Mercy Health Plans 2000
Premier Health Plans
A Health Maintenance Organization
For changes in benefits
Serving East Central and Southwest Missouri Regions see page 6
Enrollment in this Plan is limited see page 8 for requirements
Enrollment code
7M1 Self only
7M2 Self and family
Visit the OPM website at http www opm gov insure
and
Our website at http www mercyhealthplans com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
Mercy Health Plans Premier Health Plans 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organization 5
Section 2 How we change for 2000 6
Section 3 How to get benefits 8
Section 4 What to do if we deny your claim or request for service 12
Section 5 Benefits 14
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
2
2
2
Page 3
4
Mercy Health Plans Premier Health Plans 2000
Introduction
Mercy Health Plans Premier Health Plans 425 South Woods Mill Road One Corporate Centre Suite 200
Chesterfield MO 63017 1949 East Sunshine Springfield MO 65804
This brochure describes the benefits you can receive from Mercy Health Plans Premier Health Plans under its contract RI 73 756 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 five 5 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences
We refer to Mercy Health Plans Premier Health Plans 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
3
3
3
Page 4
5
Mercy Health Plans Premier Health Plans 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
4
4
4
Page 5
6
Mercy Health Plans Premier Health Plans 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 preventive
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 or point of service benefits POS 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
5
5
5
Page 6
7
Mercy Health Plans Premier Health Plans 2000
Section 2 How we change for 2000
Program wide changes 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 Plan New Benefits
Diabetes Services
Equipment supplies and self management training for the management and treatment of diabetes are covered benefits The Plan covers expenses for
nutritional counseling for up to three 3 visits in a calendar year if recommended by a physician and received from a participating provider Other
services which are covered include physician visits lab work and other testing glucose monitors test strips and lancets
Nutritional Supplements
You will pay a 0 copayment for a thirty 30 day supply of the recommended formula for the treatment of a patient with pheylketonuria PKU or any
inherited disease of amino and organic acids
Out of Network Benefits
You can access health care from the point of service plan These services are subject to a calendar year deductible coinsurance copayments and balance
billing Balance billing refers to the amount billed by a provider that exceeds the usual customary and reasonable charges allowed for payment by the Plan
Balanced billed charges are your responsibility along with the annual deductible and coinsurance and do not apply to out of pocket maximums You are
responsible for verifying that the required pre certification is given by the Plan for certain procedures Please contact Member Services for further details
If pre certification is not given eligible charges will be subject to the noncompliance reduction and the amount of the reduction will not apply toward
your out of pocket maximum or deductible
6
6
6
Page 7
8
Mercy Health Plans Premier Health Plans 2000
You will be required to pay a 500 deductible per member per calendar year and 1,000 deductible per family per calendar year Your cost is 30 coinsurance
after the deductible The out of pocket maximum per member is 3,500 including the deductible and 7,000 per family including deductible
Your share of the standard option Mercy Health Plans Premier Health Plans 2000 premium will increase by 12.1 for Self Only or 12.1 for Self and
Family
7
7
7
Page 8
9
Mercy Health Plans Premier Health Plans 2000
Section 3 How to get benefits
What is this Plan's service area To enroll with us you must live or work in our service area This is where our providers practice Our service area is
MERCY HEALTH PLANS Eastern and Central Missouri Regions include the following Missouri counties Audrain Boone Callaway Chariton Cooper
Franklin Gasconade Howard Iron Jefferson Lincoln Linn Macon Madison Maries Miller Moniteau Monroe Montgomery Morgan Osage Pettis Pike
Ralls Randolph Reynolds Saline St Charles St Francois St Louis St Louis City Warren and Washington And the following Illinois counties
Clinton Jersey Macoupin Madison Monroe Randolph and St Clair
PREMIER HEALTH PLANS Southwest Missouri Region includes the following Missouri counties Barry Barton Benton Cedar Christian
Crawford Dade Dallas Dent Douglas Greene Henry Hickory Howell Jasper Laclede Lawrence McDonald Newton Oregon Ozark Phelps Polk
Pulaski Shannon St Clair Stone Taney Texas Vernon Webster and Wright
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 or
point of service benefits 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 for services You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance a set percentage of charges Please remember
you must pay this amount when you receive services except for those services listed in Section 5 that do not require a copayment
After you pay 1,100 in copayments or coinsurance for one family member or 3,300 for two or more family members you do not have to make any further
payments for certain services for the calendar year for in network services This is called a catastrophic limit However copayments or coinsurance for your
prescription drugs and dental 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 these limits
Do I have 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 or you use point ofservice
benefits Services delivered by non network providers will require you to fill out and submit a claim form for payment and or reimbursement Claim
forms may be obtained from your employer or from the Plan You must complete the claim form attach the itemized bills and mail to Mercy Health
Plans Premier Health Plans P O Box 4568 Springfield MO 65808 4568 Any claim for reimbursement must be made in writing to the Plan and
accompanied
8
8
8
Page 9
10
Mercy Health Plans Premier Health Plans 2000
by itemized bills If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of
the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you
from filing on time
Who provides my health care You are required to select a Primary Care Physician PCP from Mercy Health Plans Premier Health Plans participating doctors in the Plan's service area
Your PCP will meet many of your health care needs and arrange for specialist care if the need arises
What do I do if my primary care Call us We will help you select a new one physician leaves the Plan
What do I do if I need to go into Talk to your Plan physician If you need to be hospitalized your primary care the hospital
physician or specialist will make the necessary hospital arrangements and supervise your care Hospital services are provided at participating hospitals in
the Plan's network
If you need hospitalization for obstetrical gynecological related care your OB GYN will arrange for your admission to a Plan hospital If you require
special hospitalization that is not available within the Plan network your PCP will request approval by the Plan's Chief Medical Officer for an appropriate outof
network hospital If the request is approved benefits will be provided as if the hospital were in the network If the authorization is denied for out ofnetwork
hospitalization services will be subject to a calendar year deductible coinsurance and balance billing Some services are available in network only
and other services require prior authorization
What do I do if I'm in the hospital First call our Member Services department at Mercy Health Plans Eastern and when I join this Plan
Central Missouri Regions at 314 214 8196 or 1 800 327 0763 or Premier Health Plans Southwest Missouri Region at 417 836 0402 or 1 800 836 0402
If you are new to the FEHB Program we will arrange for you to receive care If you are currently in the 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
How do I get specialty care When medically necessary your PCP will arrange for referrals to a specialist
Your primary care physician and specialist will work together to coordinate your total care If you access specialty care without an understanding of the number
of visits and the amount of time approved for treatment you may be responsible for the entire bill Your PCP will arrange a standing referral to a specialist or
specialists center if necessary Your PCP the Chief Medical Officer and participating specialist will determine the need and parameters of a standing
referral A standing referral is based on a diagnosis of a life threatening condition or disease a degenerative and disabling condition or disease ongoing
care from a specialist or required specialized medical care over a prolonged period of time Your primary care physician may request standing referrals
9
9
9
Page 10
11
Mercy Health Plans Premier Health Plans 2000
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 Your Plan physician must authorize visits to specialists
What do I do if I am seeing a Your primary care physician will decide what treatment you need If they decide specialist when I enroll
to refer you to a 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 leaves the Plan specialist You may receive services from your current specialist until we can
make arrangements for you to see someone else
But what if I have a serious illness and my provider leaves the Please contact us if you believe your condition is chronic or disabling You may
Plan or this Plan leaves the be able to continue seeing your provider for up to 90 days after we notify you Program that we are terminating our contract with the provider unless the termination is
for cause If you are in the second or third trimester 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 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 medical Your physician must get our approval before sending you to a hospital referring services you to 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
It is the shared responsibility of both you and your PCP or specialist to assure that referrals are obtained accurate and current You are responsible for
verifying the approved date range of the referral number of visits and types of services that have been authorized When you choose to receive services from a
participating provider without a prior referral from your chosen primary care physician the specialists will request that you be responsible for payment of the
services When this occurs you may be responsible for the charges A referral must be obtained prior to receiving certain services
It is your responsibility to verify that the required pre certification has been given by the Plan for out of network services If pre certification is not given
eligible charges will be subject to the non compliance reduction and the amount of the reduction will not apply toward your out of pocket maximum or
deductible
How do you decide if a service is The criteria for determining whether or not a procedure or treatment will be experimental or investigational considered experimental or investigational includes but is not limited to the
following
10
10
10
Page 11
12
Mercy Health Plans Premier Health Plans 2000
1 whether the patient meets the criteria treatment or other procedure with regard to age general health and determined to be a good candidate by an
accredited facility 2 whether the procedure or treatment is commonly performed on a widespread
geographic basis and or 3 whether the medical profession generally accepts the procedure or treatment
based on the opinions of organizations such as the American Medical Association
Appropriate members of the medical profession will review procedures in question for their experimental or investigational nature A final decision
regarding coverage is at the sole discretion of the Chief Medical Officer
11
11
11
Page 12
13
Mercy Health Plans Premier Health Plans 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM to review a You may ask OPM to review the denial after you ask us to reconsider our initial denial denial or refusal OPM will determine if we correctly applied the terms of our
contract when we denied your claim or request for service
What if I have a serious or life Call us at Mercy Health Plans Eastern and Central Missouri Regions at 314 threatening condition and you 214 8196 or 1 800 327 0763 or Premier Health Plans Southwest Missouri
Region at 417 836 0402 or 1 800 836 0402 and we will expedite our review haven't responded to my request
for service
What if you have denied my If we expedite your review due to a serious medical condition and deny your request for care and my condition claim we will inform OPM so that they can give your claim expedited
treatment too Alternatively you can call OPM's health benefits Contract is serious or life threatening Division II at 202 606 3818 between 8 a m and 5 p m Serious or lifethreatening
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 did 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 do 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
12
12
12
Page 13
14
Mercy Health Plans Premier Health Plans 2000
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
What if OPM upholds the Plan's OPM's decision is final There are no other administrative appeals If OPM denial agrees with our decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed
services or supplies
What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The lawsuit
Federal court 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 the Privacy Act 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 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
13
13
13
Page 14
15
Mercy Health Plans Premier Health Plans 2000
Section 5 Benefits
Summary of Benefits
These services and benefits are only available if they are provided prescribed or directed by a primary care physician and received at a participating provider Members are entitled to receive the services and benefits outlined in this Schedule of Coverage and Benefits
and other Medically Necessary benefits This is only a partial listing of plan benefits and their associated copayments
SERVICES In Mercy Network Out of Network Benefits Member Costs Member Costs
Underwritten by First Allmerica
BENEFIT REQUIREMENTS Benefits are accessed on a referred access basis Benefits subject to UCR limits All care must be rendered by a network physician Precertification required for certain
or provider and directed by your Primary Care procedures See Out of Network section Physician Precertification required for certain for further details
procedures
PLAN MAXIMUMS Medical Benefit Maximum Per Member Unlimited 2,500,000
While Covered Calendar Year Deductible Member None 500
Family None 2 x Member Calendar Year Out of Pocket Maximum Member
1,100 Per Member 3,500 Includes Deductible
Family 3 x Member 2 x Member
MEDICAL SERVICES 10 Copayment per visit for Primary care
Services and Supplies 10 Copayment per visit for Specialist care 30 Coinsurance After Deductible
Surgery performed in a Physician's Office 0 Copayment 30 Coinsurance After Deductible
Preventive care including well baby 10 Copayment Covered In Mercy Network Only care and periodic check ups
Immunizations for Children from birth to 5 years 0 Copayment Covered In Mercy Network Only
Office Consultations Non Participating If approved in 10 Copayment per office visit 30 Coinsurance After Deductible
advance by Mercy Health Plans
Allergy Services Office Visits 10 Copayment 30 Coinsurance After Deductible
Injections Treatment 0 Copayment 30 Coinsurance After Deductible Allergy serum for home 0 Copayment 30 Coinsurance After Deductible
administration
Lab and X ray 0 Copayment 30 Coinsurance After Deductible
Maternity includes prenatal delivery and postnatal care
Office Visits One Time In Network One time 10 Copayment for all office 30 Coinsurance After Deductible Copayment visits associated with prenatal care during a
single pregnancy
Lab and Diagnostic 0 Copayment 30 Coinsurance After Deductible
INPATIENT HOSPITAL SERVICES 0 Copayment per admission 30 Coinsurance After Deductible
OUTPATIENT SERVICES 50 Copayment per visit except 50 Copayment per visit except
Emergency Care Service and Copayment charge will be waived when Copayment charge will be waived Supplies inpatient admission for the same condition when inpatient admission for the
occurs within 24 hours same condition occurs within 24 hours
Non Emergency Services Outpatient Surgery 0 Copayment 30 Coinsurance After Deductible
Diagnostic tests 0 Copayment 30 Coinsurance After Deductible
14
14
14
Page 15
16
Mercy Health Plans Premier Health Plans 2000 SERVICES In Mercy Network Out of Network Benefits
Member Costs Member Costs Underwritten by First Allmerica
Urgent Care 25 Copayment per visit Covered In Mercy Network only
Outpatient Rehabilitative Therapy Services Physical Occupational Speech 10 Copayment 30 Coinsurance After Deductible
Max of up to 60 consecutive days per Max of up to 60 consecutive days calendar year per condition per calendar year per condition
MENTAL HEALTH ALCOHOLISM In Eastern and Central Missouri you must CHEMICAL DEPENDENCY
obtain authorization prior to service by calling 1 800 413 8008
Outpatient Mental Health Services Maximum of up to 20 visits per
calendar year Individual Outpatient Services 20 Copayment per session Covered In Mercy Network only
Group Outpatient Services 10 Copayment per session Covered In Mercy Network only
Outpatient Substance Abuse Maximum of up to 20 visits per
calendar year
Individual Outpatient Services 20 Copayment per session Covered In Mercy Network only
Group Outpatient Services 10 Copayment per session Covered In Mercy Network only
Inpatient Mental Health Services 0 Copayment per admission Covered In Mercy Network only
Inpatient Alcoholism and Chemical Dependency Services 0 Copayment per admission Covered In Mercy Network only
Maximum of up to 2 episodes of inpatient services per calendar year
MISCELLANEOUS COVERED SERVICES
Home Health Agency Services 0 Copayment 30 Coinsurance After Deductible includes intravenous fluids and
medications
Skilled Nursing Facility Services 0 Copayment 30 Coinsurance After Deductible
Hospice Services 0 Copayment Covered In Mercy Network Only
Ambulance 0 Copayment 30 Coinsurance After Deductible
Prosthetic Equipment 20 Copayment 30 Coinsurance After Deductible insertion of internal and external
prosthetic devices such as pacemakers and artificial joints
Durable Medical Equipment and 0 Copayment 30 Coinsurance After Deductible Supplies
Diabetes Services Copayment consistent with type of service 30 Coinsurance After Deductible required
Transplant Services 0 Copayment Covered In Mercy Network Only Specialist office visits 10 copay
Dialysis 0 Copayment Covered In Mercy Network Only
Mammography 0 Copayment Covered In Mercy Network Only routine screening and when prescribed by
the doctor as medically necessary to diagnose or treat illness
Eye Care Services 10 Copayment One eye exam and or eye Covered In Mercy Network Only refraction performed by a Participating
Provider during calendar year
Nutritional Supplements 0 Copayment for 30 day supply 30 Coinsurance After Deductible
15
15
15
Page 16
17
Mercy Health Plans Premier Health Plans 2000 SERVICES In Mercy Network Out of Network Benefits
Member Costs Member Costs Underwritten by First Allmerica
Accidental Dental 20 Copayment 30 Coinsurance After Deductible
Voluntary sterilization and family 10 Copayment Covered In Mercy Network Only planning services
Mastectomies 0 30 Coinsurance After Deductible 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
Chemotherapy radiation therapy and 0 Covered In Mercy Network Only inhalation therapy
Surgical treatment of morbid obesity 0 30 Coinsurance After Deductible
Chiropractic services 10 office visit referrals required for Covered In Mercy Network Only Eastern and Central Missouri regions
Private Duty Nursing 20 of covered charges Covered In Mercy Network Only
Eyewear Following Cataract Surgery Initial pair of lenses or glasses following 30 Coinsurance After Deductible cataract surgery 20 of charges
Infertility Services 10 Copayment per visit for the diagnosis Covered In Mercy Network Only of infertility Diagnosis and treatment of
infertility and intravaginal artificial insemination IVI is covered Member pays
50 of the first 5,000 of the customary rate of approved charges charges in excess
of the customary rate and 100 of the charges for infertility services over 5,000
Outpatient Prescription Drug Filled at PCS Network Pharmacies Generic
7 Copayment per prescription drug on Covered in PCS Network Only Formulary
Brand Name 12 Copayment per prescription drug Covered in PCS Network Only
Mail Order on Formulary Covered in PCS Network Only 2 copayments for a 90 Day Supply
16
16
16
Page 17
18
Mercy Health Plans Premier Health Plans 2000
The following provides more detailed information about your benefits
Medical and Surgical Benefits
Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and
hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the
oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction
syndrome
Transplants are covered in network only when approved by the Medical Director and include cornea heart kidney and liver transplants allogeneic donor bone
marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute
lymphocytic leukemia advanced Hodgkin's lymphoma advanced nonHodgkin's lymphoma advanced neuroblastoma breast cancer multiple
myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors You pay 10.00 for all specialist office services
Reconstructive surgery following sickness and correction of functional birth defects are not cosmetic and expenses for such are covered by the Plan Also
covered by the Plan is reconstructive surgery or treatment to remedy a deformity disfigurement or defect resulting from a disease injury sustained
while covered by the Plan or congenital anomaly An anomaly is defined as a marked deviation beyond the range of normal human variation
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
Augmentation mammoplasty is covered if performed following surgical removal of a breast because of breast cancer any breast cancer prevention
intervention in accordance with Plan guidelines or other illness or to correct asymmetrical breasts resulting from such mastectomies This service is covered
whether provided at the time of the original mastectomy or after the completion of radiation or other therapies Coverage for post mastectomy breast prostheses
includes one 1 prosthesis per breast removed and 2 bras per calendar year You will pay a 0 copayment for in network services or 30 coinsurance after
deductible and any amounts over usual and customary charges for out of network benefits
Short term rehabilitative therapy physical speech occupational pulmonary and cardiac is provided on an inpatient or outpatient basis for up to 60 consecutive
days per calendar year per condition for care that is reasonably expected to result in a material improvement in the physical functioning of the member within a
60 day period All therapy must be medically necessary and restorative to an injury or illness suffered by the member 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
17
17
17
Page 18
19
Mercy Health Plans Premier Health Plans 2000 maintain self care and improved functioning in other activities of daily living
You pay 10 copayment per outpatient session
Diagnosis and treatment of infertility is covered you pay a 10 copay per visit for the diagnosis of infertility In addition intravaginal artificial insemination
IVI is a covered benefit you pay 50 of the first 5,000 of the customary rate of approved charges charges in excess of the customary rate and 100 of
the charges for infertility services over 5,000 The cost of donor sperm and fees for preparation and storage of sperm are not covered Fertility drugs are not
covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Services and supplies that are not Physical examinations that are not necessary for medical reasons such as Covered Benefits those required for obtaining or continuing employment or insurance
attending camp or travel Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purpose Homemaker services
Hearing aids Transplants not listed as covered
Long term rehabilitative therapy Orthopedic shoes and other supportive appliances orthotics for the feet
Blood and blood derivatives not replaced by the member
Hospital Extended Care Benefits
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit
when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or
private duty nursing care Specialized care units such as intensive care or cardiac care units
Extended Care The Plan provides a comprehensive range of benefits when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged
by the skilled nursing facility when prescribed by a Plan doctor
Hospice Care 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
Ambulance Service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
18
18
18
Page 19
20
Mercy Health Plans Premier Health Plans 2000
Limited Benefits Dental Anesthesia Hospitalization for certain dental procedures is covered when a Plan doctor 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 The Chief Medical Officer or
his designee must approve all requests and prior authorization is required
Hospitalization for medical treatment of substance abuse is limited to emergency care and medical management of withdrawal symptoms
What is not covered during a Personal comfort items such as telephone and television hospital stay
Blood and blood derivatives not replaced by the member Custodial care rest cures domicilary or convalescent care
Emergency Benefits The Plan has adopted the following definition for Emergency Medical
Condition
The sudden and at the time unexpected onset of a health condition that manifests itself by symptoms of sufficient severity that would lead a prudent
layperson possessing an average knowledge of health and medicine to believe that immediate care is required which may include but shall not be limited to
a placing the person's health in significant jeopardy b serious impairment to a bodily function
c serious dysfunction of any bodily organ or part d inadequately controlled pain
e pregnant women having contractions and or f injury to self or others
If you are in an emergent or urgent situation if possible call your Plan physician immediately If the emergency is so urgent that failure to get
immediate medical attention could be life threatening or cause serious harm go immediately to the nearest emergency facility
Once an urgent or life threatening situation has been brought under control you will need to call your Plan physician within 48 hours or as soon as reasonably
possible so that any continued care can be arranged and authorized If you do not report emergency treatment with 48 hours or as soon as reasonably possible
thereafter care provided after that point may not be covered
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it
was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan facilities and a Plan doctor believes care can be better
provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or
significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
19
19
19
Page 20
21
Mercy Health Plans Premier Health Plans 2000
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 copayment per hospital emergency room visit or 25 copayment per urgent care center visit for emergency services that are covered benefits of
this Plan If the emergency results in admission to a hospital the copay is waived
Emergencies outside the service If you need to be hospitalized call Member Services as soon as possible area Member Services will notify your Plan physician and arrange to have your
medical records shared with the attending physician
Arrangements will be made for you to be transferred to the care of a Plan doctor and hospital when it is medically appropriate Your Plan physician will
coordinate all follow up care upon return to the area
If follow up care is required outside the area you must contact your Plan physician within 48 hours to receive authorization for the continued care
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
The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the
emergency results in admission to a hospital the copay is waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including
doctors services Ambulance service approved by the Plan
What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Mental Conditions Substance Abuse Benefits
in network only
Mental Health To the extent shown below the Plan provides the following services if deemed
medically necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorder
What is Covered Psychological testing
Psychiatric treatment including individual and group therapy
20
20
20
Page 21
22
Mercy Health Plans Premier Health Plans 2000
Diagnostic evaluation Hospitalization including inpatient professional services
Care for psychiatric conditions that in the professional judgement of Plan doctors are not subject to significant improvement through relatively shortterm
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
Outpatient care is covered up to a combined total of 20 outpatient visits per calendar year for covered services obtained from a Plan physician and authorized
in advance You pay a 20 copay per session for individual services and a 10 copay per session for group services
Diagnosis and treatment of inpatient and outpatient services for mental health and chemical dependency is covered You pay nothing
Substance Abuse in network This Plan provides medical necessary substance abuse services including only
detoxification
Inpatient services for detoxification are limited to two episodes of inpatient services per calendar year unless authorized in advance by the Chief Medical
Officer This limitation shall not apply to medical complications of detoxification
Outpatient care is covered up to a combined total of 20 outpatient visits per calendar year for covered services obtained from a Plan physician and authorized
in advance You pay a 20 copay per session for individual services and a 10 copay per session for group services
Services for detoxification limited to no more than 5 consecutive days unless authorized in advance by the Chief Medical Officer You pay nothing
Treatment that is not authorized by a Plan doctor is not covered
Prescription Drug Benefits 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 or one vial of insulin
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Formulary is the list of drugs approved for use in
connection with specific conditions You pay a copayment of 7 in the case of a generic drug dispensed in accordance with the formulary or a copayment of
12 in the case of a brand name drug dispensed in accordance with the formulary
If your physician prescribes a brand name drug when a generic substitute is available or if you choose to receive the brand drug you will be responsible for
the generic copayment plus the cost difference between the brand and the generic name drug
No benefits are available for non formulary products
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
21
21
21
Page 22
23
Mercy Health Plans Premier Health Plans 2000
Oral contraceptive drugs contraceptive diaphragms 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 Mail service prescription drug program allows you and your dependents to
obtain covered prescriptions through Walgreens Healthcare Plus mail service pharmacy You are allowed up to a 90 day supply Each mail service
prescription will be subject to a copayment equal to two times the retail copayment This copayment applies to both generic and brand name drugs
If your physician prescribes a brand name drug when a generic substitute is available or if you choose to receive the brand drug with the approval of
your physician you will be responsible for the higher and the generic name drug All brand copayments plus the cost difference between the brand
name mail orders are to Walgreens Healthcare Plus P O Box 29061 Phoenix AZ 85038 9061
Intravenous fluids and medication for home use implantable drugs such as Norplant and some injectable drugs such as Depo Provera are covered under
Medical and Surgical Benefits
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Prescriptions dispensed by other than a Plan pharmacy except in the case of a medical emergency
Drugs obtained at a non Plan pharmacy except for out of area emergencies Vitamins and nutritional substances that can be purchased without a
prescription Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medications Appetite suppressants and other drugs taken for the purpose of weight loss
Fertility drug
Other Benefits
Dental Care Expenses incurred to natural teeth in connection with an accidental injury
Coverage is limited to damage from external trauma to face and mouth All services must be provided within six months from the date of the accidental
injury You pay a 20 copayment and any expenses above the customary rate All services must be obtained from a Plan physician
Unless shown in this section other dental services are not covered
Dental Services We have provided for dental care at affordable prices for you and your eligible
dependent through CAREington dental network A list of participating dentists is provided with the provider directory Following are significant points of the
program
No claim forms to file You pay only the copay shown in the schedule of benefits at the time of service
22
22
22
Page 23
24
Mercy Health Plans Premier Health Plans 2000
To receive significant savings from a participating dentist merely show your CAREington membership card at each visit and you will receive the
discount CAREington only contracts with dentists who meet their credentialing
criteria and must continue to meet the high standards of quality established
Vision Care 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 for eyeglasses or contact lenses may be obtained from Plan providers you pay a 10 copay
Orthoptics vision exercises and training or any supplemental testing is not covered
Out of Network Benefits You can access health care from the point of service plan These services are
subject to a calendar year deductible coinsurance copayments and balance billing Balance billing refers to the amount billed by a provider that exceeds
the usual customary and reasonable charges allowed for payment by the Plan Balanced billed charges are your responsibility along with the annual deductible
and coinsurance and do not apply to out of pocket maximums You are responsible for verifying that the required pre certification is given by the Plan
for certain procedures Please contact Member Services for further details If precertification is not given eligible charges will be subject to the non compliance
reduction and the amount of the reduction will not apply toward your out ofpocket maximum or deductible
You will be required to pay a 500 deductible per member per calendar year and 1,000 deductible per family per calendar year Your cost is 30 coinsurance
after the deductible The out of pocket maximum per member is 3,500 including the deductible and 7,000 per family including deductible
What is not covered Well child care and immunizations
Eye and ear examinations to determine the need for vision and hearing correction
Promotion of conception including but not limited to treatment of impotency or infertility in vitro fertilization embryo transplantation
reproductive therapy artificial insemination or reversal of voluntarily induced sterility
Services for treatment of mental or nervous disorders Alcoholism and drug abuse services including but not limited to
diagnosis and medical treatment and services Hemodialysis and dialysis services
Any organ transplant surgery or procedures including services rendered on behalf of an organ recipient or an organ donor
Prescription drugs other than drugs provided by a Hospital to a Member as an Inpatient
Charges in excess of the Eligible Charge for the service provided as determined by First Allmerica or its administrator or any charges
which exceed a calendar year maximum or other benefit maximum Any loss sustained or contracted during the commission of any crime
by a Member or due to a Member being legally intoxicated under the influence of intoxicants or under the influence of any non prescribed
narcotic Chiropractic Services
23
23
23
Page 24
25
Mercy Health Plans Premier Health Plans 2000
Non symptomatic Mammography Services Any types of services supplies or treatment not specifically provided for
herein
26
24
24
Page 25
26
Mercy Health Plans Premier Health Plans 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred services see Out of Network benefits
Experimental or investigational procedures treatments drugs or devices Services provided in connection with the reversal of an elective sterilization procedure or an abortion except where the life or
health of the mother is in jeopardy Services provided by a first degree relative
Procedures services drugs and supplies related to sex transformations Services provided in connection with treatment or surgery to change gender or restore sexual function
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
26
25
25
Page 26
27
Mercy Health Plans Premier Health Plans 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and
we will coordinate the payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For
information on suspending your FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to reenroll
in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you
to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833
Other group insurance coverage When anyone has coverage with us and with another group health plan it is called 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 beyond our control Under certain extraordinary circumstances we may have to delay your services
or be unable to provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are responsible for When you receive money to compensate you for medical or hospital care for injuries
injuries or illness 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
27
26
26
Page 27
28
Mercy Health Plans Premier Health Plans 2000
must agree to let us try This is called subrogation If you need more information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both
TRICARE and this Plan cover you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State
agency determine they must provide OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government Agencies We do not cover services and supplies that a local State or Federal Government
agency directly or indirectly pays for
28
27
27
Page 28
29
Mercy Health Plans Premier Health Plans 2000
Section 8 FEHB FACTS
You have a right to information OPM requires that all FEHB plans comply with the Patients Bill of Rights about your HMO 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 Mercy Health Plans Eastern and Central Missouri Regions 314 214 8196 or 1 800 327 0763 Premier Health
Plans Southwest Missouri Region 417 836 0402 or 1 800 836 0402 or write to the Plan at
Mercy Health Plans 425 South Woods Mill Road
Chesterfield MO 63017
Premier Health Plans One Corporate Centre Suite 200
1949 East Sunshine Springfield MO 65804
You may also contact Mercy Health Plans Eastern and Central Missouri Regions by fax at 314 214 8102 or Premier Health Plans Southwest Region
by fax at 417 836 0457 or visit our website at www mercyhealthplans com
Where do I get information about Your employing or retirement office can answer your questions and give you a enrolling in the FEHB Program Guide to Federal Employees Health Benefits Plans brochures for other plans
and other materials you need to make an informed decision about
When you may change your enrollment How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or
retirement office
When are my benefits and premiums effective The benefits in this brochure are effective on January 1 If you are new to this
plan your coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
What happens when I 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
29
28
28
Page 29
30
Mercy Health Plans Premier Health Plans 2000
What types of coverage are Self Only coverage is for you alone Self and Family coverage is for you your available for my family and me spouse and your unmarried dependent children under age 22 including any
foster or step children your employing or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child
22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may
change your enrollment 31 days before to 60 days after you give birth or add the child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us
immediately when you add or remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
Are my medical and claims records confidential We will keep your medical and claims information confidential Only the
following will have access to it
OPM this Plan and subcontractors when they administer this contract Law enforcement officials when investigating and or prosecuting alleged
civil or criminal actions OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter
until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a deductible under Your old plan's deductible continues until our coverage begins my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the
condition before you enrolled
When you lose benefits
What happens if my enrollment You will receive an additional 31 days of coverage for no additional premium in this Plan ends when
Your enrollment ends unless you cancel your enrollment or
30
29
29
Page 30
31
Mercy Health Plans Premier Health Plans 2000
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse coverage If you are divorced from a Federal employee or annuitant you may not continue
to get benefits under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently
divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if
you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can receive TCC if you are not able to
continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI 79 27
which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after
you separate If you no longer qualify as a family member you can receive TCC for up to
36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends
even if several months have passed You pay the total premium and generally a 2 percent administrative charge
The government does not share your costs You receive another 31 day extension of coverage when your TCC
enrollment ends unless you cancel your TCC or stop paying the premium and
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving
this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send
you information about enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is
later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce or Loss of spouse equity coverage within 36 months after the divorce
30
30
30
Page 31
32
Mercy Health Plans Premier Health Plans 2000
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 that 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 individual You may convert to an individual policy if 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 Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health Group Health Plan Coverage Plan Coverage that indicates how long you have been enrolled with us You
can use this certificate when getting 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
31
31
31
Page 32
33
Mercy Health Plans Premier Health Plans 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 Mercy Health Plans Eastern and Central Missouri Regions at 314 214 8196
or 1 800 327 0763 or Premier Health Plans Southwest Missouri Region at 417 836 0402 or 1 800 836 0402 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
32
32
32
Page 33
34
Mercy Health Plans Premier Health Plans 2000
Summary of Benefits for Mercy Health Plans Premier Health Plans 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 A PRIMARY CARE PHYSICIAN AND RECEIVED AT A PARTICIPATING PROVIDER
Benefits Plan pays provides Page
Inpatient care 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 18
Extended care All necessary services You pay nothing 18
Mental conditions Diagnosis and treatment of inpatient and outpatient
services for mental health dependency You pay nothing 20
Substance abuse Services for detoxification limited to no more than five
consecutive days unless authorized in advance by the Chief Medical Officer You pay nothing 21
Comprehensive range of services such as diagnosis and
Outpatient care treatment of illness or injury including specialist's care preventive care in network only well baby care periodic
check ups laboratory tests and X rays and complete maternity care one time copay You pay a 10 copay per office visit
18
Home health care All necessary visits by skilled nursing professional
services when medically necessary You pay nothing 18
Mental conditions Up to a combined total of 20 outpatient visits per calendar year
for covered services obtained from a Plan physician and authorized in advance You pay a 20 copay per session for
individual services and a 10 copay per session for group services 20
Substance abuse Up to a combined total of 20 outpatient visits per calendar year
for covered services obtained from a Plan physician and authorized in advance You pay a 20 copay per session for
individual services and a 10 copay per session for group services 21
33
33
33
Page 34
35
Mercy Health Plans Premier Health Plans 2000
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay per visit for
each emergency room visit The copayment charge is waived when admitted on an inpatient basis for the same condition
within 24 hours 19
Prescription drugs Drugs prescribed by a Plan doctor or a referral doctor and obtained at a Plan pharmacy You pay a 7 copay for generic
or a 12 copay for brand name drug that is included on the formulary 21
Dental care Expenses incurred to natural teeth in connection with an accidental injury You pay a 20 Copayment 22
Vision care One eye examination annually You pay a 10 Copay 23
Out of pocket maximum Copayments are required for various benefits After your outof in network
pocket expenses reach a maximum of 1,100 per Self Only or 3,300 per Self and Family during a calendar year covered
benefits will be provided at 100 14
Out of Network You will be required to pay a 500 deductible per member per Benefits
calendar year and 1,000 deductible per family per calendar year Your cost is 30 coinsurance after the deductible The
out of pocket maximum per member is 3,500 including the deductible and 7,000 per family including deductible 23
34
34
34
Page 35
36
Mercy Health Plans Premier Health Plans 2000
2000 Rate Information for
Mercy Health Plans of Missouri Premier Health Plans in SW Missouri
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 Cod Gov't Your Gov't Your USPS Your USPS Your Enrollment e Share Share Share Share Share Share Share Share
Self Only 7M1 74.10 24.70 160.55 53.52 87.69 11.11 87.69 11.11
Self and Family 7M2 172.36 57.45 373.44 124.48 203.96 25.85 201.02 28.79
35
35
35
Page 36
Mercy Health Plans Premier Health Plans 2000
36
36