Enrollment in this Plan is limited see page 20 for requirements in benefits see page 5
Enrollment code
2C1 Self only
2C2 Self and family
Visit the OPM website at httpwwwopmgovinsure
And
The Plans website at httpwwwpchpnet
Authorized for distribution by the
United States Office of
Personnel Management RI73 799
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Piedmont Community HealthCare 2000
Table of Contents
Introduction
3
Plain language
3
How to use this brochure
4
Section 1 Health Maintenance Organizations
5
Section 2 How we change for 2000
5
Section 3 How to get benefits
67
Section 4 What to do if we deny your claim or request for service
89
Section 5 Benefits
917
Section 6 General exclusions Things we dont cover
18
Section 7 Limitations Rules that affect your benefits
19
Section 8 FEHB facts
2021
Inspector General Advisory Stop Healthcare Fraud
22
Summary of benefits
Inside Back Cover
Premiums
Back Cover
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Piedmont Community HealthCare 2000
Introduction
Piedmont Community HealthCare 2255 Langhorne Road Lynchburg VA 24501
This brochure describes the benefits you can receive from Piedmont Community HealthCare under its contract CS2858 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 5 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Governments 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 Piedmont Community HealthCare 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 under
standable
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Piedmont Community HealthCare 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 Plans benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make compari
sons 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 informa
tion about nonFEHB benefits
6 General exclusions Things we dont 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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Piedmont Community HealthCare 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 wellbaby 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 pointofservice benefits POS you may have to
submit claim forms You should join an HMO because you prefer the plans 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 andor 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
Programwide This year you have a right to more information about this Plan care management our networks facilities and
changes 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 OBGYN 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 is new to the FEHB Program for 2000
this Plan
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Piedmont Community HealthCare 2000
Section 3 How to get benefits
What is this Plans To enroll with us you must live or work in our service area This is where our providers practice Our service area service area is the cities of Bedford and Lynchburg the counties of Amherst Appomattox Bedford
Campbell Charlotte Halifax Nelson and Pittsylvania
Ordinarily you should get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care or pointofservice benefits
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 feeforservice plan or an HMO that has agreements with affiliates in
other areas Children in college are covered for emergency and urgent care however routine care is not
covered at the higher pointofservice level while outside of our service area If you or a family member
move you do not have to wait until Open Season to change plans Contact your employing or retirement
office
How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount or for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services
After you pay 1000 in copayments or coinsurance for one family member or 2000 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year for inplan services Outofplan services require 2000 for one family member or 4000 for two
or more family members This is called an outofpocket maximum limit However copayments or
coinsurance for your prescription drugs dental services and vision services and outofplan deductibles
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 submit You normally wont have to submit claims to us unless you receive services from a provider who claims doesnt contract with us or you use pointofservice 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 circum
stances beyond your control prevented you from filing on time
Who provides my Your Piedmont Community HealthCare physician provides your health care Your primary care health care physician will coordinate all of your health care needs Please note that a referral from your primary
care physician is not necessary for emergency services or for up to two office visits each year for female
members to a Plan OBGYN physician
What do I do if my Call us We will help you select a new one primary care
physician leaves the Plan
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician and the Plan need to go into the will help make the necessary hospital arrangements
hospital
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Section 3 How to get benefits continued
What do I do if Im First call our customer service department at 8886743368 If you are new to the FEHB Program we will in the hospital when arrange for you to receive care If you are currently in the FEHB Program and are switching to us your
I join this former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist If you need to see a specialist specialty care frequently because of a chronic complex or serious medical condition your primary care physician will
develop a treatment plan that allows you to see your specialist for a certain number of visits without
additional referrals Your primary care physician will use our criteria when creating your treatment plan
Your primary care physician will obtain the proper referrals or authorizations This must be done before
you receive services
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a special seeing a specialist ist ask if you can see your current specialist If your current specialist does not participate with us you
when I enroll must receive treatment from a specialist who does in order to receive inplan benefits Generally we will not pay benefits at the inplan level for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive specialist leaves the services from your current specialist until we can make arrangements for you to see someone else
Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing serious illness and your provider for up to 90 days after we notify you that we are terminating our contract with the provider
my provider leaves unless the termination is for cause If you are in the second or third trimester of pregnancy you may the Plan or this continue to see your OBGYN until the end of your postpartum care
Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and Program 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 OBGYN care you receive from your current
provider until the end of your postpartum care
How do you Your physician must send us a referral before sending you to a hospital referring you to a specialist or authorize medical recommending followup care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice
How do you decide Experimental or investigative means any service or supply which is determined to be experimental or if a service is investigative in the Plans sole discretion The Plan will apply the following criteria in exercising its
experimental or discretion investigational 1 Any supply or drug used must have received final approval to market by the United States Food and Drug
Administration
2 There must be sufficient information in the peer reviewed medical and scientific literature to enable the
Plan to make conclusions about safety and efficacy
3 The available scientific evidence must demonstrate a beneficial effect on health outcomes outside a
research setting and
4 The service or supply must be a safe and effective outside a research setting as existing diagnostic or
therapeutic alternatives
A service or supply will be experimental or investigative if the Plan determines that any one of the four
criteria is not satisfied
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Piedmont Community HealthCare 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or wont 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 60 days 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 the request is still denied you must submit another written request within 21 days
for the Plans Utilization Review Committee to review the complaint The committee will review the request within 45 days and
return the results to you within 15 days of the committee meeting
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service
What if I have a Call us 8049474463 or 18004007247 and we will expedite our review serious or life
threatening condition and
you havent 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 denied my request that they can give your claim expedited treatment too Alternatively you can call OPMs health benefits
for care and my Contract Division 3 at 202 6060755 between 8 am and 5 pm Serious or lifethreatening conditions are condition is serious ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
or life 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 limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this
brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical recordsand explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which
claim
Who can make the request Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled persons
representative They must send a copy of the persons specific written consent with the review request
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Section 4 What to do if we deny your claim or request for service continued
What if OPM OPMs decision is final There are no other administrative appeals If OPM agrees with our decision your upholds the Plans only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review file a lawsuit 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 and us to the 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
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 Xrays performed in the office during that visit Within the
service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 10 copay for a doctors house call and 10 of allowable charge for home visits by
nurses and health aides through the home health benefit
The following Preventive care including wellbaby care and periodic checkups services are
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these
included and five years for women age 40 through 49 one mammogram every one or two years for women age 50 are subject to
through 64 one mammogram every year and for women age 65 and above one mammogram every
the office visit year In addition to routine screening mammograms are covered when prescribed by thedoctor as copay unless
medically necessary to diagnose or treat your illness
stated otherwise Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and Xrays if performed at a facility then you pay 10
of the allowable charge
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal
care by a Plan doctor After the initial copay all other copays are waived for maternity care The mother
at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is
terminated during pregnancy benefits will not be provided after coverage under the Plan has ended
Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confine
ment 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Medical and Surgical Benefits continued
The following Voluntary sterilization and family planningservices services are Diagnosis and treatment of diseases of the eye
included and Allergy testing and treatment including testing and treatment materials such as allergy serum are subject to The insertion of internal prosthetic devices such as pacemakers and artificial joints you pay 10 of the
the office visit allowable charge copay unless Cornea heart heartlung kidney kidneypanceas and liver transplants allogeneic donor bone marrow
stated otherwise transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for continued the following conditions acute lymphocytic or nonlymphocytic leukemia advanced Hodgkins lymphoma
advanced nonHodgkins lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial
ovarian cancerand testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are
covered when approved by the Medical Director Transplants are covered in full Medical and hospital
expenses related to the removal of a living organ from a donor will be covered when the recipient is covered
by this Plan Donor transportation costs for covered transplants will not be covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis
andremain in the hospital up to 48 hours after the procedure You pay 10 of the allowable charge
Dialysis you pay 10 of the allowable charge
Chemotherapy radiation therapy and inhalation therapy you pay 10 of the allowable charge
Surgical treatment of morbid obesity you pay 10 of the allowable charge
Orthopedic devices such as braces you pay 10 of the allowable charge
Prosthetic devices such as artificial limbs breast prostheses and surgical bras as well as their
replacement and lenses following cataract removal you pay 10 of the allowable charge
Durable medical equipment such as wheelchairs and hospital beds bedside commode shower chair tub
rails canes crutcheswalkers slings splints cervical collars traction apparatus oxygen and oxygen equip
ment ostomy supplies indwelling catheters and catheter bags respirators and jobst stockings or equivalent
when prescribed by a vascular surgeon following vascular surgery You pay 10 of the allowable charge
Any durable medical equipment not listed is not covered
Chiropractic services 500 limit per calendar year
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 You pay 10 of the allowable charge
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan
providers you pay 10 of the allowable charge
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congeni tal defects such as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent
to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and
cysts All other procedures involving the teeth or intraoral areas surrounding the teeth are not covered You
pay 10 of the allowable charge
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 members appearance and if the condition can reason
ably be expected to be corrected by such surgery Reconstructive surgery after a mastectomy is a covered
service The initial reconstructive surgery will be covered and any medically necessary followup treatment
received within one year of the initial reconstructive 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 You pay 10 of the allowable charge
Shortterm rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient
basis for up to 90 days per condition if significant improvement can be expected within 90 days you pay 10
of the allowable charge per outpatient facility session or you pay 10 copay per office 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 selfcare and improved functioning in other activities of daily
living
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Piedmont Community HealthCare 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
Limited benefits Diagnosis and treatment of infertility is covered you pay 10 of the allowable charge Fertility drugs are continued covered under the Prescription Drug Benefit Artificial insemination and 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 90 days from initiation of treatment you pay 10 of the allowable charge
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 surgicallyinduced sterility Procedures services and supplies related to sex transforma
tions Penile implants
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Longterm rehabilitative therapy
Foot orthotics
Blood and blood derivatives not replaced by the member growth hormones and methadone maintenance at
any level of care
Corrective eyeglasses frames and contact lenses including the fitting of contact lenses except as necessary
for the first pair of corrective lenses following cataract surgery
Dental benefits
Corrective appliances artificial aids devices or equipment not listed as covered
Services for biofeedback therapy hypnotherapy smoking or nicotine addiction Weight control and related
services except those related to morbid obesity as determined by the Plan Remedial or special education
services including diagnostic and other services for learning and developmental disorders conduct disorders
behavioral disabilities mental retardation and autism Marriage counseling when such services extend
beyond the period necessary for shortterm evaluation and crisis intervention
More than one and onehalf hours of psychotherapy in a 24 hour time period Group therapy with one
therapist with greater than eight patients
Dorsal rhizotomy to treat spasticity
Routine foot care such as the removal of corns or calluses and the trimming of nails
Acupuncture therapy and similar services
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized
under the care of a Plan doctor You pay 10 of the allowable charge All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor
may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with 100 day limit per member per calendar year
when fulltime 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 10 of the allowable
charge All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility
Services include inpatient and outpatient care and family counseling these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life
expectancy of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization
but not the cost of the professional dental services Conditions for which hospitalization would be covered
include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment
detoxification 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 15 for nonmedical
substance abuse benefits
What is not Personal comfort items such as telephone and television covered Blood and blood derivatives not replaced by the member
Private duty nursing custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency 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
lifethreatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe
There are many other acute conditions that the Plan may determine are medical emergencies what they
all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if you the service area are unable to contact your doctor contact the local emergency system eg 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 unless
it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely
notified A telephone call from you to your primary care physician while at a urgent care center or emer
gency room will not be treated as a proper referral for urgent care or other nonemergency services You
must contact your primary care physician beforehand
If you need to be hospitalized in a nonPlan facility the Plan must be notified within 48 hours or on the first
working day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in nonPlan 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 nonPlan 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 followup care recommended by nonPlan providers must be approved by
the Plan or provided by Plan providers except as covered under POS benefits
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 10 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 50 emergency room
copayment is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because of the service area injury or unforeseen illness Neither elective care nor care required as a result of circumstances which
could reasonably have been foreseen prior to departure from the service area is a covered service Benefits
for maternity care do not cover normal term delivery outside the service area but do include earlier
complications of pregnancy or unexpected delivery occurring outside the service area
If you need to be hospitalized the Plan or your primary care physician 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 Failure to notify the Plan or your primary care physician may result in reduced benefits or
no benefits 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 followup care recommended by nonPlan providers must be approved by
the Plan or provided by Plan providers except as covered under POS benefits
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Piedmont Community HealthCare 2000
Section 5 Benefits continued
Emergency Benefits continued
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 10 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 50 emergency room
copayment is waived
What is covered Emergency care at a doctors 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 Elective care or nonemergency care except as covered under POS Benefits covered Emergency care provided outside the service area if the need for care could have been foreseen before
leaving the service area except as covered under POS Benefits
Medical and hospital costs resulting from a normal fullterm delivery of a baby outside the service area
except as covered under POS Benefits
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon nonPlan providers 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 explana
tion 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 Plans decision you may request reconsidera
tion in accordance with the disputed claims procedure described on page 8
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Piedmont Community HealthCare 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse
Mental conditions What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay a 10 copay for each covered office visit all charges thereafter You pay 10 of the allowable charge for
each covered outpatient hospital visit
Inpatient care Up to 30 days of hospitalization each calendar year you pay 10 of the allowable charge for the first 30 days all charges thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively shortterm treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless deter
mined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a
shortterm psychiatric condition
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
Services for the psychiatric aspects are provided in conjunction with the mental conditions benefit shown
above Outpatient visits to Plan mental health providers for followup care and counseling are covered as
well as inpatient services necessary for diagnosis and treatment The mental conditions visitday limita
tions and copays apply
Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 10 copay for each covered office visit all charges thereafter You pay 10 of the allowable charge for each covered
outpatient hospital visit
Inpatient care Up to 30 days per calendar year in a substance abuse treatment program you pay 10 of the allowable charge during the benefit period all charges thereafter There is a 90day lifetime limit for inpatient
substance abuse rehabilitation services
What is not covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dis pensed for up to a 31day supply You pay a copay per prescription unit or refill for up to a 31day supply
or 100unit supply whichever is less
You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic
substitution is not permissible When generic substitution is permissible ie 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
prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary
Nonformulary drugs will be covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs contraceptive diaphragms IUDs Norplant Depo Provera
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 glucose test tablets and test tape Benedicts
solution or equivalent glucose monitors and acetone test tablets are covered under the durable medical
equipment benefit you pay 10 of the allowable charge
Intravenous fluids and medication for home use implantable drugs such as Norplant and some injectable
drugs such as Depo Provera are covered under Medical and Surgical Benefits
Limited Benefits Drugs for the treatment of sexual dysfunction have dosage limitations Contact the plan for the dosage limitations
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a nonPlan pharmacy except for outofarea 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
Drugs and medications not approved by the US Food and Drug Administration FDA for the purpose
prescribed
DESI drugs ie drugs which are of questionable therapeutic value as designated by the FDAs Federal
Drug Efficacy Study
Other Benefits
Dental care Not 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
What is not covered Corrective lenses or frames Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Point of Service POS Benefits
Facts about this At your option you may choose to obtain benefits covered by this Plan from nonPlan doctors and hospi Plans POS option tals whenever you need care except for the benefits listed below under What is not covered Benefits not
covered under Point of Service must either be received from or arranged by Plan doctors to be covered
When you obtain covered nonemergency medical treatment from a nonPlan doctor without a referral from
your primary care physician or a Plan doctor without a referral from your primary care physician you are
subject to the deductibles coinsurance and outofpocket maximum benefits stated below
What is covered Precertification not required for outofplan benefits Deductible 500 per individual 1000 per family
Coinsurance you pay 30 of allowable charge
Outofpocket maximum benefit 2000 per individual 4000 per family
Hospitalextended care you pay 30 of allowable charge after deductible
Emergency benefits you pay 30 of allowable charge after deductible
What is not covered All items that are not covered inplan Amounts over the allowable charge amount
How to obtain benefits receive covered services from a nonPlan provider or without a referral from
your primary care physician You may be required to file claim forms for services received from nonPlan
providers
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Section 6 General exclusions Things we dont 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
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
Expenses you incurred while you were not enrolled in this Plan
ExperimentalInvestigative medical or surgical procedures and drugs as determined by the Plan in its sole discretion
Services which are not medically necessary as determined by the Plan in its sole discretion and
Services for injuries or diseases related in any way to employment when
1 You receive payment from the employer on account of the disease or injury
2 The employer is required by federal state or local laws or regulations to provide benefits to you or
3 You could have received benefits for the injury or disease if you had complied with applicable laws and regulations
This exclusion applies whether or not you have waived your rights to payment for the services available or have failed to comply
with procedures set out by the employer to receive these benefits It also applies if the employer or the employers insurance
company or group selfinsurance association reaches any settlement with you for an injury or disease related in any way to
employment
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Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form If you are eligible for Medicare you may enroll in a MedicareChoice
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 MedicareChoice plan when one is available in your area For information
on suspending your FEHB enrollment and changing to a MedicareChoice plan contact your retirement
office If you later want to reenroll in the FEHB Program generally you may do so only at the next Open
Season If you involuntarily lose coverage or move out of the MedicareChoice 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 MedicareChoice plans contact your local Social Security Administration
SSA office or request it from SSA at 18006386833
Other group When anyone has coverage with us and with another group health plan it is called double coverage You insurance coverage must tell us if you or a family member has double coverage You must also send us documents about other
insurance if we ask for them When you have double coverage one plan is the primary payer it pays
benefits first The other plan is secondary it pays benefits next We decide which insurance is primary
according to the National Association of Insurance Commissioners Guidelines If we pay second we will
determine what the reasonable charge for the benefit should be After the first plan pays we will pay either
what is left of the reasonable charge or our regular benefit whichever is less We will not pay more than
the reasonable charge If we are the secondary payer we may be entitled to receive payment from your
primary plan We will always provide you with the benefits described in this brochure Remember even
if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that another responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of treat
injuries ment 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 workplacerelated 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 Government indirectly pays for
Agencies
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Piedmont Community HealthCare 2000
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 right to information information about about your health plan its networks providers and facilities You can also find out about care management which
your HMO includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPMs website wwwopmgov lists the specific types of information that we must
make available to you If you want specific information about us call 8886743368 or write to Piedmont
Community HealthCare PO Box 2455 Lynchburg VA 24501 You may also contact us by fax at 8049474465 or
visit our website at wwwpchpnet
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees Health information about Benefits Plans brochures for other plans and other materials you need to make an informed decision about
enrolling in the When you may change your enrollment FEHB Program 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 dont 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 benefits and premi begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
ums effective
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB 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 SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and your unmarried coverage are dependent children under age 22 including any foster or step children your employing or retirement office authorizes
available for me coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older and my family who is incapable of selfsupport If you have a Self Only enrollment you may change to a Self and Family enroll
ment 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 access to it claims records
confidential OPM this Plan and subcontractors when they administer this contract This Plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation
Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating andor prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirma
tion letter
What if I paid a Your old plans deductible continues until our coverage begins deductible under my
old plan
Preexisting We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this conditions Plan solely because you had the condition before you enrolled
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Piedmont Community HealthCare 2000
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 Your enrollment ends unless you cancel your enrollment or
Plan ends 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 spouses 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 exspouses 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 7927 which describes TCC and the RI 705 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 2percent administrative charge The government does not share your
costs
You receive another 31day extension of coverage when your TCC enrollment ends unless you cancel your TCC
or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll TCC 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 60day deadline
How can I convert You may convert to an individual policy if to individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your
coverage 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 preexisting 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 how Certificate of long you have been enrolled with us You can use this certificate when getting health insurance or other health care
Group Health Plan coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce Coverage 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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Piedmont Community HealthCare 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 8886743368 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
2024183300 US
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 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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Piedmont Community HealthCare 2000
Summary of Benefits for the Piedmont Community HealthCare Health Benefit Plan 2000
Do not rely on this chart alone All benefits are 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 COV
ERED UNDER THIS PLAN WITH THE EXCEPTIONS OF EMERGENCY CARE AND POS BENEFITS ARE COVERED
ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan paysprovides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital 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 10 of
allowable charge 12
Extended care All necessary services no dollar or day limit You pay 10 of allowable charge 12
Mental Diagnosis and treatment of acute psychiatric conditions for upto 30 days of inpatient Conditions care per year You pay 10 of allowable charge 15
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay 10 of allowable charge 15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialists care preventive care including wellbaby care periodic check ups
and routine immunizations laboratory tests and Xrays complete maternity care You pay 10 copay per office visit after the initial 10 copay all copays are waived for
maternity care 10 per house call by a doctor you pay 10 of the allowable charge for outpatient facility services 9
Home health care All necessary visits by nurses and health aides you pay 10 of the allowable charge 10
Mental Conditions Up to 20 outpatient visits per year You pay a 10 copay per visit for office visits 15
Substance Abuse Up to 20 outpatient visits per year You pay a 10 copay per visit for office visits 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit and any charges for
services that are not covered by this Plan 13
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for generic drugs and a 15 copay for brand
name drugs 16
Dental care No current benefit 16
Vision care One refraction annually You pay a 10 copay per visit 16
Point of Service Benefits Services from nonPlan doctors and hospitals and services received without a referral from your primary care physician You pay deductibles and coinsurance and an outof
pocket maximum benefit applies 17
Outofpocket maximum Copayments are required for a few benefits however after your outofpocket expenses reach a maximum of 1000 per Self Only or 2000 per Self and Family enrollment per
calendar year covered benefits will be provided at 100 This copay maximum does not include charges for prescription drugs and vision benefits There is also an outof
pocket maximum for the charges you pay when you use POS benefits 6
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Piedmont Community HealthCare 2000
2000 Rate Information for
PIEDMONT COMMUNITY HEALTHCARE VIRGINIA
NonPostal rates apply to most nonPostal 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 US 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 702 to determine which rate applies to you
Postal rates do not apply to noncareer 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
NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of
Enrollment Code Govt Share Your Share Govt Share Your Share USPS Share Your Share USPS Share Your Share
Self Only 2C1 6728 2242 14576 4859 7961 1009 7961 1009
Self and 2C2 17597 8418 38127 18239 20774 5241 20102 5913
Family
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