QualChoice Health Plan 2000 of North Carolina Inc
A Health Maintenance Organization with a Point of Service Product
For changes in benefits
see page 3
Serving Northwestern North Carolina
Enrollment in this Plan is limited see page 4
for requirements
Enrollment Code 7Q1 Self only
7Q2 Self and family
Visit the OPM website at http www opm gov insure
and
our website at http www qualchoicenc com
Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
QualChoice of North Carolina Inc 2000
Table of Contents
Introduction
1
Plain language
1
How to use this brochure
2
Section 1 Health Maintenance Organizations
3
Section 2 How we change for 2000
3
Section 3 How to get benefits
4
Section 4 What to do if we deny your claim or request for service
7
Section 5 Benefits
9
Section 6 General exclusions Things we don't cover
17
Section 7 Limitations Rules that affect your benefits
18
Section 8 FEHB FACTS
20
Inspector General Advisory Stop Healthcare Fraud
24
Summary of benefits
25
Premiums
26
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QualChoice of North Carolina Inc 2000
Introduction
QualChoice of North Carolina Inc 2000 West First Street Suite 210 Winston Salem NC 27104
This brochure describes the benefits you can receive from QualChoice of North Carolina Inc under its contract CS 2822 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 3 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 QualChoice of North Carolina Inc as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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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 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
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB
program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a 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 15.3 for Self Only and by 20.2 for Self Plan and Family
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Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is Alamance Alexander Alleghany Ashe Burke Caldwell Catawba Davidson
Davie Forsyth Guilford Iredell Randolph Rockingham Rowan Stokes Surry Watauga Wilkes and Yadkin Counties
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 You must share the cost of some services This is called either a copayment a set dollar amount pay for services or coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services
Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits except for the POS options under which option 2 has a 800
individual 2,000 family maximum and option 3 has a 900 individual 2,250 family maximum
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 You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us or you use point of service benefits 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 You decide The QualChoice network includes physicians on the faculty of Wake Forest University health care School of Medicine as well as community physicians and other health care providers Network
hospitals include Wake Forest University Baptist Medical Center and other area facilities However as a member of QualChoice you are free to choose any doctor or hospital each time you
need medical care under the POS benefits
The first and most important decision you must make is the selection of a primary care physician The decision is important since it is through this physician that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care physician to obtain any necessary referrals from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other providers are covered only when you have been referred by your primary care physician or when you use POS benefits with the following
exception females age 13 years or older may see an obstetrics and gynecology PCP for obstetrical and gynecological care Female enrollees must select an OB GYN physician If your medical PCP
does your OB GYN care you may select that physician as your OB GYN PCP as well as your medical PCP
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The Plan's provider directory lists primary care physicians family practitioners pediatricians OB GYNs and internists with their locations and phone numbers and notes whether or not the
doctor is accepting new patients Directories are updated monthly and are available at the time of enrollment or upon request by calling the Customer Service Department at 336 716 0911 or
800 816 0911 you can also find out if your physician 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 or POS
benefits are provided through the Plan's delivery system
The Plan's provider directory lists primary care physicians family practitioners pediatricians OB GYNs and internists with their locations and phone numbers and notes whether or not the
doctor is accepting new patients Directories are updated monthly and are available at the time of enrollment or upon request by calling the Customer Service Department at 336 716 0911 or
800 816 0911 you can also find out if your physician 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 or POS
benefits are provided through the Plan's delivery system
If you enroll you will be asked to let the Plan know which primary care physician 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 physician call the Plan Members may change their physician selection by notifying the Plan 30 days in advance and your new primary care physician will be available the
first day of the following month
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 Talk to your Plan physician If you need to be hospitalized your primary care physician or need to go into the specialist will make the necessary hospital arrangements and supervise your care
hospital
What do I do if I'm First call our customer service department at 800 816 0911 If you are new to the FEHB in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program and are
I join this Plan 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 Your primary care physician will arrange your referral to a specialist Except in a medical specialty care emergency or when you choose to use the Plan's POS benefits you are required to obtain a
referral from your primary care doctor before seeing any other doctor or obtaining medical services Referral to a participating specialist is provided by your primary care doctor when
he she identifies a medical necessity If non Plan specialists or consultants are required your primary care doctor will work with the QualChoice Referral staff to arrange appropriate referrals
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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 refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll 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 You may specialist leaves the receive services from your current specialist until we can make arrangements for you to see
Plan someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and seeing your provider for up to 90 days after we notify you that we are terminating our contract with
my provider leaves the provider unless the termination is for cause If you are in the second or third trimester of the Plan or this Plan pregnancy you may continue to see your OB GYN until the end of your postpartum care
leaves the Program 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 Your physician must get our approval before sending you to a hospital referring you to a specialist authorize medical or recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows generally accepted medical practice Your physician is required to obtain prior authorization from QualChoice Precertification department for non emergent medical
services such as inpatient hospitalization skilled nursing facilities home health care and durable medical equipment QualChoice uses InterQual medical review criteria to confirm medical
necessity prior to authorization of requested medical services
How do you decide if This Plan may cover experimental and investigational treatment if it determines that the proposed a service is treatment has demonstrated effectiveness in treating a particular condition through phase III clinical
experimental or trials performed by a panel of medical and scientific experts This plan may also use the findings investigational and opinions of its medical quality improvement committee based on its review of publications
regulations medical literature accepted regional medical practices and reports by applicable federal agencies
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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 or refusal OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim or
denial request for service
What if I have a Call us at 336 716 0911 or 800 816 0911 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 will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my Health Benefits Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening 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 uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with
the review request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim Contract Division 3 P O Box 436 Washington D C 20044
to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claims file and is subject to the 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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Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office
visit copay but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 10 copay for a doctor's house call and 10 for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups well baby visits have no copay until age 2
Mammograms will be given as routine screenings for any woman determined to be at risk for breast cancer Mammograms are covered as follows for women age 35 through 39 one
mammogram during these five years for women age 40 through 49 one mammogram every one or two years and for women 50 years of age or older one mammogram every year In
addition to routine screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat illness
Routine immunizations and boosters with no copay except for the office visit Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays with no copay Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours
after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after
coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be covered under
either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family
enrollment Voluntary sterilization and family planning services
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 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 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 Orthopedic devices such as braces foot orthotics limited to 1 per year
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Prosthetic devices such as artificial limbs lenses following cataract removal and breast prostheses including the surgical bra for an external prosthesis following a mastectomy and
including the necessary replacement of the prostheses and bra Durable medical equipment such as wheelchairs and hospital beds
Chiropractic services except spinal manipulation Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral
areas surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and their attending physician will decide whether or not to have breast reconstruction surgery following a mastectomy
including whether or not to have surgery on the other breast in order 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 months per condition if significant improvement can be
expected within two months you pay nothing per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 10 per visit The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI
and intrauterine insemination IUI you pay nothing 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
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided you pay nothing
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Homemaker services Hearing aids
Transplants not listed as covered Long term rehabilitative therapy
Spinal manipulation Corrective eyeglasses frames and contact lenses including the fitting of contact lenses except
as necessary for the first pair of corrective lenses following cataract surgery Refractions including lens prescriptions
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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 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 with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
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
Limited benefits
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 13 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that requires emergency immediate medical or surgical care Some problems are emergencies because if not treated
promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes
poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need
for quick action If a member is confronted with a situation that a prudent layperson would reasonably consider to constitute a medical emergency the visit will be covered by the Plan
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Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies the service area if you are unable to contact your doctor contact the local emergency system e g the 911
telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member
must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify
the Plan within that time If you are hospitalized in 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 except as covered under POS benefits
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 50 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 Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time
If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers except as covered under POS benefits
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 50 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 except as covered under POS Benefits Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area except as covered under POS Benefits Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area except as covered under POS Benefits
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Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers 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
7
Mental Conditions Substance Abuse Benefits
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
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
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 Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the benefit
period all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor
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Prescription Drug Benefits
What is covered Covered medications and accessories include
Drugs for which a prescription is required by Federal law Oral contraceptive drugs contraceptive diaphragms
Fertility drugs Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication Smoking cessation drugs and medication including nicotine patches
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 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
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
Other Benefits
Dental care
What is covered
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth benefit as part of the initial emergency treatment of an accident The need for these services must result
from an accidental injury You pay nothing
What is not covered Other dental services not shown as covered
Vision No current benefit
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Point of Service POS Benefits
Facts about this With the Plan's Triple Option feature you decide each and every time how you want to obtain Plan's POS option care
Option 1 You see your Primary Care Physician PCP who treats you and or refers you to a specialist or other providers You simply pay a copayment and there is no
deductible or coinsurance in Option 1 Option 2 You go directly to any QualChoice physician without being referred by your
PCP You will pay a 25 copayment and you will pay 20 of your total bill for certain services There is no deductible for Option 2
Option 3 You go to any doctor or hospital outside the QualChoice network Option 3 also requires you to obtain precertification for hospital admissions and certain
outpatient services You must satisfy an annual deductible and then pay 30 of your total medical bill
At your option you may choose to obtain benefits covered by this Plan from non Plan doctors and hospitals whenever you need care except for the benefits listed below under What is not covered
Benefits not covered under Point of Service must either be received from or arranged by Plan doctors to be covered When you obtain covered non emergency medical treatment from a nonPlan
doctor without a referral from a Plan doctor you are subject to the deductibles coinsurance and maximum benefit stated below
What is covered The covered services are the same under the POS options except that mental health and substance abuse are covered under Option 1 and Option 3 only
Precertification Precertification is required
Deductible There is no deductible for Option 1 or Option 2 of the plan Option 3 has a 300 deductible per year for individuals and a 750 deductible per year for family
Coinsurance Once the applicable deductible is paid the plan will pay 80 of certain services charged under Option 2 and 70 of reasonable and customary charges under Option 3 The member may be
billed by the provider for the difference between the actual charges and reasonable and customary rates
Maximum benefit When the accumulated paid coinsurance reaches the annual out of pocket maximum the plan will pay 100 of all further covered reasonable and customary charges for the remainder of the
calendar year You may be billed by the provider for the difference between the actual charges and reasonable and customary rates The deductible paid and the copays are not included in the out ofpocket
maximum
Hospital extended You go directly to a network specialist or hospital without a referral from your PCP the plan will care apply the appropriate coinsurance and pay under Option 2 You go directly to a non network
specialist or hospital without a referral from your PCP the plan will apply the appropriate deductible and coinsurance and pay under Option 3
Emergency benefits Emergency room visits are covered with a 50 copay which is waived if you are admitted
Other benefits Mental Health has no Option 2 benefits Option 3 mental health inpatient and outpatient services are covered 30 days at 80 after deductible or outpatient 20 visits at 80 after deductible
Chemical Dependency has no Option 2 benefits Option 3 inpatient and outpatient chemical dependency services are covered at 80 after deductible with a maximum of 8,000 per year and
16,000 lifetime
What is not covered
How to obtain The three options are available to you at the point of service you decide each and every time how benefits you want to obtain care and how much you pay for services
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Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and
any charges for these services do not count toward any FEHB deductibles POS maximum benefits or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure
Medicare prepaid This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As plan enrollment indicated on page 18 annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later re enroll in the FEHB Program Most Federal
annuitants have Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before
you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping your FEHB enrollment and
changing to a Medicare prepaid plan Contact us at 336 716 0660 or 800 273 4115 for information on the Medicare prepaid plan and the cost of that enrollment
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call 336 716 0660 or 800 273
4115 for information on the benefits available under the Medicare HMO
The following services are available to Plan Members at no additional cost
Wellness and Health Disease Management Education Health Screenings blood pressure glucose cholesterol
Programs Literature Smoking Cessation Program Stress Management Program
Prenatal Care Program Congestive Heart Failure and Coronary Vascular Disease Program
Diabetes Program Hypertension Program
Reduced Gym Memberships Health Seminars
Wellness Newsletter
Dental Care
Accident Injury The plan will pay for any service or supply for an accidental injury to sound natural teeth if the Benefit service is performed or supplies provided as part of the initial emergency treatment for the accident
and you are still covered under this Certificate
Vision Care As a member of the QualChoice Health Plan you'll receive special prices and discounts on all eyewear at Visionworks Eckerd Optical and other fine optical professionals You'll also receive
special prices on eye exams contact lens exams and contact lenses Here are some examples of those discounts
Optometric Benefits Member Pays
Regular Eye Exam 35 Contact Lens Exam Fitting and Follow up Regular Price Less 20
Benefits on this page are not part of the FEHB contract
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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 Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
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Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage coverage You must tell us if you or a family member has double coverage You must also send us
documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover
injuries 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
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QualChoice of North Carolina Inc 2000
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 directly or Agencies indirectly pays for
If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider malpractice claim it must go to binding arbitration Contact us about how to begin our binding arbitration process
QualChoice of North Carolina Inc 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 www opm gov
lists the specific types of information that we must make available to you
If you want specific information about us call 800 816 0911 or write to QualChoice P O Box
340 Winston Salem NC 27102 0340 You may also contact us by fax at 800 283 0128 or visit our website at www qualchoicenc com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the 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 your coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorizes coverage for Under certain circumstances you may also get family and me 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 have
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QualChoice of North Carolina Inc 2000
claims records access to it confidential
OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits Individuals involved in bona fide medical research or education that does not disclose your
identity or OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form
SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under my
old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices
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QualChoice of North Carolina Inc 2000
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct Get the RI 79 27
which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I 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
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QualChoice of North Carolina Inc 2000
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However
if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan health insurance or other health care coverage You must arrange for the other coverage within 63 Coverage 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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QualChoice of North Carolina Inc 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error If the provider does not resolve the matter call us at 800 816 0911 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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QualChoice of North Carolina Inc 2000
Summary of Benefits for QualChoice 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 the 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 AND
SERVICES AVAILABLE AS POS BENEFITS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes 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 11
Extended care All necessary services no dollar or day limit You pay nothing 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 13
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay nothing 13
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit copays are waived
for maternity care and well baby visits to age 2 10 per house call by a doctor 13
Home health car All necessary visits by nurses and health aides You pay 10 per visit 9
Mental conditions Up to 20 outpatient visits per year You pay a 20 copay per visit 13
Substance abuse Up to 20 outpatient visits per year You pay 20 copay per visit 13
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan 11
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 6 generic or 12 name brand copay per prescription unit or refill 14
Dental care Accidental injury benefit you pay nothing Preventive dental care No current benefit 14
Vision care No current benefit 14
Point of Service Services of non Plan doctors and hospitals or plan doctors without a referral from Benefits your PCP Not all benefits are covered You pay deductibles and coinsurance
and a maximum benefit applies 15
Out of pocket Your out of pocket expenses for benefits under this Plan are limited to the stated maximum copayments required for a few benefits except for the POS option under which
option 2 has a 800 individual 2,000 family maximum and option 3 has a 900 individual 2,250 family maximu 4,14
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QualChoice of North Carolina Inc 2000
2000 Rate Information for QualChoice of North Carolina Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees but do not apply to non career Postal employees Postal retirees certain special Postal employment categories or associate members of any Postal employee organization If you are in a special Postal employment
category refer to the FEHB Guide for that category
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share
Self Only 7Q1 73.31 24.44 158.84 52.95 86.75 11.00 86.75 11.00
Self and 7Q2 175.97 62.02 381.27 134.38 207.74 30.25 201.02 36.97 Family
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