerized medical resources at their
fingertips to assist members and direct them to the appropriate care
Women's Health Programs New Mom's QualMed offers members a free comprehensive maternity services program that includes
Program valuable information concerning prenatal health health during pregnancy member benefits money saving coupons and a free gift for the new mom and baby
Safety Programs Bike Safety QualMed offers free helmets to kids and teens members 4 18 who attend our free class on bike
Program with safety basics with a parent or Guardian Free Helmet
Benefits on this page are not part of the FEHB contract
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QualMed Plans for Health of Ohio West Virginia Inc 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
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QualMed Plans for Health of Ohio West Virginia Inc 2000
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
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage 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
Circumstance Under certain extraordinary circumstances we may have to delay your services or be unable to provide s beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are another person caused you must reimburse us for whatever services we paid for We will cover the
responsible cost of treatment that exceeds the amount you received in the settlement If you do not seek damages for injuries you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Section 7 Limitations Rules that affect your benefits cont
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 We do not cover services and supplies that a local State or Federal Government agency directly or Government indirectly pays for
Agencies
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QualMed Plans for Health of Ohio West Virginia Inc 2000
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 information about the right to information about your health plan its networks providers and facilities You can
your HMO also find out 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 800 333 3930 or write to 121 Seventh Street Pittsburgh PA 15222 You may also contact us by fax at 412 391 0377 or visit our website at
www qualmed com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the need to make an informed decision about FEHB Program
When you may change your enrollment 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
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums January 1 Annuitants premiums begin January 1 effective
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Section 8 FEHB FACTS cont
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled 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 coverage are your unmarried dependent children under age 22 including any foster or step children your
available for my employing or retirement office authorizes coverage for Under certain circumstances you may family and me also get coverage for a disabled child 22 years of age or older who is incapable of self support
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
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 claims records access 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 Worker's Compensation Programs OWCP when coordinating benefit payment 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 We will send you an Identification ID card Use your copy of the Health Benefits Election cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Section 8 FEHB FACTS cont
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens You will receive an additional 31 days of coverage for no additional premium when if my
enrollment in Your enrollment ends unless you cancel your enrollment or this 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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse under your former spouse's enrollment But you may be eligible for your own FEHB coverage
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
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Section 8 FEHB FACTS cont
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 32 nd 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
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Section 8 FEHB FACTS cont
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under in TCC 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
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I You may convert to an individual policy if convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or coverage 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 to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health health insurance or other health care coverage You must arrange for the other coverage within 63 Plan Coverage 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
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QualMed Plans for Health of Ohio West Virginia Inc 2000
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 1 800 333 3930 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
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Notes
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QualMed Plans for Health of Ohio West Virginia Inc 2000
Summary of Benefits for QualMed Plans for Health OH WV 2000 Do not relay on this chart alone All benefits are provided in full unless otherwise indicated subject to limitations and
exclusions set forth in the brochure This chart merely summaries certain important expenses covered by the Plan If yhou 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 care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and
board general nursing care 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 13
Extended care All necessary services up to 60 days per year You pay nothing 13
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to as many days as medically necessary You pay nothing 15
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay nothing 16
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care including well
baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a
10 copay per office visit copays are waived for maternity care nothing per house call by a doctor 11
Home Health care All necessary visits by nurses and health aids You pay nothing 11
Mental conditions Up to 40 outpatient visits per year You pay nothing 15
Substance abuse Up to 30 outpatient visits per year You pay a 10 copay per visit 16
Emergency care Reasonable charges for service 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 not covered by this Plan 14
Prescription Drugs prescribed by a Plan doctor in accordance with the Plan's drugs formulary and obtained at a Plan pharmacy You pay a 10
copay per prescription unit or refill 16
Dental care Accidental injury benefit You pay nothing 17
Out of pocket Copayments are required for a few benefits however after your maximum out of pocket expenses reach a maximum of 1,500 per Self
Only or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay
maximum does not include the cost of prescription drugs 5
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2000 Rate Information for
QualMed Plans for Health of Ohio WVA
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 employee who is 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 Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share
Share Share Share Share Share Share Share
Panhandle N Central Charleston area Self Only QJ1 69.86 23.28 151.35 50.45 82.66 10.48 82.66 10.48
Self and Family QJ2 175.97 65.61 381.27 142.15 207.74 33.84 201.02 40.56
Eastern Ohio Self Only QJ1 69.86 23.28 151.35 50.45 82.66 10.48 82.66 10.48
Self and Family QJ2 175.97 65.61 381.27 142.15 207.74 33.84 201.02 40.56
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