Page Navigation Panel Document Outline
Document Outline

Introduction
Plain Language
Inspector General Advisory
Section 1. Facts about this HMO plan

How we pay providers
Who provides my health care?
Your Rights
Service Area

Section 2. How we change for 2002

Program-wide changes
Changes to this Plan

Section 3. How you get care

Identification cards
Where you get covered care

Plan providers
Plan facilities

What you must do to get covered care

Primary care
Specialty care
Hospital care

Circumstances beyond our control
Services requiring our prior approval

Section 4. Your costs for covered services

Copayments
Deductible
Coinsurance

Section 5. Benefits Overview

(a) Medical services and supplies provided by physicians and other health care professionals
(b) Surgical and anesthesia services provided by physicians and other health care professionals
(c) Services provided by a hospital or other facility, and ambulance services
(d) Emergency services/accidents
(e) Mental health and substance abuse benefits
(f) Prescription drug benefits
(g) Special features

Medical Case Management
Services for deaf and hearing impaired
Travel benefit/services overseas

(h) Dental benefits
(i) Non-FEHB benefits available to Plan members

Section 6. General exclusions „ things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage

When you have Other health coverage

What is Medicare
The Original Medicare Plan (Part A or B)
Medicare managed care plan

If you do not enroll in Medicare Part A or B
TRICARE/Workers Compensation/Medicaid
Other Government agencies
When others are responsible for injuries

Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts

Coverage information

No pre-existing condition limitation
Where you get information about enrolling in the FEHB Program
Types of coverage available for you and your family
When benefits and premiums start
Your medical and claims records are confidential
When you retire

When you lose benefits

When FEHB coverage ends
Spouse equity coverage
Temporary Continuation of Coverage (TCC)
Converting to individual coverage

Long term care insurance is coming later in 2002
Index
Summary of benefits
Rates

Pages 1--44 from Health Insurance Plan of New York

Page 1 2

2002 Health Insurance Plan (HIP/ HMO) 1
Health Insurance Plan (HIP/ HMO) http:// www. HIPUSA. com
2002

A Health Maintenance Organization

Serving: Greater New York City Area
Enrollment in this Plan is limited. You must live in our Geographic service area to
Enroll. See page 5 for requirements.

Enrollment codes:
511 Self Only
512 Self and Family

This plan has Commendable Accreditation
from the NCQA. See the FEHB 2002 Guide for
more information on NCQA.

RI 73-001

HEALTH PLAN OF NEW YORK
„ 1
1 Page 2 3

Your catastrophic protection out-of-pocket maximum .............................................................................................. 9

Section 5. Benefits Overview .................................................................................................................................................... 10

Travel benefit/ services overseas ................................................................................................................... 28
(h) Dental benefits ................................................................................................................................................. 28
(i) Non-FEHB benefits available to Plan members .............................................................................................. 29

Table of Contents 2
2 Page 3 4

No pre-existing condition limitation ................................................................................................................. 39
Where you get information about enrolling in the FEHB Program .................................................................. 39
Types of coverage available for you and your family ....................................................................................... 39
When benefits and premiums start .................................................................................................................... 39
Your medical and claims records are confidential ............................................................................................. 39
When you retire ................................................................................................................................................ 39
When you lose benefits .......................................................................................................................................... 40

When FEHB coverage ends .............................................................................................................................. 40
Spouse equity coverage .................................................................................................................................... 40
Temporary Continuation of Coverage (TCC) .................................................................................................. 40
Converting to individual coverage ................................................................................................................... 40
Getting a Certificate of Group Health Plan Coverage ...................................................................................... 40
Long term care insurance is coming later in 2002 ..................................................................................................................... 41
Index ........................................................................................................................................................................................... 42
Summary of benefits .................................................................................................................................................................. 43
Rates ............................................................................................................................................................................. Back cover

Table of Contents 3
3 Page 4 5
2002 Health Insurance Plan (HIP/ HMO) 4
Introduction
The Health Insurance Plan of Greater New York 7 West 34th Street

New York, NY 10001
This brochure describes the benefits of HIP/ HMO under our contract (CS 1040) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of benefits. No oral

statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are 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. You do not have a right to benefits that were available

before January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002 and changes are
summarized on page 43. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member, "we" means HIP.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or email us at fehbwebcomments@ opm. gov. You may also write to OPM at

the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW
Washington, DC 20415-3650

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 1-877-TELL-HIP and explain the situation.

If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States 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 the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency
may also take administrative action against you.

Introduction / Plain Language / Advisory 4
4 Page 5 6
2002 Health Insurance Plan (HIP/ HMO) 5
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, 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.
How we pay providers
HIP is a mixed model plan. We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your

copayments or coinsurance.
Who provides my health care?
At the present time, approximately 15,000 professional medical providers participate in HIP/ HMO and provide medical services to more than 770,000 enrollees. Our network covers 74 medical specialties ranging from family practice to urology. In addition

to services from participating medical providers, you can receive paramedical services including social services, nutrition and health education at group centers.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information that we

must make available to you. Some of the required information is listed below.
The HIP Health Plan of New York (HIP) was organized over 50 years ago as a non-profit corporation.
On December 1, 1978, HIP became a New York certified Health Maintenance Organization (HMO).
Responsibility for HIP/ HMO policy and operations is vested in an unpaid Board of Directors. This Board is composed of distinguished representatives of labor, consumers, doctors and the general public. The Board selects the principal

administrative officer, the President, and holds him responsible for the enforcement of Board policy and for the operations of the Plan.

HIP/ HMO has Commendable accreditation from the National Committee for Quality Assurance (NCQA).
If you want more information about us and you are a current member, call 1-800-HIP-TALK (1-800-447-8255. If you are a
potential member, please call 1-888-866-7461 for more information, or write to The HIP Health Plan of New York, 7 West
34 th Street, New York, NY 10001. You may also visit our website at http:// www. hipusa. com.

Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is: New York City (the Boroughs of Manhattan, Brooklyn, Bronx, Queens, and Staten Island), all of Nassau, Orange, Rockland,

Suffolk and Westchester Counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay
only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services
have prior plan approval.

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.

Section 1. 5
5 Page 6 7
2002 Health Insurance Plan (HIP/ HMO) 6
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits.
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does
not change benefits.

Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)

We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5 (a))

Changes to this Plan
Your share of the non-Postal premium will increase by 16.8% for Self Only or 23.1% for Self and Family.

We no longer limit total blood cholesteral tests to certain age groups. (Section 5 (a))
We now cover certain intestinal transplants. (Section 5 (b))
We no longer maintain reciprocal agreements with other HMOs throughout the country.
We have clarified the prostate cancer screening benefit. (Section 5 (a))
Your prescription drug copays are now $10.00 generic formulary, $15.00 name brand formulary, and $35.00 non-formu-lary per 30-day supply. (Section 5( f))

Section 2. 6
6 Page 7 8
2002 Health Insurance Plan (HIP/ HMO) 7
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election
Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-HIP-TALK
(1-800-447-8255).
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We
credential Plan providers according to the National Committee of Quality Assurance (NCQA) and other Industry standards.

We list Plan providers in the provider directory, which we update quarterly. For a current directory listing, members should call 1-800-HIP-TALK (1-800-447-8255).
Potential members should call 1-888-866-7461. The list is also available on our website at http:// www. HIPUSA. com.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the
provider directory, which we update quarterly. The list is also available on our website at http:// www. HIPUSA. com.

What you must do It depends on the type of care you need. First, you and each family member to get covered care must choose a primary care physician. This decision is important, since your
primary care physician provides or arranges for most of your health care.
Our directory lists the locations and phone numbers of our primary care doctors. It also indicates whether or not a doctor is accepting new patients. After you

select a specific provider from the directory, you should call the provider to verify that he or she still participates with HIP and is accepting new patients.
You may also call our Customer Service Department at 1-800-HIP-TALK (1-800-447-8255) to find out if your doctor participates with HIP.

Primary care Your primary care physician can be a family practitioner, internist, or pediatrician.
Your primary care physician will provide most of your health care, or give you a
referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may receive primary and preventative obstetric and gynecologic care,
chiropractic care and routine eye care without your primary care physician's referral. Except in a medical emergency, or when a primary care doctor has designated
another doctor to see his or her patients, you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services.
When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician
authorized a certain number of visits without additional referrals. The primary
care physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives you a referral.

Section 3. 7
7 Page 8 9
2002 Health Insurance Plan (HIP/ HMO) 8
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan

that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when
creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you
need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you
must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may
receive services from your current specialist until we can make arrangements
for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist
because we:

terminate our contract with your specialist for other than cause; or drop out of the Federal Employees Health Benefits (FEHB) Program and

you enroll in another FEHB Plan; or reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the FEHB Program,
contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist

until the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing

or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-HIP-TALK (1-800-447-8255). If you

are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will

make all reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Your physician must

get our approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical practice.
The following are other services that require prior approval:

Skilled nursing facility services Hospice care Inpatient mental health Inpatient hospital admissions (non-emergent)
Ambulatory surgery services Inpatient physical and occupational therapies Outpatient hospital services Inpatient substance abuse
Home health care services Organ transplants Durable medical equipment Growth hormone

Section 3. 8
8 Page 9 10
2002 Health Insurance Plan (HIP/ HMO) 9
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. when you receive services.

Example: When you see your primary care physician you pay a copayment
of $10 per office visit and when you go to the Emergency Room, you pay $25
per visit.

Deductible A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for them. We do not have a
deductible.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care. We do not have coinsurance.

Your catastrophic protection We do not have an out-of-pocket maximum.
out-of-pocket maximum

Section 4. 9
9 Page 10 11
2002 Health Insurance Plan (HIP/ HMO) 10
Section 5. Benefits --OVERVIEW
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning
of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-HIP-TALK (1-800-447-8255) or at
our website at www. hipusa. com. If you are a potential member, call us at 1-888-866-7641.

(a) Medical services and supplies provided by physicians and other health care professionals ......................................... 11-17
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals.................................... 18-20
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ................................................................... 21-22
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance

(d) Emergency services/ accidents....................................................................................................................................... 23-24
Medical emergency Ambulance

(e) Mental health and substance abuse benefits........................................................................................................................ 25
(f) Prescription drug benefits.............................................................................................................................................. 26-27
(g) Special features ................................................................................................................................................................... 28
Medical Case Management Progam Travel benefit/ services overseas
Services for deaf and hearing impaired

(h) Dental benefits..................................................................................................................................................................... 28
(i) Non-FEHB benefits available to Plan members ................................................................................................................. 29
Summary of benefits................................................................................................................................................................... 43

Section 5. 10
10 Page 11 12
2002 Health Insurance Plan (HIP/ HMO) 11
Professional services of physicians $10 per office visit
In physician's office

In an urgent care center
Office medical consultations
Second surgical opinion

During a hospital stay Nothing
In a skilled nursing facility
At home

Not covered: All charges
Physical Examinations that are not necessary for medical reasons, such as
those required for obtaining or continuing employment or insurance.

Section 5( a). Medical services and supplies provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions
in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9, Coordinating benefits with other
coverage, including Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit

Section 5( a). 11
11 Page 12 13
2002 Health Insurance Plan (HIP/ HMO) 12
Preventive care, adult You pay
Routine screenings, such as: $10 per office visit
Total Blood Cholesterol once every 3 years
Colorectal Cancer Screening, including:
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Standard diagnostic testing of prostate cancer, including but not limited to a digital
rectal examination and a prostate-specific antigen testing for men of any age
with a prior history of prostate cancer.

Annual standard diagnostic examination including but not limited to a digital
rectal examination and a prostate-specific antigen testing for men age fifty and
over who are asymptomatic and for men age forty and over with a family history
of prostate cancer or other prostate cancer risks.

Routine pap test $10 per office visit
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and treatment, above.

Routine mammogram covered for women age 35 and older, as follows: $10 per office visit
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Not covered: Physical exams required for obtaining or continuing employment All charges
or insurance, attending schools or camp, or travel.

Routine immunizations in accordance with accepted medical practice $10 per office visit
and standards such as:

Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Not covered: All charges
Autogenous vaccines
Adult immunizations related to foreign travel

Section 5( a).

---------------------------------------------------------------------------------------- 12
12 Page 13 14
2002 Health Insurance Plan (HIP/ HMO) 13 Section 5( a).
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Well-child care charges for routine examinations, immunizations and care Nothing
Examinations, such as:
Eye exams through age 17 to determine the need for vision correction
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours
after a cesarean delivery. We will extend your inpatient stay if medically necessary.

We cover routine nursery care of the newborn child during the covered portion of
the mother's maternity stay. We will cover other care of an infant who requires
non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and
injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$10 first office visit; waived in
subsequent visits.

Not covered: Routine sonograms to determine fetal age, size or sex. All charges
Family planning
A broad range of voluntary family planning services, limited to: $10 per office visit
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

NOTE: We cover oral contraceptives under the prescription drug benefit.
Not covered: All charges
Reversal of voluntary surgical sterilization, genetic counseling. 13
13 Page 14 15
2002 Health Insurance Plan (HIP/ HMO) 14
Infertility services You pay
Diagnosis and treatment of infertility, such as: $10 per office visit
Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)

Fertility drugs (injectables)
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Not covered: All charges
Assisted reproductive technology (ART) procedures, such as:
In vitro fertilization
Embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer

Services and supplies related to excluded ART procedures
Cost of donor sperm or sperm banking
Cost of donor egg

Allergy care
Testing and treatment $10 per office visit
Allergy injection

Allergy serum Nothing
Not covered: Provocative food testing and sublingual allergy desensitization All charges

Treatment therapies
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 20.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment.
Growth Hormone must meet medical necessity guidelines in order for
services to be approved.

Section 5( a). 14
14 Page 15 16
2002 Health Insurance Plan (HIP/ HMO) 15 Section 5( a).
Nothing per visit during
covered inpatient admission

Physical and occupational therapies You pay
Up to 2 months per condition if significant improvement can be $10 per office visit
expected for the services of each of the following:
-qualified physical therapists and
-occupational therapists.

Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction.

Speech therapy
Up to 2 months of speech therapy each calendar year for services $10 per office visit
from the following:
-licensed or certified speech therapists

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury $10 per office visit
Hearing testing for children through age 17 (see Preventive care, children)

Not covered: All charges
All other hearing testing
Hearing aids, testing and examinations for them

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye $10 per office visit

Annual eye refractions $10 per office visit
Lenses following cataract removal $10 per office visit
Not covered: All charges
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic or $10 per office visit
peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.
Not covered: All charges
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting
surgery) 15
15 Page 16 17
2002 Health Insurance Plan (HIP/ HMO) 16 Section 5( a).
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose $10 per office visit
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c) for payment information. See 5( b) for coverage of the surgery to insert
the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Note: Call us at 1-800-HIP-TALK (1-800-447-8255) as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider
to rent or sell you the equipment at discounted rates and will tell you more about
this service when you call.

Not covered: All charges
Orthopedic and corrective shoes unless we determine that the Member's
condition requires a corrective shoe that can only be made from a mold or

cast of his or her foot.

Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices

Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable Nothing
medical equipment prescribed by your Plan physician, such as oxygen and
dialysis equipment. Under this benefit, we also cover:

hospital beds
wheelchairs
crutches
walkers
blood glucose monitors and
insulin pumps

Note: Prior approval is required. Call us at 1-800-HIP-TALK (1-800-447-8255)
as soon as your Plan physician prescribes this equipment. We will arrange with
a health care provider to rent or sell you durable medical equipment at discounted
rates and will tell you more about this service when you call.

Not covered: All charges
Motorized and customized wheel chairs 16
16 Page 17 18
2002 Health Insurance Plan (HIP/ HMO) 17 Section 5( a).
Home health services You pay
Home health care ordered by a Plan physician and provided by a Nothing
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Not covered: All charges
Nursing care requested by, or for the convenience of, the patient or
the patient's family;

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative (i. e. hygiene,
feeding, exercising, moving the patient, homemaking, companionship or
giving oral medication).

Chiropractic
Manipulation of the spine and extremities $10 per office visit
Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application

Note: You do not need a referral from your primary care doctor.

Alternative treatments
No benefit. We do not cover alternative treatments such as but not limited to: All charges
Naturopathic services
Hypnotherapy
Acupuncture
Biofeedback

Educational classes and programs
Coverage is limited to: $10 per office visit
Smoking Cessation In a HIP Free & Clean Smoking Cessation Program

Up to $100 for one smoking cessation program per member per
lifetime, including all related expenses such as drugs.

Diabetes self-management 17
17 Page 18 19
2002 Health Insurance Plan (HIP/ HMO) 18 Section 5( b).
Section 5( b). Surgical and anesthesia services provided by physicians and other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section

3 to be sure which services require precertification and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Treatment of burns
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible

members must be age 18 or over.
Insertion of internal prosthetic devices. See 5( a) Orthopedic
and prosthetic devices for device coverage information.

Voluntary sterilization
Norplant (a surgically implanted contraceptive and intrauterine
devices (IUDs). Note: Devices are covered under 5 (a)

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care. 18
18 Page 19 20
2002 Health Insurance Plan (HIP/ HMO) 19 Section 5( b).
Reconstructive surgery You pay
Surgery to correct a functional defect Nothing
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant
deviation from the common form or norm. Examples of congenital anomalies
are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers;
and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Not covered: All charges
Cosmetic surgery any surgical procedure (or any portion of a procedure)
performed primarily to improve physical appearance through change in bodily
form, except repair of accidental injury

Surgeries related to sex transformation
Oral and maxillofacial surgery
Oral surgical procedures, limited to: Nothing
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

Not covered: All charges
Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone) 19
19 Page 20 21
2002 Health Insurance Plan (HIP/ HMO) 20
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single -Double
Pancreas
Allogeneic 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

Intestinal transplants (small intestine) and the small intestine with the liver or
small intestine with multiple organs such as the liver, stomach, and pancreas

Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.

Not covered: All charges
Donor screening tests and donor search expenses, except those performed for
the actual donor

Implants of artificial organs
Transplants not listed as covered

Anesthesia

Professional services provided in: Nothing
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Section 5( b). 20
20 Page 21 22
2002 Health Insurance Plan (HIP/ HMO) 21
Section 5( c). Services provided by a hospital or other facility, and ambulance services
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with

other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated

with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as: Nothing
Ward, semiprivate, or intensive care accommodations
General nursing care and
Meals and special diets

NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items

billed by a hospital for use at home

Not covered: All charges
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber
services, guest meals and beds
Private nursing care

Section 5( c). 21
21 Page 22 23
2002 Health Insurance Plan (HIP/ HMO) 22
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.
Not covered: blood and blood derivatives not replaced by the member All charges

Extended-care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): Nothing
A comprehensive range of benefits with no day limit when full-time skilled nursing care is necessary and confinement in a skilled nursing

facility is medically necessary as determined by a Plan doctor and
approved in advance by the Plan.

Not covered: custodial care, rest cures, domiciliary or convalescent care All charges
Hospice care
Up to 210 days in an approved hospice program for a terminally ill member when Nothing
a Plan doctor certifies that the member is terminal and has a life expectancy of
six months or less. Covered services as follows when provided and billed by
the hospice:

Inpatient and outpatient care
Professional services of a physician
Prescription drugs and medical supplies and
Bereavement counseling for immediate family members

Not covered: All charges
Services or supplies not listed in the Hospice Program
Services for respite care
Nutritional supplements, non-prescription drugs or substances, vitamins
and minerals
Independent nursing, homemaker services

Ambulance
Local professional ambulance service when medically appropriate Nothing

Section 5( c). 22
22 Page 23 24
2002 Health Insurance Plan (HIP/ HMO) 23
Section 5( d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including Medicare.

I M
P O
R T
A N
T

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 we may determine are
medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
Call your Primary Care Physician. In extreme emergencies, if you are unable to contact your PCP, call 911 or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so that they
notify the Plan. You or a family member should notify the Plan within 48 hours. You can call 1-888-HIP-AUTH (1-888-447-2884).

If you are outside the service area and need to be hospitalized, you must notify us within 48 hours or on the first working day after your admission, unless it was not reasonable possible to do so. If a Plan doctor believes that care can be better
provided in a Plan hospital, you will be transferred when medically feasible with any transportation charges covered in full. All follow-up care must be provided by participating providers.

We waive your emergency room copay if you are admitted to the hospital for inpatient treatment.
Claims for emergency medical treatment must be sent to HIP/ HMO within 45 days of the date you receive emergency services. The claim must include all supporting documentation.

Section 5( d). 23
23 Page 24 25
2002 Health Insurance Plan (HIP/ HMO) 24
Section 5( d). Emergency services/ accidents (Continued)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center $25 per urgent care center visit
Emergency care as an outpatient or inpatient at a hospital, $25 per emergency room visits;
including doctors' services waived if admitted

Not covered: Elective care or non-emergency care All charges

Emergency outside our service area
Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center $25 per urgent care center visit
Emergency care as an outpatient or inpatient at a hospital, $25 per emergency room visits;
including doctors' services waived if admitted

Not covered: All charges
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

Ambulance
Local ambulance service in an emergency condition or when approved Nothing
in advance by the plan.

See 5( c) for non-emergency service
Not covered: air ambulance All charges

Section 5( d). 24
24 Page 25 26
2002 Health Insurance Plan (HIP/ HMO) 25
Section 5( e). Mental health and substance abuse benefits
When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will
be no greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered service, for valuable information about how cost sharing works. Also read Section 9, about coordinating benefits

with other coverage, including Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include
services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part
of a treatment plan that we approve.

Section 5( e).

Your cost sharing responsibilities are no greater than for other
illness or conditions.

Professional services, including individual or group therapy by providers such $10 per visit as psychiatrists, psychologists, or clinical social workers
Medication management
Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based

intensive outpatient treatment.
Not covered: Services we have not approved. All charges
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us

to pay or provide one clinically appropriate treatment plan in favor of another.
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:

For mental health or substance abuse treatment, call 1-888-447-2526 for authorization and help in selecting a provider. For mental health services
only, you may call a HIP mental health center directly. A trained professional will assess your treatment needs and make all necessary arrangements for you
to see a participating provider at the center. You do not need a referral from your primary care physician for mental health and substance abuse services.

Limitation We may limit your benefit if you do not obtain a treatment plan. 25
25 Page 26 27
2002 Health Insurance Plan (HIP/ HMO) 26
Section 5( f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9, about coordinating benefits with
other coverage, including Medicare.

I M
P O
R T
A N
T

There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan doctor or referral doctor must write the prescription.
Where you can obtain prescription drugs. You may fill the prescription at a participating pharmacy. You
may obtain generic maintenance drugs by mail order.

We use a formulary. Our formulary is a list of effective medications and other items that we have approved
for our members' use. A special committee of medical and pharmacy professionals reviews the formulary annually. We add or delete items on the list based on their findings. We have found that the drugs on our

formulary are safe, effective, and therapeutic in the treatment of disease or illness. We also believe that our formulary improves patient outcomes while controlling drug costs. Please call 1-800-HIP-TALK (1-800-447-8255)
for a copy of our formulary. We cover non-formulary drugs prescribed by a Plan doctor subject to a $35.00 copay.
These are the dispensing limitations. A participating pharmacy will provide up to a 30-day supply of your
prescription. You will pay $10.00 for generic formulary drugs or $15.00 for name brand formulary drugs or $35.00 for non-formulary drugs. You may obtain up to a 90-day supply of certain formulary maintenance

drugs through our mail Order Service. We will reduce your formulary copay by 50% when you use our Mail Order Service. Please contact us to see if your maintenance medication is available through our mail order
service. Sexual dysfunction drugs are not available by mail-order and require prior approval. There are also limits on the number of pills that the pharmacy will fill. Please contact Customer Service Department at 1-
800-HIP-TALK (1-800-447-8255) for details. For further information on using our mail order program, contact Express Scripts 1-800-224-5502.

Plan pharmacies will dispense a generic equivalent if it is available, unless your physician specifically requires a name brand.
Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and
dosage to the original brand name product. Generic drugs cost you and your Plan less money than a name brand drug.

When you have to file a claim. Please call 1-800-HIP-TALK (1-800-447-8255 and we will send you a claim
form. Under normal circumstances, you do not have to file prescription drug claims. You simply present your HIP/ HMO card to the participating pharmacy and pay the appropriate copay.

Section 5( f).
Prescription drug benefits begin on the next page. 26
26 Page 27 28
2002 Health Insurance Plan (HIP/ HMO) 27
Benefit Description You pay
Section 5( f).
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician
and obtained from a Plan pharmacy or through our mail order program:

Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as excluded below
Insulin (copay applies to each vial)
Disposable needles and syringes for the administration of covered medications
Drugs for sexual dysfunction (requires prior approval)
Oral and injectable contraceptive drugs
Smoking cessation drugs and medication, including nicotine patches
Disposable needles and syringes needed to inject covered medication
Nutritional supplements for the treatment of phenylketonuria, branched chain
ketonuria, galactosemia, and homocystinuria
Fertility drugs (oral and injectable)

Note: All drugs are not available by mail order
Implanted time-release medications $10 per prescription unit
Norplant

Not covered: All charges
Drugs and supplies for cosmetic purposes
Drugs available without a prescription or for which there is a
nonprescription equivalent available

Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients and food supplements that can be purchased
without a prescription

Nonprescription medicines
Medical supplies such as dressings and antiseptics

Retail Pharmacy: $10 for generic drugs per 30-day supply
from a participating pharmacy or
$15 for brand name drugs per 30-day supply (subject to drug formulary),

$35 for non-formulary drugs per 30-day supply.

Mail-order: $15.00 per 90-day supply of formulary
generic drugs or
$22.50 per 90-day supply of formulary name brand drugs

Note: Non-formulary drugs are not available from the mail-order
pharmacy. 27
27 Page 28 29
2002 Health Insurance Plan (HIP/ HMO) 28
Section 5( g). Special features
Feature Description
Medical Case Management We offer case management programs for members with chronic or catastrophic illnesses or injuries.

Services for deaf and The telephone number for the hearing impaired is 1-888-HIP-4TDD hearing impaired (1-888-444-7352).
Travel benefit/ services Please refer to the HIP Member Handbook. overseas

Section 5( g) & 5( h).
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your care.
We do not have a calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9, about coordinating benefits with

other coverage, including Medicare.

I M
P O
R T
A N
T

Section 5( h). Dental benefits

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair Nothing sound natural teeth within 12 months of the date of the accident. The need
for these services must result from an accidental injury.
Not covered: All charges Dental services that you receive more than 1 year after the accidental injury
Dental implants Orthodontic and fixed and removable prosthetics
Injuries to teeth that happened while eating
All other dental care

Dental benefits

We have no other dental benefits. 28
28 Page 29 30
2002 Health Insurance Plan (HIP/ HMO) 29
Section 5( i). Non-FEHB benefits available to Plan members
The benefits on this part are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

HIP VIP Medicare HMO Benefits
You may enroll in our HIP VIP Medicare Plan (1) if you are enrolled in Medicare Parts A and B and/ or (2) if you have
FEHB coverage. HIP VIP Medicare Plan covers everything that Medicare covers, plus additional benefits listed below:
You are entitled to all benefits under the FEHB Program. You are entitled to coverage for everything Medicare covers.

You will have no copays for the following covered services: -PCP and specialty care
-Prescriptions for generic and brand formulary only
-Worldwide emergency and urgently needed care

One pair of free eyeglasses every 12 months $500 towards the purchase of a hearing aid every 36 months

You may still enroll in HIP VIP Medicare if you are enrolled in Medicare Parts A and B but do not have FEHB coverage.
However, your benefits will be different than those listed above. You may find out more information about HIP VIP
Medicare benefits by calling 1-888-866-7461.

Fitness Program -HIP offers members discounts to fitness centers and tennis clubs in the New York metropolitan area.
Alternative Medicine -The alternative medicine provides you with access to discounted Acupuncture, Massage and Yoga
Therapy services through an agreement with OneBody, a leading national alternative medicine services organization.*

Should you choose to seek such services, you will have access to the large OneBody network of quality screened providers
at discount rates. You pay no additional plan premiums. The fees you are charged will be at a discount off of the provider's
usual rates. Present your HIP ID card to the OneBody network provider in order to obtain the discounted rate. Call 1-888-
HIP-ALMD (1-888-447-2563) for a list of OneBody network providers.

Dental Care -We cover the following diagnostic and preventive services when provided by participating HIP General Dentists:
One examination (comprehensive or periodic every six months) -$5 per visit
One prophylaxis (cleaning) every six months -$10 per visit
One topical fluoride (for children age 16 and under) every six months -$5 per visit

If you require other additional services, such as x-rays, fillings, crowns or dentures, your participating HIP General Dentist
will provide them at a discounted rate. Please contact HIP's Dental Provider, Careington International, at 1-800-290-0523
for a complete schedule of current reduced member fees. All member fees must be paid directly to the participating HIP
General Dentist.

Questions?
If you have a question concerning Plan benefits or how to arrange for care, contact the Plan's Customer Service
Department or you may write to the Plan at HIP/ HMO, 7 West 34th Street, New York, NY 10001. A special number,
1-888-HIP-4TDD (1-888-447-4833), is available for use by the hearing impaired. You may also contact us at our
Web site at http:// www. HIPUSA. com or call us at 1-800-HIP-TALK (1-800-447-8255).

* Through HIP's agreement with OneBody, this program provides HIP members with discounts for services provided by
OneBody alternative medicine providers. OneBody is responsible for credentialing and managing all program practitioners.
This program is not a covered benefit and HIP makes no representations or guarantees regarding the efficacy or
appropriateness of the services made available. Use of these services is strictly the member's decision and HIP is not
responsible for any acts or omissions of any OneBody alternative medicine provider.

Section 5( i). 29
29 Page 30 31
2002 Health Insurance Plan (HIP/ HMO) 30 Section 6.
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,
disease, injury, or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or 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;

Services, drugs, or supplies related to sex transformations; or

Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Expenses you incurred while you were not enrolled in this Plan. 30
30 Page 31 32
2002 Health Insurance Plan (HIP/ HMO) 31
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on
the UB-92 form. For claims questions and assistance, call us at 1-800-HIP-TALK (1-800-447-8255).

When you must file a claim such as for out-of-area care submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills
and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: HIP Health Insurance Plan of New York 7 West 34th Street

New York, New York 10001
Prescription drugs Under normal circumstances, you do not have to file claims for your prescription drugs. Please call 1-800-HIP-TALK for specific instructions

and a claim form. Our address is:
HIP Health Insurance Plan of New York 7 West 34th Street
New York, New York 10001
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the

service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as
reasonably possible.
When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

Sections 7. 31
31 Page 32 33
2002 Health Insurance Plan (HIP/ HMO) 32
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: HIP Health Plan of New York, 7 West 34th Street, New York, NY 10001; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions
in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was
due. We will base our decision on the information we already have.

We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E
Street, NW, Washington, DC 20415-3630.

The Disputed Claims Process Send OPM the following information:

A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records,
and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representa-tive, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons
beyond your control.

Section 8.

Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description 32
32 Page 33 34
2002 Health Insurance Plan (HIP/ HMO) 33
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed
services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when
OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800-HIP-TALK (1-800-447-8255) and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time.

Section 8. The disputed claims process (Continued)

Section 8. 33
33 Page 34 35
2002 Health Insurance Plan (HIP/ HMO) 34
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a family member is covered under another group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary

payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular

benefit. We will not pay more than our allowance. 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.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older. Some people with disabilities, under 65 years of age.

People with End-stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered

employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or
your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health

plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the
type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is (Part A or B) the way everyone used to get Medicare benefits and is the way most people

get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays
its share and you pay your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. You still pay the
stated copays for your covered health care services.
Claims process when you have the Original Medicare Plan You will probably never have to file a claim form when you have both our plan

and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically

and we will pay the balance of covered charges. You will not need to do anything. To find out if you need to do something about filing your claims,
call us at 1-800-HIP-TALK (1-800-447-8255).
We do not waive costs when you have the Original Medical Plan.

Section 9.
(Primary payer chart begins on next page.) 34
34 Page 35 36
2002 Health Insurance Plan (HIP/ HMO) 35
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly

Primary Payer Chart
Then the primary payer is

Original Medicare This Plan

1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when a) The position is excluded from FEHB........................................................

b) Or, the position is not excluded from FEHB............................................. Ask your employing office which of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if your covered spouse
is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B services) (for other services)

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that you are (except for claims
unable to return to duty, related to Workers' Compensation)

B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) And are an annuitant.................................................................................
b) And are an active employee .....................................................................
c) Are a former spouse of an annuitant, or ....................................................
d) Are a former spouse of an active employee ..............................................

Section 9.

A. When either you --or your covered spouse --are age 65 or over and 35
35 Page 36 37
2002 Health Insurance Plan (HIP/ HMO) 36
Medicare Managed Care Plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan a Medicare
managed care plan. These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to you:

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this
case, we do waive some of our copayments, coinsurance, or deductibles for your FEHB coverage. Please contact us for details.

This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our
FEHB plan. We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area
(if you use our Plan providers), but we will not waive any of our copayments under the FEHB coverage. If you enroll in a Medicare managed care plan, tell us.
We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium.) For
information on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage or move out of the Medicare managed care plan's service area.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered under Medicare Part A or B the FEHB Program. We will not require you to enroll in Medicare Part B and, if
you can't get premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. If

both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State

agency determines they must provide; or
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 OWCP or a similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, or Federal are responsible for your care Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care for for injuries injuries or illness caused by another person, you must reimburse us for any
expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

Section 9. 36
36 Page 37 38
2002 Health Insurance Plan (HIP/ HMO) 37
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on

December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 9.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 9.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care which does not require the continuing attention of trained medical personnel. Custodial care includes any service which can be learned and
provided by an average individual who does not have medical training.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those
services. See page 9.
Durable Medical Equipment, A "Covered Appliance" is one of the following items which is prescribed by a Prosthetic Devices and your Plan physician, dispensed by a Plan provider and approved by HIP. HIP
Orthopedic Devices maintains a list of Covered Appliances that contains items in each of the categories listed below. This list is prepared by HIP and periodically reviewed
and modified. HIP will determine whether a Covered Appliance should be
customized, rented, purchased or repaired.

1. Durable Medical Equipment, which is:
A. Primarily and customarily used to serve a medical purpose;
B. Generally not useful to a person in the absence of illness or injury;
C. Appropriate for use in the home;
D. Medically necessary for the care and treatment of the Member's illness
or injury.

2. Prosthetic devices which replace all or part of an internal body organ or
external limb. However, dental prosthetics needed due to an accidental
injury to sound natural teeth if the service is provided within twelve (12)
months of the accident and necessary in treatment due to congenital
disease or anomaly will be covered.

3. Orthopedic devices which are required for the treatment of injuries or
disorders of the skeletal system and associated muscles, joints and
ligaments.

Experimental or Experimental or investigational service means any evaluation, treatment, investigational service services therapy, or device which involves the application, administration or
use, of procedures, techniques, equipment, supplies, products, remedies,
vaccines, biological products, drugs, pharmaceuticals, or chemical compounds
if, as determined solely by the Plan:

Section 10. 37
37 Page 38 39
2002 Health Insurance Plan (HIP/ HMO) 38
1) Such evaluation, treatment, therapy, or device cannot be lawfully marketed
without approval of the United States Food and Drug Administration or the
New York Department of Health and Rehabilitative Services, and approval
for marketing has not, in fact been given at the time such is furnished to the
covered person; or

2) Reliable evidence, as determined by the Plan, shows that such evaluation,
treatment, therapy, or device (a) is the subject of an ongoing Phase I or II
clinical investigation, or experimental or research arm of a Phase III clinical
investigation, or under study to determine: maximum tolerated dosage( s),
toxicity, safety, efficacy, or efficacy as compared without the standard means
for treatment or diagnosis of the condition in question; or (b) has not been
proven safe and effective for the treatment of the condition in question, as
evidenced in the most recently published medical literature in the United
States, Canada or Great Britain, using generally accepted scientific, medical
or public health methodologies or statistical practices; or (c) is not the
standard evaluation, treatment, therapy or device utilized by practicing
physicians in treating other patients with the same or similar condition; or

3) There is no consensus among practicing physicians that the evaluation,
treatment, therapy or device is safe or effective for the treatment in
question; or

4) The consensus of opinion among experts is that further studies, research,
or clinical investigations are necessary to determine maximum tolerated
dosage( s), toxicity, safety, efficacy or efficacy as compared with the
standard means for treatment or diagnosis of the condition in question.

Group health coverage An organization such as your employer arranged for your coverage under this contract. The member's group has chosen to engage HIP to make arrangements
through which Medical Services and Hospital Services will be delivered in
accordance with the terms and conditions of the certificate of coverage.

Medically necessary Medically necessary and appropriate means those health care services or
and appropriate supplies, determined solely by HIP or its designee, that are necessary to prevent, diagnose, correct or cure conditions in the member that cause acute suffering,

endanger life, result in illness or infirmity, interfere substantially with the
member's capacity for normal activity or threaten some significant disability and
that could not have been omitted under generally accepted medical standards or
provided in a less intensive setting.

Us/ We "Us" and "We" refer to HIP Health Plan of New York
You "You"-refers to the enrollee and each covered family member.

Experimental or investigational
service (Continued)

Section 10. 38
38 Page 39 40
2002 Health Insurance Plan (HIP/ HMO) 39
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See http:// www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

When you may change your enrollment; How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;
When your enrollment ends; and When the next open season for enrollment begins.

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.
Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for you, your for you and your family spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue 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 that event. The Self and Family enrollment begins on the first day of the pay period in which the child is
born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay
period that begins after your employing office receives your enrollment form; benefits will not be available to your spouse until you marry.

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, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of your first pay
period that starts on or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims information confidential. Only the records are confidential following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract; This Plan, and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits; Individuals involved in bona fide medical research or education that does
not disclose your identity; or OPM, when reviewing a disputed claim or defending litigation about a claim.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for
other forms of coverage, such as temporary continuation of Coverage (TCC).

Section 11. 39
39 Page 40 41
2002 Health Insurance Plan (HIP/ HMO) 40
When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. But, you may
be eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouse's
employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other information about your coverage choices.
Temporary Continuation If you leave Federal service, or if you lose coverage because you no longer of Coverage (TCC) qualify as a family member, you may be eligible for Temporary Continuation

of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you
are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Enrolling in TCC. 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 or from www. opm. gov/ insure. It explains
what you have to do to enroll.
Converting to You may convert to an individual policy if: individual coverage Your coverage under TCC or the spouse equity law ends (If you canceled

your coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. 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.
Getting a certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a group health plan coverage Federal law that offers limited Federal protections for health coverage

availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health
Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the
information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12
months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about
Federal and State agencies you can contact for more information.

Section 11. 40
40 Page 41 42
2002 Health Insurance Plan (HIP/ HMO) 41
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:

It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an age-related disease such as Alzheimer's.

LTC insurance can provide broad, flexible benefits for nursing home care,
care in an assisted living facility, care in your home, adult day care, hospice care, and more. LTC can supplement care provided by family members,

reducing the burden you place on them.
Welcome to the club!
76% of Americans believe they will never need long term care, but the facts
are that about half of them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They may need chronic

care due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a
plan just in case. Many people now consider long term care insurance to be vital to their financial and retirement planing.

Yes, it can be very expensive. A year in a nursing home can exceed
$50,000. Home care for only three 8-hour shifts a week can exceed $20,000 a year. And that's before inflation!

Long term care can easily exhaust your savings. Long term care insurance
can protect your savings.

Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of
your FEHB brochure. Health plans don't cover custodial care or a stay in an assisted living facility or a continuing need for a home health aide to help

you get in and out of bed and with other activities of daily living. Limited stays in skilled nursing facilities can be covered in some circumstances.

Medicare only covers skilled nursing home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or older or fully disabled. It also has a 100 day limit.

Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be received. Long term care insurance can provide choices of care and

preserve your independence.
Employees will get more information from their agencies during the LTC
open enrollment period in the late summer/ early fall of 2002.

Retirees will receive information at home.

Our toll-free teleservice center will begin in mid-2002. In the meantime, you
can learn more about the program on our web site at www. opm. gov/ insure/ ltc.

What is long term care
(LTC) insurance?

I'm healthy. I won't need
long term care. Or, will I?

Is long term care expensive?
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?

When will I get more information on how to apply for this new
insurance coverage?

How can I find out more about the
program NOW?

DoD/ FEHB Demonstration Project 41
41 Page 42 43
2002 Health Insurance Plan (HIP/ HMO) 42
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury ............................. 28
Allergy tests..................................... 14
Alternative treatment .................. 17, 29
Allogenetic (donor) bone
marrow transplant........................ 20
Ambulance....................................... 22
Anesthesia ....................................... 20
Autologous bone marrow transplant ..... 20
Biopsies ........................................... 18
Blood and blood plasma ................... 22
Breast cancer screening ................... 12
Casts ................................................. 22
Catastrophic protection..................... 9
Changes for 2002............................. 06
Chemotherapy................................... 14
Childbirth......................................... 13
Chiropractic ...................................... 17
Cholesterol tests .............................. 12
Claims............................................... 31
Coinsurance ................................. 9, 37
Colorectal cancer screening............. 12
Congenital anomalies ...................... 19
Contraceptive devices and drugs....... 13
Coordination of benefits .................. 34
Covered charges ................................ 9
Covered providers ............................. 7
Crutches........................................... 16
Deductible........................................ 37
Definitions ....................................... 37
Dental care....................................... 28
Diagnostic services.......................... 11
Disputed claims review .............. 32-33
Donor expenses (transplants) .......... 20
Dressings ......................................... 21
Durable medical equipment (DME) ...... 16
Educational classes and programs...... 17
Effective date of enrollment .............. 4
Emergency................................... 23, 24
Experimental or investigational ... 37-38

Eyeglasses......................................... 15
Family planning................................ 13
Fecal occult blood test ..................... 12
General Exclusions.......................... 30
Hearing services ............................... 15
Home health services....................... 17
Hospice care .................................... 22
Hospital.............................................. 8
Immunizations ................................. 12
Infertility.......................................... 14
Inpatient Hospital Benefits .............. 21
Insulin .............................................. 27
Laboratory and pathological services.. 11
Machine diagnostic tests.................. 11
Magnetic Resonance Imagings (MRIs) ... 11
Mail Order Prescription Drugs ......... 27
Mammograms.................................. 12
Maternity Benefits ........................... 13
Medicaid .......................................... 36
Medically necessary ........................ 38
Medicare ........................ 29, 34, 35, 36
Mental Conditions/ Substance
Abuse Benefits ......................... 25
Neurological testing......................... 11
Newborn care................................... 13
Non-FEHB Benefits ......................... 29
Nurse
Licensed Practical Nurse ............... 17
Nurse Anesthetist........................... 21
Registered Nurse ........................... 17
Nursery charges ............................... 13
Obstetrical care ................................ 13
Occupational therapy....................... 15
Ocular injury..................................... 15
Office visits...................................... 11
Oral and maxillofacial surgery .......... 19
Orthopedic devices ........................... 16
Out-of-pocket expenses ......... 9, 25, 30
Outpatient facility care .................... 22

Oxygen ...................................... 16, 17
Pap test ............................................ 12
Physical examination....................... 12
Physical therapy .............................. 15
Physician ......................................... 12
Preventive care, adult ....................... 12
Preventive care, children.................... 13
Prescription drugs ....................... 26, 27
Preventive services .......................... 12
Prior approval .................................... 8
Prostate cancer screening.................. 12
Prosthetic devices ............................. 16
Psychologist..................................... 25
Psychotherapy ................................. 25
Radiation therapy ............................ 14
Renal dialysis .................................. 34
Room and board .............................. 21
Second surgical opinion .................. 11
Skilled nursing facility care .............. 22
Smoking cessation ........................... 17
Speech therapy ................................ 15
Splints .............................................. 21
Sterilization procedures ................... 13
Subrogation ..................................... 36
Substance abuse............................... 25
Surgery ............................................ 18
Anesthesia ................................ 20
Oral........................................... 19
Outpatient ................................. 22
Reconstructive .......................... 19
Syringes ........................................... 27
Temporary continuation of coverage..... 40
Transplants................................. 14, 20
Treatment therapies .......................... 14
Vision services.................................. 15
Well child care ................................. 13
Wheelchairs ...................................... 16
Workers' compensation ................... 36
X-rays ................................................ 11

Index 42
42 Page 43 44
2002 Health Insurance Plan (HIP/ HMO) 43 Summary of benefits
Summary of benefits for the Health Insurance Plan (HIP/ HMO)
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover
on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................... Office visit copay: $10 primary care
Inpatient hospital visits or consultations .............................................. or specialist 11-17

Services provided by a hospital:
Inpatient................................................................................................ Nothing 21
Outpatient ............................................................................................. Nothing 22

Emergency benefits: 23-24
In-area................................................................................................... $10 urgent care center/ doctor and
Out-of-area ........................................................................................... $25 for hospital emergency room

Mental health and substance abuse treatment.......................................... $10 per office visit 25
Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers

Prescription drugs 26-27
Up to a 30 day supply from a participating retail pharmacy ................... $10 generic formulary/$ 15 name
brand formulary/$ 35 non-formulary

Up to a 90 day supply of generic maintenance drugs by mail-order ....... $15 generic formulary/$ 22.50 name
brand formulary

Dental Care .............................................................................................. Nothing 28
Accidental injury benefit only

Vision Care .............................................................................................. $10 15
One annual eye refraction

Special features: Service for deaf and hearing impaired, Medical Case Management Programs, Travel benefit/ services overseas

Protection against catastrophic costs (your out-of-pocket maximum) ............................................................... Nothing 9 43
43 Page 44
2002 Health Insurance Plan (HIP/ HMO) 44 Rates
2002 Rate Information for
Health Insurance Plan

Non-Postal rates apply to most non-Postal enrollees. If you are in a special
enrollment category, refer to the FEHB Guide for that category or contact the agency
that maintains your health benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should
refer to the FEHB Guide for United States Postal Service Employees, RI 70-2.
Different postal rates apply and special FEHB guides are published for Postal Service
Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector General
(OIG) employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate
members of any postal employee organization who are not career postal employees.
Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your Enrollment Code Share Share Share Share Share Share

511 $ 81.70 $ 27.23 $177.02 $ 59.00 $ 96.68 $ 12.25
512 $223.41 $103.38 $484.06 $223.99 $263.75 $ 63.04

High Option Self Only
High Option Self and Family 44

Page Navigation Panel

1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36 37 38 39
40 41 42 43 44