Enrollment Code 2G1 Self Onl y
2G2 Self and Famil y
This Plan has full accreditation from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure and
our website at http www carefirst com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service
RI 73 718
1
1
Page 2
3
CapitalCare Inc 2000
Tab le of Contents
Page
Introduction 3
Plain Languag e 3
How To Use This Brochur e 3
Section 1 Health Maintenance Or ganizations 4
Section 2 How We Change For 2000 4
Section 3 How To Get Benefits 6
Section 4 What To Do If We Deny Your Claim Or Request For Service 7 9
Section 5 Benefits 9 17
Section 6 General Exclusions Things We Don't Co ver 18
Section 7 Limitations Rules That Affect Your Benefits 18 19
Section 8 FEHB FACTS 19 22
Inspector General Advisory Stop Healthcare F r aud 23
Summary Of Benefits 24
Premiums Back cover
2
2
2
Page 3
4
CapitalCare Inc 2000
Introduction
CapitalCare Inc 550 12th Street S W Washington D C 20065
This brochure describes the benefits you can receive from CapitalCare Inc under its contract CS 2797 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 Languag e
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 CapitalCare Inc as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
How To Use This Brochur e
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
3
3
3
Page 4
5
CapitalCare Inc 2000
Section 1 Health Maintenance Or ganizations
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 or group of physicians 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
Pr ogram wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you
are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend
your record you may add a brief statement to it If they do not provide you your records call us
and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every f ive years
This screening is for colorectal cancer
Changes to this Plan Your share of CapitalCare's non postal premium will decrease by 1.4 for Self Only or 29.5 for Self and Family
The copay for visits to a primary care doctor is now 10 per office visit This includes
infertility treatment rendered by a primary care doctor Previously the copay was 5 per
office visit
The copay for rehabilitative therapy is now 10 per visit Prev i o u s ly the copay was 20 per visit
Under Facts about this Plan provision the out of pocket maximum is now 1,900 for Self
and 5,500 for Family Previously a 2,000 maximum applied for Self and 6,000 for
Family See page 5
Under Medical and Surgical Limited Benefits provision benefits will be provided for diabetes
equipment supplies and self management training See page 11
4
4
4
Page 5
6
CapitalCare Inc 2000
Section 3 How To Get Benefits
What is this Plan s To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is The District of Columbia the Maryland counties of Calvert Howard
Montgomery and Prince Georges and portions of the Maryland counties of Anne Arundel
Carroll Charles Frederick and St Mary's within the zip codes listed below the Virginia counties
of Arlington Fairfax Fauquier Lounden Prince William Spotsylvania and Stafford plus the
cities of Alexandria Falls Church and Fredericksburg
You may also enroll with us if you live or work in the following zip codes
Anne Arundel 20711 20724 20733 20751 20754 5 20758 21764 5 20776 20778 9 20794
21032 21035 21037 21054 21060 2 21076 7 21090 21098 21106 21108 21113 4 21140
21144 21225 21240 21401 5 21411 12
Carroll 21080 21104 21764 21771 21776 21784 21791 2 21797
Charles 20601 4 20607 20611 13 20616 17 20622 20632 20637 20640 20643 20646
20658 20662 20675 20677 20693 20695
Frederick 21701 2 21703 21704 21705 21709 10 21714 18 21736 21754 59 21762
21769 71 21773 78 21788 21790 91 21792 21793 21798
St Mary's 20622 20635 20659 60
Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health
care services
If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements
with affiliates in other areas If you or a family member move you do not have to wait until
Open Season to change plans Contact your employing or retirement office
How much do I pa y You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services
After you pay 1,900 in copayments or coinsurance for one family member or 5,500 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 and vision care services 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
Do I ha ve to submit claims You normally won't have to submit claims to us unless you receive emergency services 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 pr ovides my CapitalCare is an Individual Practice Association IPA model HMO in which you receive care health care from a network of physicians practicing in their private offices The CapitalCare network consist
of 38 hospitals over 1,340 primary care doctors and over 3,814 specialists at more than 10,000
5
5
5
Page 6
7
CapitalCare Inc 2000
Section 3 How To Get Benefits continued
locations In addition CapitalCare has plan designated facilities for diagnostic radiology and
laboratory services Each member may choose his or her own primary care doctor from the
CapitalCare Provider Directory
CapitalCare contracts with Health Management Strategies HMS or other vendor as determined
by the Plan to administer mental health and substance abuse benefits If you think you are in
need of mental health or substance abuse services you must first call HMS at 703 739 2434 or
800 822 4614 When treatment is necessary HMS will refer you to one of their network
providers All mental health and substance abuse services must be coordinated through HMS
rather than through your primary care doctor
What do I do if my primary Call us We will help you select a new one care physician lea ves
the Plan
What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our customer service department at 202 479 3708 or 800 680 9495 If you are new to hospital when I join the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
this Plan Program and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty care Your primary care physician will arrange your referral to a specialist
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 The physician may have to get an authorization
or approval beforehand
What do I do if I am seeing Your primary care physician will decide what treatment you need If they decide to refer you to a a specialist when I enroll specialist ask if you can see your current specialist If your current specialist does not participate
with us you must receive treatment from a specialist who does Generally we will not pay
for you to see a specialist who does not participate with our Plan
What do I do if my specialist Call your primary care physician who will arrange for you to see another specialist You may leaves the Plan receive services from your current specialist until we can make arrangements for you to see
someone else
But what if I ha ve a serious Please contact us if you believe your condition is chronic or disabling You may be able to continillness and my provider leav e s ue seeing your provider for up to 90 days after we notify you that we are terminating our contract
the Plan or this Plan lea ves with the provider unless the termination is for cause If you are in the second or third trimester the Pr ogram of pregnancy you may continue to see your OB GYN until the end of your postpartum care
You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
6
6
6
Page 7
8
CapitalCare Inc 2000
Section 3 How To Get Benefits continued
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 special medical services ist 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 To decide whether a service is experimental or investigational the Plan considers the following service is experimental questions
or in vestigational 1 Can this service be legally used in testing or other studies on human patients
2 According to generally accepted medical standards is this service recognized as safe and
effective for the treatment of this condition
3 When this service was rendered was it approved by any governmental authority whose
approval is required
4 In the case of a drug therapeutic regimen or device has it been approved for human use by
the Federal Food and Drug Administration
Service also means any treatment procedure drug facility equipment device or supply or
the usage of any of these things
Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this
time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request
We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the
information we already have
When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I ha ve a serious or Call us at 202 479 3708 or 800 680 9495 and we will expedite our review life threatening condition
and you ha ven't responded to my request for service
7
7
7
Page 8
9
CapitalCare Inc 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service continued
What if you ha ve denied m y If we expedite your review due to a serious medical condition and deny your claim we will r equest for care and m y inform OPM so that they can give your claim expedited treatment too Alternatively you can call
condition is serious or OPM's health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern life threatening Time Serious or life threatening conditions are ones that may cause permanent loss of bodily
functions or death if they are not treated as soon as possible
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we 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
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians'letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the request Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request
Where should I mail m y Send your request for review to Office of Personnel Management Office of Insurance disputed claim to OPM Programs Contract Division III P O Box 436 Washington D C 20044
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I 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
8
8
8
Page 9
10
CapitalCare Inc 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service continued
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Pri vacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become
part of the court record
Section 5 Benefits
Medical and Surgical Benefits
What is co vered 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 pa y a 10 office visit
copay for primary care or a 10 copay per visit to a specialist but no additional copay for laboratory
tests and X rays received at an approved facility Within the service area house calls will be
provided if in the judgment of the Plan doctor such care is necessary and appropriate you pa y 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 well baby care and periodic check ups and hearing screening for
children under age 18 hearing exams for adults are covered only when referred by the primary
care doctor
Routine Screening Mammograms are covered at a minimum as follows for women age 35
through age 39 one mammogram during these f ive years for women age 40 through 49 one
mammogram every one or two years for women age 50 through 64 one mammogram every
year and for women age 65 and above one mammogram every two years In addition to
routine screening diagnostic mammograms are covered when prescribed by the doctor as
medically necessary
Routine immunizations and boosters except for travel
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays rendered by a Plan facility are
covered in full
Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor A 10 copayment per visit applies with a 100 copayment
maximum per pregnancy The mother at her option may remain in the hospital up to
48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will
be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery
care of the newborn child during the covered portion of the mother's hospital confinement
for maternity will be covered under either a Self Only or Self and Family enrollment other
care of an infant who requires definitive treatment will be covered only if the infant is covered
under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTO R S
9
9
9
Page 10
11
CapitalCare Inc 2000
Section 5 Benefits continued
Allergy testing and treatment including testing and treatment materials such as allergy
serum you pa y a 25 copayment per visit
The insertion of internal prosthetic devices such as pacemakers and artificial joints including
the cost of the device breast prosthesis and surgical bras as well as their replacement
implantable drugs Dental implants are not covered
C o rnea heart heart lung lung single and double kidney and liver A l l ogeneic donor Bone
M a rr ow transplants for the following conditions acute ly m p h o cytic or non ly m p h o cy t i c
l e u kemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neur
o blastoma aplastic anemia severe combined immunodef i c i e n cy Wiscott Aldrich Syndrome
i n fantile malignant osteopetrosis Albers Schonberg disease or marble bone disease chronic
mye l ogenous leukemia CML homozygous beta thalassemia thalassemia major and panc
r e a s
Autologous Bone Marrow autologous stem cell peripheral stem cell support for the following
conditions acute lymphocytic leukemia 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
Autologous Bone Marrow peripheral stem cell Treatment for breast cancer multiple myeloma
and epithelial ovarian cancer may be provided in a non randomized plan approved clinical trial
Transplants are covered when prior authorization is obtained from CapitalCare Related medical
and hospital expenses of the donor are covered when the recipient is covered by this Plan and only
to the extent that the services are not covered under any other health insurance plan or contract
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
Norplant Depo Provera and IUDs
Home health services of skilled providers 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
Blood and blood derivatives not replaced by the member
Limited Benefits Oral and maxillofacial sur gery is provided for non dental 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTO R S 10
10
10
Page 11
12
CapitalCare Inc 2000
Section 5 Benefits continued
Reconstructi ve sur gery 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 rehabilitati ve therap y physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within 90 days you pa y 10 per outpatient session Speech therapy
is limited to treatment of certain speech impairments of organic origin Occupational therapy
is limited to services that assist the member to achieve and maintain self care and improved functioning
in other activities of daily living
Diagnosis and treatment of infertility is covered you pa y a 10 copay The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and Intrauterine insemination IUI you pa y a 10 copay cost of donor sperm is not covered
Certain fertility drugs are covered under the Prescription Drug Benefit Other assisted
reproductive technology ART procedures such as in vitro fertilization and embryo transfer are
not covered
Coverage will be provided for all medically appropriate and necessary diabetes equipment dia betes
supplies and diabetes self management training and educational services including
medical nutrition therapy when deemed by the treating physician or appropriately licensed health
care provider to be necessary for the treatment of diabetes Types I and II or elevated blood glucose
levels induced by pregnancy If deemed necessary the diabetes out patient self management
training and educational services including medical nutrition therapy shall be provided through a
program supervised by an appropriately licensed registered or certified health care provider
whose scope of practice includes diabetes education or management Please note certain diabetes
supplies are covered under the prescription section of this Plan Plan benefits provided by these
services are subject to the member copayments Please contact the Plan for additional information
on these copayments
What is not co vered Dental implants
Physical examinations that are not necessary for the prevention and detection of disease
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
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Cardiac rehabilitation
Orthopedic devices such as braces foot orthotics
Prosthetic devices such as artificial limbs and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
Chiropractic services
Blood and blood products
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTO R S
11
11
11
Page 12
13
CapitalCare Inc 2000
Section 5 Benefits continued
Treatment of obesity and weight reduction programs except for surgery for morbid obesity
Radial keratotomy and similar surgical procedures to correct retractive error
Hospital Extended Care Benefits
What is co vered
Hospital car e 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 pa y nothing All necessary services are covered
including
Semi private 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 car e 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 pa y 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 car e Supportive and palliative care for a terminally ill member is covered in the home or a hospice
facility Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness with a life expectancy of approximately six months or less You pay nothing
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate
See page 15 for non medical substance abuse benefits
What is not co vered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
Blood and blood products
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTO R S
12
12
12
Page 13
14
CapitalCare Inc 2000
Section 5 Benefits continued
Emer gency Benefits
What is a medical A medical emerg e n cy is the sudden and unexpected onset of a condition or an injury that you
e m e r ge n c y b e l i eve 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 emerg e n c i e s
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
d e t e rmine are medical emergencies what they all have in common is the need for quick action
Emer gencies within the If you are in an emergency situation please call your primary care physician If your PCP is service area unavailable call FirstHelp at 800 535 9700 to receive health care advice from a registered nurse
In extreme emergencies i e if life or limb are in jeopardy 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 in a non Plan facility the Plan must be notified at 800 680 9495 or
202 479 3708 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
B e n e fits are ava i l a ble for care from non Plan providers in a medical emerg e n cy 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 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 pa y 25 per hospital emergency room visit or 25 per non participating urgent care center or 10 per
participating urgent care center visit for emergency services that are covered benefits of this
Plan If the emergency room visit results in admission to a hospital the copay is waived
Emer gencies 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 are in an emergency situation please contact FirstHelp at 800 535 9700 to receive health
care advice from a registered nurse In extreme emergencies i e if life and limb are in jeopardy
contact the local emergency system e g the 911 telephone system or go to the nearest
hospital emergency room
If you need to be hospitalized the Plan must be notified at 800 680 9495 or 202 479 3708 within 48
hours or on the f irst 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 provided
by Plan providers
13
13
13
Page 14
15
CapitalCare Inc 2000
Section 5 Benefits continued
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pa y 25 per hospital emergency room visit or 25 per urgent care center visit for emergency services
that are covered benefits of this Plan If the emergency room visit results in admission to a hospital
the copay is waived
What is co vered 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 determined by the Plan to be medically necessary
What is not co vered Elective care or non emergency care
Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan pr ovider s 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 Prescription drug claims must be filed with the Plan within 15 months of the date incurred
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 page 7
Mental Conditions Substance Abuse Benefits
Mental conditions CapitalCare contracts with Health Management Strategies HMS or other vendor as determined by the Plan to administer mental health and substance abuse benefits If you think you are in
need of mental health or substance abuse services you must first call HMS at 703 739 2434 or
800 822 4614 When treatment is necessary HMS will refer you to one of their network
providers All mental health and substance abuse services must be coordinated through HMS
rather than through your primary care doctor
What is co vered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient car e Up to 40 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you
pay a 25 copay for each covered visit all charges thereafter
Inpatient car e Up to 30 days of hospitalization each calendar year you pa y a 50 copayment all charges
thereafter A 25 copay applies for each professional inpatient visit limited to one 1 per day
14
14
14
Page 15
16
CapitalCare Inc 2000
Section 5 Benefits continued
Partial hospitalization Available inpatient hospital days may be exchanged for a partial outpatient hospital day at the
day treatment rate of two outpatient day treatment days for each available inpatient day
What is not co vered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject
to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation
unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment
of a short term psychiatric condition
Marital family educational or other counseling or training servicies
Substance a buse
What is co vered 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 Services for the psychiatric aspects are provided
in conjunction with the mental conditions benefit shown above Outpatient visits to Plan mental
health providers for follow up care and counseling are covered as well as inpatient services necessary
for diagnosis and treatment The mental conditions visit day limitations and copays apply
However there is a 90 day inpatient hospital lifetime maximum for substance abuse
What is not co vered Treatment that is not authorized by the Plan Mental Health Substance Abuse Utilization
Management vendor
Prescription Drug Benefit
What is co vered Copays Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan retail
pharmacy will be dispensed for up to a 34 day supply You pay a 5 copay for generic drugs or a
10 copay for brand name drugs per prescription unit or refill
Mail Order Covered prescription drugs may also be obtained through the Plan's mail order
pharmacy and will be dispensed for up to a 90 day supply You pay a 10 copay per prescription
unit or refill for generic drugs or a 20 copay per prescription unit or refill for brand name drugs
Generic Substitution Under both the retail and mail program if you receive a brand name
drug when a generic is available you are responsible for the brand name copayment and the difference
in cost between the brand drug and generic drug You are not responsible for the difference
in cost if the prescriber determines the brand name drug is medically necessary
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
Medications that are not on the Formulary are still covered through the prescription drug program
and members do not have to pay any additional copayments Enrollees are not held accountable
for departures from formulary prescriptions
Prior Authorization Certain drugs require clinical prior authorization Contact the Plan for a
listing of which drugs are subject to the prior authorization policy Prior authorization may be
initiated by the Prescriber or the Pharmacy by calling Advance Secure at 1 800 294 5979 or
other vendor as determined by the Plan
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTO R S
15
15
15
Page 16
17
CapitalCare Inc 2000
Section 5 Benefits continued
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
All FDA approved contraceptive drugs and devices
Insulin and self administered injectables
Disposable needles and syringes needed to inject covered prescribed medication
Smoking deterrents
Diabetic supplies including insulin syringes needles glucose test strips lancets and alcohol
swabs
Allergy serum
Intravenous fluids and medication for home use implantable drugs such as Norplant some
injectable drugs such as Depo Provera and IUDs are covered under Medical and Surgical
Benefits
Limited Benefits Drugs to treat sexual dysfunction are subject to dosage limitations Contact the Plan for the
dosage limitations
What is not co vered D rugs ava i l a ble without a prescription or for which there is a nonprescription equivalent ava i l a bl e
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
Diabetic testing monitoring devices or meters
Drugs for weight loss
Other Benefits
Vision car e
What is co vered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases
of the eye annual eye refractions to provide a written lens prescription may be obtained
from Plan providers You pay a 10 copay per exam at participating vision centers or a 25
copay per exam at participating ophthalmologists exam by an ophthalmologist requires a referral
a 48 copay for exam and three 3 follow up fittings for daily wear contact lens exams at
participating vision centers excluding the cost of the contact lenses A 78 copay required for
disposable contact lens fitting and one year for follow up care
What is not co vered Corrective lenses or frames
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTO R S
16
16
16
Page 17
18
CapitalCare Inc 2000
Section 5 Benefits continued
Non FEHB Benefit The benefits described on this page are neither offered nor guaranteed under the contract with Availa ble To Plan the FEHB Program but are made available to all enrollees and family members of this Plan
Member s The cost of the benefits described in this section 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
Wellness pr ograms Discounts are available for the following services
fitness club memberships
child care
smoking cessation programs
weight management programs
hospital based education programs i e stress management nutrition first aid health back etc
Dental car e
What is co vered The following preventive and diagnostic services are covered when provided by Plan dentists
you pay a 14 adult copay or a 10 child copay per visit
Oral examinations
Prophylaxis or cleaning every 6 months
Fluoride treatment
Pulp Vitality tests
Diagnostic casts
Oral Hygiene instruction
You pay 50 of your participating dentist's usual and customary fees for
X rays
Fillings
Sealants
For all other non accidental services under this program you pay 75 of the participating
dentist's usual and customary fees including
Restorations
Crown and bridge services
Endodontic services
Periodontics
Prosthodontics removables
Oral surgery services
Broken appointment fee
Orthodontic services
TMJ treatment
Cosmetic and anesthetic services
Expanded Vision Plan members are entitled to a 25 discount off retail for glasses and contact lenses benefits These non FEHBP benefits are not part of the FEHBP contract
Benefits on this page are not part of the FEHB contract
17
17
17
Page 18
19
CapitalCare Inc 2000
Section 6 General Exclusions Things We Don't Co ver
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 co ver the Services drugs or supplies that are not medically necessary following
S e rvices 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
S e rvices or supplies you receive from a provider or facility barred from the FEHB Program a n d
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules That Affect Your Benefits
Medicar e Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 CapitalCare does not offer a
Medicare Choice plan
Other group insurance When anyone has coverage with us and with another group health plan it is called double cove r a g e coverag e 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
18
18
Page 19
20
CapitalCare Inc 2000
Section 7 Limitations Rules that affect your benefits continued
We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances be yond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary
care
When others are responsible When you receive money to compensate you for medical or hospital care for injuries or illness for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Go vernment Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients'Bill of Rights which gives you the right to information about your
health plan its networks providers and facilities You can also find out about care management which includes medical practice
guidelines disease 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 202 479 3708 or 800 680 9495 or write to CapitalCare Inc 550 12th Street S W
Washington D C 20065 You may also contact us by fax at 202 479 1300 or visit our website at www carefirst 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 Employees Health Benefits Plans brochures for other plans and other materials you need to
FEHB Pr ogram make an informed decision about
When you may change your enrollment
19
19
19
Page 20
21
CapitalCare Inc 2000
Section 8 FEHB FACTS continued
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverand premiums effecti ve age and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants'premiums begin January 1
What happens when I retire When you retire you can usually stay in the FEHB Program Generally you must 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
What types of co verage ar e Self Only coverage is for you alone Self and Family coverage is for you your spouse and your availa ble for my famil y unmarried dependent children under age 22 including any foster or step children your employing
and me or retirement office authorizes coverage for Under certain circumstances you may also get cove rage for a disabled child 22 years of age or older who is incapable of self support which is also authorized
by your employing or retirement office
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 No new enrollment for m
is necessary
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 claims We will keep your medical and claims information confidential Only the following will have records confidential access to it
OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of
Workers'Compensation Programs OWCP when coordinating benefit payments and subro gating
claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
20
20
20
Page 21
22
CapitalCare Inc 2000
Section 8 FEHB FACTS continued
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 member s
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 m y You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You
may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
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 21
21
21
Page 22
23
CapitalCare Inc 2000
Section 8 FEHB FACTS continued
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
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 con vert to You may convert to an individual policy if individual co verage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage
or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage of Group Health Plan that indicates how long you have been enrolled with us You can use this cert i f icate when getting
Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations
or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in
other FEHB plans you may request a certificate from them as well
22
22
22
Page 23
24
CapitalCare Inc 2000
Inspector General Advisory Stop Health Care F r aud
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 202 479 3708 or 800 680 9495 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
23
23
23
Page 24
25
CapitalCare Inc 2000
Notes
24
24
24
Page 25
26
CapitalCare Inc 2000
Notes
25
25
25
Page 26
27
CapitalCare Inc 2000
Notes
26
26
26
Page 27
28
CapitalCare Inc 2000
Summary of Benefits for CapitalCare 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 pr ovides Page
Inpatient car e Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care
private room and private nursing care if medically necessary diagnostic tests
drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 12 13
Extended care All necessary services no dollar or day limit You pay nothing 12
Mental conditions Diagnosis and treatment of acute psychiatric conditions including the
Substance abuse psychiatric aspects of substance abuse for up to 30 days of inpatient care per
year There is a 90 day inpatient lifetime maximum for substance abuse
You pay 50 copayment 14 15
Outpatient car e Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby
care periodic check ups and routine immunizations laboratory tests and
X rays complete maternity care You pay a 10 copay per office
100 copayment maximum per pregnancy nothing for labs and x rays
rendered by a Plan approved facility 9 12
Home health care All necessary visits by a home health agency You pay nothing 10
Mental conditions Up to 40 outpatient visits per year You pay a 25 copay per visit 15
Substance abuse
Emer gency car e Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each
emergency room visit and any charges for services that are not covered
by this Plan 13 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy Medications are covered through participating retail pharmacies and through
the mail service program At the retail pharmacy you pay a 5 generic or
10 brand name copay per prescription unit or refill for a 34 day supply
At the mail service pharmacy you pay a 10 generic or 20 brand name
copay per prescription for a 90 day supply 15 16
Dental car e No current benefit
Vision car e Annual routine exam You pay a 10 copay per visit at participating vision care centers 25 at participating ophthalmologist offices
requires referral 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,900 per Self Only or
5,500 per Self and Family enrollment per calendar year covered benefits
will be provided at 100 This copay maximum does not include charges
for prescription drugs and vision care benefits 5 27
27
27
Page 28
CapitalCare Inc 2000
2000 Rate Information for
CapitalCar e Inc
N o n Postal r a t e s a p p ly to most non Postal enrollees If you are in a special enrollment categ o ry refer to the FEHB Guide for that categ o ry or
contact the agency that maintains your health benefits enrollment
Postal r a t e s a p p ly to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Categ o ry A rates
and Categ o ry B rates will apply for certain career employees If you are a career postal e m p l oyee but not a member of a special postal
e m p l oyment class refer to the categ o ry definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Serv i c e
E m p l oyees RI 70 2 to determine which rate applies to yo u
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 Benefi t s
P l a n s
Non Postal Pr emium Postal Pr emium A Postal Pr emium B
Biweekly Monthl y Biweekly Biweekly
Type of Code Gov't Your Your Gov't Your Your USPS Your Your USPS Your
Enrollment Share Share Share Share Share Share Share Share Share Share Share
Self Only 2G1 77.59 25.86 168.11 56.03 91.81 11.64 91.81 11.64
Self and Family 2G2 175.97 77.47 381.27 167.85 207.74 45.70 201 .02 52.42
28