Serving Northeast Ohio
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
5M1 Self Only
5M2 Self and Family
This Plan has an accredited status
from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
this Plan's website at www mmoh com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service Federal Employees Health Benefits Program
RI 73 656
1
1
Page 2
3
SuperMed HMO 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 4 6
Section 4 What to do if we deny your claim or request for service 6 8
Section 5 Benefits 8 14
Section 6 General exclusions Things we don't cover 14 15
Section 7 Limitations Rules that affect your benefits 15 16
Section 8 FEHB facts 16 19
Inspector General Advisory Stop Healthcare Fraud 19
Summary of benefits Inside back cover
Premiums Back cover
2
2
2
Page 3
4
SuperMed HMO 2000
Introduction
Medical Mutual of Ohio dba SuperMed HMO 2060 East Ninth Street Cleveland Ohio 44115 1355
This brochure describes the benefits you can receive from SuperMed HMO under its contract CS2015 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 SuperMed HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier
These changes do not affect the benef its or services we provide We have rewritten this brochure only to make it more understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year
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
3
3
3
Page 4
5
SuperMed HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams 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 To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request
you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a phy s i c i a n
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 Your share of the non postal premium will increase by 30.4 for Self Only or 80.2 for Self Plan and Family
B e h avioral health services that were prev i o u s ly provided through the Value Options Netwo r k
formerly Value Behavioral Health will be delivered through the SuperMed Behavioral Health
N e t work Behavioral health services include treatment for mental health substance abuse or
chemical dependency
If you are currently receiving treatment for behavioral health services or if you need treatment
in the future you should cont act t he SuperMed Behavioral Health Care Management
Department at 1 800 258 3186
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our prov i d e r s Plan's service practice
area Our Service area is
The Ohio counties of Ashtabula Cuyahoga Geauga Lake Lorain Mahoning Medina Portage
Stark Summit and Trumbull
4
4
4
Page 5
6
SuperMed HMO 2000
Section 3 How to get benefits continued
Ordinarily you must get your care from providers who contract with us Benefits for care outside
the service area are limited to emergency services as described on page 12
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 Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments I pay for required for a few benefits
services
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents
for your claim as soon as possible You must submit claims by December 31 of the year after the
year you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides SuperMed HMO is a mixed model prepayment plan that provides care through a network of doctors my health using groups of doctors staff model arrangements and IPA systems Both primary care
care and specialist doctors are part of the network Different members of the same family may select different centers or doctors
The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care doctor
to obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other providers are covered only when there
has been a referral by the member's primary care doctor with the following exceptions Vision
care visits to a Plan Obstetrician Gynecologist and for care for mental conditions and substance
abuse call SuperMed Behavioral Health Care Management Department at 1 800 258 3186
What do I do if Call us We will help you select a new one my primary
care physician leaves the plan
What do I do if I Talk to your Plan physician If you require hospitalization your primary care doctor or authorized need to go into specialist will make the necessary arrangements and continue to supervise your care
the hospital
What do I do if First call our customer service department at 1 800 574 2583 If you are new to the FEHB I'm in the hospital Program we will arrange for you to receive care If you are currently in the FEHB Program and
when I join this are switching to us your former plan will pay for the hospital stay until Plan 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 become a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Except in a medical emergency or when a primary care doctor has designated another doctor to specialty care see patients when he or she is unavailable you must receive a referral from your primary care
doctor before seeing any other doctor or obtaining special services Referral to a participating
specialist is given at the primary care doctor's discretion if specialists or consultants are
required beyond those participating in the Plan the primary care doctor will arrange appropriate
referrals
5
5
5
Page 6
7
SuperMed HMO 2000
Section 3 How to get benefits continued
When you receive a referral from your primary care doctor you must return to the primary care
doctor after the consultation unless your doctor authorizes additional visits All follow up care
must be provided or authorized by the primary care doctor Do not go to the specialist for a second
visit unless your primary care doctor has arranged for and the Plan has issued an authorization
for the referral in advance
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional referrals Your primary care physician
will use our criteria when creating your treatment plan
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to I am seeing a a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay I enroll for you to see a specialist who does not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may my specialist r e c e ive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract
provider leaves the with the provider unless the termination is for cause If you are in the second or third Plan or this Plan trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
leaves the 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 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 specialist medical services 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 drug device or medical treatment or procedure is experimental or investigational service is experimental
If the drug or device has not been approved by the Food and Drug Administration FDA or investigational
If reliable evidence shows that the drug device medical treatment or procedure is the subject
of on going phase I II III clinical trials or is under study to determine maximum tolerated
dose toxicity safety efficacy or efficacy as compared with the standard means of treatment
or diagnosis
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control
6
6
6
Page 7
8
SuperMed HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 corr e c t ly applied the terms of our contract when we denied yo u r
claim or request for service
What if I have a serious or Call us at 1 800 574 2583 and we will expedite our review life threatening condition
and you haven't responded to my request for service
What if you have denied If we expedite your rev i ew 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
my condition is serious or call OPM's health benefits Contract Division 3 at 202 606 0191 between 8 a m and 5 p m 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 You must write to OPM and ask them to review our decision within 90 days after we uphold our time 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
What do I send to Your request must be complete or OPM will return it to you You must send the following information OPM
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 Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
7
7
7
Page 8
9
SuperMed HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 Send your request for rev i ew to Off ice of Personnel Management Off ice of Insurance my disputed claim Programs Contract Division 3 P O Box 436 Washington D C 20044
to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the 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
p r ovisions of the Freedom of Information Act and the Priva cy 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
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 costs 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 nothing 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 one mammogram each calendar 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
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
8
8
Page 9
10
SuperMed HMO 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
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
Cornea heart heart lung lung single and double kidney kidney pancreas 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 nonHodgkin's
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial
ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors
Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be provided
in an NCI or NIH approved non randomized clinical trial at an NCI designated center and if
approved by the Plan's Medical Director in accordance with the Plan's protocols 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
Breast Prostheses surgical bras and their replacements
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics
External prosthetic devices such as artif icial limbs and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
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 at no additional cost to you
Limited benefits O r al and maxillofacial surg e r y 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 shortening of the mandible or
maxillae for cosmetic purposes correction of malocclusion and any dental care invo l ved in
treatment of temporomandibular joint TMJ pain dysfunction syndrome
R e c o n s t r u c t i ve surg e r y 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
S h o r t term r e h ab i l i t a t i ve ther a py p hysical speech and occupational is provided on an inpatient
or outpatient basis for up to two months per condition if significant improvement can be
expected within two months These services may be rendered when referred by your primary care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
9
9
Page 10
11
SuperMed HMO 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
physician to a therapist or chiropractor you pay nothing 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 is covered you pay nothing Artificial insemination is
covered you pay nothing cost of donor sperm is not covered Fertility drugs are not covered
Other assisted reproductive technology ART procedures that enable a woman with otherwise
untreatable infertility to become pregnant through other artificial conception procedures such as
in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
is provided at a Plan facility as prescribed by your primary care doctor 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 for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Homemaker services
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
Hospital care hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay 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 S u p p o rt ive and palliative care for a term i n a l ly ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling and durable medical
equipment 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
10
10
Page 11
12
SuperMed HMO 2000
Section 5 Benefits continued
Hospital Extended Care Benefits continued
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 wh i c h
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
See page 13 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits
What is a medical emergency A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan
may determine are medical emergencies what they all have in common is the need for quick
action
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies service area if you are unable to contact your doctor contact the local emergency system e g the 911
telephone system or go to the nearest hospital emergency room Be sure to tell the emergency
room personnel that you are a Plan member so they can notify the Plan You or a family member
should notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been
timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time 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 50 per hospital emergency room visit nothing per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital
the emergency care copay is waived
11
11
11
Page 12
13
SuperMed HMO 2000
Section 5 Benefits continued
Emergency Benefits continued
Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred
when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays R e a s o n a ble charges for emerg e n cy care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit nothing per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital
the emergency care copay is waived
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
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500
claim form If you are required to pay for the services submit itemized bills and your receipts to
the Plan along with an explanation of the services and the identification information from your
ID card Payment will be sent to you or the provider if you did not pay the bill unless the
claim is denied If it is denied you will receive notice of the decision including the reasons for
the denial and the provisions of the contract on which denial was based If you disagree with the
Plan's decision you may request reconsideration in accordance with the disputed claims procedure
described on pages 7 8
Mental Conditions Care for the treatment of mental conditions and substance abuse may be arranged by calling the Substance Abuse SuperMed Behavioral Health Care Management Department at 1 800 258 3186 It is not necessary
Benefits to obtain a referral from your primary care doctor
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
12
12
12
Page 13
14
SuperMed HMO 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits continued
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay nothing for the first 20 visits all charges thereafter Available hospital inpatient
days may be converted to outpatient visits on a two for one basis for up to 60 additional
visits when the Plan certifies that inpatient care would otherwise be required
Inpatient care Up to 30 days per admission up to a maximum of two admissions per calendar year You pay nothing for the first 30 days of each admission all charges thereafter All covered admissions
must be separated by 90 days Available outpatient visits may be authorized in lieu of inpatient
d ays on a two f o r one basis when the Plan cert i f ies that inpatient care would otherwise be
required
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
Outpatient Care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay nothing
Additional outpatient visits may be authorized in lieu of inpatient days when certified by a Plan
physician
Inpatient Care Inpatient services for the psychiatric aspects are provided in conjunction with the Mental conditions
benefits shown above The Mental conditions benefit inpatient day limitation is applied to
any covered substance abuse care
What is not covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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 30 day supply You pay a 5 copay per prescription unit or refill for
generic drugs or for name brand drugs when generic substitution is not perm i s s i ble W h e n
generic substitution is perm i s s i ble i e a generic drug is ava i l a ble 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 as well as the 5 copay per prescription
unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Nonformulary drugs will be covered when prescribed by a Plan doctor A formulary is a list
of selected FDA approved prescription medications reviewed by an independent Pharmacy and
Therapeutics Committee brought together by Merck Medco Managed Care L L C These drugs
are made by many different pharmaceutical manufacturers including Merck Co Inc
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs contraceptive diaphragms
Insulin including insulin syringes and needles with a copay charge applied to each vial
13
13
13
Page 14
15
SuperMed HMO 2000
Section 5 Benefits continued
Prescription Drug Disposable needles and syringes needed to inject covered prescribed medication Benefits continued Smoking cessation drugs and medication including nicotine patches
Intravenous fluids and medication for home use and some injectable drugs are covered under
Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Diabetic supplies including glucose test tablets and test tape Benedict's solution or
equivalent and acetone test tablets
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth The need for these services must result from an accidental injury You pay nothing These s e rvices must be initiated within 90 days from the date of the accident Services necessary
because of injury as a result of chewing or biting are not covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions once every two years to provide a written lens prescription for eyeglasses
may be obtained from Plan providers You pay nothing
What is not covered Corrective lenses or frames
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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 treatment 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
14
14
14
Page 15
16
SuperMed HMO 2000
Section 6 General exclusions Things we don't cover continued
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
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us
documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances 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
injuries 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
15
15
15
Page 16
17
SuperMed HMO 2000
Section 7 Limitations Rules that affect your benefits continued
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage
Workers compensation We do not cover services that
You need because of a 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
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
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 1 800 574 2583 or write to SuperMed HMO
P O Box 94845 Cleveland Ohio 44101 4845 You may also contact us by fax at
216 694 2910 or visit our website http www mmoh com
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal about enrolling in the E m p l oyees Health Benefits Plans brochures for other plans and other materials you need to
FEHB Program make an informed decision about
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants premiums begin January 1
16
16
16
Page 17
18
SuperMed HMO 2000
Section 8 FEHB facts continued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last f ive years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Te m p o r a r y
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 Fa m i ly enrollment if yo u
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the 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 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 Your old plan's deductible continues until our coverage begins
deductible 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 Your enrollment ends unless you cancel your enrollment or
ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
17
17
17
Page 18
19
SuperMed HMO 2000
Section 8 FEHB facts continued
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 s p o u s e s employing or retirement office to get more information about your cove r a g e
choices
What is TCC Temporary Continuation of Co verage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a fa m i ly member you may be eligible for TCC Fo r
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 Fe d e ral Employ e e s
Health Benefits Plans for Te m p o rary Continuation of Cov e rage and Former Spouse Enro l l e e s
from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
in TCC 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
Fo rmer spouses You or your former spouse must notify your employing or retirement off i c e
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 off ice 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 You may convert to an individual policy if
to 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
18
18
18
Page 19
20
SuperMed HMO 2000
Section 8 FEHB facts continued
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
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 1 800 258 3466 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
19
19
19
Page 20
21
SuperMed HMO 2000
Summary of Benefits for SuperMed HMO 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 care
Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital doctor care room and board general nursing care private room and private nursing care
if medically necessary d i agnostic tests d rugs and medical supplies use of operating ro o m intensive care and complete maternity care You pay nothing 10 11
Extended care All necessary services for up to 100 days per calendar year You pay nothing 10 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per admission up to a maximum of two admissions per calendar year You pay nothing for the first
30 days of each admission 12 13
Substance Abuse Covered under Mental Conditions 13
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including s p e c i a l i s t s care preve n t ive care i n cluding we l l b aby care p e riodic ch e ck ups and ro u t i n e
i m mu n i z ations lab o rat o ry tests and X rays complete mat e rnity care You pay 10 per offi c e visit nothing for a house call by a doctor 8 9
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 nothing 12 13
Substance abuse Up to 20 outpatient visits per year You pay nothing 13
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit that does not result in your admission
as an inpatient and any charges for services that are not covered by this Plan 11 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill 13 14
Dental care Accidental injury benefit you pay nothing 14
Vision care One refraction every two years You pay nothing 14
Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits 5
20
20
20
Page 21
22
Notes
21
21
21
Page 22
23
Notes
22
22
22
Page 23
24
23
23
23
Page 24
Authorized for Distribution by the
United States Office of
Personnel Management Federal Employees Health Benefit Program
2000 Rate Information f or
SuperMed HMO
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 catagories of contribution rates referred to as
Category A rates and Catagory B rates will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health
Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable
Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Self Only 5M1 78.83 26.27 170.79 56.93 93.06 12.04 93.26 11.84
Self and Family 5M2 175.97 92.87 381.27 201.22 207.74 61.10 201.02 67.82
24 24