Pages 1--24 from Untitled

Serving Greater Flint and Saginaw areas
Enrollment in this Plan is limited see page 6 for requirements

Enrollment code X51 Self only
X52 Self and family

Visit the OPM website at http www opm gov insure
and
the Plan's website at http www healthplus com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service RI 73 648 1
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HealthPlus of Michigan 2000
Table of Contents

Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6 8
Section 4 What to do if we deny your claim or request for service 9 10
Section 5 Benefits 11 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 Health Care Fraud 22
Summary of benefits 23
Premiums 24

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HealthPlus of Michigan 2000
Introduction

HealthPlus of Michigan
2050 South Linden Road
Flint MI 48532

This brochure describes the benefits you can receive from HealthPlus of Michigan under its contract CS 2712 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 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 HealthPlus of Michigan as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not re written the Benefits section of this brochure You will find new benefits language next year

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HealthPlus of Michigan 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work

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

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that 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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HealthPlus of Michigan 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 doctor office visits Office visit physical examination and physician
house call are now covered subject to a 10 co pay per visit instead of no co pay

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 ad a brief statement to it If they do not provide you your records call us
and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer

Changes to this Plan Your share of the non postal premium will decrease by 22.7 for Self Only or 26.2 for Self and Family

Within our service area Hospital emergency room visit and urgent care center visit copay
is 25 co pay for each visit instead of no co pay If the emergency results in an
admission to the hospital the emergency care co pay is waived

Prescription drugs are covered subject to a 5 co pay per prescription unit or refill
instead of no co pay

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HealthPlus of Michigan 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 service area
Our service area is All of Arenac except Moffat and Clayton Township Bay Genesee Lapeer
Livingston Saginaw Shiawassee and Tuscola Counties in Michigan

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 Services will be covered if a nonaffiliated
provider renders them when an emergency prevents you from receiving services from a
participating provider

If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements
with affiliates in other areas If you or a family member move you do not have to wait until
Open Season to change plans Contact your employing or retirement office

How much do I pay You must share the cost of some services This is called either a co payment a set dollar for services amount or coinsurance a set percentage of charges Please remember you must pay this
amount when you receive services
Your out of pocket 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 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 Each family member that is covered by HealthPlus must choose a Primary Care Physician from health care the Provider Directory parents are expected to select for their children This list includes more
than 1,000 doctors who specialize in Family Practice Internal Medicine or Pediatrics The
listing for each Primary Care Physician also shows a primary hospital This is the hospital
where your Primary Care Physician will direct you for hospital services in most instances When
you select a Primary Care Physician you also are agreeing to use the hospital listed

The Primary Care Physician you choose will coordinate your overall medical care including
arranging for hospital admissions or care by a specialist when medically necessary with the
following exception a woman may see her Plan gynecologist for her annual routine examination
without a referral

HealthPlus strives to keep the Provider Directory as up to date as possible However
information may change after the Directory has been printed If the physician you select is no
longer accepting patients please select another You may want to call the physician you have
chosen prior to call the HealthPlus Customer Service Department at 800 332 9161 with your
selection You must notify HealthPlus before receiving covered services from the new Primary
Care Physician

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HealthPlus of Michigan 2000
Important note When you enroll in this Plan services except for emergency benefits are
provided through the Plan's delivery system the continued availability and or participation of any
one doctor hospital or other provider cannot be guaranteed

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 to Talk to your Plan physician If you need to be hospitalized your primary care physician or go into the hospital specialist will make the necessary hospital arrangements and supervise your care A scheduled
admission a hospitalization pre arranged by your Primary Care Physician or specialist requires
advanced authorization from HealthPlus An emergency hospitalization requires that HealthPlus
be notified within 24 hours or as soon thereafter as possible A hospital stay is authorized when
HealthPlus approves the admission and issues a complete authorization number to the hospital
The telephone number to call is on the back of your HealthPlus identification card

What do I do if I'm in First call our customer service department at 800 332 9161 If you are new to the FEHB the hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program and
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 Your primary care physician will arrange your referral to a specialist You will receive either specialty care written notification from HealthPlus or a referral form from your Primary Care Physician which
will specify the number of visits and the length of time covered by this referral If your referral
expires and you need additional visits contact your Primary Care Physician Services of other
providers are covered only when you have been referred by your primary care doctor with the
following exception a woman may see her Plan gynecologist for her annual routine examination
without a referral

If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician
will use our criteria when creating your treatment plan He or she may have to get an
authorization beforehand in order for the Plan to review for medical appropriateness

What do I do if I am Your primary care physician will decide what treatment you need If he or she decides to refer seeing a specialist you to a specialist ask if you can see your current specialist If your current specialist does not
when I enroll participate with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the receive services from your current specialist until we can make arrangements for you to see
Plan someone else

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HealthPlus of Michigan 2000
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our

provider leaves the Plan contract with the provider unless the termination is for cause If you are in the second or third or this Plan leaves the trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
Program care
You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
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 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 A service is determined to be experimental or investigational based on information obtained from service is experimental medical literature clinical trials and FDAapproval
or investigational

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HealthPlus of Michigan 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
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 Call us at 1 800 332 9161 and we will expedite our review or life threatening
condition 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 my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious OPM's health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m or life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible

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

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HealthPlus of Michigan 2000
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians'letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the
enrolled person's representative They must send a copy of the person's specific written
consent with the review request

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

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

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

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HealthPlus of Michigan 2000
Section 5 Benefits

Medical and Surgical Benefits
What is covered Plan doctors and other Plan providers provide a comprehensive range of preventive diagnostic
and treatment services This includes all necessary office visits you pay a 10 co pay You pay a
10 co pay for a doctor's house call or for home visits by nurses and health aides

The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows baseline mammogram by the age of 40 women
age 40 49 one mammogram every one or two years women age 50 and above one
mammogram every year
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 The mother at her option may remain in
the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean
delivery Inpatient stays will be extended if medically necessary If enrollment in the
Plan is terminated during pregnancy benefits will not be provided after coverage under
the Plan has ended Ordinary nursery care of the newborn child during the covered
portion of the mother s hospital confinement for maternity will be covered under either a
Self Only or Self and Family enrollment other care of an infant who requires definitive
treatment will be covered only if the infant is covered under a Self and Family
enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy
serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints The
cost of the implanted device is not covered
Cornea heart heart lung lung single and double pancreas kidney and liver
transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal
and ovarian germ cell tumors Related medical and hospital expenses of the donor are
covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Chiropractic services
Orthopedic devices such as braces foot orthotics
Prosthetic devices such as artificial limbs lenses following cataract removal breast
prostheses and surgical bras
Durable medical equipment such as wheelchairs and hospital beds and disposable
needles and syringes to administer covered injectables
Hearing aids
Surgical treatment of morbid obesity
Intravenous fluids and medication for home use and some injectable drugs are covered
under Medical and Surgical Benefits

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HealthPlus of Michigan 2000
Home health services of nurses and health aides including intravenous fluids and
medications when prescribed by your Plan doctor who will periodically review the
program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment
of fractures and excision of tumors and cysts All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered including any dental care involved in treatment
of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the member's appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her
attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance

Short term rehabilitative surgery physical speech and occupational is provided on an inpatient
or outpatient basis for up to two consecutive months per condition if significant improvement can
be expected within two months you pay nothing per outpatient session Speech therapy is
limited to treatment of certain speech impairments of organic origin Occupational therapy is
limited to services that assist the member to achieve and maintain self care and improved
functioning in other activities of daily living

Diagnosis and treatment of infertility are covered you pay nothing The following types of
artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay nothing cost of donor sperm is not covered
Other assisted reproductive technology ART procedures such as in vitro fertilization gamete
intrafallopian transfer zygote intrafallopian transfer artificial insemination donor pre embryo
cryo preservation techniques and embryo transfer are not covered Fertility drugs are covered
under the Prescription Drug benefit when used in conjunction with a prior authorized treatment
plan

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided at a Plan facility with no limit on the number of visits you pay nothing

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily performed for cosmetic purposes
Blood and blood derivatives not replaced by the member
Long term rehabilitative therapy
Homemaker services

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HealthPlus of Michigan 2000
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 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 up to 100 days per calendar year when fulltime
skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All
necessary services are covered including

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

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice
facility Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan doctor who certifies that the patient is in the terminal stage
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 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 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 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 Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care

Emergency Benefits What is a medical A medical emergency is the sudden and unexpected onset of a condition or injury that you believe
emergency 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 13 13
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HealthPlus of Michigan 2000
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme service area emergencies if you are unable to contact your doctor contact the local emergency system e g

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 must notify the Plan within 48 hours unless it was not reasonably possible to do
so It is your responsibility to ensure that the Plan has been notified in a timely matter

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 25 co pay for a visit to a hospital emergency room or urgent care facility Co pay is waived if
you are admitted to the hospital

Emergencies outside the Benefits are available for any medically necessary health service that is immediately required service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan doctor believes care can be better provided in a Plan hospital you would 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
covered if received from Plan providers

You pay Nothing for emergency care services which are covered benefits under this Plan

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 covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside
the service area

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HealthPlus of Michigan 2000
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim

form If you are required to pay for the services submit itemized bills and your receipts to the
Plan along with an explanation of the services and the identification information from your ID
card Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's
decision you may request reconsideration in accordance with the disputed claims procedure on
page 9

Mental Conditions Substance Abuse Benefits
Mental conditions What is covered
To the extent shown below the Plan provides the following services necessary for the diagnosis
and treatment of acute psychiatric conditions including the treatment of mental illness or
disorders

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

Outpatient care All medically necessary visits to Plan doctors consultants or other psychiatric personnel each
calendar year you pay nothing for each covered visit

Inpatient care Up to 45 days of hospitalization each calendar year you pay nothing for the first 45 days and all
charges thereafter

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 when not medically necessary to determine the appropriate
treatment of a short term psychiatric condition

Substance abuse What is covered
This Plan provides medical and hospital services such as acute detoxification services for the
medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness or condition and to the extent shown below the services necessary
for diagnosis and treatment

Outpatient care All necessary outpatient visits to Plan providers for treatment each calendar year you pay
nothing

Inpatient care All necessary inpatient days in a substance abuse rehabilitation intermediate 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

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HealthPlus of Michigan 2000
Prescription Drug Benefits
What is covered Prescription drugs covered by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply You pay a 5 co pay per prescription unit or refill for
generic drugs or for name brand drugs when generic substitution is not permissible
When generic substitution is permissible i e a generic drug is available and the prescribing
doctor does not require the use of a name brand drug but you request the name brand drug you
pay the price difference between the generic and name brand drug

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
The Plan's drug formulary is based on the effectiveness and costs of drugs Non formulary drugs
will be covered when prescribed by a Plan doctor

Covered medications and accessories include
Drugs for which a prescription is required by Federal or State law
Full range of FDA approved drugs prescriptions and devices for birth control
Insulin and insulin syringes
Diabetic testing reagents and supplies including glucose test strips test tape and alcohol
swabs
Smoking cessation drugs and medications limited to one course of therapy every two
years when prescribed by the Plan doctor or psychiatrist and accompanied by enrollment
in a smoking cessation program approved by the Plan doctor or psychiatrist
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use and some injectable drugs are covered
under Medical and Surgical Benefits
Fertility drugs when used in conjunction with prior authorized treatment plan

Limited benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay 50 coinsurance up to the dosage limits and all charges above that

What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance

Dental Care Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural
teeth The need for these services must result from an accidental injury You pay nothing

What is not covered Other dental services not shown as covered

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HealthPlus of Michigan 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 prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

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

Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage coverage You must tell us if you or a family member has double coverage You must also send
us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners'Guidelines

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HealthPlus of Michigan 2000
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances beyond 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 responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures

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

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for

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HealthPlus of Michigan 2000
Section 8 FEHB FACTS

You have a right to OPM requires that all FEHB plans comply with the Patients'Bill of Rights which gives you the information about your right to information about your health plan its networks providers and facilities You can also
HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's web site www opm gov lists the specific types of information that we must make
available to you

If you want specific information about us call 800 332 9161 or write to HealthPlus of
Michigan P O Box 1700 2050 S Linden Road Flint MI 48532 You may also contact us by
fax at 810 230 2208 or visit our web site at www healthplus 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 make
enrolling in the FEHB an informed decision about Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay
enter military service or retire
When your enrollment ends and
The next Open Season for enrollment

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

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

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

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for my unmarried dependent children under age 22 including any foster or step children your employing
family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may
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HealthPlus of Michigan 2000
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 payment 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 Plan
ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

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

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

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HealthPlus of Michigan 2000
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

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HealthPlus of Michigan 2000
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting

Health Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations
or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

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 800 332 9161 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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HealthPlus of Michigan 2000
Summary of Benefits for HealthPlus of Michigan 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 with no care dollar or day limit Includes in hospital doctor care room and board general nursing care

private room and private nursing care if medically necessary diagnostic tests drugs and
medical supplies use of operating room intensive care and complete maternity care
You pay nothing .13

Extended All necessary services up to 100 days per calendar year
care You pay nothing .13

Mental Diagnosis and treatment of acute psychiatric conditions for up
conditions to 45 days of inpatient care per year You pay nothing .15

Substance All necessary inpatient days in a substance abuse rehabilitation
abuse intermediate care program in an alcohol detoxification center
approved by the Plan You pay nothing .15

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care 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 per office visit 10 per house call by a doctor .11

Home All necessary visits by nurses and health aides
health care You pay nothing .12

Mental All necessary visits per year
conditions You pay nothing .15

Substance All necessary visits per year
abuse You pay nothing .15

Emergency Reasonable charges for service and supplies required because of a care medical emergency You pay 25 for each emergency room visit and urgent care center
visit and any charges for services that are not covered by this Plan .13 14
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy drugs You pay 5 per prescription unit or refill .16

Dental Accidental injury benefit You pay nothing .16 care
Vision No current benefit care
Out of pocket Your out of pocket expenses for benefits covered under this Plan maximum are limited to the stated copayments that are required for a few benefits 6

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HealthPlus of Michigan 2000
2000 Rate Information for
HealthPlus of Michigan

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to an 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 apply 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 Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Self Only X51 75.53 25.17 163.64 54.54 89.37 11.33 89.37 11.33
Self and Family X52 175.97 70.91 381.27 153.64 207.74 39.14 201.02 45.86

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