For changes
in benefits
see page 3
Serving The Triangle area of North Carolina
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
Self only 8B1
Self and family 8B2
Visit the OPM website at http www opm gov insure
and
our website at http www famplan com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 786
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Generations Family Health Plan 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 6
Section 5 Benefits 8
Section 6 General exclusions Things we don't cover 15
Section 7 Limitations Rules that affect your benefits 15
Section 8 FEHB Facts 17
Inspector General Advisory Stop Healthcare Fraud 20
Summary of benefits Inside Back Cover
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Generations Family Health Plan Inc 2000
Introduction
Generations Family Health Plan Inc
6330 Quadrangle Drive Suite 100
Chapel Hill North Carolina 27514
This brochure describes the benefits you can receive from Generations Family Health Plan Inc under its contract CS2846 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 Generations Family Health Plan 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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Generations Family Health Plan Inc 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with
benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they
work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay
for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about
non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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Generations Family Health Plan Inc 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventative care such
as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and
coinsurance listed in this brochure
When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or remain
under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
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 care office
changes 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 Plan Allergy immunotherapy treatments are covered in full See page 8
Your share of the non postal premium will increase by 6.3 for Self Only or 6.3 for Self and Family
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Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our service area is
Plan's service Alamance Chatham Durham Franklin Harnett Johnston Orange and Wake counties of North Carolina
area Ordinarily you must get your care from providers who contract with us If you receive care outside our service area
we will pay only for emergency care We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents
live out of the area for example if your child goes to college in another state you should consider enrolling in a fee forservice
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 or coinsurance a set
pay for services percentage of charges Please remember you must pay this amount when you receive services except for preventive care services inpatient care home health care and mental health and substance abuse services
After you pay 1,500 in copayments or coinsurance for self only or 3,000 for self and family enrollment you do not
have to make any further payments for certain services for the rest of the year This is called a catastrophic limit
However copayments or coinsurance for your prescription drugs and vision examinations do not count toward these
limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when
you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't
submit claims 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 providers whom you will see are independent doctors who practice in their own offices These doctors are not
my health care employees or agents of the Plan You must choose a primary care physician from the list of primary care physicians in our provider directory for yourself and each person in your family This is the physician who will provide the majority
of your medical care Your primary care physician will work with you to decide when you need to be referred to a
specialist physician We will only pay for services if you see your primary care physician or you have been referred to
a specialist physician by your primary care physician Services of other providers are covered only when you have been
referred by your primary care doctor with the following exception women may see any Plan participating
obstetrician gynecologist for conditions related to the female reproductive system or breast without a referral from the
primary care doctor
The primary care physician you choose may work with select groups of specialist physicians If this is the case you will
only be referred to specialist physicians with whom your primary care physician works You will only be referred to
specialist physicians outside those groups with whom the primary care physician works for services that a specialist
physician within these groups cannot provide If a primary care physician does have limitations on the specialist
physicians with whom he she works this will be noted in our provider directory
What do I do if Call us We will help you select a new one
my primary care
physician leaves
the Plan
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Generations Family Health Plan Inc 2000
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will make the
need to go into necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our Medical Management Department at 888 256 7346 If you are new to the FEHB Program we will
I'm in the arrange for you to receive care If you are currently in the FEHB Program and are switching to us your former plan will
hospital when I pay for the hospital stay until
join this Plan 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 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 work with our Medical Management Department to coordinate
this extended referral
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a specialist ask if you
am seeing a can see your current specialist If your current specialist does not participate with us you must receive treatment from
specialist when a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
I enroll
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive services from your
my specialist current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your provider
have a serious for up to 90 days after we notify you that we are terminating our contract with the provider unless the termination is for
illness and my cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of
provider leaves your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in
Plan leaves the a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second
Program 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 or recommending follow up care Before giving
authorize approval we consider if the service is medically necessary and if it follows generally accepted medical practice
medical
services
How do you Our Medical Management Committee reviews and sets all medical policies If your physician thinks you need a
decide if a procedure that may be experimental or investigational he she will contact us to get authorization We evaluate each
service is request based upon the circumstances of the case We will review all clinical information and may discuss the situation
experimental or with your physician before we make a decision
investigational
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Generations Family Health Plan Inc 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable
to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after
we receive the additional information If we do not receive the requested information within 60 days we will make our decision based on the
information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will
to review a denial determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a Call us at 888 256 5563 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 OPM so that
denied my request for they can give your claim expedited treatment too Alternatively you can call OPM's health benefits Contract
care and my condition Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that
is serious or life may cause permanent loss of bodily functions or death if they are not treated as soon as possible
threatening
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial
limits 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 information
OPM 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 Contract
my disputed claim to Division III P O Box 436 Washington D C 20044
OPM
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your only
the Plan's denial recourse is to sue If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review on
file a lawsuit the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services
supplies or drugs covered by us until you have completed the OPM review procedure described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
Privacy Act 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 judgement of the
Plan doctor such care is necessary and appropriate you pay a 10 copay for a doctor's house call and nothing
for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups no copayment
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women age 50
through 64 one mammogram every year and for women age 65 and above one mammogram every two
years In addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness no copayment
Routine immunizations and boosters no copayment
Consultations by specialists
Hearing examinations screening and testing
Diagnostic procedures such as laboratory tests and X rays no copayment
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor You pay a 10 copay for the first visit only The mother at her option may remain in the
hospital up to 48 hours after a regular delivery and 96 hours after a caesarian 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 You pay nothing no copayment for allergy immunotherapy treatments 10 per day of allergy testing
Cornea heart kidney and liver transplants allogenic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions
acute lymphocytic leukemia advanced Hodgkin's lymphoma advanced 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
The insertion of internal prosthetic devices such as pacemakers and artificial joints the cost of the device is covered
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Medical and Surgical Benefits continued
What is covered Prosthetic devices such as artificial limbs intraocular lenses following cataract removal and breast
continued prostheses and surgical bras Orthopedic devices such as braces initial prosthesis and medically necessary replacement prostheses
Durable medical equipment such as wheelchairs and hospital beds rental or purchase
Chiropractic services
Home health services 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 her attending physician may decide whether to have
breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to
produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient
basis for up to two consecutive months per condition if significant improvement can be expected within two
months you pay nothing Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist 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 a 10 copayment per visit The following type of
artificial insemination is covered intravaginal insemination IVI cost of donor sperm is not covered Fertility
drugs are covered under the Prescription Drug Benefit Other assisted reproductive technology ART
procedures such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction is provided you
pay nothing Cardiac rehabilitation services must have Authorization from Generations
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining or
covered continuing employment or insurance attending school or camp or travel Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services and other custodial care
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Blood and blood derivatives not replaced by the member
Acupuncture therapy
Foot orthotics
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of the primary care doctor or authorized specialist 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 for up to 100 days per calendar year when full time nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by the
primary care doctor or authorized specialist 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 and family counseling these services are provided under the direction of the
primary care doctor or authorized specialist who certifies that the patient is in the terminal stages of illness with
a life expectancy of approximately six months or less You pay nothing
Ambulance Benefits are provided for ambulance transportation in the event of an emergency or when ordered or authorized
service by the primary care doctor You pay nothing
Limited Benefits
Inpatient dental Hospitalization for certain dental procedures is covered when the primary care doctor or authorized specialist
procedures determines there is need for hospitalization but not the cost of the professional dental services The need for anesthesia by itself is not a condition for which hospitalization would be covered
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of
detoxification medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 12 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life
medical or could result in serious injury or disability and requires immediate medical or surgical care Some problems are
emergency 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 If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are unable to
within the contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital
service area emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member should notify the Plan or primary care doctor within 48 hours unless it was not reasonably possible
to do so It is your responsibility to ensure that the Plan or primary care doctor has been timely notified
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
primary care doctor
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
Emergencies Benefits are available for any medically necessary health service that is immediately required because of injury or
outside the unforeseen illness
service area If you need to be hospitalized the Plan or primary care doctor should be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to do so 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
primary care doctor
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 Emergency care at a doctor's office or an urgent care center
covered Emergency care as an outpatient or inpatient at a hospital including doctor's services Ambulance service approved by the Plan
What is not Elective care or nonemergency care
covered Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt of their
for non Plan claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services
providers 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 your 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 6
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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 nothing for the first 20 visits 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 Psychiatric evaluation or therapy on court order as a condition of parole or probation or for purposes of
covered obtaining or maintaining employment or insurance unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary including testing for intelligence aptitude or interest
Services which are extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation or autism disabilities
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric 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 nothing for each covered visit all charges after the maximum benefit has been reached
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 for covered services all charges thereafter
Subject to a maximum per lifetime of two 2 courses of inpatient treatment in an alcohol or drug rehabilitation
center approved by the Plan
What is not Treatment that is not authorized by a Plan doctor
covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Prescription Drug Benefits
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Generations Family Health Plan Inc 2000
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply You pay a 5 copay per generic prescription unit or refill and a 15 per name brand
prescription unit or refill when generic substitution is not permissible When generic substitution is permissible
i e a generic drug is available and the prescribing doctor does not require the use of a name brand drug but
you request the name brand drug you pay the price difference between the generic and name brand drug as well
as the 15 copay per name brand prescription unit or refill
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
Diabetic supplies including insulin syringes needles control solution or equivalent glucose monitors and test tape or strips
Intravenous fluids and medication for home use implantable drugs such as Norplant and some injectible drugs
such as Depo Provera are covered under Medical and Surgical Benefits
Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits
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
Smoking cessation drugs and medication
Other Benefits
Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need
benefit for these services must result from an accidental injury You pay nothing
What is not
covered 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 annual eye refractions to provide a written lens prescription may be obtained from Plan providers You pay
a 10 copay per visit limited to one visit per calendar year
What is not Corrective lenses or frames
covered Contact lens fitting Eye exercises or vision training
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Non FEHB Benefits Available to Plan Members
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Generations Family Health Plan Inc 2000
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
The following services are available to Plan members at no additional cost
Vision Care As a member of Generations you'll receive special discounts on eyewear and non disposable contact lenses from Plan participating vision providers
In addition Generations will reimburse you up to 75 in charges once every 24 months for vision hardware you
purchase Vision hardware eligible for reimbursement includes only standard prescription spectacle lenses and
frames or contact lenses disposable or non disposable Lens treatments sports equipment low vision aids and
non prescription lenses are not eligible for reimbursement
To receive your reimbursement submit your claim receipt and itemized statement to Generations at 6330
Quadrangle Drive Suite 100 Chapel Hill North Carolina 27514 You must submit your claim for reimbursement
no later than 180 days after your purchase
Wellness and Health Disease management programs
Education Health education programs through community providers with prior authorization from Generations including diabetes education and other classes
Access to a 24 hour nurse advice line including the ability to discuss with a nurse the difference between minor ills and those requiring medical attention and age appropriate health care advice and guidance
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
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Generations Family Health Plan Inc 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
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
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 1 800 638 6833
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Generations Family Health Plan Inc 2000
Other group When anyone has coverage with us and with another group health plan it is called double coverage You must tell us
insurance if you or a family member has double coverage You must also send us documents about other insurance if we ask for
coverage 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 provide them In that
beyond our case we will make all reasonable efforts to provide you with necessary care
control
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that another person
responsible for caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the
injuries amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the primary payer See your TRICARE
Health Benefits Advisor if you have questions about TRICARE coverage
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation Programs
OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
Government
Agencies
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Generations Family Health Plan Inc 2000
Section 8 FEHB Facts
You have a OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information
right to about your health plan its networks providers and facilities You can also find out about care management which
information includes medical practice guidelines disease management programs and how we determine if procedures are
about your experimental or investigational OPM's website www opm gov lists the specific types of information that we must
HMO make available to you
If you want specific information about us call 919 490 0102 or 888 256 5563 or write to 6330 Quadrangle Drive Suite
100 Chapel Hill North Carolina 27514 You may also contact us by fax at 919 490 1790 or visit our website at
http www famplan com You can also reach us by email at memserv famplan com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees Health
information Benefits Plans brochures for other plans and other materials you need to make an informed decision about
about enrolling When you may change your enrollment
in the FEHB How you can cover your family members
Program 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 and premiums begin
benefits and on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
premiums
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB
when I retire 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 unmarried dependent
coverage are children under age 22 including any foster or step children your employing or retirement office authorizes coverage for
available for me Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable
and my family 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 We will keep your medical and claims information confidential Only the following will have access to it
and claims OPM this Plan and subcontractors when they administer this contract
records This plan and appropriate third parties such as other insurance plans and the Office of Workers
confidential 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
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Generations Family Health Plan Inc 2000
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 enrolled in
conditions 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 under your former
spouse coverage spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office
to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can receive TCC if
you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from
your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
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Generations Family Health Plan Inc 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You must
TCC enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer
an eligible family member That office will send you information about enrolling in TCC You must enroll
your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days
of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC
Your former spouse must enroll within 60 days after the event which qualifies them for coverage or
receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your
premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must
apply in writing to us within 31 days after you receive this notice However if you are a family member who
is losing coverage the employing or retirement office will not notify you You must apply in writing to us within
31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer
questions about your health and we will not impose a waiting period or limit your coverage due to pre existing
conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Certificate of Group how long you have been enrolled with us You can use this certificate when getting health insurance or other
Health Plan health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new
Coverage 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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Generations Family Health Plan 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 919 490 0102 or 888 256 5563 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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Generations Family Health Plan Inc 2000
Summary of Benefits for Generations Family Health Plan Inc 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth
in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment
in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL
SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN
PROVIDED OR ARRANGED BY THE PRIMARY CARE DOCTOR
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 10
Extended care All necessary services up to 100 days per year You pay nothing 10
Mental conditions Diagnosis and treatment of psychiatric conditions for up to 30 days of inpatient care
per year You pay nothing 12
Substance abuse Up to 30 days per year in a substance abuse treatment program Lifetime maximum
of 2 such courses of treatment You pay nothing 12
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or
care injury including specialist 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 copay is required for the first
pre natal visit waived thereafter 10 per house call by a doctor 8
Home health care All necessary visits by nurses and health aides You pay nothing 9
Mental conditions Up to 20 outpatient visits per year You pay nothing 12
Substance abuse Up to 20 outpatient visits per year You pay nothing 12
Emergency Reasonable charges for services and supplies required because of a medical
care emergency You pay a 50 copay to the hospital for each emergency room visit a 25 copay for each visit to an urgent care center and any charges for services that are
not covered by this Plan 11
Prescription Drugs obtained at a Plan pharmacy You pay a 5 copay per generic prescription
drugs unit or refill and a 15 copay per brand name prescription unit or refill You pay the price difference between the generic and name brand drug plus the 15 copay if
you request a name brand drug when generic substitution is permissible 13
Dental care Accidental injury benefit you pay nothing 13
Vision care One refraction annually You pay a 10 copay per visit 13
Out of pocket Copayments are required for a few benefits however after your out of pocket
maximum expenses reach a maximum of 1,500 per Self Only or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay
maximum does not include charges for vision examinations and prescription drugs
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Generations Family Health Plan Inc 2000
2000 Rate Information for
Generations Family Health Plan 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 In 2000 two categories of contribution rates referred to as Category A rates
and Category B rates will apply for certain career postal employees If you are a career employee who is 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
Self Only 8B1 67.19 22.40 145.58 48.53 79.51 10.08 79.51 10.08
Self and Family 8B2 167.97 55.99 363.94 121.31 198.76 25.20 198.76 25.20
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