Enrollment code
IN1 Self Only
IN2 Self and Family
This service area has commendable
accreditation from the NCQA See the
2000 Guide for more information on
NCQA
Visit the OPM website at httpwwwopmgovinsure
and
our website at httpwwwmplancom
Authorized for distribution by the
U Un ni it te ed d S St ta at te es s O Of ff fi ic ce e of o f P Pe er rs so on nn ne el l M Ma an na ag ge em me en nt t
Re R et ti ir re em me en nt t an a nd d In I ns su ur ra an nc ce e S Se er rv vi ic ce e Federal Employees
Health Benefits Program
RI 73578
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MPlan HMO 2000
Table of Contents
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 46
Section 4 What to do if we deny your claim or request for service 78
Section 5 Benefits 917
Section 6 General exclusions Things we dont cover 18
Section 7 Limitations Rules that affect your benefits 1920
Section 8 FEHB FACTS 2124
Department of DefenseFEHB Demonstration Project 2526
Inspector General Advisory Stop Healthcare Fraud 27
Summary of benefits 31
Premiums 32
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MPlan HMO 2000
Introduction
MPlan Inc 8802 N Meridian Street Suite 100 Indianapolis IN 46260
This brochure describes the benefits you can receive from MPlan HMO under its contract CS2643 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 3
Premiums are listed at the end of this brochure
Plain Language
The President and Vice President are making the Governments 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 MPlan 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 rewritten the Benefits section of this brochure You will find new benefits language next year
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MPlan HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plans
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 nonFEHB benefits
6 General exclusions Things we dont 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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MPlan HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams wellbaby 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 you may have to submit claim forms
You should join an HMO because you prefer the plans 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
andor 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
Programwide 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
OBGYN 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 Plan Your share of the Nonpostal premium will increase by 128 for Self Only or 164 for Self and Family See back cover
Under Prescription Drug Benefits a formulary benefit schedule is being added See page 15
Under Prescription Drug Benefits you pay 5 copay for generic drugs The copay for
formulary brand name drugs is 10 The copay for nonformulary brand name drugs is 30
See page 15
Under Prescription Drug Benefits sexual dysfunction medication is subject to the threetier
copay schedule Nonformulary brand name sexual dysfunction medication copay increased
from 20 to 30 See page 15
Under Prescription Drug Benefits a mail order program is being added to cover generic and
formulary brand name drugs See page 15
Under Prescription Drug Benefits coverage is being added for diaphragms and cervical caps
See page 15
Under Limited Benefits the copay increased from 5 to 50 for the treatment of infertility
See page 10
MPlan provides health care through several networks Services are only available from
providers within the provider network you select See page 45
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MPlan HMO 2000
Section 3 How to get benefits
What is this Plans To enroll with us you must live or work in our service area This is where our providers practice
service area Our service area includes the Indiana counties of Adams Allen Bartholomew Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Decatur DeKalb Delaware Dubois
Elkhart Floyd Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry
Howard Huntington Jackson Jennings Johnson Knox Kosciusko Lagrange Lawrence
Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Noble Orange
Owen Parke Perry Pike Posey Putnam Rush St Joseph Shelby Spencer Steuben Sullivan
Tippecanoe Tipton Vanderburgh Vermillion Vigo Wabash Warrick Washington Wells White
and Whitley
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 or urgent care as described on page 12
We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a feeforservice 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 either a copayment a set dollar amount
for services or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services Your outofpocket benefits covered under this Plan are limited to the stated
copayments which are required for a few benefits
Do I have to submit You normally wont have to submit claims to us unless you receive emergency or urgent care
claims services from a provider who doesnt 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 my health The MPlan provides health care through several different networks of physicians Provider
care networks are comprised of a specific group of primary care physicians specialists and other providers affiliated with a specific hospital or network of hospitals Services are only available
from providers within the provider network you select If a particular service is not available
from your network you will be referred to another MPlan health network provider Services of a
specialty care doctor can only be received by referral from the selected 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 there
has been a referral by the members primary care doctor with the following exception a woman
may see her MPlan health networks participating gynecologist for her annual routine
examination without a referral
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MPlan HMO 2000
Section 3 How to get benefits
Continued
The Plans Provider Directory lists primary care doctors generally family practitioners internal
medicine physicians and pediatricians 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 317 5715320 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 Plans delivery system the continued availability
andor participation of any one doctor hospital or other provider cannot be guaranteed
Members are required to select a primary care physician from among participating Plan primary
care doctors You and each of your family members will need to choose one of the MPlan
provider networks identified in the physician directory Then you and each of your family
members need to choose a primary care physician within the health network youve selected You
may only change health networks during the annual open season However you and your family
members may change primary care physicians within the health network you selected up to two
times per year
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 to Talk to your Plan physician If you need to be hospitalized your primary care physician or
go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if Im in the First call our customer service department at 317 5715320 or toll free 18008167526 If you
hospital when I join this are new to the FEHB Program we will arrange for you to receive care If you are currently in the
Plan FEHB Program and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Except in a medical emergency or when a primary care doctor has designated another doctor to
care see patients when he or she is unavailable you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services Referrals to a participating
specialist are given at the primary care doctors discretion if nonPlan specialists or consultants
are required the primary care doctor will make arrangements for appropriate referrals
If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician
will use our criteria when creating your treatment plan
What do I do if 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 not 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
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MPlan HMO 2000
Section 3 How to get benefits
Continued
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 Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the Plan contract with the provider unless the termination is for cause If you are in the second or third
or this Plan leaves the trimester of pregnancy you may continue to see your OBGYN until the end of your postpartum
Program care
You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OBGYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a
medical services specialist or recommending followup care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide if a The Plan defines experimentalinvestigational as medical technology or a new application of
service is experimental or existing medical technology including medical procedures drugs and devices for treating a
investigational medical condition illness or diagnosis that
Is not generally accepted by informed health care professionals in the United States as
effective or
Has not been proven by scientific testing or evidence to be effective in treating the medical
condition illness or diagnosis for which its use is proposed
Experimental treatment evaluations will be based on the existence of any of the following
Approval from the Food and Drug Administration FDA at the time of use or proposed use
Provided pursuant of a Phase I or Phase II clinical trial or as the experimental or research arm
of a Phase III clinical trial
Provided pursuant to written protocol which describes among its objectives determinations of
safety efficacy in comparison to conventional alternatives toxicity or
The treatment is being delivered or should be delivered subject to the approval and supervision
of an Institutional Review Board IRB as defined by federal regulations particularly those of
the FDA or the Department of Health and Human Services HHS
Opinion among experts as expressed in the published authoritative literature is that usage
should be substantially confined to research settings or that the treatment is not effective or
that further research is necessary in order to define safety to toxicity or effectiveness
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MPlan HMO 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your
request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this
time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request
We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the
information we already have
When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
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 MPlan at 317 5715320 and we will expedite our review
life threatening condition
and you havent responded
to my request for service
What if you have denied If we expedite your review due to serious medical condition and deny your claim we will inform
my request for care and OPM so that they can give your claim expedited treatment too Alternatively you may call
my condition is serious or OPMs health benefit Division III at 202 6060755 between 8 am and 5 pm Serious or life
life threatening threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
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
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs
disputed claim Contract Division III P O Box 436 Washington DC 20044
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MPlan HMO 2000
Section 4 What to do if we deny your claim or request for service
Continued
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 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
persons representative They must send a copy of the persons specific written consent with
the review request
What if OPM upholds the OPMs decision is final There are no other administrative appeals If OPM agrees with our
Plans 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 if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
lawsuit 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 you
Privacy Act 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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MPlan HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office
visit copay but no additional copay for laboratory tests and Xrays 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 25 copay for a doctors house call nothing for home visits by nurses and
health aides
The following services are included
Preventive care including wellbaby care and periodic checkups
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 through 49 one mammogram every one or two
years for women age 50 through 64 one mammogram every year and for women age 65 and
above one mammogram every two years In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures including laboratory tests and Xrays
Complete obstetrical maternity care for all covered females including prenatal and postnatal
care by a Plan doctor The mother at her option may remain in the hospital for up to 48 hours
after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended
if medically necessary Ordinary nursery care of the newborn child during the covered portion
of the mothers hospital confinement for maternity will be covered under either a Self Only or
Self and Family enrollment other care of the 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
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heartlung kidney lung single or double 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
nonlymphocytic leukemia advanced Hodgkins lymphoma advanced nonHodgkins
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 preformed 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 in lieu of hospitalization including intravenous
fluids and medications when prescribed by your Plan doctor who will periodically review the
program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers at no additional cost to you except where noted
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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MPlan HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
Continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical
procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to
treatment of fractures and excision of tumors and cysts All other procedures involving the teeth
or intraoral 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 which has resulted in a
functional defect or that has resulted from injury or surgery that has produced a major effect of
the members appearance and the condition can reasonably be expected to be corrected by such
surgery A patient and their attending physician will decide whether or not to have breast
reconstruction surgery following a mastectomy including whether or not to have surgery on the
other breast in order to produce a symmetrical appearance
Shortterm rehabilitative therapy physical speech and occupational is provided on an
inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within two months you pay nothing 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 selfcare and
improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered You pay 50 coinsurance for covered
services The following type of artificial insemination is covered intrauterine insemination
IUI you pay 50 coinsurance for covered services cost of donor sperm is not covered
Infertility drugs are not covered Other assisted reproductive technology ART procedures such
as in vitro fertilization and embryo transfer are not covered
Diagnosis and treatment of sexual dysfunction is covered you pay 10 per office visit Drugs
used for the treatment of sexual dysfunction are covered See page 1516 for Prescription Drug
Benefits
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
is provided you pay nothing
Durable medical equipment Orthopedic and Prosthetic devices such as hospital beds
wheelchairs foot orthotics braces artificial limbs breast prostheses or surgical bras and their
replacements and lenses following cataract removal are covered You pay 50 coinsurance of
covered charges
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment insurance attending school or camp or travel
Reversal of voluntary surgicallyinduced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Longterm rehabilitative therapy
Chiropractic services
Homemaker services
Alternative medicine including acupuncture and naturopathic services
Immunizations for travel
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MPlan HMO 2000
Section 5 Benefits
HospitalExtended 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 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 range of benefits with no dollar limit when fulltime 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 for up to 80 days per contract year all
charges thereafter All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice
facility Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness with a life expectancy of approximately six months or less
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You
pay 20 of covered charges
Limited benefits Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
the procedures hospitalization but not the cost of the professional dental services Conditions for
which hospitalization would be covered include hemophilia and heart disease the need for
anesthesia by itself is not such a condition
Acute inpatient detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 14 for nonmedical Substance Abuse Benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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MPlan HMO 2000
Section 5 Benefits
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 lifethreatening 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 eg 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 48 hours It is your responsibility to ensure that the
Plan has been timely notified
If you need to be hospitalized in a nonPlan facility the Plan must be notified within 48 hours or
on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If you are hospitalized in nonPlan 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 nonPlan 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 followup care recommended by nonPlan providers must be
approved by the Plan or provided by Plan providers
Plan pays
Reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers
You pay
25 per hospital emergency room visit or urgent care center visit for emergency care services
that are covered benefits of this Plan
Emergencies outside the Benefits are available for any medically necessary health service that is immediately required
service area 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 followup care recommended by nonPlan providers must be
approved by the Plan or provided by Plan providers
Plan pays
Reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers
You pay
25 per emergency room visit or urgent care center visit for emergency care services that are
covered benefits of this Plan If the emergency results in admission to a hospital the emergency
care copay is waived
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MPlan HMO 2000
Section 5 Benefits
Emergency Benefits
Continued
What is covered Emergency care at a doctors office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service if approved by the Plan
What is not covered Elective care or nonemergency care covered
Emergency care provided outside the Service Area if the need for care could have been
foreseen before departing the Service Area
Medical and hospital costs resulting from a normal fullterm delivery of a baby outside the
Service Area
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the provider of your emergency
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 Plans
decision you may request reconsideration in accordance with the disputed claims procedure
described on page 7
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MPlan HMO 2000
Section 5 Benefits
Mental ConditionsSubstance Abuse Benefits
Mental Conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis
and treatment of acute psychiatric conditions including treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care
Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each
calendar year you pay a 20 copay for each covered visit all charges thereafter
Inpatient care
Up to 30 days of hospitalization each calendar year you pay nothing for first 30 days all
charges thereafter Day care in lieu of inpatient care is covered on the basis of two sessions
of day care for one inpatient day
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject
to significant improvement through relatively shortterm 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
shortterm psychiatric condition
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness or condition Services for the psychiatric aspects are provided in
conjunction with the mental conditions benefit shown above Outpatient visits to Plan providers
for treatment are covered as well as inpatient services necessary for diagnosis and treatment The
mental conditions benefit visitsday limitations and copays apply to any covered substance abuse
care
What is not covered Treatment that is not authorized by a Plan doctor
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MPlan HMO 2000
Section 5 Benefits
Prescription Drug Benefits
What is covered Prescriptions drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30day supply or 100 unit supply whichever is less or one commercially
prepaid unit ie one inhaler one vial ophthalmic medication or insulin In lieu of name brand
drugs generic equivalent drugs will be dispensed when substitution is permissible Per prescription
or refill you pay a 5 copay for generic drugs a 10 copay formulary brand name drugs you pay
30 for nonformulary brand name drugs
Drug Formulary
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary
Nonformulary drugs are covered when prescribed by a Plan doctor
Mailorder prescription program
Prescription drugs are dispensed up to a 90day supply Generic and formulary brand name drugs
are covered You pay two generic or formulary brand name drug copays for each 90day supply
For further information contact MPlan at 3175715320
At no time will the copay exceed 50 of the retail cost for the prescription
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral injectable contraceptive drugs
Insulin with a copay charge applied to each vial
Insulin syringes and diabetic supplies as ordered in writing by a participating provider and
authorized and approved by the Plan
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medications for home use implantable drugs and some injectable drugs
are covered under Medical and Surgical Benefits
Limited Benefits Contraceptive devices including diaphragms and cervical caps you pay 50 of covered charges
Implanted such as Norplant
Drugs to treat sexual dysfunction are covered you pay 30 per prescription unit or refill Contact
the Plan for further details
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a nonPlan pharmacy except for outofarea emergencies
Vitamins and nutritional substances which can be purchased without a prescription
Medical supplies such as dressings and antiseptics except diabetic supplies as ordered in writing
by a participating provider and authorized and approved by the Plan
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Experimental drugs
Drugs used in treating infertility
Smoking cessation drugs and medication including nicotine patches
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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MPlan HMO 2000
Section 5 Benefits
Other Benefits
Dental Care
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural
teeth The need for these services must result from an accidental injury Services for an injury to
sound natural teeth must be provided within 24 hours of the injury You pay nothing
Vision Care
What is covered In addition 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 for eyeglasses may be
obtained from Plan providers You pay a 5 copay per visit
What is not covered Contact lenses
Eye exercises
Corrective lenses or frames
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MPlan HMO 2000
NonFEHB Benefits Available to Plan Member
The benefits described on this page are neither offered not guaranteed under the contract
with the FEHB but are made available to all enrollees and family member of this Plan
The cost of the benefits describes on this page is not included in the FEHB premium and
any charges for these services do no count toward any FEHB deductibles or out of pocket
maximums The benefits are not subject to the FEHB disputed claims procedure
Expanded Vision Care Participating providers will grant a 20 discount on eyeglasses and lenses
Expanded Dental Benefits When you utilize a participating general dentist you receive a 25 discount off preventive and diagnostic services
You may also receive a 25 discount off UCR charges for covered minor restorative
procedures including fillings amalgams and composites
All other services will be provided at a 15 discount
Benefits on this page are not part of the FEHB Contract
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MPlan HMO 2000
Section 6 General exclusions Things we dont 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 Services drugs or supplies that are not medically necessary
following Services not required according to accepted standards of medical dental or psychiatric
practice
Care by nonPlan providers except for authorized referrals or emergencies see Emergency
Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program
and
Expenses you incurred while you were not enrolled in this Plan
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MPlan HMO 2000
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 MedicareChoice 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
MedicareChoice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a MedicareChoice plan contact your retirement office If
you later want to reenroll 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 MedicareChoice service area you may
reenroll 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 MedicareChoice plans contact your local Social Security Administration
SSA office or request it from SSA at 18006386833
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage 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
Circumstances beyond our Under certain extraordinary circumstances we may have to delay your services or be unable to
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
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MPlan HMO 2000
Section 7 Limitation Rules that affect your benefits
Continued
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 compensation We do not cover services that
You need because of a workplacerelated disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly
Agencies or indirectly pays for
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MPlan HMO 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about your right to information about your health plan its networks providers and facilities You can also
HMO find out about care management which includes medical practice guidelines disease manage ment programs and how we determine if procedures are experimental or investigational OPMs
website wwwopmgov lists the specific types of information that we must make available to
you
If you want specific information about us call 317 5715320 or toll free 18008167526 or
write to 8802 N Meridian Street Suite 100 Indianapolis IN 46260 You may also contact us
by fax at 317 5715337 or visit our website at wwwmplancom
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal
about enrolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to
FEHB Program make an informed decision about
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 dont 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 and The benefits in this brochure are effective on January 1 If you are new to this plan your
premiums effective coverage 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 I When you retire you can usually stay in the FEHB Program Generally you must have been
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 are SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and your
available for my family unmarried dependent children under age 22 including any foster or step children your employing
and me 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 selfsupport
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
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MPlan HMO 2000
Section 8 FEHB FACTS
Continued
Are my medical and claims We will keep your medical and claims information confidential Only the following will have
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 coordination benefit payments and subrogating claims
Law enforcement officials when investigating andor prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 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 deductible Your old plans deductible continues until our coverage begins
under my old plan
Preexisting 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 this Plan Your enrollment ends unless you cancel your enrollment or
ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouses 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 exspouses employing or retirement office to get more information about your coverage
choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You
may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI
7927 which describes TCC and the RI 705 the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
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MPlan HMO 2000
Section 8 FEHB FACTS
When you lose benefits
Continued
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 2percent administrative charge The government
does not share your costs
You receive another 31day 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
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 60day deadline
How can I convert to You may convert to an individual policy if
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 preexisting conditions
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MPlan HMO 2000
Section 8 FEHB FACTS
When you lose benefits
Continued
How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
of Group Health Plan that indicates how long you have been enrolled with us You can use this certificate when getting
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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MPlan HMO 2000
Department of DefenseFEHB Demonstration Project
What is the Department of The National Defense Authorization Act for 1999 Public Law 105261 established the
Defense DoD and FEHB DoDFEHBP Demonstration Project It allows some active and retired uniformed service
Program Demonstration members and their dependents to enroll in the FEHB Program The demonstration will last for
Project three years beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000 DoD and OPM have setup some special procedures to
successfully implement the Demonstration Project noted below Otherwise the provisions
described in this brochure apply
Who is Eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for
Medicare
You are a qualified former spouse of an active or retired uniformed service member and you
have not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits
Program you are not eligible to enroll under the DoDFEHBP Demonstration Project
Where are the Dover AFB DE
demonstration areas Commonwealth of Puerto Rico
Fort Knox KY
GreensboroWinston SalemHigh Point NC
Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA
When Can I Join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has setup an Information
Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff
will verify your eligibility and provide you with FEHB Program information plan brochures
enrollment instructions and forms The tollfree phone number for the IPC is 1877DODFEHB
18773633342
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MPlan HMO 2000
Department of DefenseFEHB Demonstration Project
Continued
You may select coverage for yourself selfonly or for you and your family self and family
during the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year
following the Open Season that you enrolled
If you become eligible for the DoDFEHBP Demonstration Project outside of Open Season
contact the IPC to find out how to enroll and when your coverage will begin
DoD has a web site devoted to the Demonstration Project You can view information such as
their MarketingBeneficiary Education Plan Frequently Asked Questions demonstration area
locations and zip code lists at wwwtricareosdmilfehbp You can also view information about
the demonstration project including The 2000 Guide to Federal Employees Health Benefits
Plans Participating in the DoDFEHBP Demonstration Project on the OPM web site at
wwwopmgov
Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the
Temporary Continuation only individual eligible for TCC is one who ceases to be eligible as a member of family under
of Coverage TCC your self and family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title
10 United States Code For these individuals TCC begins the day after their enrollment in the
DoDFEHBP Demonstration Project ends TCC enrollment terminates after 36 months or the end
of the Demonstration Project whichever occurs first You your child or another person must
notify the IPC when a family member loses eligibility for coverage under the DoDFEHBP
Demonstration Project
TCC is not available if you move out of a DoDFEHBP Demonstration Project area you cancel
your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends
Do I have the 31Day These provisions do not apply to the DoDFEHBP Demonstration Project
Extension and Right To
Convert
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MPlan HMO 2000
Inspector General Advisory Stop Healthcare 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 MPlan at 317 5715320 or toll free 18008167526 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
2024183300
US Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 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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MPlan HMO 2000
Notes
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MPlan HMO 2000
Notes
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MPlan HMO 2000
Notes
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MPlan HMO 2000
Summary of Benefits for MPlan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan paysprovides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or
day limit Includes inhospital doctor care room and board general nursing
care private room and private nursing care if medically necessary diagnostic
tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 11
Extended care All necessary services for up to 80 days You pay nothing 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for 30 days of
inpatient care per year You pay nothing 14
Substance abuse Covered in conjunction with mental conditions 14
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or
injury including specialists care preventive care including wellbaby care
periodic checkups and routine immunizations laboratory tests and Xrays
complete maternity care You pay 10 per office visit 25 per house call
by a doctor 11
Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Up to 40 outpatient visits per year You pay a 20 copay per visit 14
Substance abuse Covered in conjunction with mental conditions 14
Emergency care Reasonable charges for services and supplies required because of a medical
emergency You pay a 25 copay to the hospital for each emergency room
visit and any charges for services that are not covered by this Plan 1213
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay
a 5 copay per prescription unit or refill for generic drugs a 10 copay per
prescription unit or refill for formulary brand name drugs 30 copay per
prescription unit or refill for nonformulary brand name drugs you pay 30
copay per prescription unit or refill for medications to treat sexual
dysfunction 15
Dental care Accidental injury benefit You pay nothing 16
Vision care One refraction annually You pay 5 copay per visit 16
Outofpocket maximum Your outofpocket expenses for benefits under this Plan are limited to the
stated copayments that are required for a few benefits 916
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2000 Rate Information for
The MPlan
NonPostal rates apply to most nonPostal 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 US 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 702 to determine which rate applies to you
Postal rates do not apply to noncareer 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
NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Govt Your Govt Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Self Only IN1 7787 2596 16873 5624 9215 1168 9215 1168
Self and Family IN2 17337 5779 37564 12521 20515 2601 20102 3014
32 34