For changes
in benefits
see page 3
Serving Northern Illinois Eastern Iowa Eastern Tennessee and Southwestern Virginia
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
3J1 Self only
3J2 Self and family
5 97 5 00
Service Areas Reviewed by NCQA IA IL
Special Notice Heritage National Healthplan Inc Enrollment Code 3J has merged with a sister plan Heritage National Healthplan
Inc Enrollment Code 4T If you are currently enrolled in Heritage National Healthplan Inc Enrollment Code 4T your enrollment will
be transferred automatically to Heritage National Healthplan Inc Enrollment Code 3J unless you select another FEHB plan during the
1999 Open Season Additionally please note that the new name for Heritage National Healthplan Inc Enrollment Code 3J is John
Deere Health Plan Inc
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www johndeerehealth com
Authorized for distribution by the
United States
Office of
Personnel
Management
RI 73 661
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John Deere Health Plan 2000
Table of Contents
Page 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 7
Section 4 What to do if we deny your claim or request for service 10
Section 5 Benefits 12
Section 6 General exclusions Things we don't cover 23
Section 7 Limitations Rules that affect your benefits 24
Section 8 FEHB FACTS 26
Inspector General Advisory Stop Healthcare Fraud 30
Summary of benefits Inside back cover
Premiums Back cover
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John Deere Health Plan 2000
Introduction
John Deere Health Plan Inc
1300 River Drive Suite 200
Moline IL 61265
This brochure describes the benefits you can receive from John Deere Health Plan Inc under its contract
CS 2746 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This
brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described
in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
pages 5 and 6 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 John Deere Health Plan Inc as this Plan throughout this brochure even though in other legal documents you will see a
plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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John Deere Health Plan 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 You will also find information
about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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John Deere Health Plan 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and
injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for
changes all primary care office visits
This year you have a right to more information about this Plan care management
our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at
our request you may continue to see your specialist for up to 90 days If your
provider leaves the Plan and you are in the second or third trimester of pregnancy
you may be able to continue seeing your OB GYN until the end of your
postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you
want copies of your medical records ask your health care provider for them You
may ask that a physician amend a record that is not accurate not relevant or
incomplete If the physician does not amend your record you may add a brief
statement to it If they do not provide you your records call us and we will assist
you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every
five years This screening is for colorectal cancer
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John Deere Health Plan 2000
Changes to this Your share of the Non Postal premium will increase by 4.3 for Self Only and will
Plan decrease by 5.9 for Self and Family
The copay for name brand prescription drugs has increased from 10 to 15 See page 20
Insulin syringes and needles are subject to the 5 copay for generic drugs See page 20
Insulin is subject to the 15 copay for name brand drugs See page 20
Compounded prescriptions are subject to a member copay of 50 of charges See page 20
Prescription drugs purchased at a non Plan pharmacy except for out of area emergencies are subject to a member copay of 50 of charges Prescription drugs
purchased at a non Plan pharmacy for out of area emergencies are subject to the 5 copay for generic drugs or the 15 copay for name brand drugs In order to be
reimbursed for any prescription drugs purchased at a non Plan pharmacy the member will have to pay the full price initially and then submit a paper claim which
includes the prescription drug receipts to Direct Member Reimbursement for the appropriate reimbursement See page 20
Certain specified maintenance drugs may be purchased at a retail pharmacy for up to a 100 day supply subject to a member copay for each one month supply i e 3
copays See page 20
The first time a new prescription is filled it will be limited to up to a 34 day supply however refills can be for a greater supply See page 20
Smoking cessation drugs and medication are now excluded from coverage See page 21
Drugs prescribed for weight loss appetite suppressants and dietary supplements are excluded from coverage See page 21
Durable medical equipment is provided at no cost to the member See page 13
Prosthetic devices are provided at no cost to the member See page 13
Diagnostic procedures such as laboratory tests and X rays are provided at no cost to the member See page 12
Heritage National Healthplan Inc Enrollment Code 3J has merged with a sister plan Heritage National Healthplan Inc Enrollment Code 4T If you are currently
enrolled in Heritage National Healthplan Inc Enrollment Code 4T your enrollment will be transferred automatically to Heritage National Healthplan Inc Enrollment
Code 3J unless you select another FEHB plan during the 1999 Open Season See front cover
The Plan's name has changed from Heritage National Healthplan Inc to John Deere Health Plan Inc
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John Deere Health Plan 2000
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 providers
Plan's service practice Our service area is
area Illinois Bloomington Joliet Moline Peoria and Rock Island areas and the counties of
Bureau Carroll DeWitt Grundy Henry Jo Daviess Kankakee Knox LaSalle Lee Livingston McLean Marshall Mercer Peoria Rock Island Stark Tazewell Warren
Whiteside Will and Woodford
Iowa Burlington Cedar Falls Cedar Rapids Des Moines Dubuque Iowa City
Marshalltown Ottumwa Quad Cities and Waterloo areas and the counties of Allamakee Appanoose Benton Blackhawk Boone Bremer Buchanan Butler Cedar
Chickasaw Clayton Clinton Dallas Davis Delaware Des Moines Dubuque Fayette Floyd Franklin Grundy Guthrie Hardin Henry Howard Iowa Jackson Jasper
Jefferson Johnson Jones Keokuk Lee Linn Louisa Madison Mahaska Marion Marshall Monroe Muscatine Polk Poweshiek Scott Story Tama Van Buren
Wapello Warren Washington and Winneshiek
Tennessee Chattanooga Greeneville Kingsport and Knoxville areas and the counties
of Anderson Bledsoe Blount Bradley Campbell Carter Claiborne Cocke Franklin Grainger Greene Grundy Hamblen Hamilton Hancock Hawkins Jefferson Johnson
Knox Loudon McMinn Marion Meigs Monroe Morgan Polk Rhea Roane Scott Sequatchie Sevier Sullivan Unicoi Union and Washington
Virginia Bristol Radford Roanoke and Salem areas and the counties of Botetourt
Craig Floyd Franklin Giles Lee Montgomery Pulaski Scott and Washington
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for
any other health care services without a pre approved referral
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 You must share the cost of some services This is called either a copayment a set
I pay for dollar amount or coinsurance a set percentage of charges Please remember you
services must pay this amount when you receive services
After you pay 1,000 in copayments or coinsurance for one family member or 2,500 for two or more family members you do not have to make any further payments for
certain services for the rest of the year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs do not count toward these
limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
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John Deere Health Plan 2000
Do I have to You normally won't have to submit claims to us unless you receive emergency services
submit claims from a 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 John Deere Health Plan Inc is an Individual Practice Prepayment IPP plan It is a
my health Health Maintenance Organization that contracts directly with providers providing
care medical services It contracts with doctors practicing in private offices to care for our members Participating providers are located throughout the service area There are
441 primary care doctors 1,839 specialists and 29 hospitals in the Illinois service area
443 primary care doctors 2,651 specialists and 44 hospitals in the Iowa service area
878 primary care doctors 3,706 specialists and 47 hospitals in the Tennessee service
area and 310 primary care doctors 798 specialists and 8 hospitals in the Virginia
service area
You may directly access any Plan provider whether primary care doctor or specialist
including a woman being able to see her Plan gynecologist for her annual routine
examination
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 Talk to your Plan physician If you need to be hospitalized your primary care
I need to go physician or specialist will make the necessary hospital arrangements and supervise
into the hospital your care
What do I do if First call our customer service department at 1 800 247 9110 If you are new to the
I'm in the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
hospital when I Program and are switching to us your former plan will pay for the hospital stay until
join this 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 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
specialty care 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
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John Deere Health Plan 2000
What do I do if Your primary care physician will decide what treatment you need If they decide to
I am seeing a refer you to a specialist ask if you can see your current specialist If your current
specialist when specialist does not participate with us you must receive treatment from a specialist
I enroll 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 Call your primary care physician who will arrange for you to see another specialist
my specialist You may receive services from your current specialist until we can make arrangements
leaves the for you to see someone else
Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be
have a serious able to continue seeing your provider for up to 90 days after we notify you that we are
illness and my terminating our contract with the provider unless the termination is for cause If you
provider leaves are in the second or third trimester of pregnancy you may continue to see your
the Plan or this OB GYN until the end of your postpartum care
Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the
Program 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 Your physician must get our approval before sending you to a hospital referring you
authorize to a specialist or recommending follow up care Before giving approval we consider if
medical the service is medically necessary and if it follows generally accepted medical practice
services
How do you A drug device medical treatment or procedure is considered experimental or
decide if a investigational if it has not been approved for use by one of the following agencies
service is the Food and Drug Administration National Cancer Institute or Department of Health
experimental or and Human Services Also a drug device medical treatment or procedure is considered experimental or investigational if reliable evidence shows that the
investigational consensus of opinion among experts regarding the drug device medical treatment or
procedure is that further studies or clinical trials are necessary to determine its
maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared
with the standard means of treatment or diagnosis for the enrollee's medical condition
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John Deere Health Plan 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial
OPM to review a or refusal OPM will determine if we correctly applied the terms of our contract when we
denial denied your claim or request for service
What if I have a Call us at 800 247 9110 and we will expedite our review
serious or life
threatening condition
and you haven't
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we
denied my request will inform OPM so that they can give your claim expedited treatment too
for care and my Alternatively you can call OPM's Health Benefits Contracts Division 3 at 202 606 0755
condition is serious between 8 a m and 5 p m Serious or life threatening conditions are ones that may
or life threatening 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
time limits uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive
your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer
within 30 days In this case OPM must receive your request within 120 days of
the date we asked you for additional information
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John Deere Health Plan 2000
What do I send to Your request must be complete or OPM will return it to you You must send the
OPM 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 Send your request for review to Office of Personnel Management Office of Insurance
mail my disputed Programs Contracts Division 3 P O Box 436 Washington D C 20044
claim to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees
upholds the Plan's with our 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court
I file a lawsuit will base 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
the Privacy Act from you 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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John Deere Health Plan 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you
pay a 10 office visit copay but no additional copay for laboratory tests and X rays
Within the service area house calls will be provided if in the judgment of the Plan
doctor such care is necessary and appropriate you pay a 10 copay for a doctor's
house call and nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless
stated otherwise
Preventive care including routine hearing and vision screening through age 17
well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one
mammogram during these five years for women age 40 and above one
mammogram every year In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or
treat your illness
Routine immunizations and boosters
Consultations by specialists outpatient specialist consultations are also subject
to a 10 copay
Diagnostic procedures such as laboratory tests and X rays you pay nothing
Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor Copays are waived for maternity
care 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 including diaphragms
intrauterine devices IUDs injectable contraceptives such as Depo Provera and
implantable drugs such as Norplant
Infertility services diagnosis and treatment including the following types of
artificial insemination intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI in vitro fertilization and embryo
transfers You pay a 10 copay per office visit or outpatient consultation a 100
copay per inpatient surgery or inpatient facility admission and nothing for
surgical services performed in the physicians office or outpatient facility Fertility
drugs are covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as
allergy serum you pay a 10 copay per allergy testing series in addition to the 10
office visit copay
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart and lung kidney kidney and pancreas liver and lung single
or double 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
Surgical treatment of morbid obesity
Orthopedic devices such as braces
Prosthetic devices such as artificial limbs lenses following cataract removal breast
prostheses and surgical bras as well as their replacements including repair and
replacements of unusable prosthetic devices and supplies and equipment not
having any function other than in connection with the use of the prosthetic device you pay
nothing
Durable medical equipment such as wheelchairs and hospital beds and diabetic
supplies including glucose test tablets test tape lancets and acetone test tablets you pay
nothing
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 you pay nothing
All necessary medical or surgical care in a hospital or extended care facility from
Plan doctors and other Plan providers
Blood and blood derivatives
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including
but not limited to treatment of fractures and excision of tumors and cysts All other
procedures involving the teeth or intra oral areas surrounding the teeth are not
covered including any dental care involved in the 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 therapy physical speech occupational and cardiac is
provided on an inpatient or outpatient basis for up to 60 visits 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 Cardiac rehabilitation therapy is limited to treatment
following a heart transplant bypass surgery or a myocardial infarction
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or
covered camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Chiropractic services
Podiatric services
Cost of donor sperm
Foot orthotics
Corrective eyeglasses frames and contact lenses including the fitting of contact lenses except as necessary for the first pair of corrective lenses following cataract
surgery
Refractions including lens prescriptions
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism
blurring
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 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 a 100 copayment per
admission a 100 copayment for an inpatient surgical procedure and a 10 copayment
for an outpatient specialist consultation 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 with no dollar or day limit 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
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
procedures there is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental
services Conditions for which hospitalization would be covered include hemophilia
and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient
management is not medically appropriate See page 19 for nonmedical substance abuse
benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Emergency Benefits A medical emergency is the sudden and unexpected onset of a condition or an injury
What is a 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
medical not treated promptly they might become more serious examples include deep cuts and
emergency 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 If you are in an emergency situation please call your primary care doctor In extreme
within the 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
service area Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member should notify the Plan within 48 hours It is
your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a 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 nonPlan facilities and 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
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 35 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to
a hospital the copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately
outside the required because of injury or unforeseen illness
service area 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 35 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to
a hospital the 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 Elective care or nonemergency care
covered 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 non Plan With your authorization the Plan will pay benefits directly to the providers of your
providers emergency 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 10 and 11
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Mental Conditions Substance Abuse Benefits
Members may access mental health services by calling United Behavioral Health UBH at 800 867 6758
For benefits to be paid members must be evaluated by a triage consultant prior to commencement of treatment except in the event of a medical emergency Call the Member Services Representative at 800 247 9110 for the name of the triage consultant in your service area
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
Office and Outpatient care
Office visits Up to 20 office visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 20 copayment for each covered visit all charges thereafter
If group therapy is performed in place of individual therapy each group therapy visit will count as one half visit toward the 20 visit limit Psychological testing is covered
you pay nothing
Outpatient Up to 30 outpatient days for treatment at a facility each calendar year you pay a 30
facility visits copay for each covered day all charges thereafter
Outpatient Up to 30 outpatient physician visits for treatment at a facility each calendar year you
physician visits pay a 20 copay for each covered day all charges thereafter
Inpatient care
Inpatient Up to 30 inpatient days for treatment at a facility each calendar year you pay a 40
facility visits copay for each covered day all charges thereafter
Inpatient Up to 30 inpatient physician visits each calendar year you pay a 20 copay for each
physician visits covered day all charges thereafter
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
covered Psychiatric evaluation or therapy on court order or as a condition of parole or
probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
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
Office and
outpatient care
Office visits Up to 20 office visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay a 20 copayment for each covered visit all charges thereafter
If group therapy is performed in place of individual therapy each group therapy visit will count as one half visit toward the 20 visit limit
Outpatient Up to 30 outpatient days for treatment at a facility each calendar year you pay a 30
facility visits copay for each covered day all charges thereafter
Outpatient Up to 30 outpatient physician visits for treatment at a facility each calendar year you
physician visits pay a 20 copay for each covered day all charges thereafter
Inpatient care
Inpatient Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care
facility visits program in an alcohol or drug rehabilitation center approved by the Plan you pay a 40 copay for each covered day all charges thereafter
Inpatient Up to 30 inpatient physician visits each calendar year you pay a 20 copay for each
physician visits covered day all charges thereafter
What is not Treatment that is not authorized by a Plan doctor
covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply You pay a 5 copay per
prescription unit or refill for generic drugs and a 15 copay for name brand drugs Certain specified maintenance drugs in oral solid dosage forms such as tablets or
capsules and insulin may be dispensed in quantities up to a 100 day supply you pay a copay for each one month supply i e 3 copays The first time a new prescription is
filled it will be limited to up to a 34 day supply however refills can be for a greater supply
The Plan utilizes a voluntary drug formulary 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
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs diaphragms intrauterine devices IUDs Depo Provera and Norplant with the exception of oral contraceptive drugs all are covered under
Medical and Surgical Benefits
Fertility drugs
Insulin you pay a 15 copay
Insulin syringes and needles you pay a 5 copay
Diabetic supplies including glucose test tablets test tape lancets and acetone test tablets covered under Medical and Surgical Benefits as durable medical
equipment see page 13
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use covered implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs are subject to dosage limits set by the Plan Contact the Plan for details
Compounded prescriptions you pay 50 of charges
Prescription drugs purchased at a non Plan pharmacy except for out of area
emergencies you pay 50 of charges Prescription drugs purchased at a non Plan
pharmacy for out of area emergencies you pay a 5 copay for generic drugs or a
15 copay for name brand drugs In order to be reimbursed for any prescription
drugs purchased at a non Plan pharmacy the member must pay the full price
initially and then submit a paper claim which includes the prescription drug
receipts to Direct Member Reimbursement for the appropriate reimbursement
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
What is not Drugs available without a prescription or for which there is a nonprescription
covered 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
Smoking cessation drugs and medication
Drugs prescribed for weight loss appetite suppressants and dietary supplements
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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John Deere Health Plan 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB
premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits
are not subject to the FEHB disputed claims procedure
Dental care
A nationwide network of dentists have a`greed to limit their charges to a specific reduced fee schedule for John Deere Health Care
JDHC members To locate current dentists in your area call 888 596 5300 You can also nominate dentists by asking your dentist to
call for an information package 800 949 5449
This non FEHB benefit is not an insurance plan Refer to your dental fee schedule to find the maximum charge payable by you If you
choose a participating dentist show your JDHC ID card to the dentist's office staff before you receive services You pay only up to the
maximum charge and the dentist should not bill you for the balance
Vision care
A nationwide network of ophthalmologists and optometrists have agreed to offer John Deere Health Care JDHC members discounts
on frames and lenses coatings and options contact lenses and disposable contacts through any participating provider location This
network currently contracts with approximately 10,000 providers in fifty states
To locate a participating provider in your area call 800 999 5431 When you purchase eyewear show the provider your JDHC ID card
before you receive services
Benefits on this page are not part of the FEHB contract
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John Deere Health Plan 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
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John Deere Health Plan 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate
the payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also
remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and
enroll in a Medicare Choice plan when one is available in your area For information
on suspending your FEHB enrollment and changing to a Medicare Choice plan
contact your retirement office If you later want to re enroll in the FEHB Program
generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service
area you may 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
insurance double coverage You must tell us if you or a family member has double coverage
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
beyond our be unable to provide them In that case we will make all reasonable efforts to
control provide you with necessary care
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John Deere Health Plan 2000
When others When you receive money to compensate you for medical or hospital care for injuries
are responsible or illness that another person caused you must reimburse us for whatever services
for injuries 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 We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency
determine they must 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 We do not cover services and supplies that a local State or Federal Government
Government agency directly or indirectly pays for
Agencies
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John Deere Health Plan 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which
information about gives you the right to information about your health plan its networks providers
your HMO and facilities You can also 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 800 247 9110 or write to 1300 River
Drive Suite 200 Moline IL 61265 You may also contact us by fax at 309 748 1024
or visit our website at www johndeerehealth com
Where do I get Your employing or retirement office can answer your questions and give you a
information about Guide to Federal Employees Health Benefits Plans brochures for other plans and
enrolling in the other materials you need to make an informed decision about
FEHB 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 The benefits in this brochure are effective on January 1 If you are new to this plan
benefits and your coverage and premiums begin on the first day of your first pay period that
premiums effective starts on or after January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must
when I retire have been 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
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John Deere Health Plan 2000
What types of Self Only coverage is for you alone Self and Family coverage is for you your
coverage are spouse and your unmarried dependent children under age 22 including any foster
available for my or step children your employing or retirement office authorizes coverage for Under
family and me 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
not be enrolled in another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the following
claims records will have access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the
Office of Workers Compensation Programs OWCP when coordinating benefit
payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or
criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not
disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits
cards 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 We will not refuse to cover the treatment of a condition that you or a family member
conditions had before you enrolled in this Plan solely because you had the condition before you enrolled
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John Deere Health Plan 2000
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of
Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to
spouse coverage get benefits under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced
or are anticipating a divorce contact your ex spouse's employing or retirement
office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be
eligible for TCC For example you can receive TCC if you are not able to continue
your FEHB enrollment after you retire You may not elect TCC if you are fired from
your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you
separate
If you no longer qualify as a family member you can receive TCC for up to 36
months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to
pay premiums from the 32 nd 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
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John Deere Health Plan 2000
How do I enroll If you leave Federal service your employing office will notify you of your right
in TCC 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 You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your
coverage 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
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan
Certificate of Coverage that indicates how long you have been enrolled with us You can use this
Group Health certificate when getting health insurance or other health care coverage You must
Plan Coverage arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related
conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously
enrolled in other FEHB plans you may request a certificate from them as well
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John Deere Health Plan 2000
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 800 247 9110 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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John Deere Health Plan 2000
Summary of Benefits for John Deere Health Plan Inc 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in
the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment
in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED
OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital
Care 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 a 100 copayment per admission and a 100 copayment per inpatient
surgery 15
Extended care All necessary services no dollar or day limit You pay nothing 15
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per calendar
conditions year You pay a 40 facility copay for each day a 20 copay for each inpatient physician visit 18
Substance Up to 30 days per year in a substance abuse treatment program You pay a 40 facility copay for
abuse each day a 20 copay for each inpatient physician visit 19
Comprehensive range of services such as diagnosis and treatment of illness or injury including Outpatient
specialist's care preventive care including well baby care periodic check ups and routine care
immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office
visit copays are waived for maternity care 10 per house call by a doctor 10 per outpatient specialist
consultation and nothing for surgical services performed in the physician's office or outpatient facility 12
All necessary visits by nurses and health aides You pay nothing 13 Home health
care
Up to 30 days of outpatient care per calendar year You pay a 30 facility copay for Mental
each day a 20 copay for each outpatient physician visit and up to 20 office visits per conditions
calendar year You pay a 20 copay for each office visit 18
Up to 30 outpatient days per year You pay a 30 facility copay for each day a 20 Substance
copay for each outpatient physician visit and up to 20 office visits per calendar year abuse You pay
a 20 copay for each office visit 19
Reasonable charges for services and supplies required because of a medical emergency
Emergency You pay a 35 copay to the hospital for each emergency room visit and any charges for
care services that are not covered by this Plan 16 17
Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5
Prescription copay per prescription unit or refill for generic drugs a 15 copay per prescription unit
drugs or refill for name brand drugs 20 21
No current benefit Dental care
No current benefit
Vision care Copayments are required for a few benefits however after your out of pocket expenses reach a
maximum of 1,000 per Self Only or 2,500 per Self and Family enrollment per calendar year covered Out ofpocket
benefits will be provided at 100 This copay maximum does not include charges for prescription drugs 7
maximum
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John Deere Health Plan 1999
2000 Rate Information for
John Deere Health Plan Inc
Formerly Heritage National Healthplan Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide
for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to
as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but
not a member of a special postal employment class refer to the category definitions in The Guide to Federal Employees
Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or
associate members of any postal employee organization Such persons not subject to postal rates must refer to the applicable
Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Self Only 3J1 71.15 23.71 154.15 51.38 84.19 10.67 84.19 10.67
Self and Family 3J2 175.97 80.15 381.27 173.66 207.74 48.38 201.02 55.10
32 32