ConnectiCare 2000
Health Maintenance Organization
For benefits changes
in page 4
see
Serving Connecticut
Enrollment code This service area has full accreditation from
TE1 Self Only the NCQA See the 2000 Guide for more
TE2 Self and Family information on NCQA
Service Area All of the State of Connecticut
Enrollment in this Plan is limited see page 5 for requirements
Visit the OPM website at http www opm gov insure
and
the Plan s website at http www connecticare com
Authorized for distribution by the
United States
Office of
Personnel
Management
RI73 599
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ConnectiCare Inc 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
Section 3 How to get benefits 5 6
Section 4 What to do if we deny your claim of request for service 7 8
Section 5 Benefits 9 16
Section 6 General Exclusions Things we don t cover 17
Section 7 Limitations Rules that affect your benefits 17 18
Section 8 FEHB facts 19 22
Inspector General Advisory Stop Healthcare Fraud 22
Summary of Benefits 23
Premiums 24
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ConnectiCare Inc 2000
Introduction ConnectiCare Inc 30 Batterson Park Road Farmington CT 06032
This brochure describes the benefits you can receive from ConnectiCare Inc under its contract CS2662 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 4 Premiums are listed at the end of this brochure
Plain language The President and Vice President are making the Government s communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to ConnectiCare Inc 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
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ConnectiCare Inc 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventa
tive 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 copay
ments 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 heath 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 Each chiropractic manipulation therapy or office visit will require a 10 copay in addition to the
Clarification listed visit coverage for physical speech and occupational therapy See Page 10
Mental Health Substance Abuse Treatments will now be covered just as any other condition
See page 13
Your share of the ConnectiCare Inc non postal premium will increase by 4.0 for Self Only
or 45.7 for Self and Family
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ConnectiCare Inc 2000
Section 3 How to get benefits
What is this Plan s To enroll with us you must live in our service area This is where our providers practice Our
service area service area is The state of Connecticut
Ordinarily you must get your care from providers who contract with us If you receive care out
side our service area we will pay only for emergency or urgent 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 anoth
er state you should consider enrolling in a fee for service plan or an HMO that has agreements
with affiliates in other areas This Plan does provide emergency or urgent care for college stu
dents 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
for services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
Out of pocket Copayments are due when service is rendered except for emergency care Your out of pocket
maximum expenses for benefits under this Plan are limited to the stated copayments required for a few benefits
Do I have to submit You normally won t have to submit claims to us unless you receive emergency services from a
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 Please call Member Services at 1 800 241 7722 to obtain an
Out Of Area reimbursement form 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 ConnectiCare is an Independent Practice Association IPA model Health Maintenance Organization HMO
health care It offers you the services of more than 5,000 physicians including general practitioners and specialists For Plan records all members and each family member must select a primary care
doctor However members are free to choose the services of any participating doctor including
specialists except as noted below see How do I get specialty care Your personal doctor may
already participate in ConnectiCare If so you may receive comprehensive coverage with no
change in your established doctor patient relationship Also a wide range of hospitals laboratories
and pharmacies participate with ConnectiCare
What do I do if my Call us We will help you select a new one
primary care physi
cian leaves the Plan
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or
need to go into the specialist will make the necessary hospital arrangements and supervise your care
hospital
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ConnectiCare ConnectiCare Inc Inc 2000 2000
Section 3 How to get benefits continued What do I do if I m First call our customer service department at 1 800 251 7722 If you are new to the FEHB
in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program and
I join this Plan are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care 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 Members may see any participating doctor for covered services without a referral with the following
specialty care exceptions You must get a referral from a participating doctor for cardiovascular lab cardiac rehabilitation lab work pain management and behavioral medicine pulmonary rehabilitation
radiology radiation therapy and physical therapy
Your doctor will both refer you and get Plan authorization for hospital admissions except
out of service area emergencies use of surgical facilities outpatient alcohol and substance
abuse treatment durable medical equipment prostheses orthopedic devices home health care
speech therapy occupational therapy out of Plan services non participating providers human
organ transplants skilled nursing facilities and surgical treatment of morbid obesity
For information on how to obtain specialty care services contact the Member Services Department
at 1 800 251 7722 A Plan doctor can make arrangements for appropriate referrals Do not go
to a specialist for services listed above unless a referral or an authorization and a referral has
been issued in advance
What do I do if I am This plan does not require referrals for specialty care though it is always important to consult
seeing a specialist your Primary Care doctor for medical advice If your current specialist does not participate with
when I enroll 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 receive services from your current specialist until we can make arrangements for you to see someone else
Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to con
serious illness and my tinue seeing your provider for up to 90 days after we notify you that we are terminating our contract with the provider unless the termination is for cause If you are in the second or third
provider leaves the trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care
Plan or this Plan
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital or recommending
medical services follow up 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 ConnectiCare uses outside medical experts and scientific literature reviews for determining service is experimental whether a medical service is considered investigational and or experimental
6 or investigational
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ConnectiCare Inc 2000
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
Be in writing
Refer to specific brochure wording explaining why you believe our decision is wrong and
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
Maintain our denial in writing
Pay the claim
Arrange for a health care provider to give you the service or
Ask for more information
If we ask your medical provider for more information we will send you a copy of our request
We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the
information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or
OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service
What if I have a Call us 1 800 241 7722 and we will expedite our review
serious or life threat
ening condition and
you haven t responded
to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request for inform OPM so that they can give your claim expedited treatment too Alternatively you can call OPM s health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m
care and my condi Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
tion is serious or life or death if they are not treated as soon as possible
threatening
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold
limits our initial denial or refusal of service You may also ask OPM to review your claim if
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
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
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ConnectiCare Inc 2000
Section 4 What to do if we deny your claim or request continued
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
Copies of all letters you sent us about the claim
Copies of all letters we sent you about the claim and
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 Anyone enrolled in the Plan The estate of a person once enrolled in the Plan and
Medical providers legal counsel and other interested parties who are acting as the enrolled
person s representative They must send a copy of the person s specific written consent with
the review request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contracts Division IV P O Box 436 Washington DC 20044
OPM
What if OPM OPM s decision is final There are no other administrative appeals If OPM agrees with our deci
upholds the Plan s sion your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
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 infor
mation to support the disputed claim decision If you file a lawsuit this information will become
part of the court record
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ConnectiCare Inc 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 X rays Within the Service Area
house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 10 copay for a doctor s house call You pay nothing for home visits by
nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups
At a minimum 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 or as recommended by their
doctors 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 such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor A 10 copay is charged for the initial visit The mother at her
option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
cesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the
Plan is terminated during pregnancy benefits will not be provided after coverage under the
Plan has ended Ordinary nursery care of the newborn child during the covered portion of the
mother s hospital confinement for maternity will be covered under either a Self Only or elf
and Family enrollment other care of an infant who requires definitive treatment will be cov
ered 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 including refraction testing for members
under age 19
Allergy testing and treatment including testing and treatment materials such as allergy
serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney lung single or double and liver transplants allogeneic donor bone
marrow transplants high dose chemotherapy autologous bone marrow transplants autolo
gous stem cell and peripheral stem cell support for the following conditions acute lympho
cytic or non lymphocytic leukemia advanced Hodgkin s lymphoma advanced non
Hodgkin s lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and
ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer
Related medical and hospital expenses of the donor are covered when the recipient is covered
by this Plan Transplants must be preauthorized at the time of diagnosis prior to any evalua
tive services and will only be authorized at in Plan facilities contracted Centers of
Excellence or at facilities that have a predetermined negotiated per diem rate
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity when approved in advance by the Plan
Blood and blood derivatives no charge if replacement is arranged by member
Home health services of nurses and health aides when prescribed by your Plan doctor who
will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Section 5 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 intra
oral areas surrounding the teeth are not covered including any dental care involved in treatment
of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the member s appearance and if
the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have breast reconstruction surgery
following a mastectomy and whether surgery on the other breast is needed to produce a sym
metrical appearance Breast prostheses surgical bras and replacements are covered
Short term rehabilitative therapy physical speech occupational and chiropractic manipulation
is provided on an inpatient or outpatient basis for up to 60 visits per member per condition
each calendar year The first 20 visits for physical speech and occupational therapy will be cov
ered at 100 percent visits 21 40 will be covered at 80 percent and visits 41 60 will be covered
at 50 percent You pay remaining charges Each chiropractic manipulation therapy or office visit
will require a 10 copay in addition to appropriate visit copay for physical speech and occupa
tional therapy 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 main
tain self care and improved functioning in other activities of daily living Speech and occupa
tional therapy require preauthorization from the Plan
Diagnosis and treatment of infertility is covered you pay 10 per office visit The following
types of artificial insemination are covered intravaginal insemination IVI intracervical insem
ination ICI and intrauterine insemination IUI you pay 10 per office visit cost of donor
sperm is not covered Fertility drugs are covered under Prescription Drug Benefits and limited
to 1,500 per calendar year Other assisted reproductive technology ART procedures such as
in vitro fertilization and embryo transfer are not covered
Durable medical equipment DME such as wheel chairs and hospital beds orthopedic devices
including braces and prosthetics such as artificial limbs and external lenses following cataract
removal are provided when authorized in advance by the Plan and is limited to the initial acqui
sition You pay a 100 deductible per calendar year and 20 of charges up to a maximum Plan
payment of 1,500 per calendar year all charges thereafter Disposable supplies such as
colostomy bags and catheters are also provided You pay a 100 deductible per calendar year
separate from the DME deductible and 20 of charges up to a maximum Plan payment of
300 all charges thereafter
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided at a Plan facility when authorized in advance by the Plan
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Section 5 Benefits continued
What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance or attending school or camp or travel Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Dental benefits
Blood and blood derivatives not replaced by the member
Foot orthotics
Hospital Extended
Care Benefits
What is covered Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations
Specialized care units such as intensive care or cardiac care units
Extended care
The Plan provides a comprehensive range of benefits for up to 90 days 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 ser
vices 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
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 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 diagno
sis treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appro
priate See page 13 for non medical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Section 5 Benefits continued
Emergency Benefits A medical emergency is the sudden and unexpected onset of a condition or an injury that you
What is a medical 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
emergency might become more serious examples include deep cuts and broken bones Others are emergen
cies because they are potentially life threatening such as heart attacks strokes poisonings gun
shot 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 quicaction
Emergencies If you are in an emergency situation please call your primary care doctor In extreme emergen
within the service cies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency
area room personnel that you are a Plan member so they can notify the Plan You or a family mem
ber should notify the Plan within 48 hours of an admission to the hospital unless it was not rea
sonably possible to do so It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours
or on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If you are hospitalized in non Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital you will be transferred when medically
feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays
Reasonable charges for emergency services to the extent the services would have been covered
if received from Plan providers
You pay
40 per hospital emergency room visit or 20 per urgent care center visit for emergency ser
vices that are covered benefits of this Plan If the emergency results in admission to a hospital
the emergency care copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required
outside the service because of injury or unforeseen illness
area If you need to be hospitalized the Plan must be notified within 48 hours of an admission or on
the first working day following your admission unless it was not reasonably possible to notify
the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital
you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays
Reasonable charges for emergency care services to the extent the services would have been cov
ered if received from Plan providers
You pay
40 per hospital emergency room visit or 20 per urgent care center visit for emergency ser
vices that are covered benefits of this Plan If the emergency results in admission to a hospital
the emergency care copay is waived
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Section 5 Benefits continued
What is covered Emergency care at a doctor s office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not Elective care or non emergency care
covered Emergency care provided outside the service area if the need for care could have been fore seen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to
the Plan along with an explanation of the services and the identification information from your
ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you disagree with the
Plan s decision you may request reconsideration in accordance with the disputed claims proce
dure described on page 7
Mental Conditions
Substance Abuse
Benefits
What is covered This plan covers Mental Conditions and Substance Abuse treatments as any other illness or con dition The Plan provides the following services necessary for the diagnosis and treatment of
acute psychiatric conditions substance abuse
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care
Visits to a participating psychiatrist psychologist clinical nurse specialist or masters prepared
social worker are covered You pay a 10 copayment
Inpatient care
Hospitalization is covered upon referral by a participating provider is covered at 100
What is not Any psychological substance abuse treatment not medically necessary or treatment that is
covered not authorized by a Plan provider
Prescription Drug
Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply 240 milliliters of liquid 8oz 60 grams of ointment
creams or topical preparation or one commercially prepared unit i e one inhaler one vial oph
thalmic medication or Insulin of medication per prescription or refill You pay a 10 copay per
prescription unit or refill for generic drugs or for name brand Formulary drugs when generic
substitution is not permissible When generic substitution is permissible i e a generic drug is
available and the prescribing doctor does not require the use of a name brand drug but you
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Section 5 Benefits continued request the Formulary name brand drug you pay the price difference between the generic and
name brand drug as well as the 10 copay per prescription unit or refill Drugs are prescribed by
Plan doctors and dispensed in accordance with the Plan s drug Formulary Non Formulary drugs
will be covered when prescribed by a Plan doctor but at a higher copay
If you choose a non Formulary drug when a generic or Formulary name brand drug is available
you pay a 20 copayment in addition to the cost difference between the Formulary and non
Formulary drug up to 50 of the cost of the drug If the cost is less than the copayment you
pay the lesser amount
We work with our network physicians and our pharmacy network PCS Inc to build a
Formulary Drug List This Formulary Drug List includes over 80 of the drugs currently avail
able in the market including all generic and some name brand drugs Non Formulary drugs are
available at a cost difference If a physician obtains ConnectiCare s pre authorization waiver for
use of a Formulary name brand drug for medical reasons meaning there is also a generic
Formulary available then the regular 10 copayment will be charged There will be no pre
authorization waiver for non Formulary prescriptions
All members receive educational information describing the Formulary drug program For
members using non Formulary drugs a series of letters recommend that they speak to their
physician about preferred alternatives
Maintenance medication those medications needed for conditions such as diabetes high blood
pressure epilepsy and heart conditions can be obtained either via Mail Order or at the pharmacy
in a 100 day supply If you choose Mail Order at 2X the co pay or 20 call Member Provider
Services at 1 800 251 7722 and ask for an order form If you choose to go to your pharmacy
the co pay will be 3X or 30 again for Formulary drugs
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Contraceptive diaphragms
Implanted time release medications such as Norplant For Norplant and other internally
implanted time release medications you pay a one time copay of 10 per prescription
Insulin with a copay charge applied to each vial
Diabetic supplies including Insulin syringes needles glucose test tablets and test tape
Benedict s solution or equivalent and acetone test tablets
Disposable needles and syringes needed for injecting covered prescribed medication
Intravenous fluids and medication for home use copay does not apply covered implantable
drugs and covered injectable drugs are covered under Medical and Surgical Benefits
Oral and injectable contraceptive drugs
Limited benefits Drugs to treat sexual dysfunction are limited Contact the plan for dose limits you pay a 10 copay per prescription unit or refill up to the dosage limits and all charges above that
Fertility drugs subject to a 1,500 annual limit
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Section 5 Benefits continued
What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered 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 except as noted under Durable Medical
Equipment on page 10
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches and nicotine chewing gum
Anorexants weight loss drugs
Other Benefits
Vision Care In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye the Plan provides coverage for eye refractions which includes the written
lens prescription when obtained from Plan providers once every year per family member
without a referral you pay a 10 copayment This service also includes frames and lenses
prescription contact lenses available only at Plan routine vision providers offered at various
discounts not at 10 copay For full description of the Vision Care coverage please see the
routine vision information located in the provider directory
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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ConnectiCare Inc 2000
Non FEHB Benefits vailable 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 procedures
FitCare Program As a plan participant you and all covered members of your family are eligible to participate in the FitCare program at a participating YMCA or fitness center Choose a fitness center present your ConnectiCare ID card
and register as a ConnectiCare participant the first time you go Then you have the following options
Receive a one week free pass or
Pay a copayment on each visit or
Purchase a special membership for ConnectiCare participants equivalent to your center s best corporate rate
If you choose to pay a copayment there will be a 5 per visit fee for all ages with a 15 per day subscriber family maximum
Note The New England Health and Racquet Clubs Court House Plus Farmington Farms and GOLD S Gym require
membership after an initial 60 day period Fees in addition to the copayment may be required for some activities at various
centers
Benefits on this page are not part of the FEHB contract
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ConnectiCare Inc 2000
Section 6 General Exclusions Things we don t cover The exclusions in this section apply to all benefits Although we may list a specific service as a
benefit we will not cover it unless your Plan doctor determines it is medically necessary to pre
vent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
ervices not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of
an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plans offered by ConnectiCare Inc call 1 800 883 6565
Other group When anyone has coverage with us and with another group health plan it is called double cover
insurance coverage age 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 17
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ConnectiCare Inc 2000
Section 7 Limitations Rules that affect your benefits continued 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 Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible for 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
injuries seek damages you must agree to let us try This is called subrogation If you need more infor mation contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the mili tary TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must pro
vide 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 direct
Agencies ly or indirectly pays for
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ConnectiCare Inc 2000
Section 8 FEHB Facts You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
right to information about your health plan its networks providers and facilities You can also
find out about care management which includes medical practice guidelines disease manage
ment programs and how we determine if procedures are experimental or investigational OPM s
website www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 1 800 251 7722 or write to Member Services
ConnectiCare Inc 30 Batterson Park Road Farmington CT 06032 2574 You may also contact
us by fax at 860 674 2232 or visit our website at www connecticare com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the make an informed decision about When you many change your enrollment
FEHB Program 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 enroll
ment status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your cover
and premiums age and premiums begin on the first day of your first pay period that starts on or after January 1
effective 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are available unmarried dependent children under age 22 including any foster or step children your employing
for my family and me or retirement office authorizes coverage for Under certain circumstances you may also get cov erage 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 eli
gible 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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ConnectiCare Inc 2000
Section 8 FEHB Facts continued Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract This Plan and appropriate third parties such as other insurance plans and the Office of
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 We will send you an Identification ID card only when we receive a completed SF 2809 with
cards the PAYROLL CODE written on the bottom portion To get your cards on time simply FAX this form to our Enrollment Department at 1 860 674 2091 or mail to
Enrollment Department
ConnectiCare Inc
30 Batterson Park Road
Farmington CT 06032 2574
Your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation
letter will not work with our providers You still need to be in our system to receive care
What if I paid a Your old plan s deductible continues until our coverage begins
deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose
benefits
What happens imy You will receive an additional 31 days of coverage for no additional premium when
enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse coverage
If you are divorced from a Federal employee or annuitant you may not continue to get benefits
under your former spouse s enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse s employing or retirement office to get more information about your coverage
choices
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ConnectiCare Inc 2000
Section 8 FEHB Facts continued What is TCC
Temporary Continuation of Coverage TCC If you leave Federal service or if you lose cover
age because you no longer qualify as a family member you may be eligible for TCC For exam
ple 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 premi
ums 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 quali
fies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline
How can I convert You may convert to an individual policy if
to individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
coverage You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
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ConnectiCare Inc 2000
Section 8 FEHB Facts continued
Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate oGroup that indicates how long you have been enrolled with us You can use this certificate when get ting health insurance or other health care coverage You must arrange for the other coverage
Health within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
Plan Coverage 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 ser
vices you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 251 7722 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
The Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street N W 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 investi
gate 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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ConnectiCare Inc 2000
Summary of Benefits for ConnectiCare 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
Care limit Includes in hospital doctor care room and board general nursing care diagnostic tests drugs and medical supplies use of operating room intensive
care and complete maternity care You pay nothing 11
Extended care Services for up to 90 days per member per calendar year You pay nothing 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days of
inpatient care per year You pay nothing There is also coverage for serious
mental illness when medically necessary 13
Substance abuse Up to 45 days per year in a substance abuse treatment program You pay
nothing 13
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or
Care injury including specialist s care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay 10 copay per office visit initial visit only
for maternity care 10 per house call by a doctor 9 10
Home health care All necessary visits by nurses and health aides You pay nothing 9
Mental conditions Up to 20 outpatient visits per year You pay an applicable copay per visit 13
Substance abuse Up to 20 outpatient visits per year You pay an applicable copay per visit 13
Emergency Reasonable charges for services and supplies required because of a medical
Care emergency You pay a 40 copay to the hospital for each emergency room visit 20 per visit to an urgent care center and any charges for services that are not
covered by this Plan 12 13
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a
Drugs 10 copay per prescription unit or refill 13 15
Dental Care No Current Benefit
Vision Care Eye refractions including written lens prescription frames lenses contact lenses subject to discounts you pay a 10 copayment 15
Out oPocket Your out of pocket expenses for covered benefits under this Plan are limited to the
Limit stated copayments as well as deductibles and coinsurance required for durable medical equipment and prosthetic devices 5
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Authorized for distribution by the
United States Office oPersonnel Management
2000 Rate Information for ConnectiCare
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 Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov t Your Your Gov t Your Your USPS Your Your USPS Your Your Enrollment Share Share Share Share Share Share Share Share Share Share Share Share
All of Connecticut
Self Only TE1 71.73 23.91 23.91 155.42 51.80 51.80 84.88 10.76 10.76 84.88 10.76 10.76
Self and Family TE2 175.97 74.48 74.48 381.27 161.37 161.37 207.74 42.71 42.71 201.02 49.43 49.43
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