Pages 1--24 from HP PLAN FEHB 2000

For changes
in benefits 4 5
see pages

Serving Minneapolis St Paul St Cloud area
South Central Minnesota West Central Wisconsin

Enrollment Code HQ1 Self Only
HQ2 Self and Family

Enrollment in this Plan is limited see page 5 for requirements

This plan has Commendable accreditation from the NCQA See the FEHB Guide
for more information on NCQA

Special Notice This Plan has significantly reduced
its service area See page 4 for more information

Visit the OPM website at http www opm gov insure

RI 73 584 1
1 Page 2 3
HealthPartners Health Plan 2000
Table of Contents
Page
Introduction 3

Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4 5
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 16
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 17 18
Section 8 FEHB facts 18 21
Inspector General Advisory Stop Healthcare Fraud 21
Summary of benefits Inside back cover
Premiums Back cover

2 2
2 Page 3 4
HealthPartners Health Plan 2000
Introduction
HealthPartners Inc 8100 34th Avenue South
Minneapolis Minnesota 55440 This brochure describes the benefits you can receive from HealthPartners Health Plan under its contract CS 2649 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 pages 4 5 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 HealthPartners Health Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

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

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

3 3
3 Page 4 5
HealthPartners Health Plan 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure

When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or

remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

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

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

record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we
will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Plan The Plan has reduced it's service area by no longer serving the following full and partial counties Minnesota Becker Beltrami Big Stone Blue Earth Brown Cass Chippewa Clay Clearwater
Cottonwood Crow Wing Dodge Douglas Faribault Fillmore Freeborn Hubbard Jackson Kandiyohi Lincoln Mahnomen Martin Mower Murray Nicollet Nobles Norman Ottertail
Pipestone Polk Pope Red Lake Redwood Renville Sibley Stevens Swift Todd Traverse Wadena Waseca Watonwan Wilkin Winona and Yellow Medicine

and North Dakota Barnes Cass Dickey Griggs Kidder LaMoure Logan Ransom Richland Steele Stutsman and Traill
Your share of the non postal premium will increase by 38.2 for Self Only or 33.5 for Self and Family
A mail order drug benefit has been added which provides a 90 day supply for two prescription drug copays 16
The oral and maxillofacial surgery benefit has increased to include orthognathic surgery with 25 of charges coinsurance Coverage for the treatment of temporomandibular joint TMJ has
increased to include the related dental appliance See page 10
Coverage for transplants has increased to remove certain limits for kidney pancreas transplants and autologous bone marrow transplants for neuroblastoma See page 9

Benefits for the treatment of infertility does not include the cost of donor sperm or ova or storage of donor sperm ova or embryo See page 10
Hospice care has been clarified to indicate that the five day limit for respite care applies per episode and the member must pay all charges therafter See page 12
4 4
4 Page 5 6
HealthPartners Health Plan 2000
Section 2 How we change for 2000 continued
Changes to this Plan Inpatient substance abuse care in an alcohol detoxification or rehabilitation center will no continued longer be limited to emergency care detoxification and treatment planning
Durable medical equipment has been clarified to indicate that glucose monitors and insulin pumps are covered if deemed medically necessary See page 11
The brochure has been clarified to indicate that the office visit copay for group therapy mental conditions visits is 5 See page 14
Medically necessary care as determined by the Plan Medical Director for procedures services and supplies related to sex transformations are covered in full

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 our providers practice service area Our service area is
The following counties in Minnesota Anoka Benton Carver Chisago Dakota Dodge Goodhue Hennepin Isanti LeSueur McLeod Meeker Morrison Olmsted Ramsey Rice Scott Sherburne
Stearns Steele Wabasha Washington and Wright
The following partial county in Minnesota Mille Lacs
The following counties in Wisconsin Buffalo Pepin Pierce Polk and St Croix
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other health

care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another

state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office

How much do I You must share the cost of some services This is called either a copayment a set dollar amount pay for services or coinsurance a set percentage of charges
After you pay 3,000 in copayments or coinsurance for one family member or 5,000 for two or more family members you do not have to make any further payments for certain services for the
rest of the calendar year This is called a catastrophic limit
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances

beyond your control prevented you from filing on time

Who provides my HealthPartners is a mixed model prepayment plan which allows members to receive health health care services from individual doctors who practice out of their own offices and through over 300
medical clinics and 100 contracting hospitals throughout the Twin Cities and surrounding areas including St Cloud south central Minnesota and western Wisconsin HealthPartners Health Plan

medical providers include more than 1,750 primary care doctors and over 2,500 community specialists to whom patients are referred Members may choose any medical center in the
HealthPartners Health Plan network for their primary care Each covered person in a family may select a different medical center

5 5
5 Page 6 7
HealthPartners Health Plan 2000
Section 3 How to get benefits continued
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan

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

What do I do if I'm First call our customer service department at 612 883 5000 or 1 800 883 2177 hearing impaired in the hospital when individuals should call 612 883 5127 If you are new to the FEHB Program we will arrange for
I join this Plan you to receive care If you are currently in the 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 Your primary care physician will arrange your referral to a specialist with the following exception specialty care a woman may see a Plan gynecologist associated with her clinic for her annul wellness exam
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 Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do 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 continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract
provider leaves the Plan with the provider unless the termination is for cause If you are in the second or third trimester or this Plan leaves the of pregnancy you may continue to see your OB GYN until the end of your postpartum care
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 authorize Your physician must get our approval before sending you to a hospital referring you to a medical services specialist or recommending follow up care
You should check with your Plan doctor to determine if a service requires a referral or authorization before you obtain services

Plan medical directors or their designees make coverage determinations and make final authorization for certain covered services Coverage determinations are based on established
medical policies which are subject to periodic review and modification by the medical or dental directors Call the Plan for more information on referral and authorization requirements

6 6
6 Page 7 8
HealthPartners Health Plan 2000
Section 3 How to get benefits continued
How do you decide if a HealthPartners determines if a treatment or procedure is experimental investigational or unproven service is experimental if it is
or investigational Not approved by the U S Food and Drug Administration FDA to be lawfully marketed for the
proposed use or

If reliable evidence shows that the drug device or medical treatment or procedure is the subject of ongoing Phase I II or III Clinical Trials or

If reliable evidence shows that the drug device or medical treatment or procedure is under study to determine its maximum tolerated dose its toxicity its safety its efficacy as compared with the
standard means of treatment or diagnosis

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our

decision based on the information we already have

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

What if I have a serious or Call us at 612 883 5000 or 1 800 883 2177 and we will expedite our review For hearing life threatening condition impaired individuals call 1 612 883 5127
and you haven't responded to my request for service

What if you have denied If we expedite your review due to a 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 can call OPM's
my condition is serious or Health Benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening life 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 You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
7 7
7 Page 8 9
HealthPartners Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make 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 should I send Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contract Division IV P O Box 436 Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base I file a 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

8 8
8 Page 9 10
HealthPartners Health Plan 2000
Section 5 Benefits

Medical and A comprehensive range of preventive diagnostic and treatment services is provided by Plan Surgical Benefits doctors and other Plan providers This includes all necessary office visits You pay a 10 copay
per office visit but no additional copay for laboratory tests and X rays What is covered
The following services are included and are subject to the office visit copay unless stated otherwise

Preventive care including well baby care and periodic check ups routine screening for cancer routine eye and hearing exams and voluntary family planning services You pay nothing
Routine immunizations and boosters You pay nothing
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 age 64 one mammogram every year and for women age 65 and above one mammogram every two years You pay nothing for routine mammograms In
addition to routine screening mammograms are covered when prescribed by a Plan doctor as medically necessary to diagnose or treat your illness

Consultations by specialists
Diagnostic procedures including laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48

hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for
maternity will be covered under either a Self Only or Self and Family enrollment other care of the infant requiring definitive treatment will be covered only if the infant is covered under a
Self and Family enrollment You pay nothing for prenatal and postnatal care
Voluntary sterilizations and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum You pay nothing for allergy injections

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung or single and double lung for primary pulmonary hypertension Eisenmenger's syndrome end stage pulmonary fibrosis alpha 1 antitrypsin disease cystic

fibrosis and emphysema kidney pancreas for diabetes kidney liver transplants for bilary atresia in children primary bilary cirrhosis post acute viral infection including hepatitis A
hepatitis B antigen e negative and hepatitis C causing acute atrophy or post necrotic cirrhosis primary sclerosing cholangitis and alcoholic cirrhosis allogenic donor bone marrow
transplants or peripheral stem cell support associated with high dose chemotherapy for acute myelogenous leukemia acute lymphocytic leukemia chronic myelogenous leukemia severe
combined immunodeficiency disease Wiscott Aldrich syndrome and aplastic anemia autologous bone marrow transplants or peripheral stem cell support for acute lymphocytic and
non lymphocytic leukemia advanced Hodgkin's lymphoma non Hodgkin's lymphoma neuroblastoma breast cancer multiple myloma epithelial ovarian cancer and testicular
mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical Director Related medical and hospital expenses of the donor are
covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this 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
Chiropractic services Chiropractic therapy does not include ongoing maintenance therapy or therapy other than for treatment of acute musculoskeletal conditions

Surgical treatment of morbid obesity if approved by the Plan Medical Director
9 9
9 Page 10 11
HealthPartners Health Plan 2000
Section 5 Benefits continued
Medical and Breast reduction surgery if approved by the Plan Medical Director Surgical Benefits Home health services of nurses and health aides including intravenous fluids and medications
What is covered when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need You pay 10 per visit for health aides physical therapists occupational
continued therapists respiratory therapists and speech therapists You pay nothing for all other covered home health services

Plan doctors also provide 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

Non Plan services for voluntary family planning the diagnosis of infertility testing and treatment of sexually transmitted diseases and testing for HIV and HIV related conditions You pay
the same as you would for the applicable service provided by a Plan provider
Procedures services drugs and supplies related to sex transformations are covered when determined medically necessary by the Plan Medical Director

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 and surgical
procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures treatment of temporomandibular joint TMJ pain disfunction syndrome

including the related dental appliance and excision of tumors and cysts Treatment of cleft lip and cleft palate including orthodontia and oral surgery is limited to dependent children to age 18

Orthognathic surgery is covered for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non surgical treatment alone and a demonstrable functional
impairment exists Functional impairments include but are not limited to difficulties in chewing breathing or swallowing You pay 25 of charges Associated orthodontic services pre or post
operative are not covered
All other procedures involving the teeth and intra oral areas surrounding the teeth are not covered
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 affect on the member's

appearance and the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery
following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

Diagnosis and treatment of infertility is covered you pay 20 of the cost of injectable prescription drugs for infertility therapy if there is prior authorization by a Plan doctor before therapy
begins Artificial insemination is covered you pay 20 of charges Cost of donor sperm or ova or cost of storage of donor sperm ova or embryo is not covered Fertility drugs are covered Other
assisted reproductive technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant through other artificial procedures such as in vitro fertilization
and embryo transfer are not covered
Short term rehabilitation therapy physical speech respiratory and occupational is provided on an inpatient or out patient basis for up to two months per condition if significant improvement

can be expected within two months You pay a 10 copay per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin or to correct the effects of
illness or injury Occupation therapy is limited to services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living

Habilitative care is covered in full for speech physical or occupational therapy that is provided for congenital developmental or medical conditions which have significantly limited the successful
initiation of normal speech and motor development To be considered habilitative significant functional improvement and measurable progress must be made toward achieving functional
goals within a predictable period of time toward an enrollee's maximum potential ability The Plan will supplement and coordinate such services with similar benefits made available by other
agencies including the public school system The determination of whether such measurable progress has been made is within the sole discretion of the Plan Medical Director based on
objective documentation
10 10
10 Page 11 12
HealthPartners Health Plan 2000
Section 5 Benefits continued
Medical and Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction is Surgical Benefits provided for Phase I Phase II is provided if the Plan determines it is medically necessary Phase
III is not covered You pay nothing Limited Benefits
Hair prostheses when required because of hair loss due to alopecia areata are covered at 80 up continued to a maximum benefit of 350 per year you pay 20 of the charges and all charges after the Plan

pays 350
Orthopedic devices such as braces or foot orthotics prosthetic devices such as artificial limbs breast prostheses and surgical bras and lenses following cataract surgery and durable medical

equipment such as medically necessary glucose monitors wheel chairs and hospital beds are covered You pay 20 of the charges Rental of durable medical equipment is covered for up to one
month while the enrollee's own equipment is being repaired The Plan will determine whether an item is approved for purchase or for rental Durable medical equipment and supplies must be
obtained from approved vendors
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility including related treatment for infertility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives no charge if replacement is arranged by member
Long term rehabilitation therapy
Speech therapy services to correct development delays
Genetic counseling and studies not required for diagnosis and treatment
Homemaker services
Hearing aids
Rental of durable medical equipment while enrollee's own equipment is being repaired beyond one month rental of medically necessary equipment

Over the counter foot orthotics

Hospital Extended Care Benefits

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

Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended Care The Plan provides a comprehensive range of benefits for up to l50 days per period of confinement when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including

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

Period of confinement means 1 continuous inpatient stay in a hospital or skilled nursing facility or 2 a series of two or more stays in a hospital or skilled nursing facility for the same condition
in which the end of each inpatient stay is separated from the beginning of the next one by less than 90 days Same condition means illness or injury related to a former illness or injury in that it is
a within the same ascertainable diagnosis or b within the scope of complications or related conditions

11 11
11 Page 12 13
HealthPartners Health Plan 2000
Section 5 Benefits continued
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient care family counseling and respite and continuous care Coverage for
respite care is limited to five days per episode you pay 20 of charges for the first 5 days of respite care and all charges thereafter Periods of respite and continuous care combined are limited

to thirty days 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 You pay nothing for part time and intermittent care provided in the home inpatient services medications for pain and symptom management durable medical equipment and continuous care

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay 20 of charges Transfers between hospitals for treatment by Plan physicians are covered at
100 if initiated by a Plan physician You pay nothing for transfers

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a procedures need for hospitalization for reasons totally unrelated to the dental procedure This is limited to

charges incurred by a covered person who 1 is a child under age 5 2 is severely disabled or 3 has a medical condition and requires hospitalization or general anesthesia for dental care
treatment The Plan will cover the hospitalization and anesthesia charges but not the cost of the professional dental services

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate What is not covered See page 14 for nonmedical substance abuse benefits

Personal comfort items such as telephone and television
Blood and blood derivatives no charge if replacement is arranged by member
Custodial care rest cures domiciliary or convalescent care

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires immediate

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

Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies if Plan Network 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 48 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 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that

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

Plan pays Charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 40 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital within 24
12 hours the emergency room copay is waived 12
12 Page 13 14
HealthPartners Health Plan 2000
Section 5 Benefits continued
Emergencies outside Benefits are available for any medically necessary health service that is immediately required the Plan Network 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

Plan pays 80 of the first 2,500 of charges and 100 thereafter per calendar year for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 20 of the first 2,500 of charges and nothing thereafter per calendar year for emergency care services to the extent the services would have been covered if received from Plan providers
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 if approved by the Plan

Ambulance service approved by the Plan
Emergency dental care from non Plan dentists see page 15

What is not covered Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Elective care or non emergency care
Medical and hospital costs resulting from a normal full term delivery of a baby outside the Service Area

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

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on
pages 7 8

Mental Conditions Substance Abuse Benefits
Mental Conditions The medical management of mental conditions will be covered under this Plan's medical and Surgical Benefits provisions Related drug costs will be covered under this Plan's Prescription
Drug Benefits and any costs for psychological testing or psychotherapy will be covered under this Plan's Mental Conditions Benefits

What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

13 13
13 Page 14 15
HealthPartners Health Plan 2000
Section 5 Benefits continued
Outpatient care All necessary outpatient care from Plan doctors consultants or other psychiatric personnel You pay 10 copay per office visit and a 5 copay per group therapy visit

Inpatient care All necessary inpatient care when hospitalized under the care of Plan provider You pay nothing
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the

same as for any other illness or condition

Outpatient care All necessary outpatient care You pay 10 copay per office visit
Inpatient care Treatment in a substance abuse rehabilitation intermediate care care program in an alcohol detoxification or rehabilitation center approved by the Plan You pay nothing
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs must be prescribed by a Plan or referral doctor obtained at a Plan pharmacy and dispensed in accordance with the Plan's formulary You pay an 8 copay per prescription unit

or refill for each 30 day supply or portion thereof If you are requesting a brand name drug and there is a generic equivalent the brand name drug will only be covered up to the charge that would
apply to the generic drug minus any required copayment If your Plan doctor has indicated on the prescription that the brand name drug should be dispensed as written the brand name drug will be
covered in full minus any required copayment
The Plan's formulary is a list of drugs chosen for coverage by the Plan's Pharmacy and Therapeutics P T Committee based on a drug's safety effectiveness and cost The Plan's P T

Committee evaluates any needed changes to the formulary on a quarterly basis
Non formulary drugs will be covered when prescribed by a Plan doctor It is the Plan doctor's responsibility to obtain authorization for non formulary drugs before they are dispensed

Covered medications and accessories include
Drugs that by law require a prescription
Oral contraceptive drugs and contraceptive barrier devices a single copay charge will apply for 3 cycles of oral contraceptive drugs and for each barrier device

Insulin with a copay charge applied to each vial
Diabetic testing supplies
Disposable needles and syringes needed to inject covered prescribed medication including insulin

Intravenous fluids and medications for home use
Tobacco cessation products as determined by the Plan limited to a 60 consecutive day supply per calendar year Benefits are limited to one product at a time and no more than a 30 day

supply will be covered and dispensed at a time

14 14
14 Page 15 16
HealthPartners Health Plan 2000
Section 5 Benefits continued
Mail order benefit You may also get outpatient prescription drugs which can be self administered through HealthPartners mail order service You pay a 16 copay for each prescription unit or refill for each
90 day supply or portion thereof For information on how to obtain drugs through HealthPartners mail order service please call our Member Services Department at 1 800 883 2177 This benefit

does not apply to drugs covered under the Limited benefits shown below

Limited benefits Injectable drugs such as Depo Provera and implantable drugs or devices such as Norplant and IUD's you pay 20 of charges
Growth hormones you pay 20 of charges
Injectable drugs for the treatment of infertility you pay 20 of charges
Special dietary treatment of phenylketonuria PKU you pay 20 of charges
Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Contraceptive devices other than described above
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Over the counter foot orthotics

Other Benefits
Dental care The following preventive and diagnostic dental services are covered for all members when
What is covered provided by participating Plan dentists You pay nothing Routine dental examinations per Plan dentist's recommendation

Teeth cleaning prophylaxis or periodontal maintenance recall limited to twice per year
Topical application of fluoride per Plan dentist's recommendation
Oral hygiene instructions per Plan dentist's recommendation
Bitewing x rays limited to once per year
Full mouth panoramic x rays limited to once every three years

Accidental injury Services of Plan dentists necessary to promptly repair or replace sound natural teeth limited to benefit restorative services and supplies plus prescription and installation of necessary dental prosthetic
items or devices The need for these services must directly result from an accidental injury not including injury from biting or chewing occurring while the member is covered under the

FEHBProgram and treatment and repair must be completed within twelve months of the date of injury You pay dental laboratory's actual charge for prescription dental prosthetic items and
devices related to the accident plus any dental services rendered in connection with previously missing teeth or for teeth not injured in the accident

Emergency dental services for accidental injury as described above are covered when they are provided by non Plan dentists if the services require immediate treatment After a 50 calendar
year deductible you pay 20 of the charges up to a maximum Plan benefit of 300 per calendar year and any charges thereafter

What is not covered Other dental services not shown as covered

15 15
15 Page 16 17
HealthPartners Health Plan 2000
Section 5 Benefits continued
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions including lens prescriptions are covered You pay nothing

What is not covered Corrective eye lenses frames or contact lenses
Eye exercises
Radial keratotomy

Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are
made available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB
deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedure

Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare without payment of an FEHB premium As indicated on page 17 certain annuitants and former spouses who are
covered by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB Contact your retirement system for information on changing your FEHB enrollment Contact us at 883 5601 for information
on the Medicare prepaid plan and the cost of that enrollment
Benefits on this page are not part of the FEHB Contract

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

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

16 16
16 Page 17 18
HealthPartners Health Plan 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion
you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may 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 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 16

Other group When anyone has coverage with us and with another group health plan it is called double insurance 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

Circumstancs beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover
the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information

contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers compensation We do not cover services that
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
17 17
17 Page 18 19
HealthPartners Health Plan 2000
Section 7 Limitations Rules that affect your benefits continued
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

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 right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's 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 612 883 5000 or 1 800 883 2177 hearing impaired individuals should call 612 883 5127 or write to HealthPartners Member Services Department

8100 34th Avenue South P O Box 1309 Minneapolis MN 55440 1309

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

When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for me unmarried dependent children under age 22 including any foster or step children your employing
and my family or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove

family members from your coverage for any reason including divorce
18 If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan 18
18 Page 19 20
HealthPartners Health Plan 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 coordinating benefit payments and subrogating

claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim

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

What if I paid a deductible Your old plan's deductible continues until our coverage begins under my old plan

Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

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

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

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

choices

19 19
19 Page 20 21
HealthPartners Health Plan 2000
Section 8 FEHB FACTS continued
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll 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 60 day 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 pre existing conditions

20 20
20 Page 21 22
HealthPartners Health Plan 2000
Section 8 FEHB FACTS 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

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 at 612 883 5000 or 1 800 2177 hearing impaired individuals should call 612 883 5127 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

21 21
21 Page 22 23
22
22 Page 23 24
HealthPartners Health Plan 2000
Summary of Benefits for HealthPartners 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 ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes care in hospital doctor care room and board general nursing care private room and private nursing

care if medically necessary diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 11

Extended Care All necessary services for up to 150 days per period of confinement
You pay nothing 11
Mental Conditions All necessary inpatient care without dollar or day limit You pay nothing 14

Substance Abuse All necessary inpatient care without a dollar or day limit You pay nothing 14

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including care specialist's care laboratory tests and X rays complete maternity care You pay 10 per visit
Preventive care including well baby care periodic check ups and routine immunizations You pay
nothing for preventive care 9

Home Health Care All necessary visits by nurses and health aides You pay a 10 copay per visit for physical therapy occupational therapy speech therapy respiratory therapy

and home health aide services 10
Mental Conditions All necessary outpatient care You pay 10 per visit 14
Substance Abuse All necessary outpatient care You pay 10 per visit 14

Emergency care Charges for services and supplies required because of a medical emergency You pay 10 at Plan clinics or urgent care centers 40 per authorized outpatient Plan hospital visit
20 of the first 2,500 of authorized charges at non Plan facilities 20 of authorized ambulance charges 12 13

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 8 copay per prescription unit or refill mail order benefit is two copays per 90 day supply 14 15
Dental care Accidental injury benefit you pay 20 of the charges Preventive dental care you pay nothing You pay dental laboratory charges for accidental injury 15
Vision care Eye refractions including lens prescription You pay nothing 16
Out of pocket limit Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 3,000 per member per calendar year or 5,000 for a family covered benefits
will be provided at 100 5 23
23 Page 24
HealthPartners Health Plan 2000
2000 Rate Information for HealthPartners Health Plan

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

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

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

Self Only HQ1 78.83 43.47 170.80 94.18 93.06 29.24 93.26 29.04
Self and Family HQ2 175.97 117.58 381.27 254.76 207.74 85.81 201.02 92.53

24 24

Page Navigation Panel