Serving Broward Dade and Palm Beach Counties
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code 4A1 Self Only
4A2 Self and Family
Visit the OPM website at http www opm gov insure
Special notice The Federal Employees Health Benefits Program offers this Plan for the first time during the 1999 Open Season
Authorized for distribution by the
United States Office of
Federal Employees Personnel Health Benefits Program
Management RI 73 795
1
1
Page 2
3
Total Health Choice 2000
Table of Contents
Page
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 15
Section 7 Limitations Rules that affect your benefits 15
Section 8 FEHB facts 16
Inspector General Advisory Stop Healthcare Fraud 19
Summary of benefits 20
Premiums 22
i
2
2
Page 3
4
Total Health Choice 2000
Introduction
Total Health Choice Inc 8701 SW 137th Avenue Suite 200 Miami Florida 33183
This brochure describes the benefits you can receive from Total Health Choice HMO under its contract CS 2854 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 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 Total Health Choice HMO as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
1
3
3
Page 4
5
Total Health Choice 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
2
4
4
Page 5
6
Total Health Choice 2000
Section 1 Health Maintenance Organizations
Health Maintenance Organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals 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 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 premiums as low as possible OPM has set a minimum copay of 10 for all primary changes
care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB
program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we
will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
3
5
5
Page 6
7
Total Health Choice 2000
Section 3 How to get benefits
What is this To enroll with us you must live and or work in our service area This is where our providers Plan's service practice Our service area is Broward Dade and Palm Beach Counties
area Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area but within the United States we will pay only for emergency care We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office
How much do You must share the cost of some services This is called either a copayment a set dollar amount I pay for or coinsurance a set percentage of charges Please remember you must pay this amount when
services you receive services
After you pay 1,500 in copayments for one family member or 3,000 for two or more family members 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 for your prescription drugs do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims
provider who doesn't contract with us 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 All of your health care is provided at your primary care doctor's office or through written referrals my health from your doctor except in the case of self referral or in an emergency If you have a medical
care emergency go directly to the nearest hospital for treatment You may also call the Total Health Choice Member Services Hotline at 305 408 5823 or outside Dade County at 800 213 1133
You must always contact either your primary care doctor or Total Health Choice after emergency room care
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 care doctor will make the I need to go necessary hospital arrangements and supervise your care
into the hospital
4
6
6
Page 7
8
Total Health Choice 2000
What do I do if First call our member service department at 305 408 5823 or outside Dade County at 800 213 I'm in the 1133 If you are new to the FEHB Program we will arrange for you to receive care If you are
hospital when I currently in the FEHB Program and are switching to us your former plan will pay for the hospital join this Plan 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 doctor will arrange your referral to a specialist specialty care
Referrals for specialty care
Except in a medical emergency or when a primary care doctor has designated another doctor to see patients when he or she is unavailable you must receive a referral from your primary care
doctor before seeing any other doctor or obtaining special services Referral to a participating specialist is given at the primary care doctor's discretion if specialists or consultants are required
beyond those participating in the Plan the primary care doctor will make arrangements for appropriate referrals When you receive a referral from your primary care doctor you must return
to the primary care doctor after the consultation
All follow up care must be provided or arranged by the primary care doctor On referrals the primary care doctor will give specific instructions to the consultant as to what services are
authorized If the consultant suggests additional services or visits you must first check with your primary care doctor Do not go to the specialist unless your primary doctor has arranged for and
the Plan has issued an authorization for the referral in advance
If you have a chronic complex or serious medical condition that causes you to see a Plan specialist frequently your primary care doctor will develop a treatment plan with you and your
health plan that allows an adequate number of direct access visits with that specialist The treatment plan will permit you to visit your specialist without the need to obtain further referrals
Self Referrals
Self referrals provide direct access to certain specialists without a referral from your primary care doctor A list of participating chiropractors dermatologists gynecology specialists and podiatrists
are in your Total Health Choice Provider Directory The following visits are self referrals and do not require a referral from your primary care doctor
Chiropractic Care You may self refer to a Chiropractor Provider List in the Provider Directory for
up to 20 visits within a 12 month period without a referral from your primary care doctor
Dermatology Care You may self refer to a dermatologist for up to 5 visits within a 12 month
period without a referral from your primary care doctor for minor procedures and testing The dermatologist must be selected from within your Network medical group in the Provider
Directory
Well Woman Care Adult women may self refer to a gynecology specialist for an annual wellwoman
exam You may choose a gynecologist from within your own Network medical group without a referral You can do this 1 time each year However continued gynecology specialty care
does require a referral from your primary care doctor
Podiatric Care You may self refer to a podiatrist for a podiatric evaluation by selecting any
podiatrist in the Total Health Choice Provider Directory without a referral from your primary care doctor However if you require on going podiatric treatment surgery or diagnostic tests you must
have this prior authorized by either your Medical Group or Total Health Choice
5
7
7
Page 8
9
Total Health Choice 2000
What do I do if Your primary care doctor will decide what treatment you need If they decide to refer you to a I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you I enroll to see a specialist who does not participate with our Plan
What do I do if Call your primary care doctor who will arrange for you to see another specialist You may receive my specialist services from your 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 have a serious continue seeing your provider for up to 90 days after we notify you that we are terminating our
illness and my contract with the provider unless the termination is for cause If you are in the second or third provider leaves trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Plan or this care Plan leaves the
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a authorize specialist or recommending follow up care Before giving approval we consider if the service is
medical medically necessary a covered benefit and if it follows generally accepted medical practice services
How do you The Plan's Medical Director and Board of Directors review experimental or investigational cases decide if a based on specific information Consultation with other outside physicians within a specialty is
service is often sought as a part of the review process The experimental investigational status of a treatment experimental or procedure or technique is evaluated based on publications made available through New
investigational Technologies Assessment The Plan's Pharmacy and Therapeutics Committee reviews information on a regular basis regarding new experimental investigational medical technologies to determine
potential treatments which should be made available to members
6
8
8
Page 9
10
Total Health Choice 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
What if I have a Call us at 305 408 5823 and we will expedite our review serious or life
threatening condition and you
haven't responded to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for
additional information
What do I send to Your request must be complete or OPM will return it to you You must send the following OPM
information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
7
9
9
Page 10
11
Total Health Choice 2000
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 Send your request for review to Office of Personnel Management Office of Insurance Programs should I send my Contracts Division IV P O Box 436 Washington D C 20044
disputed claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base I file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record
8
10
10
Page 11
12
Total Health Choice 2000
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 or 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 visit and nothing for home health 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 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
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery
Inpatient stays 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
Eye and ear exams for children through the end of the year of their 18th birthday
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are
covered when approved by the Medical Director Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Chiropractic services
Orthopedic devices such as braces
Prosthetic devices such as artificial limbs external lenses following cataract removal external breasts prostheses and bras including their replacement
Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
11
11
Page 12
13
Total Health Choice 2000
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 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 months per condition if significant improvement can be expected within two consecutive months You pay 10 per visit 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 50 per visit The following types of artificial insemination are covered intravaginal insemination IVI and intracervical insemination ICI The cost of donor sperm is not covered Fertility drugs are not
covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for up to 21 days you pay 10 per visit
Hearing aids are covered if medically necessary limited to one every three years
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
Blood and blood derivatives not replaced by the member
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Long term rehabilitative therapy
Homemaker services
Foot orthotics except when part of a leg brace
Transplants not listed as covered
Hospital Extended Care Benefits
What is covered
Hospital care
The Plan provides a comprehensive range of benefits with no dollar or day limit when a member is hospitalized You pay 100 per admission All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care
The Plan provides a comprehensive range of benefits when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan You pay 100 per admission 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
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
12
12
Page 13
14
Total Health Choice 2000
Hospice Care
Supportive and palliative care for a terminally ill member is covered in the home or 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 procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services
Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient detoxification
Hospitalization for medical treatment of substance abuse is limited to 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 13 for non medical substance abuse benefits
What is not covered
Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
Blood and blood derivatives not replaced by the member
Emergency Benefits
What is a medical emergency
A medical emergency is the sudden and unexpected onset of a condition 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 the service area
If you are in an emergency situation please call your primary care 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 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 within 48 hours It is your responsibility to ensure that the Plan has been timely notified
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 you are hospitalized in non Plan facilities and Plan doctors believe
care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition To be covered by this Plan any follow up care recommended by non Plan
providers must be approved by the Plan or provided by Plan providers
Plan pays
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay
25 at participating hospitals or 75 at non participating hospitals per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is waived
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
13
13
Page 14
15
Total Health Choice 2000
Emergencies outside the service area
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness outside of the service area yet within the United States
If you need to be hospitalized the Plan must be notified within 48 hours 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 would 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
75 copay at non participating hospitals per hospital emergency room 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 non emergency 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 non Plan providers
With your authorization the Plan will pay benefits directly to the 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 itemized bills
and your receipts to the Plan along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based If you
disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 7
Mental Conditions Substance Abuse Benefits
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 consultants or other psychiatric personnel each calendar year you pay a 10 copay for each covered visit
Inpatient care
Up to 45 days of hospitalization each calendar year you pay nothing for the first 45 days all charges thereafter
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
14
14
Page 15
16
Total Health Choice 2000
What is not covered
Care for psychiatric conditions that in the professional judgement 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 short term psychiatric condition
Substance abuse
What is covered
This plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other illness or condition and to the extent shown
below the services necessary for diagnosis and treatment
Outpatient care
Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay 10 copay for each covered visit all charges thereafter
These substance abuse benefits may be combined with the outpatient mental conditions benefit shown above provided such treatment is necessary as a Mental conditions benefit and is approved by the Plan to permit an additional 20 outpatient visits per calendar year
You pay 10 copay per visit
Inpatient care
Up to two 10 day substance abuse rehabilitation intermediate care programs per calendar year in an alcohol detoxification or 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 or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply You pay 5 per prescription unit or refill for generic drugs or 15 for name brand drugs when generic substitution is not permissible
When generic substitution is permissible i e a generic drug is available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay a 15 brand name copay and the price difference between the generic and
name brand drug
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The Plan's Pharmacy and Therapeutic develop the formulary The drugs shown on the Plan's formulary are evaluated for their therapeutic value and cost New
drugs are added or deleted from the formulary based on determinations made by the Pharmacy and Therapeutics Committee
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive devices and implanted time release medications such as Norplant
Insulin
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets
Compounded dermatological preparations
Nitroglycerine phenobarbital or Thyroid U S P
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
15
15
Page 16
17
Total Health Choice 2000
Limited benefits
Drugs to treat sexual dysfunction are covered Contact the Plan for dose limits You pay 50 coinsurance and all charges thereafter
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
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Other Benefits
Dental Care
Accidental Injury Benefit
Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury occurring while the member is covered under the FEHB Program You pay nothing
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
16
16
Page 17
18
Total Health Choice 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
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 reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage You must tell us if you or a family member has double coverage You must also send us
coverage 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
15
17
17
Page 18
19
Total Health Choice 2000
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly Government or indirectly pays for
Agencies
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also find
your HMO 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 305 408 5823 or 1 800 213 1133 outside Dade County or write to
Total Health Choice P O Box 830010
Miami Florida 33283 0010
You may also contact us by fax at 305 408 5710
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the an informed decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
16
18
18
Page 19
20
Total Health Choice 2000
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for me or retirement office authorizes coverage for Under certain circumstances you may also get and my family coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60
days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it
confidential Contract
OPM this Plan and subcontractors when they administer this contract
This Plan an appropriate third party such as other insurance plans and the office of worker compensation program OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form cards 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 conditions you enrolled in this Plan solely because you had the condition before you enrolled
17
19
19
Page 20
21
Total Health Choice 2000
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices
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 If you leave Federal service your employing office will notify you of your right to enroll under in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
18
20
20
Page 21
22
Total Health Choice 2000
How can I You may convert to an individual policy if convert to
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did individual not pay your premium you cannot convert
coverage You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions How can I get a
Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Group Health that indicates how long you have been enrolled with us You can use this certificate when getting
Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well
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 305 408 5823 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
19
21
21
Page 22
23
Total Health Choice 2000
Summary of Benefits for Total Health Choice 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 PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care private
room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care
You pay 100 per admission 10
Extended care All necessary services without day limit You pay 100 per admission 10
Mental Diagnosis and treatment of acute psychiatric conditions for up to 45 days of conditions inpatient care per year
You pay nothing 12
Substance Up to two 10 day substance abuse programs per year abuse You pay nothing 12
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic
check ups and routine immunizations laboratory tests and X rays complete maternity care
You pay a 10 copay per office visit and nothing per doctor's house call 9
Home health All necessary visits by nurses and health aides care You pay nothing 9
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay at a participating hospital or a 75 copay at a non participating
hospital for each emergency room visit that does not result in a hospital admission and any charges for services that are not covered by this Plan 11
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay for generic drugs or a 15 copay for brand name drugs per
prescription unit or refill .1 3
Dental care Accidental injury benefit you pay nothing 14
Vision care No current benefit
Out of pocket Your out of pocket expenses for benefits covered under this Plan are limited to the maximum stated copayments required for a few benefits 4
20
22
22
Page 23
24
23
23
Page 24
Total Health Choice 2000
2000 Rate Information for Total Health Choice
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a
career postal employee but not a member of a special postal employment class refer to the category definitions
in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees
RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment
classes or associate members of any postal employee organization Such persons not subject to postal rates
must refer to the applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Broward Dade Plam Beach Counties
Self Only 4A1 58.91 19.63 127.63 42.54 69.70 8.84 69.70 8.84
Self and Family 4A2 146.67 48.89 317.78 105.93 173.56 22.00 173.56 22.00
22 24