National HMO Health Plan
A Health Maintenance Organization
For changes
in benefits
see page 4
Serving Central California
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
MN1 Self Only
MN5 Self and Family
Visit the OPM website at http www opm gov insure
and
our website at http www nationalhmo com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 512
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NATIONAL HEALTH PLANS 2000
National HMO
Table of Contents Page
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
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 9
Section 5 Benefits 12
Section 6 General exclusions Things we don't cover 28
Section 7 Limitations Rules that affect your benefits 29
Section 8 FEHB facts 33
Inspector General Advisory Stop Healthcare Fraud 39
Summary of benefits Inside back cover
Premiums Back cover
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NATIONAL HEALTH PLANS 2000
National HMO
Introduction National Health Plans
National HMO
1005 West Orangeburg Avenue Suite B
Modesto California 95350
This brochure describes the benefits you can receive from National HMO under its contract CS2508
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 NATIONAL HMO 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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NATIONAL HEALTH PLANS 2000
National HMO
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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NATIONAL HEALTH PLANS 2000
National HMO
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 should notify the Plan within 24 hours
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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NATIONAL HEALTH PLANS 2000
National HMO
Section 2 How we change for 2000 Program wide To keep your premium as low as possible OPM has set a minimum copay of 10
changes 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 over age 50 all FEHB plans will cover a screening sigmoidoscopy
every five years This screening is for colorectal cancer
Changes to this How National HMO Changes for 2000
Plan Your share of the non postal premium will decrease by 13 for Self Only or
13.2 for Self and Family
San Bernadino Los Angeles Orange Riverside Tuolumne and Calaveras
Counties are no longer part of our Service area
Generic prescription unit or refill is a 5 copayment for a 30 day supply Brand name prescription unit or refill is a 10 copayment for a 30 day
supply
Rx Mail Order is a 13 copayment for a generic 90 day supply and a 26 copayment for a brand name 90 day supply
Do not rely on this page it is not an official statement of benefits
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NATIONAL HEALTH PLANS 2000
National HMO
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where
service area our providers practice Our service area is the California counties or partial counties of Alameda Contra Costa Fresno Kings Madera Merced San
Joaquin Stanislaus and Tulare Our service area includes the following zip
codes 93230 93242 93245 93602 93609 93610 93611 93612 93614
93616 93618 93620 93625 93626 93627 93630 93631 93635 93637
93638 93643 93644 93645 93646 93648 93650 93651 93652 93654
93656 93657 93660 93661 93662 93665 93667 93675 93701 93702
93703 93704 93705 93706 93710 93711 93720 93721 93722 93725
93726 93727 93728 93729 94506 94506 94506 94507 94526 94528
94550 94551 94566 94568 94582 94583 94588 94595 94596 94597
95201 95202 95203 95204 95205 95206 95207 95208 95209 95210
95211 95212 95213 95214 95215 95219 95220 95227 95230 95231
95234 95236 95237 95240 95241 95242 95253 95258 95267 95269
95301 95303 95304 95307 95312 95313 95315 95316 95317 95319
95320 95322 95323 95324 95326 95328 95329 95330 95333 95334
95336 95337 95340 95341 95342 95343 95344 95348 95350 95351
95352 95353 95354 95355 95356 95357 95358 95360 95361 95363
95365 95366 95367 95368 95369 95374 95376 95377 95378 95380
95381 95382 95384 95385 95386 95387 95388 95686 96361
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 that are not
coordinated by your Primary Care Physician
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 National HMO offers a Student Plan rider for students
temporarily residing outside of our service area Please call 1 800 468
8600 for more information 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
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How much do I pay You must share the cost of some services This is called either a copayment
for services a set dollar amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
There is an out of pocket maximum for hospital copays of 750 per member
and 2,250 per family per calendar year In addition copayments will not be
required for the remainder of the calendar year after your out of pocket
expenses for all services provided or arranged by the Plan reach 3,475 for
yourself or 8,641 for yourself and family This is called a catastrophic
limit However copayments for your prescription drugs dental vision or
chiropractic services do not count toward these limits and you must continue
to make these copayments
Be sure to keep accurate records of your copayments 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
submit claims 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 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 This Plan is an Independent Practice Association IPA model HMO that contracts
my health with physicians and other healthcare providers operating out of their own private
care offices and facilities Each member enrolling in the Plan may select his her own primary care physician from the Plan's participating provider roster All specialty care
except OB GYN specialists must be arranged through the member's primary care
physician Members may change their doctor selection by notifying the Plan by the
25 th of each month The change will then be effective the first day of the following
month
What do I do if Call us We will help you select a new one If you are receiving services from a
my primary doctor who leaves the Plan the Plan will pay for covered services until the Plan can
care physician arrange for you to be seen by another participating doctor
leaves the
Plan
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National HMO
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care
I need to go physician or specialist will make the necessary hospital arrangements and supervise
into the your care
hospital
What do I do if First call our customer service department at 1 800 468 8600 If you are new to the
I'm in the FEHB Program we will arrange for you to receive care If you are currently in the
hospital when I FEHB Program and are switching to us your former plan will pay for the hospital stay
join this Plan until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist A woman may
specialty care see her plan gynecologist for unlimited visits without a referral
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 Do not go to the specialist unless your primary care physician has arranged
for the visit and the plan has issued an authorization for the referral in advance
What do I do if Your primary care physician will decide what treatment you need If they decide to
I am seeing a refer you to a specialist ask if you can see your current specialist If your current
specialist when specialist does not participate with us you must receive treatment from a specialist
I enroll 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 Call your primary care physician who will arrange for you to see another specialist
my specialist You may receive services from your current specialist until we can make arrangements
leaves the for you to see someone else
Plan
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National HMO
But what if I Please contact us if you believe your condition is chronic or disabling You may be
have a serious able to continue seeing your provider for up to 90 days after we notify you that we are
illness and my terminating our contract with the provider unless the termination is for cause If you
provider leaves are in the second or third trimester of pregnancy you may continue to see your
the Plan or this OB GYN until the end of your postpartum care
Plan 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
How do you Your physician must get our approval before sending you to a hospital referring you
authorize to a specialist or recommending follow up care Before giving approval we consider
medical if the service is medically necessary and if it follows generally accepted medical
services practice
How do you The Plan's Medical Director is responsible for evaluation of new technologies
decide if a including medical surgical drugs and devices and new application of existing
service is technologies The evidence in literature and the opinions of relevant medical experts
experimental or when available are reviewed to assist the Medical Director in making determinations
investigational
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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
OPM to review a denial or refusal OPM will determine if we correctly applied the terms of our
denial contract when we denied your claim or request for service
What if I have a Call us at 1 800 468 8600 and we will expedite our review
serious or life
threatening
condition and you
haven't responded
to my request for
service
What if you have If we expedite your review due to serious medical condition and deny your
denied my request claim we will inform OPM so that they can give your claim expedited treatment
for care and my too Alternately you can call OPM's Health Benefits Contract Division IV at
condition is serious 202 606 0737 between 8 00 a m and 5 00 p m EST Serious or lifethreatening
or life threatening conditions are ones that may cause permanent loss of bodily
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functions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days
time limits 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 Your request must be complete or OPM will return it to you You must send the
OPM 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
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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
What address Send your request for review to Office of Personnel Management Office of
should I send my Insurance Programs Contract Division IV P O Box 436 Washington D C
disputed claim to 20044
What if OPM OPM's decision is final There are no other administrative appeals If OPM
upholds the Plan's agrees with our decision your only recourse is to sue OPM
denial If you decide to sue you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received the disputed
services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The
I file a lawsuit Federal court will 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
the Privacy Act collects from 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 preventative diagnostic and treatment
services are provided by Plan doctors and other Plan providers
This includes all necessary office visits you pay a 10 copay per
primary care office visit or a 10 copay for specialist office visit
but no additional copay for laboratory tests and x rays You pay
a 10 copay for office visits after 6 00 p m and on weekends and
holidays Within the Service Area house calls will be provided if
in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 10 copay for a doctor's house call
nothing for home visits by nurses and health aides
The following services are included
Preventative care including well baby care and periodic check ups you pay a 10 copay for each check up after age
two
Mammograms are covered as needed when prescribed by a Plan physician 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 a 5 copay in addition to the office visit copay except for Hepatitis B for
which you pay 20 of charges plus the office visit copay
Children pay only the office visit copay for routine
immunizations boosters and Hepatitis B vaccinations
Consultations by specialists Diagnostic procedures such as laboratory tests and x rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan
doctor You pay a 10 copay for each maternity care visit
The mother at her option may remain in the hospital for up to
48 hours after a regular delivery and 96 hours after caesarian
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
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Only or Self and Family enrollment other care of the infant
requiring definitive treatment will be covered only if the infant
is covered under a Self and Family enrollment You pay a
25 copayment per day up to 100 per admission subject to
the 750 per member 2250 per family per year inpatient
copay maximum
Eye and Ear examinations for children through age 17 Diagnosis and treatment of diseases of the eye
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart lung kidney single lung double lung liver and pancreas transplants allogenic 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
Treatment for breast cancer multiple myeloma and epithelial
ovarian cancer is limited to non randomized clinical trials
performed at Plan Centers of Excellence Related medical
and hospital expenses of the donor are covered when the
recipient is covered by the 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 Orthopedic devices such as braces
Home health services of nurses and health aides when prescribed by your Plan doctor who will periodically review
the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan
providers at no additional cost to you
The medical management of mental conditions will be covered under the Plan's Medical and Surgical Benefits
provisions Related drug costs for psychological testing and
psychotherapy will be covered under this Plan's Mental
Conditions Benefits See page 22 for more information
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Chiropractic Chiropractic care is covered You pay a 10 copayment per visit
Benefit Services must be provided by a Plan provider Copayment amounts
do not accumulate toward the copayment maximum for covered
services and services are subject to an annual 1000 maximum
allowable benefit Services covered include manipulations and
adjustment and diagnostic radiology and laboratory services Up to
three visits per calendar year may be used for maintenance care
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 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 the condition
can reasonable 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
congnitive is provided on an inpatient or outpatient basis for up to two
months per condition if significant improvement can be expected
within two months you pay a 5 copayment 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
Voluntary family planning services and sterilization are covered
You pay 25 for an IUD insertion 50 for a vasectomy and 100 for a
tubal ligation
Diagnosis and treatment of infertility is covered fertility drugs are
covered under the Prescription Drug Benefit The following types of
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artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI
you pay the specialist office visit copay of 10 per visit cost of donor
sperm is not covered Other assisted reproductive technology ART
procedures such as in vitro fertilization and embryo transfer and drugs
related to such procedures are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or
a myocardial infarction is provided for up to 12 consecutive weeks per
calendar year you pay a 20 copayment per visit
Allergy testing and treatment including allergy serum test and
treatment materials are covered You pay a 25 copay per visit for
allergy testing and 10 per visit for allergy treatments
Nutritional Counseling in conjunction with Plan approved disease
management programs when referred by a Plan doctor and approved by
the Plan You pay nothing
Total parenteral nutrition is covered You pay 20 of charges
Durable medical equipment and prosthetic devices such as
wheelchairs and hospital beds and artificial limbs are covered You
pay 50 of covered charges up to maximum Plan payment of 2500
per year Durable medical equipment and prosthetic devices are
combined benefits that are subject to a maximum of 2500 per calendar
year Drugs used in conjunction with durable medical equipment are
covered under the Prescription Drug Benefit and are subject to
applicable copayments Supplies such as tubing masks and nebulizers
are considered durable medical equipment and are subject to the 50
copayment
Outpatient surgical procedures are provided in the outpatient
department of a hospital or a surgical facility on a same day in and out
basis You pay a 25 copay per outpatient surgical procedure up to the
750 per member 2250 per family per year inpatient copay
maximum
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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
Blood and blood derivatives not replaced by the member Reversal of voluntary surgically induced sterility
Transplants not listed as covered Hearing aids
Refractions including lens prescriptions Surgical refractive procedures including but not limited to radial
keratotomy photorefractive keratectomy keratomileusis and
synthetic intracorneal rings
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
Long term rehabilitation therapy Homemaker services
Foot orthotics
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Hospital extended care benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or
hospital care day limit when you are hospitalized under the care of a Plan doctor
You pay a 25 copay per day up to 100 per admission up to the
annual inpatient copay maximum of 750 per member 2250 per
family per calendar year 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
What is covered extended The plan provides a comprehensive range of benefits for up to 60 days
care 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 a 25
copay per day up to 100 per admission up to the annual copay
maximum of 750 per member 2250 per family calendar year All
necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies including intravenous fluids and
medications and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan doctor
What is covered Supportive and palliative care for a terminally ill member is covered in
hospice care the home 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 services Benefits are provided for ambulance transportation ordered or
authorized by a Plan doctor
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Limited benefits Hospitalization for certain dental procedures is covered when a Plan
inpatient dental doctor determines there is a need for hospitalization for reasons totally
procedures 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 You pay a 25 copay per day up to 100 per
admission subject to the annual inpatient copay maximum of 750 per
member 2250 per family per calendar year
Limited benefits Hospitalization for medical treatment of substance abuse is limited to
acute inpatient emergency care diagnosis treatment of medical conditions and
detoxification medical management of withdrawal symptoms acute detoxification if the Plan doctor determines the outpatient management is not medically
appropriate
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
emergency condition or an injury that you 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 If you are in an emergency situation please call your primary care
the service area doctor In extreme emergencies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room 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
To be covered by this Plan any follow up care recommended by Plan
or non Plan providers must be coordinated through your Primary Care
Physician or approved by National HMO
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NATIONAL HEALTH PLANS 2000
National HMO
Plan pays Reasonable charges for emergency services to the extent
the services would have been covered if received from Plan providers
You pay 25 copay per hospital emergency room visit or a 10
copay per urgent care center visit for emergency services that are
covered benefits of this Plan If the emergency results in admission to
a hospital you pay a 25 copay per day up to 100 per admission if
you have not met the annual inpatient copay maximum The
emergency room visit copay will apply to this maximum
Emergencies outside Benefits are available for any medically necessary health service that
the service area is immediately required because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48
hours or on the first working day following your admission unless it
was not reasonably possible to notify the Plan within that time If a
Plan doctor believes care can be better provided in a Plan hospital you
will be transferred when medically feasible with any ambulance
charges covered in full
To be covered by this Plan any follow up care recommended by Plan
on non Plan providers must be coordinated through your Primary Care
Physician or approved by National HMO
Plan pays Reasonable charges for emergency care services to the
extent the services would have been covered if received from Plan
providers
You pay 25 copay per hospital emergency room visit or a 25
copay per urgent care center visit for emergency services that are
covered benefits of this Plan If the emergency results in admission to
a hospital you pay a 25 copay per day up to 100 per admission if
you have not met the annual inpatient copay maximum The
emergency room visit copay will apply to this maximum
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 doctors services
Ambulance service approved by the Plan
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NATIONAL HEALTH PLANS 2000
National HMO
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 nonPlan With your authorization the Plan will pay benefits directly to the
providers providers of your emergency 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 in denied If it is denied you will receive notice
of the decision including the reasons for the denial and provision 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 See Section 4 page 9
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NATIONAL HEALTH PLANS 2000
National HMO
Mental conditions substance abuse benefits
Mental conditions what To the extent shown below the Plan provides the following services
is covered 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
Mental conditions Up to 20 outpatient visits to Plan doctors consultants or other
outpatient care psychiatric personnel each calendar year you pay a 20 copay per
individual visit or a 10 copay per group visit all charges thereafter
Two group therapy visits equal one individual therapy visit and
reduce the combined individual therapy visits available for treatment
of mental conditions by one
Mental conditions Up to 30 days of hospitalization each calendar year you pay nothing
inpatient care for the first 30 days all charges thereafter
Mental conditions Care for psychiatric conditions that in the professional judgment of
what is not covered 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 when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse This plan provides medical and hospital services such as acute
what is covered detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addition the same as
for any other illness or condition and to the extent shown below the
services necessary for diagnosis and treatment
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NATIONAL HEALTH PLANS 2000
National HMO
Substance abuse Up to 20 outpatient visits to Plan providers for treatment of substance
outpatient care abuse each calendar year you pay a 5 copay for each covered visit
all charges thereafter
Substance abuse One 30 day substance abuse rehabilitation intermediate care program
Inpatient care per calendar year in an alcohol detoxification or rehabilitation center
approved by the Plan you pay nothing during the benefit period all
charges thereafter
Substance abuse Treatment that is not authorized by a Plan doctor
what is not covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NATIONAL HEALTH PLANS 2000
National HMO
Prescription drug benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan participating pharmacy will be dispensed for up to a 30 day supply
You pay a 5 copayment for generic drugs and a 10 copayment for brand
name drugs per prescription unit or refill when obtained at Plan contracted
pharmacies except for out of area emergencies
Drugs are prescribed by Plan doctors and dispensed in accordance with the
Plan's drug formulary Nonformulary drugs will be covered when
prescribed by a Plan doctor
The Formulary Drug List includes both generic and name brand drugs
Generic drugs will be dispensed whether or not the drug is on the
Formulary Drug List When generic drugs cannot be dispensed due to
medical reasons as determined by the Plan the Plan will authorize a name
brand drug When a generic drug can be substituted but the member
requests a name brand drug the additional cost of the mane brand drug is
not a covered benefit and must be paid by the member in addition to the
copayment Drugs are periodically reviewed by the Plan's Pharmacy
Committee for either inclusion or exclusion from the Plan's drug
formulary The committee reviews drugs for therapeutic value safety
and cost effectiveness Based on these factors drugs are added or
deleted from the formulary
Up to a 90 day supply of most drugs on the Formulary Drug List is available
through the National HMO Rx Mail order service Allow approximately 14
days from the day you mail your order for delivery You pay a 13
copayment for generic or 26 copayment for brand name per covered
prescription unit or refill
Covered medications Drugs for which a prescription is required by Federal Law
and accessories Oral contraceptive drugs and contraceptive devices injectable
include contraceptive drugs are covered as part of a doctor's office visit You
pay a 5 generic 10 brand name copay in addition to the office visit
copay
Insulin with a copayment charge applied to each vial
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NATIONAL HEALTH PLANS 2000
National HMO
Diabetic supplies limited to insulin syringes needles and chem strips You pay a 13 generic 26 brand name copayment per 90
day supply of chem strips subject to a 3 box limit if purchased
through the mail order service You pay 50 of the cost of chem
strips if purchased through select pharmacies
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use
Limited benefits Prescription drugs for the treatment of Acquired Immune
Deficiency Syndrome are covered at 80 of charges You pay
20 of charges for each 30 day supply or 100 units whichever is
greater
Hepatitis B Vaccine is covered You pay 20 of charges The Norplant contraceptive device is covered You pay 300 for
insertion and 100 for removal There is no charge when the device
is implanted during a covered hospitalization There will be no
refund of any portion of these copayments if the implanted timerelease
medication is removed before the end of its expected life
Drugs to treat sexual dysfunction are limited Please contact the Plan for dose limits You pay 50 up to the dose limits and all
charges after that
Fertility drugs preauthorized by the Plan are covered once per lifetime You pay 50 of charges
Smoking cessation drugs and medication according to Formulary guidelines including nicotine patches are covered only while you
attend a smoking cessation program and only for one such program
of up to 90 days per lifetime You pay 50 of charges
Injectable drugs for home use and preauthorized by the Plan are covered You pay 20 of charges
Prescriptions filled out of the service area required in conjunction with an approved out of area emergency service will be reimbursed
according to the Plan Pharmacy copayment requirements If you are
charged for the prescription you should pay in full and submit the
pharmacy receipt to National HMO within 30 days of the date the
prescription was filled Coverage for these prescriptions is limited
to a 10 day supply Out of area locations of contracted chain
pharmacies may be able to provide service under your prescription
plan
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NATIONAL HEALTH PLANS 2000
National HMO
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NATIONAL HEALTH PLANS 2000
National HMO
Other benefits
Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair but
benefit not replace sound natural teeth are covered The need for these services must result from an accidental injury and not from biting or
chewing only services rendered within 24 hour of the injury are
covered You pay a 25 copay
What is not covered Other dental services not shown as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NATIONAL HEALTH PLANS 2000
National HMO
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NATIONAL HEALTH PLANS 2000
National HMO
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate
the payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also
remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and
enroll in a Medicare Choice plan when one is available in your area For information
on suspending your FEHB enrollment and changing to a Medicare Choice plan
contact your retirement office If you later want to re enroll in the FEHB Program
generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area
you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB
Program and your benefits will not be reduced We cannot require you to enroll in
Medicare
For information on Medicare Choice plans contact your local Social Security
Administration SSA office or request it from SSA at 1 800 638 6833 For
information on the Medicare Choice plan offered by this Plan see page 30
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NATIONAL HEALTH PLANS 2000
National HMO
Non FEHB Benefits Available to Plan Members
SecurityCare Medicare Choice plan enrollment This plan offers Medicare recipients the opportunity to enroll in SecurityCare a federally qualified HMO with a
Medicare Contract without payment of an FEHB premium As indicated on
page 16 annuitants and former spouses with FEHB coverage and Medicare Part
B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan
when one is available in their area They may then later reenroll in the FEHB
Program Most Federal Annuitants have Medicare Part A Those without
Medicare Part A may join this Medicare prepaid plan but will probably to have
to pay for hospital coverage in addition to the Part B premium Before you join
the plan ask whether the plan covers hospital benefits and if so what you will
have to pay Contact your retirement system for information on dropping your
FEHB enrollment and changing to a Medicare prepaid plan Contact us at 1
800 468 8600 for information on the SecurityCare Medicare Choice prepaid
plan and the cost of that enrollment
National The National Assured Dental Plan offers a dental care plan accessible through
Assured any dental provider The plan offers 50 deductible with a 1000 annual per
Dental 1000 member maximum In addition to the dental plan orthodontia coverage is
available
You can review this brief summary of benefits For a more detailed explanation
of benefits please refer to the dental information enclosed in your member
material For more comprehensive information please call National Health
Plans at 1 800 468 8600
Benefits Maximum dental benefit amount for each calendar year per person 1,000
Maximum lifetime Orthodontia benefit amount under age 19 1,000
Deductible amount each calendar year per insured person 50
maximum deductible per family per calendar year is 3
Class I benefit Preventative dental services paid at 100
Class II benefit Basic dental services paid at 80
Class III benefit Major services paid at 50
Class IV benefit Orthodontia paid at 50
Monthly Premium
Single 31.87 Two Party 60.48 Family 95.32
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NATIONAL HEALTH PLANS 2000
National HMO
Non FEHB Benefits Available to Plan Members Continued
Vision Vision Service Plan VSP has an extensive nation wide network of doctors
Service who provide quality eyecare and materials With only a minimal copayment
Plan services can be received for eye examinations lenses and frames VSP offers you even more value by providing a 20 discount on non covered pairs of
prescription glasses Scheduled reimbursement is available if non network
providers are accessed For more information please see the vision
information packet enclosed in your member materials Please call National
Health Plans at 1 800 468 8600 for additional information
Benefits Eye Examination Once each 12 months 10 copayment
Spectacle Lenses Once each 24 months 20 copayment for lenses and
Frame Once each 24 months or frames
Monthly Premium
Single 10.44 Couple 16.15 Family 25.84
Other group When anyone has coverage with us and with another group health plan it is called
insurance double coverage You must tell us if you or a family member has double coverage
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
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NATIONAL HEALTH PLANS 2000
National HMO
Circumstances Under certain extraordinary circumstances we may have to delay your services or be
beyond our unable to provide them In that case we will make all reasonable efforts to provide
control you with necessary care
When others When you receive money to compensate you for medical or hospital care for injuries
are or illness that another person caused you must reimburse us for whatever services we
responsible for paid for We will cover the cost of treatment that exceeds the amount you received in
injuries the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for our subrogation
procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and
this Plan cover you we are the primary payer See your TRICARE Health Benefits
Advisor if you have questions about TRICARE coverage
Workers We do not cover services that
compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency
determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment
we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government
Government agency directly or indirectly pays for
Agencies
NATIONAL HEALTH PLANS 2000
National HMO
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights
information about which gives you the right to information about your health plan its networks
your HMO providers and facilities You can 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 1 800 468 8600 or write to
National Health Plans 1005 West Orangeburg Avenue Modesto CA 95350
You may also contact us
by fax at 209 576 0242 or visit our website at
www nationalhmo com
Where do I get Your employing or retirement office can answer your questions and give you a
information about Guide to Federal Employees Health Benefits Plans brochures for other plans
enrolling in the and other materials you 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
benefits and plan your coverage and premiums begin on the first day of your first pay period
premiums that starts on or after January 1 Annuitants premiums begin January 1
effective
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NATIONAL HEALTH PLANS 2000
National HMO
What happens When you retire you can usually stay in the FEHB Program Generally you
when I retire must have been 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
coverage are spouse and your unmarried dependent children under age 22 including any
available for me foster or step children your employing or retirement office authorizes coverage
and my family 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
claims records following will have access to it
confidential
OPM this Plan and subcontractors when they administer this contract 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
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NATIONAL HEALTH PLANS 2000
National HMO
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health
cards Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card
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
conditions member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium
my enrollment in when
this 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
spouse coverage to get benefits 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
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NATIONAL HEALTH PLANS 2000
National HMO
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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NATIONAL HEALTH PLANS 2000
National HMO
How do I enroll If you are leave Federal service your employing office will notify you of your
in TCC right to enroll under 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
coverage 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
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NATIONAL HEALTH PLANS 2000
National HMO
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
Certificate of Plan Coverage that indicates how long you have been enrolled with us You can
Group Health use this certificate when getting health insurance or other health care coverage
Plan 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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NATIONAL HEALTH PLANS 2000
National HMO
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 1 800 468 8600 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 National HMO Health Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change
your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this
brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE AND
SERVICES AVAILABLE AS POS BENEFITS PLAN SPECIFIC ARE COVERED ONLY WHEN PROVIDED OR
ARRANGED BY PLAN PHYSICIANS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital physician 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 a 25 copay per day up to 100 per admission up to the 750 per
person 2,250 per family annual inpatient copay maximum 17
Extended care All necessary services no dollar or day limit You pay a 25 copay per day up to
100 per admission up to the 750 2,250 annual inpatient copay maximum 17
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of
conditions inpatient care per year You pay nothing for the first 30 days 22
Substance abuse One 30 day substance abuse program per year You pay nothing 23
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 10 copay per office visit no additional copay
for laboratory tests and x rays 10 per house call by a physician 12
Home health All necessary visits by nurses and health aides You pay nothing 13
care
Mental Up to 20 individual or 40 group therapy outpatient visits per year You pay a 20
conditions copay per individual or a 10 copay per group visit 22
Substance abuse Up to 20 outpatient visits per year You pay a 5 copay per visit 23
Emergency care Reasonable charges for services and supplies required because of a medical
emergency Within the Service Area you pay a 25 copay per emergency room
visit or a 10 copay per urgent care center visit Outside the Service Area you pay
a 25 copay per visit for emergency care services and any charges for services that
are not covered benefits under this plan If admitted you pay a 25 copay per day
up to 100 per admission up to the 750 2,250 annual inpatient copay maximum 19
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5
drugs generic 10 brand name copay per prescription unit or refill Up to a 90 day supply
of most drugs are available through a mail order service you pay a 13 generic
26 brand name copay 24
Dental care Accidental injury benefit you pay a 25 copay per visit 27
Chiropractic You pay a 10 copay per visit 1000 annual benefit maximum 14
care
Out of pocket Copayments are required for a few benefits However there is a 750 per member or 2,250 per family annual inpatient copay maximum In addition after your out
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NATIONAL HEALTH PLANS 2000
National HMO of pocket expenses reach a maximum of 3,475 per Self Only or 8,641 per Self
and Family enrollment per calendar year covered benefits will be provided at
100 This copay maximum does not include prescription drugs 6
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