Pages 1--24 from Untitled

Serving Central Southern Southwestern Southeastern Northern Ohio
Enrollment in this Plan is limited see page 5 for requirements

Enrollment code
MG 1 Self Only
MG 2 Self and Family

Visit the OPM website at http www opm gov insure
United States of
Personnel Management
Retirement and Insurance Service RI 73 508 1
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Community Health Plan of Ohio 2000
Table of Contents
Page
Plain Language 3

How to use this brochure 3
Section 1 Health Maintenance Organization 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 16
Section 7 Limitations Rules that affect your benefits 16
Section 8 FEHB facts 18
Inspector General Advisory Stop Healthcare Fraud 21
Summary of benefits 23
Premiums 24

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Introduction
The Community Health Plan of Ohio CHP of Ohio 1915 Tamarack Road Newark Ohio 43055 has entered into a contract CS2504 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law to
provide a comprehensive medical plan herein called CHPO or the Plan
This brochure describes the benefits you can receive from Community Health Plan of Ohio under its contract CS2504 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 Community Health Plan of Ohio 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 effect 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
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that effect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this information about the Federal Employees Health Benefits FEHB Program

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Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physician 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 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

Section 2 How We Change For 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care 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 age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Plan Your share of the non postal standard option premium will increase by 10.0 for Self Only or decrease 42 for Self and Family
Inpatient Hospital care now requires a 50 copay per day up to a maximum 250 copay per admission
Outpatient Surgery 50 copay per case
Cardiac Rehabilitation 20 copay per visit
Physical Speech Occupational Therapy 20 copay per visit for up to 90 treatments per contract year combined

Primary Care Physician PCP 10 copay per visit
Specialty Care Physician SPC 20 copay per visit
Non Surgical Spinal Treatments are now covered at a 10 copay PCP 20 copay SCP for up to 20 visits per contract year

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How We Change For 2000 continued
Mental Health Inpatient care now requires a 50 copay per day up to 250 copay per admission

Mental Health Outpatient 20 copay per visit
Alcoholism Substance Abuse Inpatient 50 copay per day maximum of 250 copay per admission

Alcoholism Substance Abuse Outpatient 20 copay per visit
Ambulance 100 per trip
Hospital Emergency Room 50 copay per visit
Temporalmandibular Joint Dysfunction requires a 30 copayment
Infertility Services now require a 30 copayment coverage includes testing and medical services drugs excluded

Out of Pocket Maximum per contract year are now reduced to 500 Single and 1,000 Family
Mental Health Alcoholism and Substance Abuse Copays do not apply toward the out of pocket maximum

Decrease the Plan's service area by eliminating Butler and Hamilton counties

Section 3 How to get benefits
What is the Plan's To enroll with us you must live or work inside the service area This is where our providers service area practice Our service area is

Athens Belmont Brown Clermont Clinton Coshocton Delaware Fairfield Fayette Franklin Gallia Greene Guernsey Harrison Highland Hocking Holmes Jackson Knox Lawrence
Licking Marion Meigs Monroe Morgan Morrow Muskingum Noble Ottawa Perry Pickaway Pike Richland Ross Sandusky Seneca Scioto Tuscarawas Union Vinton Warren
Washington
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

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 pay You must share the cost of some services This is called a copayment a set dollar amount or for services coinsurance a set purchase of charges Please remember you must pay this amount when you
receive services
After you pay 500 in copayments or coinsurance for one family member or 1,000 per 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 Mental Health Alcoholism and Substance Abuse 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

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How To Get Benefits continued
Do I have to submit claims You normally won't have to submit claims to us unless you receive emergency services from a 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 receive the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time If you are required to pay for health care services send itemized bills and proof of payment within 60 days of performance of
the services or within 30 days of your receipt of billing to Community Health Plan of Ohio 1915 Tamarack Road Newark Ohio 43055

Who provides health care Community Health Plan of Ohio CHPO is an IPA Model Individual Practice Association where patient care is obtained in the privacy of a doctor's office When you enroll in CHPO you
will choose a local provider network for your entire family A network is the participating providers in a specific local geographic area who have entered into agreements to provide health
care services to plan enrollees CHPO members must select a network for their entire family All family members must select a primary care physician from the same network All health services
must be accessed from health care providers within the selected network except for the treatment of medical emergencies The services of providers outside the network are covered only when
there has been a referral by the member's primary care doctor There is no limit on the number of primary care doctors per family There can be one for each family member or you can all choose
one doctor The choice is yours Primary care doctors are defined as doctors specializing in family practice general practice internal medicine and pediatrics

If members need to see a specialist they will be referred by their primary care doctor Members needing specialty care not provided in the network selected will be referred by their primary care
doctor to the appropriate specialist outside the network at no additional cost to the member
The primary hospital for scheduled inpatient admissions is the hospital associated with the network selected

Role of primary care doctor 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 specialists 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 you have been referred by your primary care doctor with the following exception a woman may see her
Plan obstetrician gynecologist directly with no need to be referred by her primary care doctor
Choosing your doctor The Plan's provider directory lists primary care doctors general practitioners pediatricians and internists with their locations and phone numbers and notes whether or not the doctor is accepting
new patients Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at 740 348 1400 you can
also find out if your doctor participates with this Plan by calling this number If you are interested in receiving care from a specific provider who is listed in the directory call the provider to verify
that he or she still participates with the Plan and is accepting new patients Important note When you enroll in this Plan services except for emergency benefits are provided through the
Plan's delivery system the continued availability and or participation of any one doctor hospital or other provider cannot be guaranteed

If you enroll you will be asked to let the Plan know which primary care doctor s you've selected for you and each family member of your family by sending a selection form to the Plan If you
need help in choosing a doctor call the Plan Members may change their doctor selection by notifying the Plan 30 days in advance

If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services until the Plan can arrange with you for you to be seen by another participating doctor

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How To Get Benefits continued
What do I do if my primary Call us We will help you select a new one care physician leaves
the Plan
What do I do if I need Talk to your Primary Care physician If you need to be hospitalized your primary care physician to go to the hospital or authorized specialist will make the necessary hospital arrangements and supervise your care
All hospital services must be accessed from the hospital in the network you selected except for treatment of emergencies If you need hospital care not provided in the network selected you
will be referred by your primary care doctor to the appropriate hospital outside the network at no additional cost to you

What do I do if I'm First call our customer service department at 1 740 348 1400 If you are new to the FEHB in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program and
I join this Plan are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care 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 except in a medical specialty care emergency Referral to a participating specialist is given at the primary care doctor's 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 unless your doctor authorizes additional visits All follow up care must be provided or authorized by the primary care doctor Do not go to the specialist
for a second visit unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance The Plan will provide benefits for covered services only
when the services are medically necessary to prevent diagnose or treat your illness or condition Your Plan doctor must obtain the Plan's determination of medical necessity before you may be
hospitalized referred for specialty care or obtain follow up care from a specialist
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 The treatment plan will permit you to
visit your specialist without the need to obtain further referrals
What do I do if I am seeing Your primary care physician will decide what treatment you need If they decide to refer you to a a specialist when I enroll specialist ask if you can see your current specialist If your current specialist does no participate
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 if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see
someone else
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to illness and my provider continue seeing your provider for up to 90 days after we notify you that we are terminating our
leaves the Plan or this Plan contract with the provider unless the termination is for cause leaves the Program
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

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How To Get Benefits continued
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a medical services specialist or recommending follow up care Before giving approval we consider if the service is
medically necessary and if it follows generally accepted medical practice If you seek the services of any Provider without Prior Authorization you will be responsible for the cost of such services
Referral to a participating specialist is given at the discretion of your Primary Care Physician and The Plan and is not open ended The referral will specify a number of visits and a
time frame in which they may occur A specialist may not refer to another specialist without the Prior Authorization of your Primary Care Physician and the Plan except for emergencies All follow
up care must be provided or authorized by your Primary Care Physician If you go to the specialist for additional visits without obtaining Prior authorization from your Primary Care
Physician and the Plan you will be responsible for the cost of such services
How do you decide if a The Plan uses peer reviewed medical literature FDA regulations and review by any Institutional service is experimental or Review board to determine experimental investigative or unproved services such as medical
investigational surgical diagnostic psychiatric substance abuse or other health care technologies supplies treatments diagnostic procedures drug therapies and devices

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 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 or Call us 740 348 1400 and we will expedite our review life threatening condition
and you haven't responded to my request for services

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious or OPM's health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible

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What To Do If We Deny Your Claim or Request For Service Continued
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold 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 OPM Your request must be complete or OPM will return it to you You must send the following 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 the request Those who have a legal right to file a disputed claim with OPM are
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 my Send your request for review to Office of Personnel Management Office of Insurance Programs disputed claim to OPM Contract division IV P O Box 436 Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base if I file a law suit 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from 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
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 laboratory tests and Xrays
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 a 10 copayment to the Primary Care Physician
and 20 copayment to the Specialist you pay nothing for a doctor's house call or for home visits by nurses and health aides

The following services are included
Preventive care including well baby care and periodic checkups
Annual preventive mammograms for women In addition to routine screening mammograms are covered when prescribed by a Plan doctor as medically necessary to treat or diagnose an

illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures including 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 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 services
Diagnostic and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of penile and scrotal implant devices is not covered

Cornea heart heart lung kidney single lung double lung liver 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 mastectomies 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
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

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Benefits continued
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you except where noted

Outpatient surgery provided with a copay of 50 per case
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 or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures 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 impatient or outpatient basis for up to 90 treatments per year combined per condition if significant improvement
can be expected within two months you pay 20 per outpatient session 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

Diagnosis and treatment of infertility and the following types of artificial insemination are covered intravaginal insemination IVI and intracervical insemination ICI You pay 30 of
charges cost of donor sperm is not covered Other assisted reproductive techonology ART procedures such as in vitro fertilization and embryo transfer are not covered Fertility drugs are not
covered
Durable Medical Equipment such as wheelchairs and hospital beds and prosthetic devices such as artificial limbs external lenses following cataract removal pacemakers breast prosthesis and
surgical bras as well as their replacement are covered for the initial device only unless required for life support up to a lifetime maximum Plan payment per member of 5,000 you pay all
charges thereafter The Plan will cover replacements only when required due to growth from maturity

Orthopedic supplies including casts splints trusses braces and crutches and medical supplies such as colostomy bags are covered up to a maximum Plan payment of 500 per member per
contract year you pay all charges thereafter
Cardiac Rehabilitation following a heart transplant bypass surgery or myocardial infarction is provided on an inpatient basis including teaching and on an outpatient basis including exercise
programs and cardiac monitoring You pay 20 per visit Outpatient exercise programs without cardiac monitoring are not covered

Non surgical Coverage for non surgical treatment limited to 20 visits per contract year with a copay of 10 if Spinal Treatment provided by the Primary Care Physician and 20 if provided by a Plan Specialty Care Physician
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
Transplants not listed as covered Hearing aids
Long term rehabilitative therapy Homemaker services
Chiropractic services Foot orthotics
Blood and blood derivatives not replaced by the member
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 11
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Benefits continued
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 50 copay per day maximum 250 copay
per admission 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 60 days per contract 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 nurs
ing 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 Transportation by professional ground ambulance or air ambulance when transportation is service medically necessary You pay 100 per trip
Limited benefits
Inpatient Hospitalization for certain dental procedures is covered when a plan doctor determines there is a dental need for hospitalization for reasons totally unrelated to the dental procedures the Plan will cover
procedures the hospitalization but not the cost of professional dental services Conditions for which hospitalization would not be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis inpatient treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 14 for non medical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary
or convalescent care blood and blood derivatives not replaced by the member
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 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 the If you are in an emergency situation please call your primary care doctor In extreme service area emergencies if you are unable to contact your doctor contact the local emergency system e g

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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Hospital Extended Care Benefits continued
the 911 telephone 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 should notify the Plan within 24 hours It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized the Plan must be notified within 24 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 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

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 30 per 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
Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 24 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 provider
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 30 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency visit 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 by professional ground ambulance or air ambulance when medically necessary you pay 100 per trip

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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 13
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Hospital Extended Care Benefits continued
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 treatment of mental illness or disorders

Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services

Outpatient Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each care calendar year you pay a 20 copay for each covered visit all charges thereafter
Inpatient Up to 30 days of hospitalization each contract year you pay 50 copay per day maximum 250 care copay per admission all charges after 30 days
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

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 Up to 30 outpatient visits to Plan providers for treatment each contract year you pay a 20 copay care for each covered visit all charges after 30 visits
The substance abuse benefit may be combined with the outpatient mental conditions benefit shown above provided such treatment is necessary and is approved by the Plan to permit an
additional 30 outpatient visits per contract year with the applicable mental conditions benefit copayments

Inpatient Up to 30 days per contract year in substance abuse rehabilitation intermediate care program in care an alcohol detoxification or rehabilitation center approved by the plan you pay 50 copay per day
maximum 250 per admission
What is not covered Treatment that is not authorized by a Plan doctor
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 30 day supply or 100 unit supply whichever is less 240 milliliters of liquid
8oz 60 grams of ointment creams or topical preparation or one commercially prepared unit e g one inhaler one vial ophthalmic medication or insulin Drugs are prescribed by Plan doctors
and dispensed in accordance with the Plan's drug formulary The Plan uses a formulary that includes generic and preferred name brand drugs Your doctor can ask for exceptions to the formulary
Non formulary drugs will be covered when prescribed by a Plan doctor You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution
is not permissible When generic substitution is permissible i e a generic drug is available and the prescribing doctor does not require the use of a name brand drug but you request
the name brand drug you pay the price difference between the generic and name brand drug as well as the 5 copay per prescription unit or refill

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Prescription Drug Benefits continued
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs
Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets

Disposable needles and syringes needed to inject covered prescribed medication
Intraveneous fluids and medications for home use
Limited Benefits Glucometers are covered for one per family per lifetime you pay a 30 copay Immunosuppressant drugs are covered you pay 50 of charges
Growth hormones are covered only for documented growth hormone deficiency in individuals under the age of 18 you pay 20 of charges

What is not covered Fertility drugs are 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
Drugs to aid in smoking cessation
Other Benefits
Dental Care
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury You pay
nothing
What is not covered Other dental services not shown as covered
Vision Care
What is covered In additional to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription may be obtained from
Plan providers You pay a 20 copay per visit
What is not covered Corrective lenses or frames Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 15
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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 Services drugs or supplies that are not medically necessary the following 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 Limitation 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 please contact our office at 888 999 6608
Other Group Insurance Coverage
When anyone has coverage with us and with another group health plan it is called double 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

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond 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 responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the 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 any questions about TRICARE coverage
Workers compensation
We do not cover You need because of a workplace related disease or injury that the Office of Workers services that Compensation Programs OWPC or a similar Federal or State agency determine they must
provide OWPC 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 Agencies
We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 17
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Community Health Plan of Ohio 2000
Section 8 FEHB Facts
You have the right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which give you the information about right to information about your health plan its networks providers and facilities You can also
your HMO 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 web
site www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 740 348 1400 or write to 1915 Tamarack Road Newark Oh 43055 You may also contact us by fax at 740 348 1500

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the 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 benefits The benefits in this brochure are effective January 1 If you are new to this plan your coverage and premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants premiums begin January 1
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 coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for me unmarried dependent children under age 22 including any foster or step children your employing
and my family or 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

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 confidential access to it
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

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FEHB Facts continued
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
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
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 my You will receive an additional 31 days of coverage for no additional premium when enrollment in the
Plan ends Your enrollment ends unless you cancel your enrollment or 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 coverage under 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 If you leave Federal service or if you lose coverage because you no longer qualify as a family of Coverage TCC 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 Plan 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 in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

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FEHB Facts continued
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 convert You may convert to an individual policy if to individual coverage
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 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 Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan Coverage 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

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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 740 348 1400 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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Summary of Benefits for Community Health Plan of Ohio 2000
The following benefits are available to Plan enrollees when provided arranged or authorized by Plan Primary Care Physician Covered health services must be Medically Necessary 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 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 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 50 per day maximum 250 copay per admission 12
Extended Care All necessary services for up to 60 days per contract year You pay nothing .12

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay 50 copay per day maximum 250
per admission .14
Substance Abuse Up to 30 days per year in a substance abuse treatment program You pay 50 copay per day maximum 250 per admission .14

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness 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 20 copay per office visit nothing
per house call by a doctor .10
Home Health Care All necessary visits by nurses and health aides You pay nothing .10
Mental Conditions Up to 30 outpatient visits per year You pay a 20 copay per visit .14
Substance Abuse Up to 30 outpatient visits per year You pay a 20 copay per visit .14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room
visit or 30 per urgent care center and any charges for services that are not covered by this Plan .12 13

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 co pay per prescription unit or refill .14 15
Dental care Accidental injury benefit You pay nothing .15
Vision care One refraction annually You pay a 20 copay per visit .15
Out of pocket maximum Co payments are required for a few benefits however after your out of pocket expenses reach a maximum of 500 for one family member or 1,000 per Family
per contract year covered benefits will be provided at 100 This co pay maximum does not include prescription drugs Mental Health and Substance Abuse 5

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2000 Rate Information for Community Health Plan of Ohio
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 Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share Share Share Share Share Share Share Share

Central South East
Self Only MG1 65.37 21.79 141.64 47.21 77.35 9.81 77.35 9.81

Self and Family MG2 139.10 46.37 301.39 100.46 164.60 20.87 164.60 20.87

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