Pages 1--62 from GHI HMO

This Plan has new health plan accreditation from NCQA. See the 2002 Guide for more
information on accreditation.

Enrollment codes for this Pl an: Albany – Capital District, Hudson Valley Area
X41 Self Only X42 Self and Family

New York City Area 6V1 Self Only
6V2 Self and Family

For changes in benefits,
see page 8. 1
1 Page 2 3
2002 GHI HMO 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………. ....................................................................... 4
Plain Language………………………………………………………………....................................................................... 4
Inspector General Advisory………………………………....................................................................................................... 4
Section 1. Facts about this HMO plan ......................................................................................................................................... 6
How we pay providers ................................................................................................................................................. 6
Who provides my health care?…………………………………………………………………………….. 6
Your Rights.................................................................................................................................................................... 6
Service Area................................................................................................................................................................... 7
Section 2. How we change for 2002……………………………………….......................................................................... 8
Program-wide changes................................................................................................................................................. 8
Changes to this Plan ..................................................................................................................................................... 8
Section 3. How you get care …………... .................................................................................................................................... 9
Identification cards....................................................................................................................................................... 9
Where you get covered care........................................................................................................................................ 9
Plan providers......................................................................................................................................................... 9
Plan facilities .......................................................................................................................................................... 9
What you must do to get covered care ...................................................................................................................... 9
Primary care ............................................................................................................................................................ 9
Specialty care ....................................................................................................................................................... 10
Hospital care ......................................................................................................................................................... 10
Circumstances beyond our control........................................................................................................................... 11
Services requiring our prior approval...................................................................................................................... 11
Section 4. Your costs for covered services................................................................................................................................ 13
Copayments .......................................................................................................................................................... 13
Deductible ............................................................................................................................................................. 13
Coinsurance.......................................................................................................................................................... 13
Your out-of-pocket maximum.................................................................................................................................. 13
Section 5. Benefits…………………………………………………………....................................................................... 14
Overview...................................................................................................................................................................... 14
(a) Medical services and supplies provided by physicians and other health care professionals ............. 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals ......... 25
(c) Services provided by a hospital or other facility, and ambulance services........................................... 29
(d) Emergency services/ accidents ...................................................................................................................... 32
(e) Mental health and substance abuse benefits............................................................................................... 34
(f) Prescription drug benefits.............................................................................................................................. 37 2
2 Page 3 4
2002 GHI HMO 3 Table of Contents
Table of Contents (Continued)
(g) Special features ................................................................................................................................................. 41
Flexible benefits option
(h) Dental benefits ................................................................................................................................................ 42
Section 6. General exclusions --things we don't cover......................................................................................................... 43
Section 7. Filing a claim for covered services .......................................................................................................................... 44
Section 8. The disputed claims process..................................................................................................................................... 45
Section 9. Coordinating benefits with other coverage............................................................................................................. 47
When you have…
Other health coverage .............................................................................................................................................. 47
Original Medicare ..................................................................................................................................................... 47
Medicare managed care plan……………………………………………………………………………. 50
TRICARE/ Workers' Compensation/ Medicaid ...................................................................................................... 50
Other Government agencies...................................................................................................................................... 51
When others are responsible for injuries ................................................................................................................ 51
Section 10. Definitions of terms we use in this brochure ....................................................................................................... 52
Section 11. FEHB facts................................................................................................................................................................. 54
Coverage information................................................................................................................................................. 54
No pre -existing condition limitation .............................................................................................................. 54
Where you get information about enrolling in the FEHB Program.......................................................... 54
Types of coverage available for you and your family ................................................................................. 54
When benefits and premiums start.................................................................................................................. 55
Your medical and claims records are confidential....................................................................................... 55
When you retire................................................................................................................................................. 55
When you lose benefits.............................................................................................................................................. 55
When FEHB coverage ends............................................................................................................................. 55
Spouse equity coverage ................................................................................................................................... 55
Temporary Continuation of Coverage (TCC).............................................................................................. 55
Converting to individual coverage................................................................................................................. 56
Getting a Certificate of Group Health Plan Coverage................................................................................ 56
Long term care insurance is coming later in 2002 .................................................................................................................... 57
Index .................................................................................................................................................................................. 59
Summary of benefits ...................................................................................................................................................................... 60
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2002 GHI HMO 4 Introduction/ Plain Language/ Advisory
Introduction
GHI HMO Select, Inc.
25 Barbarosa Lane Kingston, NY 12401

This brochure describes the benefits of GHI HMO under our contract (CS2655) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official statement of benefits. No oral
statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002 and changes are
summarized on page 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means GHI 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 us at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.

Inspector General Advisory
Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you
twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-877-244-4466 and explain the situation.

If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300

The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Stop health care fraud! 4
4 Page 5 6
2002 GHI HMO 5 Introduction/ Plain Language/ Advisory
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. 5
5 Page 6 7
2002 GHI 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.

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 and coinsurance 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 coinsurance.

Who provides my health care?
GHI HMO Select, an individual practice prepayment plan, is a New York State certified, for-profit community-sponsored,
primary care network model Health Maintenance Organization (HMO).

GHI HMO Select organizes preventative and routine health care as well as needed services for serious illness or
injury. Care and coverage is provided by approximately one thousand seven hundred and eighty nine ( 1,789) individually affiliated primary care doctors, seventy two (72) area hospital, eleven thousand two hundred and fifty two

(11,252) local specialist.
GHI HMO Select administrative offices are located at 25 Barbarosa Lane and 120 Wood Road, Kingston, NY 12401; and at 80 Wolf Road, Albany, NY 12205. Affiliated primary care doctors, specialists and other health care providers
are conveniently located throughout the service area.
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.
Years in existence -GHI HMO Select, Inc. is a subsidiary of GHI, the largest, not-for-profit health services
corporation operating state-wide in New York, and has been operating in 25 counties of NYS since July 1999.
Company profit status -GHI HMO Select, Inc. is a for-profit HMO.
Drug Formulary -GHI HMO offers an open drug formulary.
Percentage of Board Certified Physicians -86% of GHI HMO physicians are Board Certified.

If you want more information about us, call 1-877-244-4466, or write to GHI HMO, Customer Service, 120 Wood
Road, Kingston, NY 12401. You may also contact us by fax at (845) 334-8950 or visit our website at http:// www. ghihmo. com. 6
6 Page 7 8
2002 GHI HMO 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our
service area is:

Albany – Capital District Area: Albany, Broome, Columbia, Delaware , Fulton, Greene, Montgomery, Rensselaer,
Saratoga, Schenectady, Schoharie, Warren and Washington Counties.

Hudson Valley Area: Dutchess, Orange, Otsego, Putnam, Rockland, , Sullivan, and Ulster Counties.
New York City Area: Bronx, Brooklyn, Manhattan, Queens, and Westchester.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will only pay for emergency care benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you should 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 the Open Enrollment Season to change plans. Contact your employing or
retirement office. 7
7 Page 8 9
2002 GHI HMO 8 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

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

Your share of the non-Postal premium will increase by 9.8% for Self Only or 14.5% for Self and Family for Code X4. Your share will decrease by 50.4% for Self Only or 27.5% for Self and Family for Code 6V.

We no longer limit total blood cholesterol tests to certain age groups. (Section 5( a))
You pay $10 for generic, $20 for preferred brand and $30 for non-preferred brand for prescription drugs at a retail
pharmacy. The retail co-pay applies to a 30-day supply. You pay $20 for generic, $40 for preferred brand and $50 for non-preferred brand for maintenance medications prescription drugs using mail-order. The mail order

copay covers up to a 90-day supply for maintenance medication.
If a brand drug is selected and there is a generic equivalent available you pay the brand co-pay and the difference in price between the generic and brand drug. 8
8 Page 9 10
2002 GHI 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 Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment

confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 1-877-244-4466.

Where you get covered care You get care from " Participating Plan providers" and "Participating Plan facilities." You will only pay copayments, or coinsurance, and you will
not have to file claims
Plan providers Plan providers are physicians, including primary care physicians and
specialists and other health care professionals in our service area that we contract with to provide covered services to our members. We credential

Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The directory is divided alphabetically by county. Primary
Care Physicians are listed first, Specialty Care Physicians are listed
second and all other providers (ancillary) are listed third under each county. The list is also on our website www. ghihmo. com.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. The list is also
on our website.

It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for

most of your health care. Primary care physicians are listed in our
provider directory and also on our web site. You may also call our Customer Service Department (1-877-244-4466) and they may assist you

in selecting a provider near your home or office.

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

What you must do
to get covered care 9
9 Page 10 11
2002 GHI 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

primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits

unless your primary care physician gives you a referral. However, you
may see your OB/ GYN twice a year without a referral and a participating optometrist for a routine vision exam annually without a referral.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will work with specialists to develop a treatment plan that allows you

to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our 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. Yo u 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 1-877-244-4466. If you
are new to the FEHB Program, we will arrange for you to receive care. 10
10 Page 11 12
2002 GHI HMO 11 Section 3
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 benefits of the hospitalized person

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

Services requiring our prior approval Your primary care physician has authority to refer you for most services.
For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.
We call this review and approval process percertification. Your physician must obtain prior authorization from the GHI HMO Medical
Director. These services may include but are not limited to:
a. Specialist Referrals
b. Ambulatory Surgery c. Hospital/ Nursing Home admissions and any care rendered during stay

d. Physical Therapy and Cardiac Rehabilitation
e. Home Care and Hospice f. Durable Medical Equipment over $250 and all Orthotics

g. Non-Participating Providers
h. Member requests for experimental or investigative health care services.

i. Mental Health and Substance Abuse (MH/ SA)
GHI HMO may request supporting documentation from your provider to substantiate Medical Necessity of the requested service. All inpatient
admissions are reviewed to evaluate that the services are covered services, Medically Necessary and being rendered at the appropriate level
of care.
You have the right to designate a representative for utilization review. GHI HMO will notify you and your provider, by phone and in writing for
prospective, concurrent and retrospective utilization review decisions. If we deny services or won't pay your claim, you may ask us to
reconsider our decision. Your request must: 11
11 Page 12 13
2002 GHI HMO 12 Section 3
1. Be in writing 2. Refer to specific brochure wording in explaining why you believe our
decision is wrong; and
3. Be made within six months from the date of our initial denial or refusal. We may extend this time limit if you show that you were

unable to make a timely request due to reasons beyond your control.
We have 30 days from the date we receive your reconsideration request to:

1. Maintain our denial in writing; 2. Pay the claim;
3. Arrange for a health care provider to give you the service; or 4. Ask for more information

If we ask your medical provider for more information, we will send you a copy of our request. We must make a decision within 30 days after we
receive the additional information. If we do not receive the requested
information within 60 days, we will make our decision based on the in-formation we already have. 12
12 Page 13 14
2002 GHI HMO 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you
pay nothing.
Deductible We do not have a deductible
Coinsurance Coinsurance is the percentage of our negotiated that you must pay for your care.

Example: In our plan you pay 50% of our allowance for infertility services. Also, you pay 20% for durable medical equipment up to a
maximum of $1500 per person, per year.
Your catastrophic protection We do not have an catastrophic protection out-of-pocket maximum. out-of-pocket maximum for

deductibles, coinsurnace, and copayments 13
13 Page 14 15
2002 GHI HMO 14 Section 5
Section 5. Benefits – OVERVIEW
(See page 8 for how our benefits changed this year and page 60 for a benefits summary.)

NOTE: This benefits section is divided broken 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
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-877-2GH-IHMO or 1-877-244-4466 or at our website at www. ghihmo. com.
(a) Medical services and supplies provided by physicians and other health care professionals……………………. 15-24
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
Diabetic supplies
Treatment therapies
Physical and occupational therapies

Speech therapy
Hearing services (testing, treatment, and supplies)

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................... 25-28
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ............................................................ 29-31
Inpatient hospital
Outpatient hospital or ambulatory surgical
center

Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance

(d) Emergency services/ accidents................................................................................................................................ 32-33
Medical emergency Ambulance

(e) Mental health and substance abuse benefits........................................................................................................ 34-36
(f) Prescription drug benefits ............................................................................................................................................... 37-40
(g) Special features....................................................................................................................................................................... 41
Flexible benefits option
Services for the deaf and hearing impaired
Center of Excellence for transplant/ heart surgeries
PHIP – Personal Health Improvement Program (h) Dental benefits ........................................................................................................................................................................ 42

Summary of benefits...................................................................................................................................................................... 60 14
14 Page 15 16
2002 GHI HMO 15 Section 5( a)
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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office

Physical examinations
Routine eye exams
Chiropractic services (with referral from PCP)

Routine cervical Cytology (PAP smear)
Well Baby and Well Child Care visits (including immunizations)

Mammogram Exam

$10 per office visit
Nothing

Professional services of physicians
In an urgent care center
Office medical consultations
Second surgical opinion

$10 per office visit

During a hospital stay
In a skilled nursing facility / 120 day limit

Nothing

Diagnostic and treatment services --Continued on next page 15
15 Page 16 17
2002 GHI HMO 16 Section 5( a)
Diagnostic and treatment services (Continued) You pay
At Home

Not covered:
Routine foot care and foot orthotics
Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or
insurance, attending school or camp, or travel
Long-term rehabilitative therapy
Homemaker services

Nothing
All Charges

.

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

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

CAT Scans/ MRI
X-ray

$10 copay

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening -every five years starting at age 50
Prostate Specific Antigen (PSA test) -one annually for men age 40 and older

$10 per office visit

Routine pap test
Note: The pap test is covered if the office visit is on the same day the
office copay still applies; see Diagnosis and Treatment on page 15.

$10 per office visit 16
16 Page 17 18
2002 GHI HMO 17 Section 5( a)
Preventive care, adult (continued) You pay
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 and older, one every calendar year

Nothing

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

$10 per office visit

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing

Examinations, such as:
-Eye exams through age 19 to determine the need for vision correction.

-Ear exams through age 19 to determine the need for hearing
correction by a primary care physician

$10 per office visit

-Examinations done on the day of immunizations ( under age
22)

-Well-child care charges for routine examinations, immunizations and care (under age 22)

Nothing 17
17 Page 18 19
2002 GHI HMO 18 Section 5( a)
Maternity Care You Pay
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 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).

Initial $10 copay, subsequent pre and post natal care you pay
nothing

Not covered: Routine sonograms to determine fetal sex. All charges
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges. 18
18 Page 19 20
2002 GHI HMO 19 Section 5( a)
Infertility services
Diagnosis of infertility $10 per office visit
Treatment of Infertility, such as:

Artificial insemination
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)

50% of charges

Not covered:
Assisted reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer
Services and supplies related to excluded ART procedures

Fertility Drugs
Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment

Allergy injection
$10 per office visit

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

Diabetic Supplies and Equipment
Blood glucose monitors, data management systems, test strips for glucose monitoring, insulin, injection aids, cartridges for legally

blind, syringes, insulin pumps, insulin infusion devices, oral agents for controlling blood sugar
$10 copay for supplies 19
19 Page 20 21
2002 GHI HMO 20 Section 5( a)
Treatment therapies
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 xx.
Respiratory and inhalation therapy– Hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy

Nothing

Growth hormone therapy (GHT)
Note: – Growth hormone is covered under the prescription drug
benefit.

Note: – We will only cover GHT when we preauthorize the treatment. Call or have your physician 1 877-2GH-IHMO or 1 877-244-
4466 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. This benefit is provided under our Prescription Drug Benefits. See Services requiring our prior approval in Section 3.

$10 copay for prescriptions

Not covered:
Treatment for experimental or investigational procedure
Therapy necessary for transsexual surgery

All charges. 20
20 Page 21 22
2002 GHI HMO 21 Section 5( a)
Physical and occupational therapies You pay
Up to two consecutive months per condition if significant improvement can be expected within two months for the following

services:
qualified physical therapists;
occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or

injury. Physical and occupational therapy is provided on an
inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can be expected within two

months; you pay $10 copay per outpatient visit. Speech therapy is
limited to treatment if certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member

to achieve and maintain self-care and improved functioning in other
activities of daily living.

Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, is provided for up to 30
visits within 60 days.

$10 per office visit
$10 per outpatient visit
Nothing per visit during covered inpatient admission

Not covered:
Long term rehabilitative therapy
Exercise programs

All charges.

Speech therapy
Up to two consecutive months per condition when medically necessary. $10 per office visit

Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)
$10 per office v isit

Not covered:
all other hearing testing
hearing aids, testing and examinations for them

All charges. 21
21 Page 22 23
2002 GHI HMO 22 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Eye exam to determine the need for vision correction (see preventive care)

Annual eye refractions
Note: See preventive care, children for eye exam

$10 per office visit

Not covered:
Eyeglasses or contact lences
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.

$10 per office visit

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
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant following mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see

Section 5 (c) for payment information. See 5( b) for coverage of the
surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) paid dysfunction syndrome.

20% coinsurance to a maximum of
$1,500 per person, per calendar year. 22
22 Page 23 24
2002 GHI HMO 23 Section 5( a)
Orthopedic and prosthetic devices (Continued)
Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than 3 years after the last one we covered

All charges.

Durable medical equipment (DME)
Rental or purchase, as determined by GHI HMO, 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;
standard wheelchairs;
apnea monitors;
nebulizers;
crutches and;
walkers;

Note: Call us at 1-877-244-4466 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider

to rent or sell you durable medical equipment and will tell you more about this service when you call.

20% coinsurance to a maximum
benefit $1,500 per person, per calendar year.

Not covered:
Motorized wheel chairs
Hearing aids

All charges.

Home health services
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), or other
Home Health Care Agency personnel licensed vocational nurse (L. V. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and
medications.

Nothing 23
23 Page 24 25
2002 GHI HMO 24 Section 5( a)
Home health services (Continued)
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family;

Home health care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.

All charges.

Chiropractic
Manipulation of the spine and extremit ies
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Chiropractic services when authorized by PCP

$10 per office visit

Alternative treatments
Not covered:
Acupuncture services Naturopathic services
Hypnotherapy Biofeedback

All charges.

Educational classes and programs
No Benefit 24
24 Page 25 26
2002 GHI HMO 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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Here are some i mportant 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 p rovide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

surgical center, etc).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure

which services require prior authorization and identify which surgeries require prior authorization .

I M
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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre -and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.

Voluntary sterilization
Treatment of burns
Note: Generally we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for

a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing for
hospital visits

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

All charges. 25
25 Page 26 27
2002 GHI HMO 26 Section 5( b)
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 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.

$10 per office visit; nothing for hospital visits

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

See above.

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

Temporanmandibular Joint treatment (TMJ)
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit

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 other procedures involving the teeth or intra-oral areas surrounding the teeth are not covered, including any dental care
involved in the treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome.

All charges. 26
26 Page 27 28
2002 GHI HMO 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogenic (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) and the small intestine with
the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

National Transplant Program (NTP) – GHI HMO will cover
transplants approved as safe and effective for a specific disease by the Federal Drug Administration (FDA) or National Institute of

Health or which GHI HMO's Medical Director determines is
medically necessary, appropriate and advisable on a case-by-case basis. GHI HMO will cover the medical and hospital services, and

related organ acquisition costs. Eligibility for transplants shall be
determined solely by GHI HMO's Medical Director upon recommendation of an Enrollee's Primary Care Physician.

Eligibility for transplants mu st be approved in advance of surgery
by GHI HMO's Medical Director. Additionally, all transplants must be performed at hospitals specifically approved and designated by

GHI HMO to perform these procedures. Specialty physician experts
from our designated centers of excellence will provide clinical review and support to the Medical Director's decision.

Limited Benefits – Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical trial at a Plan-designated center of excellence and if approved

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:
Donor screening tests and donor search expenses, except those
performed for the actual donor
Implants of artificial organs
Transplants not listed as covered

Nothing
All Charges 27
27 Page 28 29
2002 GHI HMO 28 Section 5( b)
Anesthesia You Pay
Professional services provided in –
Hospital (inpatient)

Nothing

Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Nothing 28
28 Page 29 30
2002 GHI HMO 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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. Als o read Section 9 about

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

associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF
HOSPITAL STAYS. Please refer to Section 3 to be sure which services require prior authorization precertification

I M
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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
special duty nursing and private rooms during inpatient hospitalization when medically necessary and approved by GHI

HMO Medical Director

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

Nothing

Inpatient hospital continued on next page. 29
29 Page 30 31
2002 GHI HMO 30 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

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

Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment if in connection with an accidental injury to sound natural teeth within

twelve (12) months of the accident, or in the judgement of GHI HMO's
Medical Director, a hazardous concurrent medical condition requires hospitalization. Hospital care is only available when a medical

condition necessitates such care. We do not cover the dental
procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges 30
30 Page 31 32
2002 GHI HMO 31 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): Limited to 120 days per person per calendar year :

Bed, board and general nursing care
Drugs, biologicals, supplied and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your

plan doctor.

Nothing

Not covered: custodial care All charges
Hospice care
Supportive and palliative care for the terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care and

family counseling. Benefits are limited to 210 days; bereavement counseling services are covered up to five (5) days.
Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 31
31 Page 32 33
2002 GHI HMO 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that a prudent
layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in a condition 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. These conditions would be defined as urgent care. 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:
In the event of a medical emergency you should seek immediate medical treatment at the nearest emergency facility anywhere in the world whether or not they participate with GHI HMO. You do not need prior
approval by GHI HMO or your PCP to receive emergency treatment. However, you or a family member must
contact your PCP, unless it not reasonably possible to do so. If you are unable to contact your PCP, please call GHI HMO at 1-877-244-4466. It is your PCP's responsibility to contact GHI HMO with this information.

All emergency room visits that do not result in a hospital admission will require emergency room $35 copay.

Urgent care is defined as a sudden onset of illness or accident that does not require acute care treatment and would not result in a several disability. Examples of conditions we do not consider to be emergencies are but
are not limited to: head colds, influenza, tension headaches, toothaches, minor cuts and bruises, muscle strain, hemorrhoids and intoxication. You must contact your PCP prior to obtaining care. Your PCP will provide
care for your situation, arrange for you to receive care in a GHI HMO affiliated facility or refer you to the
nearest emergency room. You will be responsible for the full cost of the visit if you do not contact your PCP. If referred to the emergency room by PCP, you will pay a $35 copay. If you are unable to reach your PCP,

please call GHI HMO at 1-877-244-4466.
Emergencies outside our service area:
If you are out of the GHI HMO Service Area, your PCP or the on-call physician to authorize your care at the nearest emergency facility as appropriate. It is your responsibility or that of a family member to contact your

PCP prior to receiving non-emergency care, unless it was not reasonably possible to do so. 32
32 Page 33 34
2002 GHI HMO 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
Your membership care instructs physicians and hospitals outside the GHI HMO Service Area to send all claims for services rendered directly to GHI HMO. However, if the emergency care you receive is
relatively minor in cost, you may be asked to pay for services rendered. In these cases, keep all receipts
and bills (indicating the provider's name, date of service, procedures performed, amount charged and amount paid) and present them along with an explanation to GHI HMO's Customer Service department for

review and appropriate reimbursement. GHI HMO, Customer Service, 120 Wood Road, PO Box 4443,
Kingston, NY 12401

If you were admitted to the hospital from the Emergency Room the $35 day copay is waived. Follow-up care after an emergency must be provided with a participating GHI HMO provider. Care

provided by a non-participating provider will not be covered for follow-up visits.
What is an accidental injury? An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal bites, and poisonings. We do cover dental care for

accidental injury to sound natural teeth only.

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient at a hospital, including doctors'
services

Note: copay waived if admitted to the hospital.

$10 per office visit
$35 copay
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

Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Note: copay waived if admitted to the hospital

$10 per office visit
$35 copay

Emergency outside our service area
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

All charges.

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance unless medically necessary and approved by GHI HMO's Medical Director All charges. 33
33 Page 34 35
2002 GHI HMO 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

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

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

I M
P O
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A N
T

Benefit Description You pay
Mental health and substance abuse benefits

All Diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan
includes 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, nurse, or clinical social workers.

Medication Management

$10 per office visit 34
34 Page 35 36
2002 GHI HMO 35 Section 5( e)
Mental health and substance abuse benefits (Continued) You Pay
Diagnostic test
Lab work
Nothing

X-rays $10 per office visit

Services provided by a hospital or other facility
Services in approved alternative care settings such as: -partial hospitalization

-residential treatment -full-day hospitalization
-facility based intensive outpatient treatment

Nothing

Not covered in the network: The same exclusions contained in this brochure that apply to other benefits apply to these mental health and
substance abuse benefits, unless the services are included in a treatment plan that we approve.

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.

Network mental health and substance abuse benefits --Continued on next page. 35
35 Page 36 37
2002 GHI HMO 36 Section 5( e)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all of our network authorization processes.
Merit Behavioral Health Care an affiliate of Magellan Behavioral Health
has been contracted to manage your behavioral health benefits. In order to access your benefits, please call the Merit Behavioral Health Care toll

free number at 1-800-836-2256. You will be connected to a customer
service representative who will be able to assist you in identifying a behavioral health care provider in your area or to verify if your current

provider is a participating provider in the Behavioral Health network.
If participating, the customer service representative will verify benefits/ eligibility and an authorization for treatment will be sent out to
your provider. They will continue to follow their contractual obligations and submit treatment plan reports for continued authorization. The
treatment reports will be reviewed by a New York State licensed
clinician to determine if the treatment you are receiving meets medical necessity criteria for the level of care and the intensity of treatment you

are receiving.
If non-participating, the customer service representative will either offer you a provider participating in the network that specializes in your area
of need or will offer to forward a treatment report to you. You will be responsible for your provider completing the forms in their entirety and
returning them to the address provided. The treatment reports will be
reviewed by a New York State licensed clinician to determine if the treatment you are receiving meets medical necessity criteria for the level

of care and the intensity of treatment you are receiving.
Treatment will not be interrupted if the licensed clinician reviewer finds your treatment to be needed and appropriately provided. At that point,
your non-participating provider will be required to sign an ad hoc agreement, which will allow you to continue in treatment. Your non-participating
provider will be required to accept contracted rates. They
will be required to follow all the same contract requirements as a participating provider.

Inpatient and alternative levels of care, which are more intense, than routine outpatient therapy must be called in by using the same toll free
number. New York State licensed staff is available 24 hours a day, 7
days a week, 365 days a year.

Participating provider directories can be obtained by calling the
Customer Service department at GHI HMO Select at 1-877-244-4466 or view the directory on our website www. ghihmo. com.

How to submit claims There are no claim forms. You must work through participating providers. In the event you are in the transitional period, you must notify the Plan and
have the provider contact the Plan. If you have mistakenly received a bill
for covered services or your provider needs to contact GHI HMO, please contact customer service at 1-877-244-4466. Mail billing statements to

GHI HMO, Attn: Claims, PO BOX 4332, Kingston, NY 12402.

Limitation We may limit your benefits if you do not obtain a treatment plan. 36
36 Page 37 38
2002 GHI HMO 37 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M P

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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.

There are no deductibles.
Your prescription drug program provides coverage for some drugs only if they are prescribed for certain uses. For this reason, some medications must receive Prior

Authorization before they can be covered by your benefit plan. If the prescribed medications require Prior Authorization, please contact or have your provider contact
the GHI HMO Medical Management Department at 1-877-244-4466 for approval. If
your medication is not approved for coverage under your Plan, you will be responsible for paying the full cost of the drug. Below is a partial list of those medications needing

prior authorization.
Tretinoin Topical (Retin-A) for Age >35
COX-II Inhibitors (Celebrex/ Vioxx)
Onychomycosis therapy (Sporanox)
Growth Hormones
Interferons
Galtiramer Acetate
Alglucerase
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
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A
N T

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician, PCP or Specialist must write the prescription.
Where you can obtain them. You may fill the prescription at any participating pharmacy within the Merck Medco network, or by mail for maintenance medications. The Merck Medco network

pharmacies are identified as participating in PAID PRESCRIPTIONS. Merck Medco has over 55,000 pharmacies in its network. Some of these pharmacies are CVS, Eckerd, Walgreen's. Rite
Aid, PriceChopper and many others. You may also obtain maintenance medications through the
mail. To find the participating pharmcy nearest to you, visit Merck Medco at www. merck-medco. com. You can use the interactive pharmacy locator online or call your toll-free 1 800 473-3455

Merck-Medco Member Services to use the voice-activated Pharmacy Locator System.
Retail Pharmacy – Original prescriptions and refills. The supply amount will be a 30 day supply for each prescription.

Mail Order Prescriptions – Maintenance Medications refills may be obtained through
this benefit. The supply amount will be up to a 90 day consecutive supply for each prescription.

Note: Certain controlled substances and several other prescribed medications maybe subject to other dispensing limitations (e. g quantities dispensed) and the professional judgement of the
pharmacist. Federal Law prohibits the return of dispensed controlled substances. 37
37 Page 38 39
2002 GHI HMO 38 Section 5( f)
We use a formulary. Your prescription drug program includes a open "formulary" feature. A formulary is a list of commonly prescribed medications that are preferred based on their clinical
effectiveness and opportunities to help contain your Plan's costs. There are approximately 1132 drugs on the formulary. The list includes products manufactured by most major pharmaceutical
manufacturers, including Merck & Co., Inc. By asking your doctor to prescribe formulary
medications, you can help control rising health care costs while maintaining high-quality care. Use of a formulary drug is, voluntary; there is no financial penalty if your physician does not prescribe a

formulary drug. Sometimes your physician may prescribe a medication when a formulary preferred
brand or generic alternative drug is available, including in some cases, a prescription to be dispensed as written. As part of your prescription drug Plan, the pharmacist may discuss with your

physician whether and alternative drug listed on the formulary might be appropriate for you. If
your physician agrees, your prescription will be filled with the alternative drug. A confirmation will be sent to you and your physician explaining the change. Let your physician know if you have

any questions about a change in prescription. Your physician always makes the final decision on
your medication and you can always choose to keep the original prescription.

These are the dispensing limitations. Prescriptions obtained in retail pharmacies are filled with a thirty (30) consecutive day supply. You pay $10 for generic, $20 for preferred brand and $30 for

non-preferred brand for prescription drugs at a retail pharmacy. The retail co-pay applies to a 30-day supply. You pay $20 for generic, $40 for brand, $50 for non-preferred brand for maintenance
medications prescription drugs through using mail-order. The mail order copay covers up to a 90-day
supply for maintenance medication. A member shall pay the lesser of the copay charge if the medication is less than the copay amount. If a prescription refill is submitted prior to either the 30

day or 90 day limit, the medication will not be filled until the appropriate length of time has lapsed.
Medications needing prior authorization must be submitted to Medical Affairs for approval. All medications are subject to the same rigid US Food and Drug Administration (FDA) standards for

quality, strength and purity.
Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less

money than a name -brand drug.
When you have to file a claim. You would only file a claim for a prescription if you have paid for your prescriptions. This can happen if you need to fill a prescription out-of-area, if your name does not appear

in the pharmacies database, etc. You may have to pay for the prescription and the Plan will reimburse you
the expense. Submit a completed claim form to PAID Prescriptions. The prescription receipt must be attached to the form. To obtain claim forms, visit the Merck/ Medco website at www. merck-medco. com

or call member services. Pharmacy claim forms are also available by calling GHI HMO's Customer
Service Department at 1-877-2GH-IHMO or 1 877-244-4466. You are responsible for 100% of the price of the prescription at the time of purchase when using a non-participating pharmacy. You will be

reimbursed usually within 21 days from the date your claim form is received.
Prescription drug benefits begin on the next page. 38
38 Page 39 40
2002 GHI HMO 39 Section 5( f)
Benefit Description You pay
Covered medications and supplies
The following drug categories are available for dispensing through Merck Medco Rx Services. For a complete formulary listing call 1-877-
244-4466 (GHI HMO ) or Merck Medco at 1-800-445-9709.
Anti-infectives
Cardiovascular
Endocrine
Gastrointestinal
Psychotherapeutics
NSAIDS (Pain relievers)
Respiratory

G

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order
program:
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan retail pharmacy will be dispensed for up to a 34-day

supply or 100 unit supply, whichever is less, 240 milligrams of
liquid (8 oz.); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i. e. one inhaler, one vial

ophthalmic medication or insulin).
Contraceptive drugs and devices
Insulin
Disposable needles and syringes for the administration of covered medications

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded below.

-Prescription drugs for diet or weight control including anorexic agent
-Drugs utilized for treatment of sexual dysfuntion are limited to
6 doses per month
-Prescription drugs not obtained at a GHI HMO participating pharmacy or Mail Order Pharmacy

-Initial prescriptions or refills in excess of a 34 consecutive day supply or one month's cycle of any oral contraceptive drug
(Mail order available for up to a 90 day supply)
-Drugs related to non-covered medical services
-OTC drugs
-Contraceptive devices such as condoms and spermacidal
agents
-Drugs not approved by the FDA
-Medications for cosmetic purposes only

Hen generic equivalent is available, member pays the copay$ 10 and the difference between
Retail Pharmacy: $10 co pay -generic
$20 co pay – preferred brand
$30 co pay – non-preferred brand (30-day supply )

Mail Order: $20 co pay – generic
$40 co pay – preferred brand
$50 co pay – non-preferred brand (90-day supply for maintenance medications)

of generic and brand.

Retail Pharmacy: $10 co pay -generic
$20 co pay – preferred brand
$30 co pay – non-preferred brand (30-day supply )

Mail Order: $20 co pay – generic
$40 co pay – preferred brand
$50 co pay – non-preferred brand
(90-day supply for maintenance medications) 39
39 Page 40 41
2002 GHI HMO 40 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs {plan specific}
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines

All Charges 40
40 Page 41 42
2002 GHI HMO 41 Section 5( g)
Section 5 (g). Special features
Feature Description

Services for deaf and hearing impaired We provide a TDD Line for the deaf and hearing impaired, 1-877-208-7920

Centers of excellence for transplants/ heart
surgery/ etc

Life Trac – National Ancillary providers for organ transplants utilizing 31 Centers of Excellence throughout the United States

PHIP -Personal Health Improvement Program GHI HMO is now offering the Personal Health Improvement Program (PHIP) to our members. PHIP is a behavioral medicine intervention
for the following types of patients:

(1) those with stress related illnesses such as headaches, back pain, fatigue, insomnia, and gastrointestinal discomfort.

(2) those learning to deal with a chronic disease such as multiple sclerosis, fibromyalgia and diabetes.
(3) patients whose mood (anxiety, depression, etc.) seems to
influence their physical health.

PHIP is based on the mind-body theory that mood and physical health
are closely correlated. It helps patients reduce suffering and the symptoms of chronic illnesses by allowing participants to become aware

of how their bodily reactions are related to behavioral patterns, including
coping styles. By making such connections, participants learn to adopt new behaviors that will relieve their pain or discomfort.

The program consists of six weekly two hour classes led by a trained
facilitator. The classes consist of a combination of group discussion and specific exercises designed to help participants become aware of their

own reactions to daily life. Participants are provided with a workbook
and home-study questions, as well as audiotape to guide them through an awareness exercise that they are asked to do daily. 41
41 Page 42 43
2002 GHI HMO 42 Section 5( h)
Section 5 (h). 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.

GHI HMO does not provide dental benefits.
We cover hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is described below.

Be sure to read Section 4, Your costs for covered services, for valuable information about how costsharing 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. The services must be provided within
12 months of the injury.

Nothing

Dental benefits
We have no other dental benefits. 42
42 Page 43 44
2002 GHI HMO Section 6 43
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury or condition and we agree, as discussed under What Service Require

Prior Authorization on page 11.
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;
Services related to the professional fee for treatment of cavities and extractions, care of gums or bones supporting the teeth, orthodontia, false teeth, odontoma (tumors that are of dental origin and

comprised of hard dental tissue), or any other dental services. 43
43 Page 44 45
2002 GHI HMO 44 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 & Drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-877-244-4466.

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 following information
shown below. Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the
service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your claims to: GHI HMO Claims Department
PO Box 4141 Kingston, NY 12401

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.

If a claim is denied, you will receive notice of the decision, including
reasons for the denial and the provisions of the contract on which the denial was based. If you disagree with the plans decision, you may

request reconsideration in accordance with the disputed claims procedure
described on page

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 44
44 Page 45 46
2002 GHI HMO Section 8 45
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: GHI HMO, 120 Wood Road, Kingston, NY 12401; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or if applicable arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request— go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.
We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630. 45
45 Page 46 47
2002 GHI HMO 46 Section 8
The Disputed Claims Process (Continued)
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 include a copy of your specific written consent with the review request.

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs or supplies or from the year you were denied precertification or prior approval.
This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of
benefits in dispute.

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-877-244-4466 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/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 46
46 Page 47 48
2002 GHI HMO Section 9 47
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 health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.

What is Medicare Medicare is a Health Insurance Program for:
People 65 years of age and older
Some people with disabilities, under 65 years of age
People with End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a transplant).

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

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

information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social

Security check or your retirement check.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have. 47
47 Page 48 49
2002 GHI HMO Section 9 48
The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere (Part A or Part B) in 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 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 authorized and arranged by your Plan
PCP.

(Primary payer chart begins on next page.) 48
48 Page 49 50
2002 GHI HMO Section 9 49
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for
you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is… A. When either you --or your covered spouse --are age 65 or over and …

Original Medicare This Plan
1) Areanactiveemployee withtheFederalgovernment (includingwhenyouor
afamilymemberare eligibleforMedicaresolely becauseofadisability),

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

b) 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, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

49
49 Page 50 51
2002 GHI HMO Section 9 50
Claims process when you have the Original Medicare Plan – You
probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.

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

automatically and we will pay the balance of covered charges. You will not need to do anything. To find out is you need to do
something about filing your claims, call us at 1-877-244-4466 or
visit our website at www. ghihmo. com.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --a
Medicare managed care plan. These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you
can only go to doctors, specialists or hospitals that are part of the plan.
Medicare managed care plans provide all of 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 fo llowing 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, 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 correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage and enroll in Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Mediare managed care plan premium.). For information on suspending your

FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open season unless you involuntarily lose coverage or move out of the

Medicare managed care plan's service area.

If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered 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 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. 50
50 Page 51 52
2002 GHI HMO Section 9 51
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness 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 care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies when a local, State, 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 for injuries care 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. You must assist us in receiving our excess payment, for
example, by completing and filing claim forms with other Health Plans
and endorsing checks over to us. If you need more information, contact us for our subrogation procedures. 51
51 Page 52 53
2002 GHI HMO Section 10 52
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.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Any service which can be learned and provided by an average individual who does not have medical training. Examples of Custodial Care
include:
a. Assistance in meeting activities of daily living such as feeding, dressing and personal hygiene;

b. Administration of oral medications, routine changing of
dressing, or preparation of special diets; c. Assistance in walking or getting out of bed;

d. Child care necessitated by the incapacity of a parent; or
e. Respite Care

Experimental or Investigational services Any drug, device or medical treatment or procedure is experimental or
investigational:
If the drug or device has not been approved by the Food and Drug
Administration (FDA)

If reliable evidence, (reports in respected medical and scientific literature) shows that the opinion of experts is that further study is

needed to decide how a drug, device or medical treatments or
procedures compares with the standard method of treatment or diagnosis.

Medical necessity Medically necessary health care services are those necessary to preserve and maintain an Enrollee's health in accordance with acceptable
standards of medical practice and received in an appropriate setting. The
GHI HMO Medical Director shall determine whether a particular health care service rendered to an Enrollee is Medical Necessary for the purpose

of determining whether such health care services are covered services
and not for the purpose of practicing medicine or determining a course of treatment, which course is to be determined by the Participating

Physician.

Plan allowance The plan allowance is a fee negotiated between the providers of service and the plan. These agreed upon fees are considered to be
payment in full for services rendered by all participating providers. Your coinsurance (50% for infertility services, and 20% for
durable medical equipment) will be applied to these negotiated fees. 52
52 Page 53 54
2002 GHI HMO 53 Section 10
Us/ We Us and we refer to GHI HMO
You You refers to the enrollee and each covered family member. 53
53 Page 54 55
2002 GHI HMO 54 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 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 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 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. 54
54 Page 55 56
2002 GHI HMO Section 11 55
When benefits and premiums start The benefits in this brochure are effective on January 1. If you joined
this 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 premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective
date of coverage.
.

Your medical and claims We will keep your medical and claims information confidential. Only 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 spouse's enrollment. But, you may be eligible for your own FEHB coverage under the spouse equity

law. If you are recently divorced or are anticipating a divorce, contact
your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary

Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.

Temporary Continuation
of Coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for 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. 55
55 Page 56 57
2002 GHI HMO Section 11 56
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.

Converting to You may convert to 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 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 availability and continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled
with us. You can use this certificate when getting health insurance or other health
care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in

the certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a

certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked 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 information. 56
56 Page 57 58
2002 GHI HMO 57 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you can't take care of yourself because of an extended illness or
injury, or an age-related disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care, care in an assisted living facility, care in your home, adult day

care, hospice care, and more. LTC insurance can supplement care provided by family members, reducing the burden you place on
them.

Welcome to the club!
76% of Americans believe they will never need long term care, but the facts are that about half them will. And it's not just the old

folks. About 40% of people needing long term care are under age 65. They may need chronic care due to a serious accident, a stroke,
or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan just in case. Many people now consider long term care

insurance to be vital to their financial and retirement planning.

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

Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health plans don't cover custodial
care or a stay in an assisted living facility or a continuing need for a home health aide to help you get in and out of bed and with other
activities of daily living. Limited stays in skilled nursing facilities
can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65

or older or fully dis abled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty guidelines, but has restrictions on covered services and

where they can be received. Long term care insurance can provide choices of care and preserve your independence.

Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.

What is long term care
(LTC) insurance?

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

Is long term care expensive?
But won't my FEHB plan,
Medicare or Medicaid cover
my long term care? 57
57 Page 58 59
2002 GHI HMO Long Term Care Insurance 58
Employees will get more information from their agencies during the LTC open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
Our toll-free teleservice center will begin in mid -2002. In the meantime, you can learn more about the program on our web site at
www. opm. gov/ insure/ ltc.

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

How can I find out more about the
program NOW? 58
58 Page 59 60
2002 GHI HMO 59 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury 42 Allergy tests 19
Alternative treatment 24 Allogenetic (donor) bone marrow
transplant 27 Ambulance 33
Anesthesia 28 Autologous bone marrow
transplant 20,27 Biopsies 25
Blood and blood plasma 30 Casts 30
Catastrophic protection 60 Changes for 2002 8
Chemotherapy 20 Chiropractic 15,24

Cholesterol tests 8,16 Claims 36,44,45
Coinsurance 13 Colorectal cancer screening 16
Congenital anomalies 25 Contraceptive devices and drugs 39
Coordination of benefits 46 Copayments 13
Covered services 52 Covered providers 9

Crutches 23 Deductible 13
Definitions 52 Dental care 42
Diabetic Supplies 19 Diagnostic services 15
Disputed claims review 45 Donor expenses (transplants) 27
Dressings 30 Durable medical equipment
(DME) 23 Effective date of enrollment 55
Emergency 32

Experimental or investigational 52
Family planning 18 Fecal occult blood test 16
Foot care 22 General Exclusions 43
Hearing services 21 Home health services 23
Home nursing care 23 Hospice care 31
Hospital 10,29 Immunizations 17
Infertility 19 In hospital physician care 15
Insulin 19 Inpatient Hospital Benefits 29
Laboratory and pathological services 15
Mail Order Prescription Drugs 38,39
Mammograms 15, 16,17 Maternity Benefits 18
Medicaid 51 Medically necessary 11
Medicare 47 Mental Conditions/ Substance
Abuse Benefits 34 MRI 16
Newborn care 18 Nursery care 18
Obstetrical care 18 Occupational therapy 21
Office visits 15 Oral and maxillofacial surgery 26
Orthopedic devices 22 Out of Pocket maximum 13
Outpatient facility care 30 Oxygen 23
Pap test 15,16

Physical examination 15 Physical therapy 21
Physician 9 Pre-admission testing 30
Preauthorization 36 Preventive care, adult 16
Preventive care, children 17 Prescription drugs 37
Prior approval 11,36 Prostate cancer screening 16
Prosthetic devices 22 Psychologist 34
Radiation therapy 20 Renal dialysis 20
Room and board 29 Second surgical opinion 15
Skilled nursing facility care 31 Speech therapy 21
Sterilization procedures 25 Subrogation 51
Substance abuse 34 Surgery 25
Anesthesia 28 Oral 26
Outpatient 30 Reconstructive 26
Syringes 19 Temporary continuation of
coverage 55 Transplants 28
Treatment therapies 20 Vision services 22
Well child care 15,17 Wheelchairs 23
Workers' compensation 51 X-rays 16 59
59 Page 60 61
2002 GHI HMO 60 Summary
Summary of benefits for the GHI HMO – 2002
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.

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

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

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ................... Office visit copay: $10 primary care; $10 specialist 15

Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
Lab …………………………………………………………………
X-Ray………………………………………………………………

Nothing

$10 copay
30

Emergency benefits:
In-area ........................................................................................................

Out-of-area ................................................................................................

$35 per office visit
$35 per office visit 33
Mental health and substance abuse treatment.......................................... Regular cost sharing. 34
Prescription drugs........................................................................................... $10 copay for retail
$20 copay for mail order
37

Dental Care .................................................................................................. Accidental injury to sound natural teeth only. You pay nothing 42
Vision Care .................................................................................................. One refraction annually. You pay $10 copay per office visit 22
Special features:
Services for deaf and hearing impaired
Centers of Excellence for transplans/ heart surgeries
PHIP – Personal Health Improvement Pro ject

41

Protection against catastrophic costs (your out-of-pocket maximum) ............................................................... Your out-of-pocket expenses for benefits under this Plan are limited
to the stated copayments which are required for few benefits 60
60 Page 61 62
2002 GHI HMO 61 Notes
NOTES: 61
61 Page 62
2002 GHI HMO 62 Rates
2002 Rate Information for
GHI HMO Select, Inc.

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

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

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

Bronx/ Brooklyn/ Manhattan/ Queens/ Westchester
Self Only 6V1 $96.14 $32.05 $208.31 $69.44 $113.77 $14.42

Self and Family 6V2 $223.41 $98.91 $484.06 $214.30 $263.75 $58.57
Albany/ Broome/ Columbia/ Delaware/ Dutchess/ Fulton/ Greene/ Montgomery/ Orange/ Otsego/ Putnam/ Rensselaer/ Rockland/ Saratoga/ Schenectday/ Schoharie/ Sullivan/ Ulster/ Warrren/ Washington

Self Only X41 $85.67 $28.56 $185.63 $61.87 $101.38 $12.85
Self and Family X42 $220.87 $73.62 $478.55 $159.51 $261.36 $33.13 62

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