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Heart of America HMO

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Table of Contents
- Page 2
Introduction
- Page 2
Section 1 - Facts about this HMO plan
- Service Area
Section 2 - How we change for 2003
Section 3 - How you get care
- Specialty & Hospital Care
- Circumstances & Services
Section 4 - Your costs for covered services
Section 5 - Benefits/Overview
Section 6 - General exclustions
Section 7 - Filing a claim for covered services
Section 8 - The disputed claims process
- Section 8 page 2
Section 9 - Coordinating benefits w/other coverage
Section 10 - Definitions of terms
- Section 10 page 2
Section 11 - FEHB facts
Long Term Care Still Available
Index
Summary of Benefits
2003 Rate Information

Pages 1--55

Page 1 2

Heart of America HMO 2003
Serving: North Central North Dakota
Enrollment in this Plan is limited. You must live in our geographic service area
to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
RU1 Self Only
RU2 Self and Family

.
1 Page 2 3

Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.

The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.

Sincerely,

Kay Coles James Director 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT
CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is
also required to give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy
is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil criminal actions, and
Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For
example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your
behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:

For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical infor-mation
for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any
time, except if OPM has already acted based on your permission.

By Law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if infor-mation
is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement

3 Page 4 5

added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing
will not cover your personal medical information that was given to you or your personal representative, and
information that you authorized OPM to release, or that was given out for law enforcement purposes or to
pay for your health care or a disputed claim.

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address.

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be
able to agree to your request if the information is used to conduct operations in the manner described
above.

Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You
may also call 202-606-0191 and ask for OPM's FEHB Program privacy for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the
Secretary of the Department of Health and Human Services.

By Law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your per-sonal
medical information is used and given out. If OPM makes any changes, you will get a notice by mail within 60
days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

Table of Contents 5.
5 Page 6 7

2003 Heart of America HMO 4 Introduction/ Plain Language/ Advisory
Introduction
Plain Language
Stop Health Care Fraud!

This brochure describes the benefits of Heart of America HMO under our contract (CS 2606) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Heart
of America HMO administrative office is:

Heart of America HMO
810 South Main
Rugby, ND 58368

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, lim-itations,
and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

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 bene-fits
that were available before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and are
summarized on page 8. Rates are shown at the end of this brochure.

All FEHB brochures are written in plain language 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 Heart of America HMO.
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 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.

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Program (FEHB)
premium.

OPM's Office of the Inspector General investigates allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know,
except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know
how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us. 7.
7 Page 8 9
2003 Heart of America HMO 5 Introduction/ Plain Language/ Advisory
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an
item or service.
If you suspect that a provider 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 776-5848 or 1-800-525-5661 and explain the
situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
Your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or
Your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are
employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to
obtain FEHBP benefits or try to obtain services for someone who is not an eligible family member or who
is no longer enrolled in the Plan.

CALL THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of Inspector General Fraud Hotline
1900 E. Street NW, Room 6400
Washington DC, 20415 8.
8 Page 9 10

2003 Heart of America HMO 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. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

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 prescrib-ing
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
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 coin-surance.

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.

We are Federally qualified
We have been in existence for 20 Years
We are a non-profit organization

If you want more information about us, call 701-776-5848 or 1-800-525-5661, or write to Heart of America HMO,
810 South Main. You may also contact us by fax at 701-776-5425. 9.
9 Page 10 11
2003 Heart of America HMO 7 Section 1
Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is:
All of Pierce, Rolette, Bottineau, McHenry, Towner, Ward, and Renville counties in North Dakota and the portions of
Benson, Wells, Sheridan, McLean, Mountrail, and Burke Counties represented by the following zip codes:

58310 58339 58365 58450 58754 58741 58763 58783
58313 58341 58366 58451 58722 58744 58768 58784
58316 58343 58367 58540 58723 58746 58769 58785
58317 58346 58368 58701 58725 58747 58770 58787
58318 58348 58369 58704 58731 58750 58772 58789
58320 58353 58384 58705 58733 58752 58773 58790
58324 58356 58385 58710 58734 58756 58775 58792
58325 58357 58386 58711 58735 58758 58776 58793
58329 58359 58418 58712 58736 58759 58778
58331 58360 58422 58713 58737 58760 58779
58332 58362 58423 58716 58739 58761 58781
58337 58363 58438 58718 58740 58762 58782

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care. We will not pay for any other health care services 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 depen-dents
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. 10.
10 Page 11 12
2003 Heart of America HMO 8 Section 2
Section 2. How we change for 2003
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
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family
coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may sus-pend
their FEHB Program enrollment.
Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this plan
Your share of the non-Postal premium will increase by 9.9% for Self Only or 5.6% for Self and Family. 11.
11 Page 12 13
2003 Heart of America HMO 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 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 701-776-5848.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or coinsurance, and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our ser-vice area that we contract with to provide covered services to our members.
We list Plan providers in the provider directory, which we update periodical-ly.
All doctors of the Johnson Clinic Professional Corporation and Trinity
Medical Group and affiliated clinics are available to HAHMO members.
The doctors of the Johnson Clinic, P. C. are available to provide health care
from offices located in Leeds, Towner, Maddock, Dunseith and Rugby,
North Dakota. The doctors of the Trinity Medical Group are available to
provide health care from offices located in Minot, Bottineau, Garrison, Velva,
Newtown, Kenmare, Parshall and Westhope, North Dakota. Your plan doctor
will coordinate your health care needs including referrals to specialists when
necessary. Services of specialists other than Johnson Clinic and Trinity
Medical Group primary care doctors are covered only when there has been a
referral by the member's primary care doctor with the following exception:
a woman may see her plan gynecologist for an annual routine examination
without a referral.

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.
What you must do It depends on the type of care you need. First, you and each family to get covered care 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. Provider directories are available at the time of enrollment or
upon request by calling the Heart of America HMO office at 701-776-5848
or 1-800-525-5661.

Primary care Your primary care physician can be a family practitioner, internist, pediatri-cian or an OB-GYN. 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 physi-cian
leaves the Plan, call us. We will help you select a new one. 12.
12 Page 13 14
2003 Heart of America HMO 10 Section 3
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 pri-mary
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, a woman may see her plan gynecol-ogist
for her annual routine examination 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 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 pri-mary
care physician. Your primary care physician will decide what treat-ment
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 partici-pate
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 partici-pate
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 spe-cialist
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. 13.
13 Page 14 15
2003 Heart of America HMO 11 Section 3
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 701-776-5848 or 1-800-525-
5661. 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 hospital benefit of the hospitalized per-son;
we cover your other non-hospital care.

Circumstances Under certain extraordinary circumstances, such as natural disasters, we may beyond our control 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 Your physician must get our approval before sending you to a hospital, prior approval referring you to a specialist, or recommending follow-up care. Before giv-ing
approval, we consider if the service is medically necessary, and if it fol-lows
generally accepted medical practice. 14.
14 Page 15 16
2003 Heart of America HMO 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 when you
receive services.

Example: When you see your primary care physician you pay a copayment
of $10 per office visit

Deductible A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for those services. Copayments
do not count toward any deductible.

We have a $600 per member calendar year deductible for prescription drugs.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care.

Example: In our Plan, you pay 20% of charges up to a maximum coinsur-ance
of $500 per year for prosthetic devices that exceed $25

Your catastrophic protection The copayment and coinsurance maximum is 50% of your annual premium out-of-pocket maximum per calendar year. When the copayment and coinsurance maximum
for deductibles, coinsurance, applicable to your contract has been fulfilled, copayment and coinsurance and copayments will no longer be applied to the following services:

Emergency room services Outpatient hospital services
Inpatient hospital services
Outpatient mental health services
Outpatient chemical dependency services
Inpatient mental health services
Inpatient chemical dependency services
Durable equipment and prosthetic devices
Referral services provided by non participating providers 15.
15 Page 16 17

2003 Heart of America HMO 13 Section 5
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 sub-sections.
To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 701-776-5848 or
at 1-800-525-5661.

(a) Medical services and supplies provided by physicians and other health care professionals ...................... 14 21
Diagnostic and treatment services Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Rehabilitative therapies Educational classes and programs
Physical and occupational therapies

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................... 22 24
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services.................................................. 25 26
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory facility benefits
surgical center Hospice care
Ambulance

(d) Emergency services/ accidents...................................................................................................................... 27 28
Medical emergency Ambulance
(e) Mental health and substance abuse benefits ................................................................................................. 29 30
(f) Prescription drug benefits .............................................................................................................................. 31 32
(g) Dental benefits........................................................................................................................................................ 33
Summary of benefits.............................................................................................................................................................. 51

Section 5. Benefits OVERVIEW (See page 8 for how our benefits changed this year and page 51 for a benefits summary.) 16.
16 Page 17 18

2003 Heart of America HMO 14 Section 5( a)
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.
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.

Professional services of physicians $10 per visit
In physician's office No copayment for visits to a
plan specialist.

Professional services of physicians Nothing
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations by a specialist
Second surgical opinion by a specialist

At home -doctor's house call Nothing

Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

Benefit Description

Diagnostic and treatment services

You pay
After the calendar year deductible

Note: When you receive authorized services from a non-Plan specialist, you pay 20% of charges up to a maximum
coinsurance of $1,000 per year. 17.
17 Page 18 19
2003 Heart of America HMO 15 Section 5( a)
Laboratory tests, such as: Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Routine screenings such as: Nothing
Total Blood Cholesterol -once every three years
Colorectal Cancer Screening, including
---Fecal occult blood test -yearly after age 50

---Sigmoidoscopy, screening -every five years starting at age 50

Prostate Specific Antigen (PSA test) -one annually for men age 40 and older

Routine pap test
Note: There is a $10 copay for an office visit with a pap test.

Routine mammogram -covered for women age 35 and older, as follows:
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, or travel.

Routine immunizations, limited to: Nothing
Tetanus-diphtheria (Td) booster -once every 10 years, ages 19 and over
(except as provided for under Childhood immunizations)

Influenza vaccines, annually

Pneumococcal vaccines, age 65 and over

Lab, X-ray and other diagnostic tests You Pay
Preventive care, adult 18.
18 Page 19 20
2003 Heart of America HMO 16 Section 5( a)
Childhood immunizations recommended by the American Nothing
Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and care
(through age 22) $10 per visit

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 (through age 22)

Complete maternity (obstetrical) care, such as: $10 copay on first prenatal visit
Prenatal care only
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 10 for other
circumstances, such as extended stays for you or your baby.

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).

Not covered: Routine sonograms to determine fetal age, size or sex All charges

Preventive care, children
Maternity care
You Pay 19.
19 Page 20 21

2003 Heart of America HMO 17 Section 5( a)
A broad range of voluntary family planning services, limited to: $10 per visit
Voluntary sterilization (See surgical procedures, Section 5 (b))
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
For covered medications and accessories, you pay 50% of charges after a $600 deductible.

Not covered: reversal of voluntary surgical sterilization, genetic counseling All charges

Diagnosis and treatment of infertility, such as: $10 per visit
Artificial insemination:
---intrauterine insemination (IUI)

Not covered: All charges
Intracervical insemination (ICI)
Intravaginal insemination (IVI)
Assisted reproductive technology (ART) procedures, such as:
---in vitro fertilization
---embryo transfer, gamete GIFT and zygote
---zygote transfer
Services and supplies related to excluded ART procedures
Fertility drugs
Cost of donor sperm
Cost of donor egg

Testing and treatment $10 per visit
Allergy injection

Allergy serum Nothing

Not covered: provocative food testing and sublingual allergy desensitization All charges

Family planning
Infertility services

Allergy care

You Pay 20.
20 Page 21 22

2003 Heart of America HMO 18 Section 5( a)
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 24.

Respiratory and inhalation therapy
Dialysis -Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: We cover growth hormone under the prescription drug benefit.
Note: -We will only cover GHT when we preauthorize the treatment. Call your
plan physician to get a referral for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will only cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically necessary, we will not cover the GHT or related
services and supplies. See Services requiring our prior approval in Section 3.

Up to two consecutive months per condition for the services of each of the $10 per visit
following:
---qualified physical therapists; and Nothing per visit during covered
---occupational therapists inpatient admission

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

We Cover cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, for up to three (3) sessions per week up to three (3)
months. Any sessions beyond three (3) months require authorization by
HAHMO Medical Director.

We cover long-term rehabilitative therapy (physical and occupational) after the
short-term therapy benefit has been exhausted. Benefits are provided for one
supervisory physical therapy visit per month and one supervisory occupational
therapy visit per month.

Not covered: All charges
exercise programs

Up to two consecutive months per condition. $10 per outpatient visit
NOTE: We cover speech therapy in all situations where it is medically necessary. Nothing per visit during
covered inpatient admission

Treatment therapies
Physical and occupational therapies
You Pay

Speech therapy 21.
21 Page 22 23
2003 Heart of America HMO 19 Section 5( a)
Hearing testing for children through age 17 (see Preventive care, children) Nothing
Not covered: All charges
all other hearing testing
hearing aids, testing and examinations for them

Eye exam to determine the need for vision correction for children through age Nothing
17 (see Preventive care, children)

Not covered: All charges
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Routine foot care when you are under active treatment for a metabolic or Nothing
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)

Hearing services (testing, treatment, and supplies)
Foot care
Vision services (testing, treatment, and supplies)
You Pay 22.
22 Page 23 24
2003 Heart of America HMO 20 Section 5( a)
Artificial limbs, lenses following cataract surgery
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers and cochlear
implants and sugically implanted breast implant or TRAM-flap procedure fol-lowing
mastectomy. Note: 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: There is a maximum benefit of $3,500 per member per calendar year for
orthopedic and prosthetic devices and durable equipment combined.

Not covered: All charges
Orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, and other supportive devices

Rental or purchase, at our option, including repair and adjustment, of durable
medical equipment prescribed by your Plan physician, such as oxygen and dialy-sis
equipment. Under this benefit, we also cover:

hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors
insulin pumps

Note: There is a maximum benefit of $3,500 per member per calendar year for
orthopedic and prosthetic devices and durable equipment combined.

Not covered: All charges
Motorized wheel chairs

Orthopedic and prosthetic devices
Durable medical equipment (DME)
You Pay
20% coinsurance on items
which exceed $25.00 up to a
maximum coinsurance of $500
per contract per calendar year.

20% coinsurance on items
which exceed $25.00 up to a
maximum coinsurance of $500
per contract per calendar year. 23.
23 Page 24 25
2003 Heart of America HMO 21 Section 5( a)
Home health care ordered by a Plan physician and provided by a registered Nothing
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

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

No benefit for services such as: All charges
naturopathic services
hypnotherapy
biofeedback
acupuncture

Coverage is limited to: $10 per visit
Smoking cessation up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.

Diabetes self-management which includes: individual instruction by primary
care physician, diabetic course up to five days, diabetic camps for children
up to age 16 and dietary instruction by a dietician

Home health services
Alternative treatments
Educational classes and programs

You Pay
Chiropractic 24.
24 Page 25 26

2003 Heart of America HMO 22 Section 5( b)
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.
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.)

A comprehensive range of services, such as: $10 per office visit
Operative procedures (nothing for hospital visits)
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
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 braces and
prosthetic devices for device coverage information.

Voluntary sterilization (e. g. Tubal ligation, Vasectomy) Nothing
Treatment of burns

Note: When you receive authorized services from a non-Plan specialist, you pay 20% of charges up to a maximum
coinsurance of $1,000 per year.

Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.

Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals

I M
P O
R T
A N
T

Benefit Description

Surgical procedures
You pay 25.
25 Page 26 27
2003 Heart of America HMO 23 Section 5( b)
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: Nothing
---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 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
periodntal membrane, gingiva, and alveolar bone)

Reconstructive surgery
Oral and maxillofacial surgery
You Pay 26.
26 Page 27 28
2003 Heart of America HMO 24 Section 5( b)
Limited to: Nothing
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine)
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer is subject to approval by the Plan's medical
director in accordance with the Plan's protocols.

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

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

Organ/ tissue transplants
Anesthesia
You Pay 27.
27 Page 28 29

2003 Heart of America HMO 25 Section 5( c)
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.

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
Section 5( a) or (b).

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 given in the hospital
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
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home

Note: When you receive authorized services at a non-Plan facility, you pay 20% of charges up to a maximum
coinsurance of $1,000 per year.

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

Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

I M
P O
R T
A N
T

Benefit Description
Inpatient hospital
You pay 28.
28 Page 29 30
2003 Heart of America HMO 26 Section 5( c)
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines given in the outpatient hospital or
ambulatory surgical center
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.

Extended care benefit: Nothing
The Plan provides a comprehensive range of benefits for up to sixty (60) days
per calendar year, unless such limitation is waived by the Medical Director,
when full-time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor and
approved by the Plan. All necessary services are covered, including:

Bed, board and general nursing care
Drugs, biologicals, supplies and equipment ordinarily provided or arranged
by the skilled nursing facility when prescribed by a Plan doctor.

Not covered: custodial care All charges

Supportive and palliative care for a terminally ill member is covered in the Nothing
home or hospice facility. Services include inpatient and outpatient care and
family counseling. These services are provided under the care of a plan doctor
who certifies that the patient is in the terminal stages of illness, with a life
expectancy of approximately six months or less.

Not covered: Independent nursing, homemaker services All charges

Local professional ambulance service when medically appropriate Nothing

Outpatient hospital or ambulatory surgical center You Pay
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance 29.
29 Page 30 31

2003 Heart of America HMO 27 Section 5( d)
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.

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 bro-ken
bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poison-ings,
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:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In
extreme emergencies, if you are unable to contact your doctor, contact the local emergency 911 system or go to the
nearest hospital emergency room. There are physicians on call 24 hours a day at our contracted hospitals at Heart of
America Medical Center, Rugby, ND at 701-776-5261 or Trinity Hospital in Minot, ND at 701-857-5260. Be sure to
tell the emergency room personnel that you are a Plan member so that they can notify the Plan. You or a family mem-ber
must notify the Plan within 48 hours if medically feasible.

If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that time. If you are hos-pitalized
in non-Plan facilities and a Plan believes care can be better provided in a Plan hospital, you will be trans-ferred
when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan
provider would result in death, disability, or significant jeopardy to your condition.

To be covered by this plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission unless it was not reasonably possible to notify the plan within that time. If a Plan doctor believes that care
can better be provided in a Plan hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.

Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

I M
P O
R T
A N
T 30.
30 Page 31 32
2003 Heart of America HMO 28 Section 5( d)
Benefit Description
Emergency within our service area
You pay

Emergency care at a doctor's office Nothing
Emergency care at an urgent care center

Emergency care at a hospital, including doctors' services. $30 per visit
Note: If emergency results in admission, we waive the copayment.

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

Emergency care at a doctor's office Nothing
Emergency care at an urgent care center

Emergency care at a hospital, including doctors' services. $30 per visit
Note: If emergency results in admission, we waive the copayment.

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

Professional ambulance service when medically appropriate. Nothing
We cover air ambulance when medically appropriate.

See 5( c) for non-emergency service.

Emergency outside our service area
Ambulance 31.
31 Page 32 33

2003 Heart of America HMO 29 Section 5( e)
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.
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.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.

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.

Professional services, including individual or group therapy by providers such Nothing
as psychiatrists, psychologists, or clinical social workers

Medication management

Mental health and substance abuse benefits -Continued on next page

Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
Your cost sharing
responsibilities are no greater
than for other illness or
conditions. 32.
32 Page 33 34
2003 Heart of America HMO 30 Section 5( e)
Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial hospitalization,
residential treatment (under 21 years of age) and full-day hospitalization.

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 the following authorization processes:
Inpatient service and outpatient therapy services must be directed by
your primary care physician and approved by the HAHMO Medical
Director. Available providers for Mental Health and Substance
Abuse Benefits are listed on your Provider Directory that you
receive when you enroll or you may call the HAHMO office at
701-776-5848 or 1-800-525-5661 to obtain one.

Limitation We may limit your benefits if you do not obtain a treatment plan.

Mental health and substance abuse benefits (Continued) You pay 33.
33 Page 34 35

2003 Heart of America HMO 31 Section 5( f)
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.

The calendar year deductible is: $600 per member. The calendar year deductible
applies to almost all benefits in this Section.

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription
Where you can obtain them. You may fill the prescription at any pharmacy. We do
not have a network pharmacy.

Why use generic drugs. To reduce your out-of-pocket expenses! A generic drug is
the chemical equivalent of a corresponding brand name drug. Generic drugs are less
expensive than brand name drugs; therefore, you may reduce your out-of-pocket costs
by choosing to use a generic drug.

When you have to file a claim. See Section seven (7) Filing a claim for covered
services.

We cover the following medications and supplies prescribed by a Plan physician:
Drugs for which a prescription is required by law
Diabetic supplies, including insulin syringes, needles, glucose test tablets and
test tape, Benedict's solution or equivalent, glucose monitors and acetone test
tablets

Insulin
Disposable needles and syringes for the administration of covered medications
Drugs for sexual dysfunction
Contraceptive drugs and devices for birth control that are FDA approved.

Note: We cover intravenous fluids and medication for home use, implantable
drugs, and some injectable drugs under Medical and Surgical Benefits.

Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible
Covered medications and supplies
50% of charges per
prescription unit or refill, after
you meet your $600 per
member deductible. 34.
34 Page 35 36
2003 Heart of America HMO 32 Section 5( f)
Not covered: All Charges
Drugs and supplies for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a
prescription

Nonprescription medicines
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Fertility drugs

Covered medications and supplies (Continued) You pay 35.
35 Page 36 37

2003 Heart of America HMO 33 Section 5( g)
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.
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.

We cover restorative services and supplies necessary to promptly repair Nothing
(but not replace) sound natural teeth. The need for these services must result
from an accidental injury.

We have no other dental benefits.

Section 5 (g). Dental benefits
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Accidental injury benefit You pay

Dental benefits 36.
36 Page 37 38
2003 Heart of America HMO 34 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 ill-ness
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;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service. 37.
37 Page 38 39
2003 Heart of America HMO 35 Section 7
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, or
coinsurance.
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, hospital and In most cases, providers and facilities file claims for you. Physicians must drug benefits 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 701-
776-5848.

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 pri-mary
payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Heart of America HMO
810 South Main
Rugby, ND 58368

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 Please reply promptly when we ask for additional information. We may more information delay processing or deny your claim if you do not respond. 38.
38 Page 39 40
2003 Heart of America HMO 36 Section 8
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
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: Heart of America HMO, 810 South Main, Rugby, ND 58368; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit pro-visions
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 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 medical 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, Health Benefits Contracts
Division 3, 1900 E Street, NW, Washington, DC 20415-3630.

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 more than one claim , you must clearly identify which documents apply to
which claim.

Section 8. The disputed claims process 39.
39 Page 40 41
2003 Heart of America HMO 37 Section 8
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your re
resentative, such as medical providers, must provide 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.

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.

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 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 deci-sion.
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 over-turn
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
701-776-5848 or 1-800-525-5661 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 may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. east-ern
time. 40.
40 Page 41 42
2003 Heart of America HMO 38 Section 9
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you or a covered family member have coverage under health coverage another group health plan or have automobile insurance that pays medical
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 sec-ondary
payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners' guide-lines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine what the reasonable
charge for the benefit should be. After the primary plan pays, we will pay
what is left of the reasonable charge up to our regular benefit. We will not
pay more than our reasonable charge.

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 insur-ance.
(Someone who was a Federal employee on January1, 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 The Original Medicare Plan (Original Medicare) is available everywhere in Medicare Plan the United States. It is 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 41.
41 Page 42 43
2003 Heart of America HMO 39 Section 9
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. Your care
must continue to be directed by your Primary Care Physician and referrals
for specialty care must be approved by the HAHMO Medical Director in
order for us to pay our share.

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 then provide secondary benefits for covered charges.
You will not need to do anything. To find out if you need to do something to file your claims, call us at
701-776-5848 or 800-525-5661.

We waive our copayment for visits to your primary care physician or authorized visits to a specialist. We waive our
copayment for emergency room visits

(Primary payer chart begins on next page.) 42.
42 Page 43 44
2003 Heart of America HMO 40 Section 9
The following chart illustrates whether Original Medicare 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
A. When either you or your covered spouse are age 65 or over and Then the primary payer is

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,
a) And are an annuitant
b) And are an active employee
c) Are a former spouse of an annuitant
b) Are a former spouse of an active employee

Original Medicare This Plan 43.
43 Page 44 45

2003 Heart of America HMO 41 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from 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 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 or coinsurance. 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 cor-rectly
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 cov-erage
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 involuntar-ily
lose coverage or move out of the Medicare managed care plans service
area.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered
Medicare Part A or Part B under 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 and CHAMPVA TRICARE is the health care program for eligible dependents of military per-sons, and retirees of the military. TRICARE includes the CHAMPUS pro-gram.
CHAMPVA provides health coverage to disabled Veterans and their
eligible dependents. If TRICARE or CHAMPVA and this Plan cover you,
we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if
you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If
you are an annuitant or former spouse, you can suspend your FEHB cover-age
to enroll in one of these programs, eliminating your FEHB premium.
(OPM does not contribute to any applicable plan premiums.) For informa-tion
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 under
the program. 44.
44 Page 45 46
2003 Heart of America HMO 42 Section 9
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 similar agency pays its maximum benefits for your treat-ment,
we will cover your eligible care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State
sponsored program of medical assistance: If you are an annuitant or for-mer
spouse, you can suspend your FEHB coverage to enroll in one of these
State programs, eliminating your FEHB premium. For information on sus-pending
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 under the State
program.

When other Government We do not cover services and supplies when a local, State, agencies are responsible for or Federal Government agency directly or indirectly pays for them.
your care
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 sub-rogation.
If you need more information, contact us for our subrogation pro-cedures. 45.
45 Page 46 47

2003 Heart of America HMO 43 Section 10
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 reasonable charge that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care that HAHMO determines is essential to assist the patient in meeting the activities of daily living and is not primarily provided
for therapeutic treatment of an illness, disease, injury or condition. Care that
exceeds 90 days may also be classified as Long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for cer-tain covered services and supplies before we start paying benefits for those
services. See page 12.
Experimental or A drug, device or medical treatment or procedure is experimental or investigational services investigational:

If the drug or device does not have required Food and Drug
Administration (FDA) approval.

If reliable, (reports in respected medical and scientific literature) shows
that the opinion of experts determine that further study is needed to decide
how a drug, device or medical treatment or procedure compares with the
standard method of treatment or diagnosis.

Group health coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group
that provides payment for hospital, medical, or other health care services or
supplies.

Medical necessity Services, supplies or treatment rendered by a hospital physician, skilled nursing facility, home health agency, or other provider to treat an illness or
injury which is:
Consistent with the symptoms or diagnosis of the condition, disease, ail-ment
or injury;

Appropriate and accepted according to good medical practice standards;
Not primarily for the convenience of the member or the provider of care; 46.
46 Page 47 48
2003 Heart of America HMO 44 Section 10
Medical necessity (cont'd) The most appropriate supply or level of service that can safely be provided to a member. When a member receives inpatient care, it further means
that the member's medical symptoms or condition could not safely be
treated on an outpatient basis.

Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowance in
different ways. We determine our allowance as follows:
Our payment is based on usual, customary and reasonable charges. Usual,
Customary, and Reasonable means the usual charge made by a physician or
other supplier of services, medicines or supplies. The charge cannot exceed
the general level of charges made by other suppliers within the area in which
the charge is incurred for injury or sickness comparable in severity and
nature to the injury and sickness being treated.

Us/ We Us and we refer to Heart of America HMO.
You You refers to the enrollee and each covered family member. 47.
47 Page 48 49

2003 Heart of America HMO 45 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get See www. opm. gov/ insure. Also, your employing or retirement office information about enrolling can answer your questions, and give you a Guide to Federal Employees
in the FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:
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 for you and your family you, your 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 inca-pable
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. 48.
48 Page 49 50
2003 Heart of America HMO 46 Section 11
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and
Family coverage in the Federal Employees Health Benefits (FEHB)
Program, if you are an employee subject to a court or administrative order
requiring you to provide health benefits for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a
health plan that provides full benefits in the area where your children live or
provide documentation to your employing office that you have obtained
other health benefits coverage for your children. If you do not do so, your
employing office will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office will enroll you for
Self and Family coverage in the Blue Cross and Blue Shield Service
Benefit Plan's Basic Option,

if you have a Self Only enrollment in a fee-for-service plan or in an HMO
that serves the area where your children live, your employing office will
change your enrollment to Self and Family in the same option of the same
plan; or

if you are enrolled in an HMO that does not serve the area where the chil-dren
live, your employing office will change your enrollment to Self and
Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option.

As long as the court/ administrative order is in effect, and you have at least
one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or change
to a plan that doesn't serve the area in which your children live, unless you
provide documentation that you have other coverage for the children. If the
court/ administrative order is still in effect when you retire, and you have at
least one child still eligible for FEHB coverage, you must continue your
FEHB coverage into retirement (if eligible) and cannot make any changes
after retirement. Contact you employing office for further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined this premiums start Plan 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 premi-ums
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. 49.
49 Page 50 51
2003 Heart of America HMO 47 Section 11
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).

When you lose benefits When FEHB You will receive an additional 31 days of coverage, for no additional
coverage ends 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 If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's enrollment. This is the
case even when the court has ordered your former spouse to supply health
coverage to you. But, you may be eligible for your own FEHB coverage
under the spouse equity law or Temporary Continuation of Coverage (TCC).
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. You can also download the guide from OPM's website
ww. opm. gov/ insure.

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 employ-ing
or retirement office or from www. opm. gov/ insure. It explains what you
have to do to enroll. 50.
50 Page 51 52

2003 Heart of America HMO 48 Section 11
Converting to You may convert to a non-FEHB 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 cov-erage,
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 cov-erage.

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.

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 question. 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 infor-mation.

Getting a Certificate of Group Health Plan Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage avail-ability
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 cover-age.
Your new plan must reduce or eliminate waiting periods, limitations, or
exclusions for health related conditions based on the information in the certifi-cate,
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 previous-ly
enrolled in other FEHB plans, you may also request a certificate from those
plans. 51.
51 Page 52 53

2003 Heart of America HMO 49 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long-term care by applying for insurance in the Federal
Long-Term Care Insurance Program.

Open Season to apply for long-term care insurance through LTC Partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health dur-ing
Open Season.

If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open
Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long-term care. Also called "custodial care", long-term
care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide
help you may need due to a severe cognitive impairment such as Alzheimer's disease.

You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance
Program Open Season ends, but they will have to answer more health-related questions.

For annuitants and other qualified relatives, the number of health-related questions that you need to answer
is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically.
You must request one through the toll-free number or website listed below.

Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting avail-able
to employees and their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing
impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 52.
52 Page 53 54
2003 Heart of America HMO 50 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 33
Allergy tests 17
Alternative treatment 21
Allogeneic (donor) bone marrow
transplants 24
Ambulance 26
Anesthesia 22
Autologous bone marrow
transplant 24
Biopsies 22
Birthing centers 16
Blood and blood plasma 26
Breast cancer screening 15
Casts 25
Catastrophic protection 12
Changes for 2003 8
Chemotherapy 18
Childbirth 16
Chiropractic 21
Cholesterol tests 15
Claims 35-37
Coinsurance 12
Colorectal cancer screening 15
Congenital anomalies 23
Contraceptive devices and drugs 17
Coordination of benefits 38-39
Covered charges 51
Covered providers 9
Crutches 20
Deductible 12
Definitions 43-44
Dental care 33
Diagnostic services 14-15
Disputed claims review 36.37
Donor expenses (transplants) 24
Dressings 25-26
Durable medical equipment
(DME) 20
Educational classes and
programs 21
Effective date of enrollment 46

Emergency 27-28
Experimental or investigational 34
Eyeglasses 19
Family planning 17
Fecal occult blood test 15
Fraud 4
General Exclusions 34
Hearing services 19
Home health services 21
Hospice care 26
Home nursing care 21
Hospital 10
Immunizations 15-16
Infertility 17
Inhospital physician care 14
Inpatient Hospital Benefits 25
Insulin 20, 31
Laboratory and pathological
services 15
Machine diagnostic tests 14-15
Magnetic Resonance Imagings
(MRIs) 15
Mammograms 15
Maternity Benefits 16
Medicaid 42
Medically necessary 43
Medicare 38
Members 45
Mental Conditions/ Substance
Abuse Benefits 29
Neurological testing 15
Newborn care 16
Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits 14
Oral and maxillofacial surgery 23
Orthopedic devices 20
Ostomy and catheter supplies 20
Out-of-pocket expenses 12
Outpatient facility care 26

Oxygen 20
Pap test 15
Physical examination 15
Physical therapy 18
Physician 14
Preventive care, adult 15
Preventive care, children 16
Prescription drugs 31-32
Preventive services 15-16
Prior approval 11
Prostate cancer screening 15
Prosthetic devices 20
Psychologist 29
Psychotherapy 29
Radiation therapy 18
Rehabilitation therapies 18
Renal dialysis 18
Room and board 25
Second surgical opinion 14
Skilled nursing facility care 26
Smoking cessation 21
Speech therapy 18
Splints 25
Sterilization procedures 17
Subrogation 42
Substance abuse 29
Surgery 22
Anesthesia 24
Oral 23
Outpatient 26
Reconstructive 23
Syringes 31
Temporary continuation of
coverage 47
Transplants 24
Treatment therapies 18
Vision services 19
Well child care 16
Wheelchairs 20
Workers' compensation 42
X-rays 15 53.
53 Page 54 55
2003 Heart of America HMO 51 Summary
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.
Below, an asterisk (*) means the item is subject to the $600 calendar year deductible.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office Office visit copay: $10 primary 14
care; $ 0 specialist

Services provided by a hospital:
Inpatient Nothing 25
Outpatient 26
Emergency benefits:
In-area $30 copay for each emergency 28
room visit

Out-of-area $30 copay for each emergency 28
room visit.

Mental health and substance abuse treatment Regular cost sharing. 29
Prescription drugs *$ 600 deductible and 50% of 31
charges thereafter.

Dental Care No benefit. 33
(Accidental injury benefit only)

Vision Care No benefit.
Protection against catastrophic costs Nothing after you have met the
(your out-of-pocket maximum) maximum of 50% of your annual 12
premium per calendar year.

Some costs do not count toward
this protection

Summary of benefits for the Heart of America HMO -2003 54.
54 Page 55
2003 Heart of America HMO 52 Rates
2003 Rate Information for
Heart of America HMO Health 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 a special FEHB guide is published 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 employ-ee
organization who are not career postal employees. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly

Type of Enrollment Code Gov't Share Your Share Your Share Your Share Gov't Share USPS Share
Biweekly

Self Only
Self and Family
RU1
RU2
$29.16
$72.03
$87.50
$216.11
$189.57
$468.23
$103.54
$255.72
$63.19
$156.07
$13.12
$32.42 55.

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