Table of Contents

Introduction................................................................................... 4

Plain Language.................................................................................. 4

Section 1. Facts about this HMO plan......................................................................................................................................... 5

How we pay providers................................................................................................................................................. 5

Patients' Bill of Rights.................................................................................................................................................. 5

Service Area.................................................................................................................................................................. 6

Section 2. How we change for 2001.................................................................................. 7

Program-wide changes................................................................................................................................................. 7

Changes to this Plan.................................................................................................................................................... 7

Section 3. How you get care ......................................................................................................................................... 8

Identification cards....................................................................................................................................................... 8

Where you get covered care....................................................................................................................................... 8

Plan providers........................................................................................................................................................ 8

Plan facilities........................................................................................................................................................... 8

What you must do to get covered care..................................................................................................................... 8

Primary care............................................................................................................................................................ 8

Specialty care......................................................................................................................................................... 9

Hospital care........................................................................................................................................................... 9

Circumstances beyond our control.......................................................................................................................... 10

Services requiring our prior approval...................................................................................................................... 10

Section 4. Your costs for covered services............................................................................................................................... 11

Copayments.......................................................................................................................................................... 11

Deductible............................................................................................................................................................. 11

Coinsurance.......................................................................................................................................................... 11

Your out-of-pocket maximum.................................................................................................................................... 12

Section 5. Benefits................................................................................. 13

Overview...................................................................................................................................................................... 13

(a) Medical services and supplies provided by physicians and other health care professionals........... 13

(b) Surgical and anesthesia services provided by physicians and other health care professionals....... 22

(c) Services provided by a hospital or other facility, and ambulance services........................................... 26

(d) Emergency services/accidents..................................................................................................................... 29

(e) Mental health and substance abuse benefits............................................................................................ 30

(f) Prescription drug benefits............................................................................................................................. 31

(g) Dental benefits................................................................................................................................................ 34

Section 6. General exclusions -- things we don't cover........................................................................................................... 38

Section 7. Filing a claim for covered services............................................................................................................................ 39

Section 8. The disputed claims process..................................................................................................................................... 41

Section 9. Coordinating benefits with other coverage............................................................................................................. 43

When you have

Other health coverage........................................................................................................................................ 43

Original Medicare............................................................................................................................................... 43

Medicare managed care .................................................................................................................................... 45

TRICARE/Workers' Compensation/Medicaid....................................................................................................... 45

Other Government agencies...................................................................................................................................... 46

When others are responsible for injuries................................................................................................................ 46

Section 10. Definitions of terms we use in this brochure........................................................................................................ 47

Section 11. FEHB facts.................................................................................................................................................................. 49

Coverage information................................................................................................................................................. xx

No pre-existing condition limitation................................................................................................................ xx

Where you get information about enrolling in the FEHB Program............................................................. xx

Types of coverage available for you and your family.................................................................................. xx

When benefits and premiums start.................................................................................................................. xx

Your medical and claims records are confidential......................................................................................... xx

When you retire................................................................................................................................................. xx

When you lose benefits............................................................................................................................................. xx

When FEHB coverage ends............................................................................................................................. xx

Spouse equity coverage................................................................................................................................... xx

Temporary Continuation of Coverage (TCC)................................................................................................ xx

Converting to individual coverage................................................................................................................. xx

Getting a Certificate of Group Health Plan Coverage................................................................................... xx

Inspector General advisory:...................................................................................................................................... 55

Index ................................................................................................................................................................................... 56

Summary of benefits....................................................................................................................................................................... 57

Rates..Back cover

Section 1. Facts about this HMO plan

This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plans benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available 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 coinsurance.

Patients Bill of Rights

OPM requires that all FEHB Plans comply with the Patients Bill of Rights, recommended by the Presidents Advisory Commission on consumer Protection and Quality in the Health Care Industry. You may get information about us, our networks, providers, and facilities. OPMs 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 18 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.

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 58718 58740 58762 58782

58313 58341 58366 58451 58754 58741 58763 58783

58316 58343 58367 58540 58722 58744 58768 58784

58317 58346 58368 58701 58723 58746 58769 58785

58318 58348 58369 58705 58725 58747 58770 58787

58320 58353 58384 58704 58731 58750 58772 58789

58324 58356 58385 58705 58733 58752 58773 58790

58325 58357 58386 58710 58734 58756 58775 58792

58329 58359 58418 58711 58735 58758 58776 58793

58331 58360 58422 58712 58736 58759 58778

58332 58362 58423 58713 58737 58760 58779

58337 58363 58438 58716 58739 58761 58781

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.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example,if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until open season to change plans. Contact your employing or retirement office.

Section 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. 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 service area that we contract with to provide covered services to our members.

We list Plan providers in the provider directory, which we update periodically. All doctors of the Johnson Clinic Professional Corporation and Medical Arts Clinic 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 Medical Arts Clinic and UniMed Medical Center are available to provide health care from offices located in Minot, Bottineau, 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 Medical Arts Clinic primary care doctors are covered only when there has been a referral by the members 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 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, internest, pediatrician 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 physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, a woman may see her plan gynecologist 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 primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

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

terminate our contract with your specialist for other than cause; or

drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

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

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 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 person; we cover your other non-hospital care.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring prior approval Your physician must get our approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care. Before giving approval, we consider if the service is medically necessary, and if it follows generally accepted medical practice.

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 when you receive services.

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

Deductible Adeductible 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.

Coinsurance Coinsurance is thepercentage of our negotiated fee that you must pay for your care.

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

Your out-of-pocket maximum The copayment and coinsurance maximum is 50% of your

for deductibles, coinsurance, annual premium per calendar year. However, copayments and

and copayments coinsurance applicable to office visit copayments shall not be counted toward the copayment and coinsurance maximum. When the copayment and coinsurance maximum applicable to your contract has been fulfilled, copayment and coinsurance 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

Section 5. Benefits -- OVERVIEW

(See page 7 for how our benefits changed this year and page 52 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 701-776-5848 or at 1-800-525-5661.

(a) Medical services and supplies provided by physicians and other health care professionals...... xx-xx{page #'s of section}

Diagnostic and treatment services

Lab, X-ray, and other diagnostic tests

Preventive care, adult

Preventive care, children

Maternity care

Family planning

Infertility services

Allergy care

Treatment therapies

Rehabilitative therapies

Hearing services (testing, treatment, and supplies)

Vision services (testing, treatment, and supplies)

Foot care

Orthopedic and prosthetic devices

Durable medical equipment (DME)

Home health services

Alternative treatments

Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................... xx-xx

Surgical procedures

Reconstructive surgery

Oral and maxillofacial surgery

Organ/tissue transplants

Anesthesia

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

Inpatient hospital

Outpatient hospital or ambulatory surgical center

Extended care benefits/skilled nursing care facility benefits

Hospice care

Ambulance

(d) Emergency services/accidents................................................................................................................................. xx-xx

Medical emergency Ambulance

(e) Mental health and substance abuse benefits........................................................................................................ xx-xx

(f) Prescription drug benefits...................................................................................................................................................... xx

(g) Dental benefits......................................................................................................................................................................... xx

Summary of benefits....................................................................................................................................................................... xx

{insert page # for summary at back of brochure}

Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
	I M P O R T A N T	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.		I M P O R T A N T
Benefit Description			You pay After the calendar year deductible

Diagnostic and treatment services
Professional services of physicians In physicians office			$10 per visit; No copayment for visits to a plan specialist.
Professional services of physicians In an urgent care center During a hospital stay In a skilled nursing facility Initial examination of a newborn child covered under a family enrollment Office medical consultations by a specialist Second surgical opinion by a specialist			Nothing
At home doctors house call			Nothing
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

Lab, X-ray and other diagnostic tests	You Pay
Laboratory tests, such as: Blood tests Urinalysis Non-routine pap tests Pathology X-rays Non-routine Mammograms Cat Scans/MRI Ultrasound Electrocardiogram and EEG	Nothing
Preventive care, adult
Routine screenings such as: Blood lead level One annually Total Blood Cholesterol once every three years, ages 19 through 64 Colorectal Cancer Screening, including Fecal occult blood test yearly after age 50	Nothing

Sigmoidoscopy, screening every five years starting at age 50	Nothing
Prostate Specific Antigen (PSA test) one annually for men age 40 and older	Nothing
Routine pap test Note: There is a $10 copay for an office visit with a pap test.	Nothing
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	Nothing
Not covered: Physical exams required for obtaining or continuing employment or insurance, or travel. Physicals required for school or camp will be covered.	All charges.
Routine Immunizations, limited to: Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations) Influenza/Pneumococcal vaccines, annually, age 65 and over	Nothing

Preventive care, children	You pay
Childhood immunizations recommended by the American Academy of Pediatrics	Nothing
Examinations, such as: Eye exams through age 17 to determine the need for vision correction. Ear exams through age 17 to determine the need for hearing correction Examinations done on the day of immunizations ( through age 22) Well-child care charges for routine examinations, immunizations and care (through age 22)	$10 per visit
Maternity care
Complete maternity (obstetrical) care, such as: Prenatal care Delivery Postnatal care Note: Here are some things to keep in mind: You do not need to precertify your normal delivery; see page xx 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 mothers maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).	$10 copay on first prenatal visit only
Not covered: Routine sonograms to determine fetal age, size or sex	All charges
Family planning	You pay
Voluntary sterilization Surgically implanted contraceptives Injectable contraceptive drugs Intrauterine devices (IUDs) For covered medications and accessories, you pay 50% of charges after a $600 deductible.	$10 per visit
Not covered: reversal of voluntary surgical sterilization, genetic counseling,	All charges.
Infertility services
Diagnosis and treatment of infertility, such as: Artificial insemination: intrauterine insemination (IUI)	$10 per visit
Not covered: Assisted reproductive technology (ART) procedures, such as: in vitro fertilization embryo transfer and GIFT Services and supplies related to excluded ART procedures Fertility drugs Cost of donor sperm	All charges.
Allergy care
Testing and treatment Allergy injection	$10 per visit
Allergy serum	Nothing
Not covered: provocative food testing and sublingual allergy desensitization	All charges.
Treatment therapies	You pay
Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 26. Respiratory and inhalation therapy Dialysis Hemodialysis and peritoneal dialysis Intravenous (IV)/Infusion Therapy Home IV and antibiotic therapy Growth hormone therapy (GHT) 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.	$10 per office visit
Rehabilitative therapies
Physical therapy, occupational therapy and speech therapy -- Up to two consecutive months per condition for the services of each of the following: qualified physical therapists; speech therapists; and occupational therapists. Note: We only cover therapy to restore bodily function or speech when there has been a total or partial loss of bodily function or functional speech due to illness or injury. Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided 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. Long-term rehabilitative therapy (physical and occupational) is provided 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.	$10 per visit
Not covered: exercise programs	All charges.

Hearing services (testing, treatment, and supplies)	You pay
Hearing testing for children through age 17 (see Preventive care, children)	Nothing
Not covered: all other hearing testing hearing aids, testing and examinations for them	All charges.
Vision services (testing, treatment, and supplies)
Eye exam to determine the need for vision correction for children through age 17 (see preventive care)	Nothing
Not covered: Eyeglasses or contact lenses and, after age 17, examinations for them Eye exercises and orthoptics Radial keratotomy and other refractive surgery	All charges.
Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. See orthopedic and prosthetic devices for information on podiatric shoe inserts.	Nothing
Not covered: 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)	All charges.

Orthopedic and prosthetic devices	You pay
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. 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.	20% coinsurance on items which exceed $25.00 up to a maximum coinsurance of $500 per contract per calendar year.
Not covered: Orthopedic and corrective shoes arch supports foot orthotics heel pads and heel cups lumbosacral supports corsets, trusses, and other supportive devices	All charges.
Durable medical equipment (DME)	You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover: hospital beds; wheelchairs crutches; walkers; blood glucose monitors; and insulin pumps.	20% coinsurance on items which exceed $25.00 up to a maximum coinsurance of $500 per contract per calendar year.
Not covered: Motorized wheel chairs Electric wheel chairs	All charges.
Home health services	You Pay
Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide. Services include oxygen therapy, intravenous therapy and medications.	Nothing
Not covered: nursing care requested by, or for the convenience of, the patient or the patients family; nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.	All charges.
Alternative treatments
Chiropractic services	$10 per visit
Not covered: naturopathic services hypnotherapy biofeedback acupuncture	All charges.
Educational classes and programs
Coverage is limited to: 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	$10 per visit

Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
	I M P O R T A N T	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.)		I M P O R T A N T
Benefit Description			You pay
Surgical procedures
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.			Nothing
Voluntary sterilization Treatment of burns Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are covered under 5(a).			Nothing
Not covered: Reversal of voluntary sterilization Routine treatment of conditions of the foot; see Foot care.			All charges.

Reconstructive surgery	You pay
Surgery to correct a functional defect Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the members 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.	Nothing
All stages of breast reconstruction surgery following a mastectomy, such as: surgery to produce a symmetrical appearance on the other breast; treatment of any physical complications, such as lymphedemas; breast prostheses and surgical bras and replacements (see Prosthetic devices) Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.	Nothing
Not covered: 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	All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited to: 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. Note: Dental treatment of tempormandibular joint disorder and craniomandibular disorder is limited to a lifetime maximum Plan payment of $2,500.	Nothing
Not covered: Oral implants and transplants Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)	All charges.
Organ/tissue transplants	You pay
Limited to: 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 Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer is subject to approval by the Plans medical director in accordance with the Plans protocols. Note: We cover related medical and hospital expenses of the donor when we cover the recipient.	Nothing
Not covered: Donor screening tests and donor search expenses, except those performed for the actual donor Implants of artificial organs Transplants not listed as covered	All charges
Anesthesia	You pay
Professional services provided in Hospital (inpatient) Hospital outpatient department Skilled nursing facility Ambulatory surgical center Office	Nothing

	Section 5 (c). Services provided by a hospital or other facility, and ambulance services
		I M P O R T A N T	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).			I M P O R T A N T
	Benefit Description			You pay

	Inpatient hospital
	Room and board, such as 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.				Nothing
Other hospital services and supplies, such as: 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					Nothing
Not covered: Custodial care Non-covered facilities Personal comfort items, such as telephone, television, barber services, guest meals and beds Private nursing care					All charges.
Outpatient hospital or ambulatory surgical center					You pay
Operating, recovery, and other treatment rooms 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.					Nothing
Extended care benefits/skilled nursing care facility benefits
Extended care benefit: 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.					Nothing .
Not covered: custodial care					All charges
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care and family counseling. These services are provided under the 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.					Nothing
Not covered: Independent nursing, homemaker services					All charges
Ambulance
Local professional ambulance service when medically appropriate					Nothing

Section 5 (d). Emergency services/accidents

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:

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 physicans on call 24 hours a day at our contracted hospitals at Heart of America Medical Center, Rugby, ND at 701-776-5261 or UniMed Medical Center in Minot, ND at 701-857-2260. 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 member 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 hospitalized in non-Plan facilities and a Plan believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from 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 believe that care can better be provided in 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.

Benefit Description	You pay
Emergency within our service area
Emergency care at a doctor's office Emergency care at an urgent care center	Nothing
Emergency care at a hospital, including doctors' services. Note: If emergency results in admission, we waive the copayment.	$30 per visit
Not covered: Elective care or non-emergency care	All charges.
Emergency outside our service area
Emergency care at a doctor's office Emergency care at an urgent care center	Nothing
Emergency care at a hospital, including doctors' services. Note: If emergency results in admission, we waive the copayment.	$30 per visit
Not covered: Elective care or non-emergency care Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area	All charges.
Ambulance
Professional ambulance service when medically appropriate. We cover air ambulance when medically appropriate. See 5(c) for non-emergency service.	Nothing

Section 5 (e). Mental health and substance abuse benefits
	I M P O R T A N T	Parity Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve "parity" with other benefits. This means that we will provide mental health and substance abuse benefits differently than in the past. 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.		I M P O R T A N T
Benefit Description			You pay After the calendar year deductible
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.			Your cost sharing responsibilities are no greater than for other illness or conditions.
Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers Medication management			Nothing

Mental health and substance abuse benefits - Continued on next page

Mental health and substance abuse benefits (Continued)

You pay

Diagnostic tests

Nothing

Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, residential treatment (under 21 years of age) and full-day hospitalization.

Nothing

Not covered: Services we have not approved.

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.

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and 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.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued coverage with your provider for up to 90 days under the following conditions:

If your mental health or substance abuse professional provider with whom you are currently in treatment leaves the plan at our request for other than cause

If this condition applies to you, we will allow you reasonable time to transfer your care to a Plan mental health or substance abuse professional provider. During the transitional period, you may continue to see your treating provider and you will not pay any more out-of-pocket than you did in the year 2000 for services. This transitional period will begin with our notice to you of the change in coverage and will end 90 days after you receive our notice. If we write to you before October 1, 2000, the 90-day period ends before January 1 and this transitional benefit does not apply.

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

Section 5 (f). Prescription drug benefits
	I M P O R T A N T	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. 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.		I M P O R T A N T
	There are important features you should be aware of. These include: Who can write your prescription. A licensed 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. When you have to file a claim. See Section seven (7) Filing a claim for covered services.
Benefit Description			You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say No deductible when it does not apply.
Covered medications and supplies
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, Benedicts solution or equivalent, glucose monitors and acetone test tablets Insulin Disposable needles and syringes for the administration of covered medications Drugs for sexual dysfunction (see Prior authorization below) 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.			50% of charges per prescription unit or refill

Covered medications and supplies (continued)

You pay

Here are some things to keep in mind about our prescription drug program:

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

Not covered:

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

Smoking cessation drugs and medication

All Charges

Section 5 (g). Dental benefits
	I M P O R T A N T	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.			I M P O R T A N T
Accidental injury benefit				You pay
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.			Nothing
Dental benefits
We have no other dental benefits.

Section 6. General exclusions -- things we don't cover

The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness or condition.

We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

Services, drugs, or supplies you receive while you are not enrolled in this Plan;

Services, drugs, or supplies that are not medically necessary;

Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;

Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

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

Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

Section 8. The disputed claims process

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

Step	Description
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 provisions in this brochure; and (d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
2	We have 30 days from the date we receive your request to: (a) Pay the claim (or 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 requestgo to step 3.
3	You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
4	If you do not agree with our decision, you may ask OPM to review it.
	You must write to OPM within: 90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or 120 days after we asked for additional information.
	Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, P.O. Box 436, Washington, D.C. 20044-0436.
	Send OPM the following information: A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure; Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms; Copies of all letters you sent to us about the claim; Copies of all letters we sent to you about the claim; and Your daytime phone number and the best time to call. Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
	Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, 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.
6	If you do not agree with OPMs 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. This is the only deadline that may not be extended. OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
	You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/prior approval, then call us at 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 can call OPM's Health Benefits Contracts Division 3 at 202/606-0755 between 8 a.m. and 5 p.m. eastern time.

Section 9. Coordinating benefits with other coverage

When you have other health coverage You must tell us if you are covered or a family member is covered under 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 secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.

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

When we are the secondary payer, we will determine 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.

Part B (Medical Insurance). Most people pay monthly for Part B.

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. {RV 5/12}

The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B benefits. You may go to any doctor, specialist, or hospital that accepts Medicare. Medicare pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in this Plan and Original Medicare, 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.

There is no copayment for visits to your primary care physician or authorized visits to a specialist. There is also no copayment for emergency room visits.

(Primary payer chart begins on next page.)
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
	Original Medicare	This Plan
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when a) The position is excluded from FEHB	..
b) Or, the position is not excluded from FEHB. Ask your employing office which of these applies to you.	..
4) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,	(for Part B services)	(for other services)
6) Are a former Federal employee receiving Workers Compensation and the Office of Workers Compensation Programs has determined that you are unable to return to duty,	(except for claims 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	..	.

Claims Process You must tell us if you or a family member is enrolled in Part A or B. Medicare will determine who is responsible for paying for medical services and we will coordinate the payments. On occasion, you may need to file Medicare claim forms.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in a Medicare managed care plan. 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 Plans Medicare managed care plan: You may enroll in another plans 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.

Suspended FEHB coverage and a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the Medicare managed care service area.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be

Medicare Part B covered under the FEHB Program. We cannot require you to enroll in Medicare.

TRICARE TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.

Workers Compensation We do not cover services that:

you need because of a workplace-related disease or injury that the Office of Workers Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State,

are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care

for injuries for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

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

Section 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 information See www.opm.gov/insure. Also, your employing or retirement office

about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

When you may change your enrollment;

How you can cover your family members;

What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and

When the next open season for enrollment begins.

We dont 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 incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

When benefits and The benefits in this brochure are effective on January 1. If you are new

premiums start to this Plan, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. Annuitants premiums begin on January 1.

Your medical and claims We will keep your medical and claims information confidential. Only

records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;

This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when coordinating benefit payments and subrogating claims;

Law enforcement officials when investigating and/or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;

Individuals involved in bona fide medical research or education that does not disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.

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

When you lose benefits

When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or

You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not

coverage continue to get benefits under your former spouses enrollment. But, you may be eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact your ex-spouses 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.

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www.opm.gov/insure.

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 coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group

Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

Inspector General Advisory Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.

If the provider does not resolve the matter, call us at 701-776-5848 or 800-525-5661 and explain the situation.

If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/418-3300 or write to: The United States Office of Personnel Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the person tries to obtain services for someone who is not an eligible family member, or is no longer enrolled in the Plan and tries to obtain benefits. Your agency may also take administrative action against you.

Accidental injury xx

Allergy tests xx

Alternative treatment xx

Ambulance xx

Anesthesia xx

Autologous bone marrow transplant xx

Biopsies xx

Birthing centers xx

Blood and blood plasma xx

Breast cancer screening xx

Carryover xx

Casts xx

Catastrophic protection xx

Changes for 2001 xx

Chemotherapy xx

Childbirth xx

Cholesterol tests xx

Claims xx

Coinsurance xx

Colorectal cancer screening xx

Congenital anomalies xx

Contraceptive devices and drugs xx

Coordination of benefits xx

Covered charges xx

Covered providers xx

Crutches xx

Deductible xx

Definitions xx

Dental care xx

Diagnostic services xx

Disputed claims review x

Donor expenses (transplants) xx

Dressings xx

Durable medical equipment (DME) xx

Educational classes and programs xx

Effective date of enrollment xx

Emergency xx

Experimental or investigational xx

Eyeglasses xx

Family planning xx

Fecal occult blood test xx

General Exclusions xx

Hearing services xx

Home health services xx

Hospice care xx

Home nursing care xx

Hospital xx

Immunizations xx

Infertility xx

Inhospital physician care xx

Inpatient Hospital Benefits xx

Insulin xx

Laboratory and pathological services xx

Machine diagnostic tests xx

Magnetic Resonance Imagings (MRIs) xx

Mail Order Prescription Drugs xx

Mammograms xx

Maternity Benefits xx

Medicaid xx

Medically necessary xx

Medicare xx

Members xx

Mental Conditions/Substance Abuse Benefits xx

Neurological testing xx

Newborn care xx

Nursery charges xx

Obstetrical care xx

Occupational therapy xx

Ocular injury xx

Office visits xx

Oral and maxillofacial surgery xx

Orthopedic devices xx

Ostomy and catheter supplies xx

Out-of-pocket expenses xx

Outpatient facility care xx

Oxygen xx

Pap test xx

Physical examination xx

Physical therapy xx

Physician xx

Preventive care, adult xx

Preventive care, children xx

Prescription drugs xx

Preventive services xx

Prior approval xx

Prostate cancer screening xx

Prosthetic devices xx

Psychologist xx

Psychotherapy xx

Radiation therapy xx

Rehabilitation therapies xx

Renal dialysis xx

Room and board xx

Second surgical opinion xx

Skilled nursing facility care xx

Smoking cessation xx

Speech therapy xx

Splints xx

Sterilization procedures xx

Subrogation xx

Substance abuse xx

Surgery xx

Anesthesia xx

Oral xx

Outpatient xx

Reconstructive xx

Syringes xx

Temporary continuation of coverage xx

Transplants xx

Treatment therapies xx

Vision services xx

Well child care xx

Wheelchairs xx

Workers compensation xx

X-rays xx

2001 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 special FEHB guides are published for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

Non-Postal Premium

Postal Premium

Biweekly

Monthly

Biweekly

Type of

Enrollment

Code

Govt

Share

Your

Share

Govt

Share

Your

Share

USPS

Share

Your

Share

Self Only

RU1

$79.25

$26.42

$171.71

$57.24

$93.78

$11.89

Self and Family

RU2

$190.77

$63.59

$413.33

$137.78

$225.74

$28.62

Benefits	You Pay	Page
Medical services provided by physicians: Diagnostic and treatment services provided in the office...................	Office visit copay: $10 primary care; $ 0 specialist	xx
Services provided by a hospital: Inpatient...................................................................................................... Outpatient...................................................................................................	Nothing	xx xx
Emergency benefits: In-area......................................................................................................... Out-of-area.................................................................................................	$30 copay for each emergency room visit. $30 copay for each emergency room visit.	xx xx
Mental health and substance abuse treatment........................................	Regular cost sharing.	xx
Prescription drugs..........................................................................................	$600 deductible and 50% of charges thereafter.	xx
Dental Care.................................................................................................. (Accidental injury benefit only)	No benefit.	xx
Vision Care...................................................................................................	No benefit.	xx
Protection against catastrophic costs (your out-of-pocket maximum)..................................................................	Nothing after you have met the maximum of 50% of your annual premium per calendar year. Some costs do not count toward this protection	xx

Diagnostic and treatment services

Lab, X-ray and other diagnostic tests

Preventive care, adult

Preventive care, children

Not covered:

naturopathic services

hypnotherapy

biofeedback

acupuncture

Educational classes and programs

Other hospital services and supplies, such as:

Outpatient hospital or ambulatory surgical center

You pay

Hospice care

Section 5 (d). Emergency services/accidents

Mental health and substance abuse benefits

Mental health and substance abuse benefits (Continued)

You pay

Not covered: Services we have not approved.

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.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for continued coverage with your provider for up to 90 days under the following conditions:

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

NOTE: The calendar year deductible applies to almost all benefits in this Section. We say No deductible when it does not apply.

Accidental injury benefit

1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD,