Visit the OPM website at http www opm gov insure And
First Choice Health Plan at http www fchn com
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First Choice Health Plan HMO 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 6
Section 3 How to get benefits 7
Section 4 What to do if we deny your claim or request for service 11
Section 5 Benefits 13
Section 6 General exclusions Things we don't cover 25
Section 7 Limitations Rules that affect your benefits 26
Section 8 FEHB facts 28
Inspector General Advisory Stop Healthcare Fraud 32
Summary of benefits 33
Premiums 35
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First Choice Health Plan HMO 2000
Introduction
First Choice Health Plan 601 Union Street Suite 1100
Seattle WA 98101 4072
This brochure describes the benefits you can receive from First Choice Health Plan HMO under its contract CS2809 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 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 First Choice Health Plan HMO as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year
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First Choice Health Plan HMO 2000
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format
and similar information to make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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First Choice Health Plan HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care
services The care you receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services you may have
to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or
other provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
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First Choice Health Plan HMO 2000
Section 2 How We Change For 2000
Program wide To keep your premiums 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
Changes to this Your share of the non postal premium will increase by 20.2 for Self Only or 51.9 Plan for Self and Family
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First Choice Health Plan HMO 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 service area providers practice Our service area is Grays Harbor King Lewis Mason Pierce
Snohomish and Thurston counties in Washington State
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 pay You must share the cost of some services This is called either a copayment a set for services dollar amount or coinsurance a set percentage of charges Please remember you
must pay this amount when you receive services except for prescription drugs or vision care
After you pay 1,500 in copayments or coinsurance for one family member or 4,500 for a family you do not have to make any further payments for certain services for the
rest of the year except for prescription drugs or vision care This is called a catastrophic limit However copayments or coinsurance for your prescription drugs
and vision care 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 have to submit You normally won't have to submit claims to us unless you receive emergency services 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
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Who provides my The Plan's provider directory lists primary care providers family practitioners health care pediatricians and internists with their locations and phone numbers and notes
whether or not the provider is accepting new patients Directories are updated twice a year and are available at the time of enrollment or upon request by calling the Member
Services Department at 1 800 783 7312 You can also find out if your provider participates with this Plan by calling this number If you are interested in receiving
care from a specific provider who is listed in the directory call the provider to verify that he or she still participates with the Plan and is accepting new patients
Important note When you enroll in this Plan services except for emergency benefits are provided through the Plan's delivery system the continued availability and or
participation of any one provider hospital or other provider cannot be guaranteed
If you enroll you will be asked to let the Plan know which primary care doctor s you've selected for you and each member of your family by sending a selection form to
the Plan If you need help choosing a doctor call the Plan Members may change their doctor selection by notifying the Plan Changes take effect the first day of the month
following 15 days notice
If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services until the Plan can arrange with you to be seen by another participating
doctor
What do I do if my Call us We will help you select a new one primary care
physician leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care to go into the physician or specialist will make the necessary hospital arrangements and supervise
hospital your care
What do I do if I'm in First call our customer service department at 1 800 783 7312 If you are new to the the hospital when I FEHB Program we will arrange for you to receive care If you are currently in the
join this Plan FEHB 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
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How do I get Your primary care physician will arrange your referral to a specialist A woman may specialty care see her obstetrician gynecologist for her annual routine examination without a referral
Except in a medical emergency or when a primary care doctor has designated another doctor to see his or her patients you must receive a referral from your primary care
doctor before seeing any other doctor or obtaining special services Referral to a participating specialist is given at the primary care doctor's discretion if non Plan
specialists or consultants are required the primary care doctor will arrange appropriate referrals
When you receive a referral from your primary care provider you must return to the primary care provider after the consultation All follow up care must be provided or
referred by the primary care provider unless your doctor authorizes additional visits Do not go to the specialist unless your primary care provider has arranged for and the
Plan has issued an authorization for the referral in advance
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your
treatment plan
What do I do if I am Your primary care physician will decide what treatment you need If they decide to seeing a specialist refer you to a specialist ask if you can see your current specialist If your current
when I enroll 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 Call your primary care physician who will arrange for you to see another specialist specialist leaves the You may receive services from your current specialist until we can make arrangements
Plan for you to see someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able serious illness and my to continue seeing your provider for up to 90 days after we notify you that we are
provider leaves the terminating our contract with the provider unless the termination is for cause If you Plan or this Plan are in the second or third trimester of pregnancy you may continue to see your
leaves the Program 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 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
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First Choice Health Plan HMO 2000
How do you authorize Your physician must get our approval before sending you to a hospital referring you to medical services
a specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
The Plan will provide benefits for covered services only when the services are medically necessary to prevent diagnose or treat your illness or condition Your Plan
doctor must obtain the Plan's determination of medical necessity before you may be hospitalized referred for specialty care or obtain follow up care from a specialist
How do you decide if The Plan determines if a service is experimental or investigational by the following a service is criteria Whether the service is in general use in the medical community if recognized
experimental or outside sources indicate the service is proven effective and shows demonstrable benefit investigational for a particular illness or disease if the service is under continued scientific testing and
research if utilization of the service results in a greater benefit for a particular illness or disease over other services that are generally available and if the service poses
significant risks to the health and safety of the patient
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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
denial we denied your claim or request for service
What if I have a Call us at 1 800 808 0450 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 Contract Division IV at 202 606 condition is serious 0737 between 8 a m and 5 p m EST Serious or life threatening conditions are ones
or life threatening that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we limits uphold our initial denial or refusal of service You may also ask OPM to review your
claim if
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1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the
date we asked you for additional information
What do I send to Your request must be complete or OPM will return it to you You must send the 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
What address should Send your request for review to Office of Personnel Management Office of Insurance I send my disputed Programs Contracts Division IV P O Box 436 Washington D C 20044
claim to
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 I Federal law governs your lawsuit benefits and payment of benefits The Federal court 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 from you and us to determine if our denial of your claim is correct The information
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the Privacy Act 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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First Choice Health Plan HMO 2000
Section 5 Benefits
Medical and Surgical
Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by 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 provider such care is
necessary and appropriate you pay a 10 copay for a doctor's house call and nothing for home visits by nurses
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care and annual physical examinations including gynecological exams and well baby care
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one
mammogram every one or two years for women age 50 through 64 one mammogram every year and for women 65 and above one mammogram every
two years In addition to routine screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan provider office visit copays are waived for
obstetrical care The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery Inpatient stays
may 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Voluntary sterilization and family planning services diaphragms and intrauterine devices
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung kidney liver and pancreas 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 Transplants are covered when approved by the Medical Director 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
Home health services of nurses and health aides when prescribed by your primary care provider 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 providers and other Plan providers at no additional cost to you
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CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Limited Benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as a 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 and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if
significant improvement can be expected within two months you pay nothing Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist functioning in other activities of daily living
The initial purchase or rental of orthopedic and prosthetic devices such as braces and artificial limbs breast prostheses and surgical bras and their replacement and durable
medical equipment such as wheelchairs and hospital beds is covered You pay 20 of charges
Medical supplies are covered coverage includes but is not limited to dressings catheters and colostomy bags and related supplies You pay nothing Diabetic
equipment such as insulin pumps is covered Advanced authorization is required Foot care appliances used to prevent complications associated with diabetes are covered if
medically necessary and authorized You pay 20 of the cost
Diagnosis and treatment of infertility is covered you pay a 10 copay The following types of artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI The cost of donor sperm is not covered Fertility drugs are not covered under the prescription drug
benefit Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered Blood and blood derivatives donor
and processing charges are covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for up to 45 visits per year You pay a 10 copay per visit
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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What is not Physical examinations that are not necessary for medical reasons such as those covered required for obtaining or continuing employment or insurance attending school or
camp or travel
Foot orthotics shoe inserts corrective shoes elastic stockings and temporary prosthetics
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Plastic surgery primarily for cosmetic purposes
Hearing aids
External lenses following cataract removal
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Services provided by non network providers unless specifically authorized by First Choice Health Plan
Use of emergency facilities for non emergency conditions
Transportation except as specified in this brochure
Orthoptics pleoplics visual analysis therapy and or training and radial keratotomy
Blood and blood derivatives not replaced by the member
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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 provider You pay nothing All necessary services are covered including
Semiprivate room accommodations when a Plan provider determines it is medically necessary the provider 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 limit for up to 90 days per calendar year when full time skilled nursing care is necessary and confinement
in a skilled nursing facility is medically appropriate as determined by a Plan provider and approved by the Plan You pay nothing All necessary services are covered
including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or
hospice facility limited to a maximum of 10 days inpatient per calendar year and one period of continuous home care for up to five days not to exceed four hours per day and
120 hours of respite care during each three month period of hospice care to include any days of extended care already used Services include inpatient and outpatient care and
family counseling these services are provided under the direction of a Plan provider who certifies that the patient is in the terminal stages of illness with a life expectancy
of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan
doctor The Plan pays 80 of charges for ambulance transportation
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Limited Benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan provider procedures determines there is a need for hospitalization for reasons totally unrelated to the dental
procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include
hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient 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 provider determines that outpatient management is not medically appropriate Benefits are continued with non medical
substance abuse benefits See Page 20 for non medical substance abuse benefits
What is not Personal comfort items such as telephone and television covered
Custodial care rest cures domiciliary or convalescent care
Take home drugs
Blood and blood derivatives not replaced by the member
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury emergency that you believe endangers your life or could result in serious injury or disability
and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly can become more serious examples include deep cuts
and broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisoning gunshot wounds or sudden inability to
breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care provider In extreme the service area emergencies if you are unable to contact your provider contact the local emergency
system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can
notify the Plan You or a family member must notify the Plan within 48 hours It is your responsibility to ensure that the plan has been notified in a timely manner If you
need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first business day following your admission unless it was not reasonably
possible to notify the Plan within that time If you are hospitalized in non Plan facilities and Plan providers believe care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant
jeopardy to your condition To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan
Plan Pays providers Reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers You Pay
A 50 copay per hospital emergency room visit or 50 per urgent care center visit for emergency care services that are covered benefits of this Plan If the emergency results
in admission to a hospital the emergency copay is waived
Emergencies outside the service area benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified on the first business day following your admission unless it was not reasonably possible to notify the Plan
within that time If a Plan provider 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
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CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Plan pays Reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers
You pay A 50 copay per hospital emergency room visit or 50 per urgent care center visit If the emergency results in admission to a hospital the emergency 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 The Plan pays 80 of charges for ambulance transportation
What is not Elective or non emergency 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 With your authorization the Plan will pay benefits directly to the providers of your non Plan 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 Page 11
Mental Health Substance Abuse
Mental Conditions What is covered To the extent shown below the Plan provides the following services necessary for the
diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care You pay 50 of the allowed charge Visits are only covered when preauthorized and through plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Inpatient care You pay 50 of the allowed charge Services are only covered when authorized and through plan providers
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and
drug addiction the same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care You pay 50 of the allowed charge Visits are only covered when preauthorized and through plan providers
Inpatient care You pay 50 of the allowed charge Services are only covered when authorized and through plan providers
What is not covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay a 10 copay per
prescription unit or refill for brand name drugs for up to a 30 day supply or 100 unit supply whichever is less 240 milliliters of liquid 8 oz 60 grams of ointment creams
or topical preparation or one commercially prepared unit i e one inhaler one vial ophthalmic medication or insulin
You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not permissible When generic substitution is
permissible i e a generic drug is available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay the price
difference between the generic and name brand drug as well as the 10 copay per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The Plan has an open formulary developed by First Choice's Pharmacy and
Therapeutics P T Committee Most FDA approved drugs are included on the formulary The Committee's review process requires evaluation of the drugs safety
effectiveness comparison studies approved indications adverse effects contraindications pharmacokinectics patient compliance considerations medical
outcome and pharmacoeconomic studies The Committee evaluates new drugs relative to similar drugs currently on the formulary When the Committee decides not to add a
drug to the formulary it is determined that the drug offers no known clinical or cost advantage over comparable formulary drugs or that there is insufficient current
scientific information to determine the drugs appropriate clinical role
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs contraceptive diaphragms
Levonorgestrel Norplant
Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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First Choice Health Plan HMO 2000
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Fertility drugs
Injectible drugs except Chlorpeniramine Ephinephrine and Epinephrine
Investigational or experimental drugs
Drugs for cosmetic purposes
Smoking cessation drugs and medications except when used in conjunction with a FCHP approved smoking cessation program
Vitamins and nutritional substances that can be purchased without a prescription
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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First Choice Health Plan HMO 2000
Other Benefits
Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental
injury not biting or chewing occurring while the member is covered under the FEHB Program You pay nothing
Vision Care This plan provides the following vision care benefits
What is covered Copayments Limitations
Examination every 12 months You pay 10 Copay
Vision Hardware You receive 20 discount towards Lenses and Frames only purchase
If purchased within 12 months of exam Contact Lenses
You receive 15 discount on professional services associated with all prescription
contact lenses
The provider must be a Vision Service Plan VSP participating provider to be covered
All services provided must be medically necessary
No referral is necessary from the member's primary care provider for vision care
Discounts only offered through the VSP Participating Provider who last provided the eye examination
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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First Choice Health Plan HMO 2000
Acupuncture Services by referral for treatment and management of pain You pay a 10 copay per visit
Chiropractic A plan provider provides services You pay a 10 copay per visit with a 250 annual maximum benefit
Health Education Coverage includes PCP referred nutritional counseling health education and health prevention You pay a nominal fee
Naturopathic Care A naturopathic physician provides the services You pay a 10 copay per visit with a 500 per member annual maximum
Massage Therapy A PCP or if referred a participating massage therapist provides the services Coverage is provided for treatment of trauma or injury if sustainable improvement can be
expected within a 60 day period You pay a 10 copay per visit
Smoking Cessation Services through a First Choice Health Plan approved smoking cessation program for smoking cessation education is covered in full up to 500 per member lifetime
maximum Prescription drugs prescribed for smoking cessation are covered under Prescription Drug Benefits
Out of Area Benefit Coverage for dependents residing in Washington State but outside the service area of First Choice Health Plan Benefits vary
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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First Choice Health Plan HMO 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A and 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 an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information
on suspending your FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally
you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in
Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information
on the Medicare Choice plan offered by this Plan contact FCHP at 1 800 864 1190
Other group When anyone has coverage with us and with another group health plan it is called insurance coverage double coverage You must tell us if you or a family member has double coverage You
must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is
primary according to the National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or
our regular benefit whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary
plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have
double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be beyond our control unable to provide them In that case we will make all reasonable efforts to provide you
with necessary care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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First Choice Health Plan HMO 2000
When others are When you receive money to compensate you for medical or hospital care for injuries or responsible for illness that another person caused you must reimburse us for whatever services we paid
injuries 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 Government We do not cover services and supplies that a local State or Federal Government agency Agencies directly or indirectly pays for
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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First Choice Health Plan HMO 2000
Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out about care
management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website Error Bookmark not defined lists the specific
types of information that we must make available to you
If you want specific information about us call 1 800 783 7312 or write to 601 Union Suite 1100 Seattle WA 98101 You may also contact us by fax at 1 888 206 3092 or visit our website at www fchn com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials
enrolling in the 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 starts on
premiums effective or after January 1 Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have I retire 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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First Choice Health Plan HMO 2000
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse coverage are and your unmarried dependent children under age 22 including any foster or step
available for my children your employing or retirement office authorizes coverage for Under certain family and me 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 will claims records 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 payment and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits Individuals involved in bona fide medical research or education that does not
disclose your identity or OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive
your ID card You can also use an Employee Express confirmation letter
What if I paid a 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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First Choice Health Plan HMO 2000
When you lose What happens if my enrollment in this Plan ends benefits
You will receive an additional 31 days of coverage for no additional premium when
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 spouse coverage 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 You can pick a new plan TCC 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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First Choice Health Plan HMO 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll TCC under TCC You must enroll within 60 days of leaving or receiving this notice
whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information
about enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event
which qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I convert to You may convert to an individual policy if individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this
notice However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days
after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting
period or limit your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Certificate of Group Coverage that indicates how long you have been enrolled with us You can use this
Health Plan certificate when getting health insurance or other health care coverage You must 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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First Choice Health Plan HMO 2000
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First Choice Health Plan HMO 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 1 800 783 7312 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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First Choice Health Plan HMO 2000
Summary of Benefits for First Choice Health Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the definitions 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 PROVIDERS
Benefits Plan pays provides Page
Inpatient Care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital provider
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 17
Extended Care All necessary service no dollar or day limit You pay 17 nothing
Mental Diagnosis and treatment of acute psychiatric conditions You Conditions pay 50 20
coinsurance
Substance Abuse Diagnosis and treatment of substance abuse conditions You pay 50 20
coinsurance
Outpatient Comprehensive range of services such as diagnosis and Care treatment of illness or injury including specialist's care
preventive care including well baby care periodic checkups and routine immunizations laboratory tests and X rays
complete maternity care You pay a 10 copay per office visit 10 per house call by a provider copays are waived for
prenatal care
Home Health All necessary visits by nurses and health aids You pay Care nothing 17
Mental You pay a 50 20 Conditions coinsurance
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First Choice Health Plan HMO 2000
Substance Abuse You pay a 50 20 coinsurance
Emergency Reasonable charges for services and supplies required Care because of a medical emergency You pay a 50 copay to
the hospital for each emergency room visit a 50 copay for each visit to an urgent care facility and any charges for
services that are not covered benefits of this Plan 19
Prescription Drugs prescribed by a Plan provider and obtained at any Plan Drugs participating pharmacy You pay a 5 copay per generic
prescription unit or refill and a 10 copay per brand name plus the difference in cost between the generic and brand
name when a generic is available and you purchase a brand name 22
Vision Care Annual vision exam You pay 10 copay Lenses and frames 20 discount a 15
discount on professional services related to contact lenses 24
Dental Care Accidental injury benefit You pay nothing 24
Out of pocket Copayments are required for a few benefits however after Maximum your out of pocket expenses reach a maximum of 1,500 per
Self Only or 4,500 per Self and Family enrollment per calendar year covered benefits will be provided at
100 This copay maximum does not include prescription drugs 7
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First Choice Health Plan HMO 2000
2000 Rate Information for
First Choice Health Plan
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 Share Share Share Enrollment Share
Share Share Share Share
Greater Seattle area
Self Only 5G1 74.17 24.72 160.70 53.56 87.76 11.13 87.76 11.13
Self and 5G2 175.97 81.14 381.27 175.80 207.74 49.37 201.02 56.09 Family
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