Enrollment in this plan is limited see page 5 for requirements
Enrollment code
5W1 Self Only
5W2 Self and Family
Visit OPM website at http www opm gov insure
and
The SummaCare Health Plan website at http www summacare com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service
RI 73 768
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SummaCare Health Plan 2000
Table of Contents
Introduction 3
Plain Language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 23
Section 7 Limitations Rules that affect your benefits 24
Section 8 FEHB facts 26
Inspector General Advisory Stop Healthcare Fraud 31
Summary of Benefits 32
Premiums Outside Back Cover
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SummaCare Health Plan 2000
Introduction
SummaCare Health Plan 400 West Market Street Akron Ohio 44303 330 996 8410 or 800 996 8411
This brochure describes the benefits you can receive from SummaCare Health Plan under its contract CS 2830 with the Office
of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the
official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this
brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown
on page 4 Premiums are listed at the end of this brochure
Plain 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 SummaCare Health Plan as this Plan throughout this brochure even though in other legal documents you will see
a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
How to Use This 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
Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
How we change for 2000 If you are a current member and want to see how we have changed read this section
How to get benefits Make sure you read this section it tells you how to get services and how we operate
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
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
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SummaCare Health Plan 2000
How to Use This Brochure continued
General exclusions Things we don't cover Look here to see benefits that we will not provide
Limitations Rules that affect your benefits This section describes limits that can affect your benefits
FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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 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
changes of 10 for all primary care office visits
This year you have a right to more information about this Plan care
management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the
Plan at our request you may continue to see your specialist for up to 90
days If your provider leaves the Plan and you are in the second or third
trimester of pregnancy you may be able to continue seeing your OB GYN
until the end of your postpartum care You have similar rights if this Plan
leaves the FEHB program See Section 3 How to get benefits for more
information
You may review and obtain copies of your medical records on request If
you want copies of your medical records ask your health care provider for
them You may ask that a physician amend your 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 your records
call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening
sigmoidoscopy every five years This screening is for colorectal cancer
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SummaCare Health Plan 2000
How We Change For 2000 continued
Changes to this Your share of the non postal premium will increase by 10 5 for Self Only
plan or 10.5 for Self and Family
The out of pocket maximums have been removed
A Primary Care Physician referral is no longer required for visits to a
network urgent care center
Diagnosis and treatment of infertility no longer requires copayments
Section 3 How to Get Benefits
What is this To enroll with us you must live or work in our service area This is
Plan's service where our providers practice Our service area is The following counties
area in Ohio Ashtabula Carroll Cuyahoga Geauga Mahoning Medina Lorain Portage Stark Summit Trumbull Tuscarawas Wayne
You may also enroll with us if you live or work in the following places
A county contiguous next to one of the counties listed above
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
emergencies 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 You must share the cost of some services This is called either a
I pay for copayment a set dollar amount or coinsurance a set percentage of
services charges Please remember you must pay this amount when you receive
services except in some instances if you receive emergency services from a
non network provider In these instances you may be required to pay at
the time you receive services The Plan will then reimburse you for any
applicable charges
Your out of pocket expenses for benefits covered under this Plan are
limited to the stated copayments which are required for a few benefits
Be sure to keep accurate records of your copayments and coinsurance
since you are responsible for informing us when you reach the limits
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SummaCare Health Plan 2000
How To Get Benefits continued
Do I have You normally won't have to submit claims to us unless you receive
to submit claims emergency services from a provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as
possible You must submit claims by December 31 of the year after the
year you received the service Either OPM or we can extend this deadline
if you show that circumstances beyond your control prevented you from
filing on time
Who provides The Plan has contracted with thousands of healthcare providers to provide
my health medical services These providers are listed in the Plan's Provider
care Directory You can also call our customer service department to determine if a specific provider contracts with the Plan
What do I do if Call us We will help you select a new one
my primary
care physician
leaves the Plan
What do I do if Talk to your Plan physician If you need to be hospitalized your primary
I need to go care physician or specialist will make the necessary hospital arrangements
into the and supervise your care
hospital
What do I do if First call our customer service department at 330 996 8700 or 800
I'm in the 996 8701 If you are new to the FEHB Program we will arrange for
hospital when 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
specialty care However in the following instances you may self refer to a participating plan provider a woman may see her Plan gynecologist for her annual
routine exam without a referral and visits to a Plan urgent care center to
not require a referral
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 and must receive prior
authorization from the Plan before a standing referral may be issued
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SummaCare Health Plan 2000
How To Get Benefits continued
What do I do Your primary care physician will decide what treatment you need If they
if I am seeing a decide to refer you to a specialist ask if you can see your current specialist
specialist when If your current specialist does not participate with us you must receive
I enroll 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 Call your primary care physician who will arrange for you to see another
if my specialist specialist You may receive services from your current specialist until we
leaves the Plan can make arrangements for you to see someone else
But what if I have a serious illness and my provider leaves the Plan or this
Plan leaves the Program
Please contact us if you believe your condition is chronic or disabling You
may be able to continue seeing your provider for up to 90 days after we
notify you 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 Your physician must get our approval before sending you to a hospital
authorize medical referring you to a specialist or recommending follow up care Before
services giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide In determining is a service is experimental or investigational the Plan
if a service is researches the safety and effectiveness of medical treatment The Plan's
experimental or Utilization Review Committee which consists of physicians may also be consulted to assist in determinations In the course of the determination
investigational process numerous medical and healthcare industry journals and
healthcare databases may be used For many procedures the Plan
follows guidelines set by the Health Care Financing Administration
HCFA
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SummaCare Health Plan 2000
Section 4 What to Do If We Deny Your Claim or Request for Service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong
and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within
30 days after we receive the additional information If we do not receive the requested information within 60 days we will
make our decision based on the information we already have
When may I You may ask OPM to review the denial after you ask us to reconsider our
ask OPM to initial denial or refusal OPM will determine if we correctly applied the
review a denial terms of our contract when we denied your claim or request for service
What if I have a Call us 330 996 8410 and 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
denied my request your claim we will inform OPM so that they can give your claim
for care and my expedited treatment too Alternatively you can call OPM's health
condition is serious benefits Contract Division IV at 202 606 0737 between 8 a m and 5
or life threatening p m Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon
as possible
Are there other You must write to OPM and ask them to review our decision within 90
time limits days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM
must receive your request within 120 days of the date you asked us to
reconsider your claim
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SummaCare Health Plan 2000
Section 4 What to Do If We Deny Your Claim or Request for Service continued
Are there other 2 You provided us with additional information we asked for and we did
time limits not answer within 30 days In this case OPM must receive your request
continued within 120 days of the date we asked you for additional information
What do I send to Your request must be complete or OPM will return it to you You must
OPM send the following information
1 A statement about why you believe our decision is wrong based on
specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters
operative reports bills medical records and explanation of benefits
EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify
which documents apply to which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are
acting as the enrolled person's representative They must send a copy of
the person's specific written consent with the review request
What address should Send your request for review to Office of Personnel Management Office
I send my disputed of Insurance Programs Contracts Division IV P O Box 436
claim to Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If
the Plan's denial OPM 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
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SummaCare Health Plan 2000
Section 4 What to Do If We Deny Your Claim or Request for Service continued
What laws apply Federal law governs your lawsuit benefits and payment of benefits The
if I file a 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 Chapter 89 of title 5 United States Code allows OPM to use the
and the Privacy Act 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
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SummaCare Health Plan 2000
Section 5 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 nothing for a doctor's house call and
nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay
unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through 64 one mammogram every year and for women age 65 and above one
mammogram every two years In additional to routine screening
mammograms are covered when prescribed by the doctor as medically
necessary to diagnose or treat your illness
Routine immunizations and booster office visit copay waived
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan 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 office visit copayment waived for allergy shots
only
The insertion of internal prosthetic devices such as pacemakers and artificial joints
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SummaCare Health Plan 2000
Section 5 Benefits Continued
What is covered immunizations and booster office visit copay waived
continued
Cornea heart lung heart lung kidney liver and pancreas transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the
following conditions acute lymphocytic or non lymphocytic leukemia
advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial
ovarian cancer and testicular mediastinal retroperitoneal and ovarian
germ cell tumors Transplants are covered when approved by the Medical
Director Related medical and hospital expenses of the donor are covered
when the recipient is covered by this Plan including reasonable travel and
lodging expenses of the recipient when care is received out of area
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
The rental or purchase of durable medical equipment such as wheelchairs and hospital beds when preauthorized by the Plan
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Limited Benefits Diagnosis and treatment of infertility is covered The following
types of artificial insemination are covered intravaginal insemination
IVI intracervical insemination ICI and intrauterine insemination
IUI 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
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 with the exception of any dental care involved
in the treatment of temporomandibular joint TMJ pain dysfunction
syndrome You pay a 10 copay per covered visit
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has
produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have
breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce a symmetrical
appearance
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is covered either the primary care physician
or attending specialist must preauthorize course of treatment
Initial purchase of prosthetic devices such as artificial limbs and medically necessary replacement of prosthetic devices breast
prosthetic and surgical bras Lenses following cataract removal are
not covered
Orthopedic devices such as braces Foot orthotics are not covered
Home health services 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
In hospital administration of blood and blood products including blood processing
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Limited benefits The rental or purchase of durable medical equipment such as wheelchairs
continued and hospital beds when preauthorized by the Plan
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
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive
months per condition if significant improvement can be expected within
two months you pay 10 per outpatient session Speech therapy is limited
to treatment of certain speech impairments of organic origin Occupational
therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily
living
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
Foot orthotics
Lenses following cataract removal
Hospital extended cre
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
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Extended care The Plan provides a comprehensive range of benefits for up to 100
days of skilled care after hospitalization 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
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan
procedures 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
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to
detoxification emergency care diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if
the Plan doctor determines that outpatient management is not medically
appropriate See page 19 for non medical 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
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Emergency benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition
emergency or an injury that you believe endangers your life or could result in
serious injury or disability and requires immediate medical or surgical
care Some problems are emergencies because if not treated promptly
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
Emergencies within If you are in an emergency situation please call your primary care
the service area doctor In extreme emergencies if you are unable to contact your
doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room or approved
urgent care center 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 should 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
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 at an approved urgent care center for emergency services that are
covered benefits of this Plan If the emergency results in admission to a
hospital the copay is waived
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Emergencies outside Benefits are available for any medically necessary health service that is
the service area immediately required 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
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
Filing claims for With your authorization the Plan will pay benefits directly to the
non plan providers providers of your emergency care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are
required to pay for the services submit itemizes bills and your receipts to
the Plan along with an explanation of the services and the identification
information from your ID card
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Filing claims for Payment will be sent to you or the provider if you did not pay the
non plan providers bill unless the claim is denied If it is denied you will receive
continued notice of the decision including the reason for the denial and the provisions of the contract on which denial was based If you
disagree with the Plan's decision you may request reconsideration
in accordance with the disputed claims procedure described on
pages 8 9 and 10
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 Up to 20 outpatient visits to Plan doctors or other psychiatric personnel
each calendar year you pay a 30 copay for each covered visit all
charges thereafter
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
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SummaCare Health Plan 2000
Section 5 Benefits Continued
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 30 copay for each covered visit all charges thereafter
The substance abuse benefit may be combined with the outpatient mental
conditions benefit shown above provided such treatment is necessary and
is approved by the Plan to permit an additional 20 outpatient visits per
calendar year with the applicable mental conditions benefit copays
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
Prescription drug benefits
What is covered Prescription drugs prescribed by a Plan doctor or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply
You pay a 5 copay per prescription unit or refill for generic drugs or a 10
copay for name brand drugs when generic substitution is not permissible
Prescription drugs are available through the Plan's Mail Order Program
You pay a 10 copay for a 90 day supply of generic drugs or a 20 copay
for a 90 day supply of brand name drugs
Please call the Plan's Customer Service Department at 800 996 8701 for
information on how you may receive prescription drugs by mail
Drugs are prescribed by Plan doctors and dispensed in accordance with the
Plan's drug formulary Nonformulary drugs will be covered when
prescribed by a Plan doctor
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Covered medications
and accessories Drugs for which a prescription is required by Federal law
include Oral contraceptive drugs contraceptive diaphragms
Insulin a copay charge applies to each prescription
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin syringes needles glucose test tablets and test tape
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
Limited benefits Drugs to treat sexual dysfunction are covered Contact the Plan for
dose limits You pay a 10 copayment up to the dosage limits and all
charges after that
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
Fertility drugs
Smoking cessation drugs and medication
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Other benefits
Dental care
What is covered Accidental Injury Benefit
Restorative services and supplies necessary to promptly repair
but not replace sound natural teeth 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 care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye biannual eye
refractions to provide a written lens prescription are covered when
performed by Plan providers You pay a 10 copay per visit
What is not covered Corrective lenses or frames
Eye exercises
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SummaCare Health Plan 2000
Section 5 Benefits Continued
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums
These benefits are not subject to the FEHB disputed claims procedure
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare
As indicated on page 24 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 reenroll 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 888 464 8440 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 888 464 8440 for information on the benefits available under the Medicare HMO
Benefits on this page are not part of the FEHB Contract
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SummaCare Health Plan 2000
Section 6 General Exclusions Things We Don't Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it
unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits 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 Plan specific
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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SummaCare Health Plan 2000
Section 7 Limitations Rules that Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B
Medicare will determine who is responsible for paying for medical
services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice
plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB
coverage and enroll in a Medicare Choice plan when one is available in
your area For information on suspending your FEHB enrollment and
changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do
so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice
service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under
the FEHB Program and your benefits will not be reduced We cannot
require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social
Security Administration SSA office or request it from SSA at 1800
638 6833 For information on the Medicare Choice plan offered by
this Plan please call SummaCare at 330 996 8440 or 888 464 8440 or
visit the Plan's website at www summacare com
Other group When anyone has coverage with us and with another group health
insurance coverage 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
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SummaCare Health Plan 2000
Section 7 Limitations Rules that Affect Your Benefits Continued
Circumstances beyond Under certain extraordinary circumstances we may have to delay your
our control 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 When you receive money to compensate you for medical or hospital
responsible for injuries care for 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 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
If you have a If you have a malpractice claim because of services you did or did
malpractice claim not receive from a plan provider it must go to binding arbitration Contact us about how to begin our binding arbitration process
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SummaCare Health Plan 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 customer service at 330 996 8700 or 800 996 8701 or write to SummaCare
Health Plan Atten FEBH Program 400 West Market Street Akron Ohio 44303 You may also contact us by fax at 330 996
8454 or visit our website at http www summacare com
Where do I get information about enrolling in the FEHB Program
Your employing or retirement office can answer your questions and give you a 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
What types of coverage are available for me and my family
Self Only coverage is for you alone Self and Family coverage is for you your 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
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SummaCare Health Plan 2000
Section 8 FEHB Facts Continued
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 This plan and appropriate third parties such as other insurance plans and the office of Workers Compensation Program
OWCP when coordinating benefit payment and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or OPM when reviewing a disputed claim or defending litigation about a claim
Information for New Members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant
confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan
Pre existing 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 You will receive an additional 31 days of coverage for no
enrollment in this additional premium when
plan ends
Your enrollment ends unless you cancel your enrollment or You are a family member
27 no longer eligible for coverage
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SummaCare Health Plan 2000
When You Lose Benefits Continued
What happens if my You may be eligible for former spouse coverage or Temporary
enrollment in this Continuation of Coverage
plan ends continued
What is former If you are divorced from a Federal employee or annuitant you
spouse coverage 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 exspouse's
employing or retirement office to get more
information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer
qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue
your FEHB enrollment after you retire You may not elect TCC
if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the
Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse
Enrollees from your employing or retirement office
Key points about TCC You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months
after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you
still have to pay premiums from the 32nd day after your regular
coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
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 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
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SummaCare Health Plan 2000
When You Lose Benefits Continued
How do I enroll in TCC That office will send you information about enrolling in TCC
continued 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 You may convert to an individual policy if
to individual coverage Your coverage under TCC or the spouse equity law ends If you
canceled your coverage or did not pay your premium you cannot
convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you
if individual coverage is available You must apply in writing to us
within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31
days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB
Program however you will not have to answer questions about
your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of
certificate of group Group Health Plan Coverage that indicates how long you have been
health plan coverage enrolled with us You can use this certificate when getting health
insurance or other health care coverage
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SummaCare Health Plan 2000
When You Lose Benefits Continued
How can I get a You must arrange for the other coverage within 63 days of leaving
certificate of group this Plan Your new plan must reduce or eliminate waiting periods
health plan coverage limitations or exclusions for health related conditions based on the
continued 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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SummaCare Health Plan 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error If the provider does not resolve the matter call us at 330 996 8700 or 800 996 8701 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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SummaCare Health Plan 2000
Summary of Benefits for SummaCare Health Plan
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 AND URGENT CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN
DOCTORS
Benefits Plan pays Provides Page
Inpatient care Hospital Comprehensive range of medical and surgical 14 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
Extended Care All necessary services for up to 100 days of 15
skilled care after a hospitalization You pay
nothing
Mental Conditions Diagnosis and treatment of acute psychiatric 18
conditions for up to 30 days of inpatient care per
year You pay nothing
Substance Abuse Up to 30 days per year in a substance abuse 19
treatment program You pay nothing
Outpatient care Comprehensive range of services such as diagnosis 11 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
you pay nothing per house call by a doctor
Home health care All necessary visits by nurses and health aides for 13
up to 30 days per pre authorization
You pay nothing
Mental conditions Up to 20 outpatient visits per year You pay a 30 18
copay per visit
Substance abuse Up to 20 outpatient visits per year You pay a 30 19
copay per visit
Emergency care Reasonable charges for services and supplies 16
required because of a medical emergency You
pay a 50 copay for each visit to a hospital
emergency room or a 25 copay for each visit to
an approved urgent care center when inside the
service area or a 25 copay for each visit to an
urgent care center when outside the service area
and any charges for services that are not covered
by this Plan
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SummaCare Health Plan 2000
Summary of Benefits for SummaCare Health Plan Continued
Benefits Plan pays Provides Page Prescription drugs Drugs prescribed by a Plan doctor and obtained at 19
a Plan pharmacy You pay a 5 copay for generic
drugs and a 10 copay for brand name drugs per
prescription unit or refill
Dental care Accidental injury benefit you pay nothing 21
Vision care One refraction biannually You pay a 10 copay 21
per visit
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2000 Rate Information for
SummaCare Health Plan
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but are not a member of a special postal employment class refer to the category definitions in
The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to
determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes
or associate members of any postal employee organization Such persons not subject to postal rates must refer to
the applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Northern Ohio
Self Only 5W1 60.92 20.31 132.00 44.00 72.09 9.14 72.09 9.14
Self and 5W2 167.55 55.85 363.02 121.01 198.27 25.13 198.27 25.13
Family
0
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