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Pages 1--60 from Health Plan of Nevada


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This Plan has "Accredited" status from the National Committee for Quality Assurance (NCQA) for
Commercial and Medicare Products.

Health Plan of Nevada http:// www. sierrahealth. com
2002

Serving: Las Vegas and Reno metropolitan areas
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
NM1 Self Only NM2 Self and Family

RI 73-129

For changes in benefits
see page 8.

A Health Maintenance Organization with a point of service product 1
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2002 Health Plan of Nevada, Inc. 2 Table of Contents
Table of Contents
Introduction ........................................................................................................................................................................................... 4
Plain Language ....................................................................................................................................................................................... 4
Inspector General Advisory.................................................................................................................................................................... 5
Section 1. Facts about this HMO plan ................................................................................................................................................... 6
We also have point-of service (POS) benefits....................................................................................................................... 6
How we pay providers .......................................................................................................................................................... 6
Your Rights........................................................................................................................................................................... 6
Service Area.......................................................................................................................................................................... 7
Section 2. How we change for 2002 ...................................................................................................................................................... 8
Changes to this Plan.............................................................................................................................................................. 8
Section 3. How you get care ................................................................................................................................................................. 9
Identification cards................................................................................................................................................................ 9
Where you get covered care.................................................................................................................................................. 9
Plan providers................................................................................................................................................................. 9
Plan facilities .................................................................................................................................................................. 9
What you must do to get covered care.................................................................................................................................. 9
Specialty care.................................................................................................................................................................. 9
Hospital care................................................................................................................................................................. 10
Circumstances beyond our control...................................................................................................................................... 10
Services requiring our prior approval.................................................................................................................................. 11
Section 4. Your costs for covered services .......................................................................................................................................... 12
Copayments .................................................................................................................................................................. 12
Deductible..................................................................................................................................................................... 12
Coinsurance .................................................................................................................................................................. 12
Your out-of-pocket maximum............................................................................................................................................. 12
Section 5. Benefits ............................................................................................................................................................................... 13
Overview............................................................................................................................................................................. 13
(a) Medical services and supplies provided by physicians and other health care professionals .................................... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................. 25
(c) Services provided by a hospital or other facility, and ambulance services............................................................... 29
(d) Emergency services/ accidents.................................................................................................................................. 32
(e) Mental health and substance abuse benefits............................................................................................................. 34
(f) Prescription drug benefits......................................................................................................................................... 36 2
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2002 Health Plan of Nevada, Inc. 3 Table of Contents
(g) Special features ....................................................................................................................................................... 39
Flexible benefits option
24 hour nurse line
Services for deaf & hearing impaired
Preventive Health/ Disease Management
(h) Dental benefits.......................................................................................................................................................... 40
(i) Point of service product ........................................................................................................................................... 41
(j) Non-FEHB benefits available to Plan members ...................................................................................................... 44
Section 6. General exclusions --things we don't cover........................................................................................................................ 45
Section 7. Filing a claim for covered services ..................................................................................................................................... 46
Section 8. The disputed claims process................................................................................................................................................ 47
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 49
When you have…
Other health coverage.................................................................................................................................................... 49
Original Medicare.......................................................................................................................................................... 49
Medicare managed care plan ........................................................................................................................................ 51
TRICARE/ Workers' Compensation/ Medicaid ................................................................................................................... 52
Other Government agencies................................................................................................................................................ 52
When others are responsible for injuries............................................................................................................................. 52
Section 10. Definitions of terms we use in this brochure...................................................................................................................... 53
Section 11. FEHB facts ........................................................................................................................................................................ 54
Coverage information........................................................................................................................................................ 54
No pre-existing condition limitation......................................................................................................................... 54
Where you get information about enrolling in the FEHB Program.......................................................................... 54
Types of coverage available for you and your family .............................................................................................. 54
When benefits and premiums start ........................................................................................................................... 55
Your medical and claims records are confidential ................................................................................................... 55
When you retire........................................................................................................................................................ 55
When you lose benefits ..................................................................................................................................................... 55
When FEHB coverage ends...................................................................................................................................... 55
Spouse equity coverage............................................................................................................................................ 55
Temporary Continuation of Coverage (TCC) .......................................................................................................... 55
Converting to individual coverage ........................................................................................................................... 56
Getting a Certificate of Group Health Plan Coverage .............................................................................................. 56
Long Term Care Insurance is coming later in 2002.............................................................................................................................. 57
Index ..................................................................................................................................................................................................... 58
Summary of benefits............................................................................................................................................................................. 59
Rates ....................................................................................................................................................................................... Back cover 3
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2002 Health Plan of Nevada, Inc. 4 Introduction/ Plain Language/ Advisory
Introduction
Health Plan of Nevada P. O. Box 15645
Las Vegas, NV 89114-5645
This brochure describes the benefits of Health Plan of Nevada under our contract (CS 1942) 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 8. 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 Health Plan of Nevada.

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 OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM 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. 4
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2002 Health Plan of Nevada, Inc. 5 Introduction/ Plain Language/ Advisory
Inspector General Advisory
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 (702) 242-7300 or (800)
777-1840 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

Stop health care fraud! 5
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2002 Health Plan of Nevada, Inc. 6 Section 1
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.
We also have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a participating provider without a required referral, or from a non-participating provider. These out-of-network benefits have higher out-of-pocket costs than our in-network
benefits.
How we pay providers
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.

When we contract with a doctor or medical group to provide health care services, the contract specifies the amount the doctor or
medical group will be paid for providing serviceseither on a fixed monthly basis or as a payment per service provided. In some cases, we and the doctor or group agree upon financial goals based in part on the expected use of special services by patients of the

doctor who belongs to our plan. These special services may include referrals to specialists, lab tests, and hospital admissions. These types of arrangements are known as incentive plans. In most incentive plans, the health plan retains a portion of this money. At the end
of the year, if the doctor or medical group meets the budgeted goals, the health plan may give part or all of the withheld money to the doctor or medical group.

We have several types of payment arrangements with our doctors:
Arrangement A: Your doctor may be part of a contracted medical group and may receive a salary. Some medical groups may pay their doctors a bonus.

Arrangement B: Your doctor may receive a fixed amount of money each month, called a "capitation" to provide services to all Health Plan patients they see. Capitation may be considered to be an incentive plan.
Arrangement C: Your doctor may be paid a pre-determined amount for each service he/ she provides. The plan may designate a separate amount of money to pay for special services (as described above). At the end of the year, that money may be paid to the
doctor or medical group, depending upon the management and use of special services.
Your Rights
OPM requires that all FEHB Plans to 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.
Health Plan of Nevada, Inc. has operated as a mixed model HMO in Nevada for 19 years. Health Plan of Nevada, Inc., has been awarded "Accredited" status by the National Committee for Quality Assurance (NCQA), an independent, not-for-profit organization 6
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2002 Health Plan of Nevada, Inc. 7 Section 1
dedicated to measuring the quality of America's healthcare. Accreditation is for the Commercial HMO, Commercial POS and Medicare HMO product lines in Nevada effective August 2000.
We understand the importance of getting your questions answered. Whether you need an answer to a benefit question or have a concern about a claim, or need help in selecting a provider, we are available Monday through Friday, 8am to 5pm at (702) 242-7300
or (800) 777-1840.
At times, services requested on your behalf by your provider may not be approved by Health Plan of Nevada, Inc. The decision to deny coverage for services requested, courses of treatment or inpatient care is made by a physician. These denials are based upon

medical necessity, benefit coverage and your individual needs. Written notification of the denial will be sent to you, your primary care physician and the provider who requested the service. You have the right to appeal these decisions.

If you want more information about us, call (702) 242-7300 or (800) 777-1840, or write to Health Plan of Nevada, P. O. Box 15645, Las Vegas, NV 89114-5645. You may also contact us by fax at (702) 242-9350 or visit our website at www. sierrahealth. com.

Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
The Nevada counties of Clark, Nye, Mineral and Lyon. Portions of Washoe County in Nevada are also within the service area, as indicated by the zip codes: 89431, 89432, 89433, 89434, 89435, 89436, 89442, 89501, 89502, 89503, 89504, 89505, 89506, 89507,
89509, 89510, 89511, 89512, 89513, 89515, 89520, 89523, 89533, 89570.
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. 7
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2002 Health Plan of Nevada, Inc. 8 Section 2
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.
Changes to this Plan

Your share of the non-Postal premium will increase by 7.9% for Self Only or 8.0% for Self and Family.
We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
We now cover routine screening for chlamydial infection. (Section 5( a))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5( a))

We require a 50% coinsurance for Vision care (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b)) 8
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2002 Health Plan of Nevada, Inc. 9 Section 3
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 (702) 242-7300 or (800) 877-
1840.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file claims. If you use our point-of-
service program, you can also get care from non-Plan providers, or from participating providers without a required referral, but it will cost you more.

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 national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

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 periodically. The list is also on our website.
It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. This plan has a provider directory, which we urge you to review before choosing your primary care physician.

Primary care Your primary care physician can be a family practitioner, pediatrician, Obstetrician/ Gynecologist or internist. 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. 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. However, women may see their
Obstetrician/ Gynecologist without a referral.
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 work with the plan and your
specialist to 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

What you must do to get covered care 9
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2002 Health Plan of Nevada, Inc. 10 Section 3
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 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 (702) 242-7300 or (800) 777-1840. 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 92 nd 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. 10
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2002 Health Plan of Nevada, Inc. 11 Section 3
Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain prior authorization for the following services:
All non-emergency hospital admissions
Admissions to skilled nursing facilities and inpatient hospice facilities
All non-emergency inpatient and outpatient surgeries
Many diagnostic services
Physical, occupational and speech therapy
Inpatient and outpatient mental health and substance abuse services
Home health services
Prosthetic devices and durable medical equipment
It is best to contact your plan physician before you seek any services. Failure to follow the requirements of the referral process will result in higher out of pocket costs to you.

In order for certain services to be covered under your Point of Service benefit, you must also get prior authorization from the plan. Failure to comply with the prior
authorization requirements may result in a reduction of benefits. Refer to Section 5( i) for additional details on coverage under the Point of Service benefit.

Contact our customer service department at (702) 242-7300 or (800) 777-1840 for additional details.

Services requiring our prior approval 11
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2002 Health Plan of Nevada, Inc. 12 Section 4
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 in the hospital, you pay $100 per day, not to exceed $200
per admission.
Deductible A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any
deductible. We do not have a deductible for HMO coverage, but your point of service benefit does include a deductible.

The calendar year deductible is $250 per person for Point of Service benefits. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all
Could not acquire words on page 13 Fatal System Error: Raise at top of Exception Stack family members when the combined covered expenses applied to the calendar year deductible for family members reach $750.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the
deductible of your new option.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. Coinsurance doesn't begin until you meet your deductible.

Example: In our Plan, you pay 50% of our allowance for infertility services and durable medical equipment. You also pay 20% of our allowance for most services obtained
under the point of service benefit.
After your copayments total $3,320 per person or $7,804 per family enrollment in any calendar year, you do not have to pay any more for covered services.

After you have met the calendar year deductible for point of service benefits, if your coinsurance payments total $1,500 per person or $4,500 per family enrollment in any
calendar year, you do not have to pay any more for covered services.
Be sure to keep accurate records of your copayments and coinsurance payments since you are responsible for informing us when you reach the maximum.

Your catastrophic protection out-of-pocket maximum for
deductibles, coinsurance, and copayments 12
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