Pages 1--53 from AultCAre HMO

Serving: Stark, Carroll, Holmes, Tuscarawas and Wayne counties and the Canton metropolitan area in Ohio
Enrollment in this Plan is limited; see page 7 for requirements.

Enrollment codes for this Plan:
3A1 Self Only 3A2 Self and Family

RI 73-699

For changes in benefits
see page 8 1
1 Page 2 3
2002 AultCare HMO Table of Contents 2
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector General advisory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Section
1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your out-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
( i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2
2 Page 3 4
2002 AultCare HMO Table of Contents 3
Section 6. General exclusions --things we don' t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
When you have
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
What is Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
The Original Medicare Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
TRICARE/ Workers' Compensation/ Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Other Government agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When others are responsible for injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Your medical and claims records are confidential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Long term care insurance is coming later in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover 3
3 Page 4 5
2002 AultCare HMO 4 Introduction/ Plain Language
Introduction
AultCare HMO 2600 Sixth Street SW
Canton, Ohio 44710
This brochure describes the benefits of AultCare HMO under our contract ( CS2723) 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 are summarized on
page 8. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; ; we
means AultCare.

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 plan s brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM' s " Rate Us"
feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 4
4 Page 5 6
2002 AultCare HMO 5 Introduction/ Plain Language
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-344-8858 and explain the situation.
If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer enrolled in the Plan and
tries to obtain benefits. Your agency may also take administrative action against you. 5
5 Page 6 7
2002 AultCare 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,
coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.

You should join an HMO because you prefer the plan s benefits, not because a particular provider is available. You cannot
change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

AultCare HMO is an IPA model HMO, whereby the HMO has individual agreements with select physicians who have agreed to
provide care for AultCare HMO enrollees. Each family member must select a primary care doctor who coordinates care for the HMO
enrollee. There are approximately 251 primary care physicians from which to choose and nearly 642 specialists in our network.

The first and most important decision each member must make is the selection of a primary care doctor. The decision is important
since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of
your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization. Services of other providers are covered only when there has been a referral by the member s
primary care doctor with the following exception( s) : a woman may see her Plan gynecologist for her annual routine examination
without a referral.

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.

If you want more information about us, call 330-438-6360, or write to AultCare HMO, 2600 Sixth Street SW, Canton, Ohio 44710.
You may also contact us by fax at 330-580-5527 or visit our website at www. aultman. com. 6
6 Page 7 8
2002 AultCare HMO 7 Section 1
Service Area
To enroll with us, you must live in or work in our service area. This is where our providers practice. Our service area is:
Stark; Carroll;

Holmes; Tuscarawas;
Wayne Counties in Ohio.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only
for emergency care. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the
area, ( for example, if your child goes to college in another state) , you should consider enrolling in a fee-for-service plan or an HMO
that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to
change plans. Contact your employing or retirement office. 7
7 Page 8 9
2002 AultCare 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 change speech therapy benefits by removing the requirement that services must be required to restore functional speech. ( Section 5( a) )

Changes to this Plan
Your share of the non-Postal premium will decrease by 5.3% for Self Only or 9.0% for Self and Family.
We cover smoking cessation drugs up to an annual $ 200 maximum per member under our prescription drugs benefit. ( Section 5( f) )

We now cover certain intestinal transplants. ( Section 5( b) ) 8
8 Page 9 10
2002 AultCare 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
330-438-6360.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list
is also on our website.

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

What you must do to get
covered care

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

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

Specialty care Your primary care physician will refer you to a specialist for needed care. 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
obstetrician/ gynecologist once yearly without a referral.

Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your
treatment plan ( the physician may have to get an authorization or approval
beforehand) .

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he 9
9 Page 10 11
2002 AultCare HMO 10 Section 3
or she decides to refer you to a specialist, ask if you can see your current specialist.
If your current specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see a specialist
who does not participate with our Plan.

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

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

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

_ reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or
other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 330-438-6360. If you are new to the FEHB
Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:

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

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

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 precertification. Precertification is required 10
10 Page 11 12
2002 AultCare HMO 11 Section 3
for all non-AultCare admissions and all Home Health Care programs. You must notify
the AultCare Utilization Management Department prior to any planned non-AultCare
admissions or to any Home Health Care program.

Other services requiring precertification include:
Partial hospitalization programs provided out-of-network; Intensive out patient programs provided out-of-network;
Rehabilitation facility admissions; Skilled nursing facility admissions;
Hospice care; Therapies, including physical, occupational, speech, cognitive and
growth hormone;
Mental Health and Substance Abuse; and Certain drugs. 11
11 Page 12 13
2002 AultCare HMO 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. , when you receive services.

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

Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.

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

We do not have an out-of-pocket maximum. 12
12 Page 13 14
2002 AultCare HMO 13 Section 5
Section 5. Benefits --OVERVIEW
( See page 7 for how our benefits changed this year and page 51 for a benefits summary. )

NOTE : This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at 330-438-6360 or at our website at
www. aultman. com.

( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-22
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupation therapies

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

( b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27

Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29
Medical emergency Ambulance
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-32
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Aultman Healthline I Can Cope
Common Ground
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 13
13 Page 14 15
2002 AultCare HMO 14 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.
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

$ 10 per office visit

Professional services of physicians
In an urgent care center
During a hospital stay
Office medical consultations
Second surgical opinion

$ 10 per office visit

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

Nothing if you receive these services
during your office visit; otherwise, $ 10 per
office visit 14
14 Page 15 16
2002 AultCare HMO 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Physicals
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including

Fecal occult blood test
Sigmoidos opy, s reening

$ 10 per office visit

Prostate Spe ifi Antigen ( PSA test) $ 10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and treatment services , above.

$ 10 per office visit

Routine mammogram covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Nothing

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

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Nothing

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

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

Well-child care charges for routine examinations, immunizations and care ( under age 22)
Examinations, such as:
_ Eye exams through age 17 to determine the need for vision
correction. ( see Vision services ( testing, treatment, and supplies) )

_ Ear exams through age 17 to determine the need for hearing
correction.

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

$ 10 per office visit

Maternity care
Complete maternity ( obstetrical) care, such as: Nothing 15
15 Page 16 17
2002 AultCare HMO 16 Section 5( a)
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.

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

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

Surgery benefits ( Section 5b) .

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning services, such as:
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, elective abortion
All charges.

Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
_ intravaginal insemination ( IVI)
_ intracervical insemination ( ICI)
_ intrauterine insemination ( IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

$ 10 per office visit 16
16 Page 17 18
2002 AultCare HMO 17 Section 5( a)
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

Cost of donor sperm
Cost of donor egg

All charges.

Allergy care You pay
Testing and treatment
Allergy injection
Allergy serum

Nothing

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

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 24.

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

Growth hormone therapy ( GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. .
Call 330-438-6360 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.

$ 10 per office visit

Physical and occupational therapies 17
17 Page 18 19
2002 AultCare HMO 18 Section 5( a)
60 visits per condition for the services of each of the following:
_ qualified physical therapists and
_ occupational therapists
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.

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

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

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Speech therapy
60 visits per condition for the services of speech therapists. $ 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 visit

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

Vision services ( testing, treatment, and supplies)
In addition to the medical and surgical benefits provided for diagnosis
and treatment of diseases of the eye, annual eye refractions ( to provide a
written lens prescription) may be obtained from Plan providers.

$ 10 per office visit

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
( such as for cataracts)
$ 10 per office visit 18
18 Page 19 20
2002 AultCare HMO 19 Section 5( a)
Eye exam to determine the need for vision correction for children
through age 17 ( see Preventive care, children)

Coverage includes:
one complete refractory eye examination by a Plan provider every 24 months; and

one set of prescribed frames with a $ 55 maximum Plan payment; or
one set of single vision lenses with a $ 35 maximum Plan payment; or

one set of bi-focal lenses with a $ 55 maximum Plan payment; or
one set of tri-focal lenses with a $ 150 maximum Plan payment; or
one set of prescribed contact lenses with a $ 150 maximum Plan payment.

$ 10 per office visit

Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye exams from an optometrist

All charges.

Foot care You pay
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 19
19 Page 20 21
2002 AultCare HMO 20 Section 5( a)
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras ( two per calendar year) , including necessary replacements, following a

mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See 5( b)
for coverage of the surgery to insert the device.

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

Nothing

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

All charges.

Durable medical equipment ( DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

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

Note: Call us at 330-438-6360 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Nothing 20
20 Page 21 22
2002 AultCare HMO 21 Section 5( a)
Not covered:
Motorized wheelchairs
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. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
nursing care requested by, or for the convenience of, the patient or the patient s family;

home 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 extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$ 10 per office visit

Not covered:
Maintenance care All charges.

Alternative treatments You pay

Not covered:
naturopathic services hypnotherapy

biofeedback massotherapy
acupuncture

All charges. 21
21 Page 22 23
2002 AultCare HMO 22 Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and other health
care professionals

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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subje t to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
Be sure to read Se tion 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.

The amounts listed below are for the charges billed by a physi ian or other health are professional for your surgical care. Look in Section 5( c) for charges asso iated with the facility ( i. e. hospital, surgical center, etc. ) .
YOUR NON-AULTCARE PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to Section 3 to be sure whi h services require precertification.

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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.

Reconstructive surgery You pay 22
22 Page 23 24
2002 AultCare HMO 23 Section 5( b)
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.

Not covered:
Cosmetic surgery any surgical procedure ( ( or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$ 10 per office visit; nothing for hospital
visits

Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures

( such as the periodontal membrane, gingiva, and alveolar bone)

All charges.

Organ/ tissue transplants You pay 23
23 Page 24 25
2002 AultCare HMO 24 Section 5( b)
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic ( donor) bone marrow transplants

Autologous bone marrow transplants ( autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin' s
lymphoma; advanced non-Hodgkin' s lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

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

Nothing

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

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in
Hospital ( inpatient)
Nothing

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

Nothing 24
24 Page 25 26
2002 AultCare HMO 25 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. Also read Section 9 about coordinating benefits with other coverage, including with

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

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

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Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations; general nursing care; and

meals and special diets.

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

Nothing

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays Administration of blood and blood products
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 Personal comfort items, such as telephone, television, barber

services, guest meals and beds
Private nursing care

All charges. 25
25 Page 26 27
2002 AultCare HMO 26 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
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. We
do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives if replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care/ skilled nursing care benefit:

The Plan provides a comprehensive range of benefits, with no day or
dollar limit when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan. All necessary
services are covered, including:

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

doctor

Nothing

Not covered: custodial care, rest cures, domiciliary or convalescent
care
All charges

Hospice care
Supportive and palliative care

Inpatient and outpatient care
Family counseling
Note: limited to life expectancy of six ( 6) months or less

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 26
26 Page 27 28
2002 AultCare HMO 27 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
I M
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T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subje t to the definitions, limitations, and ex lusions in this bro hure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.

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

What to do in case of emergency:
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system ( e. g. , the 911 telephone system) or go to the nearest hospital
emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You
or a family member should notify the Plan unless it is not reasonably possible to do so. It is your responsibility to ensure that
the Plan has been timely notified.

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

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

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

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 or inpatient at a hospital, including doctors' services

Nothing

Not covered: Elective care or non-emergency care
All charges. 27
27 Page 28 29
2002 AultCare HMO 28 Section 5( d)
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

Nothing

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 28
28 Page 29 30
2002 AultCare HMO 29 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

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

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social
workers
Medication management

$ 10 per office visit

Diagnostic tests $ 10 per office visit
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day

hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan s clinical appropriateness. OPM will generally not order
us to pay of provide one clinically appropriate treatment plan in favor of
another.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
All non-AultCare admissions, partial hospitalization programs and intensive out-patient
programs require preauthorization. For preauthorization, call 330-438-6360. 29
29 Page 30 31
2002 AultCare HMO 30 Section 5( f)
Section 5 ( f) . Prescription drug benefits
I
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Here are some important things to keep in mind about these benefits:
We over pres ribed drugs and medi ations, as des ribed in the hart beginning on the next page.
All benefits are subje t to the definitions, limitations and exclusions in this bro hure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available,
and your physician has not specified Dispense as Written for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.

Certain drugs require prior authorization where your physician will submit a letter of medical necessity. For a list of these drugs, call 330-438-6360.

I
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There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy or a non-network pharmacy. We pay a higher level of benefits when you use a network pharmacy.

These are the dispensing limitations. Prescriptions are filled up to a 34 day supply per copay. Maintenance drugs are dispensed up to a 90 day supply for one copay at retail.
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 brand name drug. The
U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand name drugs. You can save money by using generic drugs. However, you and
your physician have the option to request a brand name if a generic option is available. Using the most cost-effective
medication saves money.

Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

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

excluded below.
Insulin; a copayment applies to each 34 day supply. Diabetic supplies, including insulin syringes, needles, glucose test

tablets and test tape, Benedict s solution or equivalent, and acetone
test tablets
Disposable needles and syringes for the administration of covered medications

Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
Drugs for sexual dysfunction ( see Prior authorization) Contraceptive drugs and devices
Smoking cessation drugs up to an annual $ 200 maximum per member

$ 5 generic
$ 10 brand
Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay. 30
30 Page 31 32
2002 AultCare HMO 31 Section 5( f)
Covered medications and supplies ( Continued) You Pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements that can be purchased without a prescription

Nonprescription medicines
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance

All Charges 31
31 Page 32 33
2002 AultCare HMO 32 Section 5( g)
Section 5 ( g) . Special Features
Feature Description

Aultman Healthline For any of your health concerns, 7 days a week, you may call 1-800-393-9337 and talk with a registered nurse who will discuss treatment options and answer your health
questions.

I Can Cope Weekly cancer education sessions are presented by doctors, nurses and other professionals. The sessions are held by the Aultman Cancer Center and co-sponsored
by the American Cancer Society. For information/ registration, you may call 330-438-
6290. Free parking is available.

Common Ground A cancer support group for cancer patients and their caregivers. It s led by an Aultman oncology social worker. For information, call 330-438-6290. Free parking
is available. 32
32 Page 33 34
2002 AultCare HMO 33 Section 5( h)
Section 5 ( h) . Dental benefits
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T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subje t to the definitions, limitations, and ex lusions in this bro hure and are payable only when we determine they are medically necessary.

Plan dentists must provide or arrange your are.
We over hospitalization for dental pro edures only when a nondental physi al impairment exists whi h makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is

des ribed below.
Be sure to read Section 4, Your costs for covered services , for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.

I M
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Accidental injury benefit You pay

We cover restorative services and supplies necessary to promptly repair
( but not replace) sound natural teeth. The need for these services must
result from an accidental injury.

Nothing

Dental Benefits
Preventive and Diagnostic
Oral exam ( one per year) Prophylaxis or cleaning ( one per year)

Annual application of fluoride up to age 12 Sealants
X-rays, including bite wings ( limited to once per year) and panoramic ( limited to once every 5 years)
Vitality test Oral cancer exam
Study models Emergency treatment, limited to the relief of pain, bleeding, swelling
or life threatening conditions
Diagnostic services

Basic Restorative
Restorative Endodontics

Periodontics Oral surgery
Prosthodontics
Major Restorative
Full and partial dentures Fixed bridges

Crowns Inlays

30%

Not covered: other dental services not shown as covered All Charges 33
33 Page 34 35
34
34 Page 35 36
2002 AultCare HMO 35 Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them.

Aultman Aulternatives

Aultman Aulternatives is committed to health promotion and disease prevention. Programs are offered to individuals
and businesses designed to help participants learn to control risk factors and make healthier decisions. Weight
management, healthy nutrition, teen nutrition, smoking cessation and stress management programs are developed and
presented by medical professionals and are approved by a physician steering committee. Day and evening sessions are
available for most classes. Call 330-363-6209 for fee and registration information. 35
35 Page 36 37
2002 AultCare HMO 36 Section 6
Section 6. General exclusions --things we don' t cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.

We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies ( see Emergency Benefits) ;
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 36
36 Page 37 38
2002 AultCare HMO 37 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.

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 330-438-6360.

When you must file a claim --such as for out-of-area care --submit it on the HCFA-1500
or a claim form that includes the information shown below. Bills and receipts should be
itemized and show:

Covered member s name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice ( MSN) ; and

Receipts, if you paid for your services.
Submit your claims to: AultCare HMO
2600 Sixth Street SW
Canton, Ohio 44710

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 37
37 Page 38 39
2002 AultCare HMO 38 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies including a request for preauthorization: :

Step Description

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: AultCare HMO, 2600 Sixth Street SW, Canton, Ohio 44710; 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.

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. 38
38 Page 39 40
2002 AultCare HMO 39 Section 8
Disputed Claims ( Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must provide a copy of your specific written consent with the review request.

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

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

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

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

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

( a) We haven' t responded yet to your initial request for care or preauthorization/ prior approval, then call us at 330-438-6360 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. 39
39 Page 40 41
2002 AultCare HMO 40 Section 9
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) .

Medi are 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 Medi are-overed employment, you should be able to

qualify for premium-free Part A insurance. ( Someone who was a Federal employee on
January 1, 1983 or sin e automati ally 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 So ial Se urity he k or your retirement he k.

If you are eligible for Medi are, you may have hoi es in how you get your health are. Medicare
managed care plan 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 Medi are, depending on the type of Medi are managed are plan you have.

The Original Medicare Plan ( Part A or Part B) The Original Medicare Plan ( Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medi are benefits and is the way most people get their Medi are Part
a and Part B benefits now. You may go to any do tor, specialist, or hospital that accepts Medicare.
The Original Medi are Plan pays its share and you pay your share. Some things are not overed
under Original Medi are, like pres ription 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.

( Primary payer chart begins on next page. ) 40
40 Page 41 42
2002 AultCare HMO 41 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.

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

Original Medicare This Plan
1) Are ana tive employee with theFederalgovernment( including whenyou or
afamily member areeligiblefor Medicaresolely becauseof adisability) ,

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,

( exceptfor 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.
41
41 Page 42 43
2002 AultCare HMO 42 Section 9
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 if you
need to do something about filing your claims, call us at 1-800-344-8858 or visit
our website at www. aultman. com.

We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --a Medicare managed care plan.
These are health care choices ( like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some plans cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare at 1-800-
MEDICARE ( 1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to
you:

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

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

If you do not enroll in Medicare Part A or Part B If you do not have one or both parts of Medicare, you can still be covered 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. 42
42 Page 43 44
2002 AultCare HMO 43 Section 9
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
are responsible for your care

We do not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.

When others are responsible for
injuries

When you receive money to compensate you for medical or hospital 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. If
you need more information, contact us for our subrogation procedures. 43
43 Page 44 45
2002 AultCare HMO 44 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

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

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided primarily for maintenance of the patient or which is designed essentially to assist the patient in meeting his activities of daily living and which is not primarily
provided for its therapeutic value in the treatment of an illness, disease, bodily injury or
condition.

Custodial care includes, but is not limited to, help in walking, bathing, dressing,
feeding, preparation of special diets and supervision over self-administration of oral
medications not requiring constant attention of trained medical personnel.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. We do not have
deductibles.

Experimental or investigational
services The Plan s Utilization Management team gathers information from various sources before making an independent evaluation to determine medical appropriateness and/ or

the experimental/ investigational nature of new technology, i. e. , the application of
existing technology or new medical procedures, drugs, or devices. The Plan s decision
is made in good faith, following a detailed factual background investigation of the claim
and proposed service and interpretation of the Plan provisions. Sources the Plan may
use include the Federal Drug Administration, Medicare guidelines, published scientific
articles, and related medical society guidelines. If the plan decides that a service or
supply is not medically appropriate and/ or is experimental/ investigational, that service
or supply will not be eligible.

Group health coverage Coverage provided by the Company for the Plan participant and dependents, if applicable.

Medical necessity A service or supply given by a Provider that is required to diagnose or treat your condition, illness or injury and which we determine is:
Appropriate with regard to standards of good medical practice; Not solely for the convenience of you or a provider;
The most appropriate supply or level or service which can be safely provided to you. When applied to the care of an Inpatient, this means that
your medical symptoms or conditions require that the services cannot be
safely provided to you as an Outpatient.

Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We
determine our allowance as follows: a Provider s charge is considered Usual,
Customary and Reasonable when it is comparable to the fee usually charged for the
same or similar service rendered by other Providers in the same geographical area 44
44 Page 45 46
2002 AultCare HMO 45 Section 10
whose training, education, and professional standing is equivalent to that of the
Provider making the charge.

Us/ We Us and we refer to AultCare HMO
You You refers to the enrollee and each covered family member. 45
45 Page 46 47
2002 AultCare HMO 46 Section11
Section 11. FEHB facts
No pre-existing condition
limitation

We will not refuse to cover the treatment of a condition that you had
before you enrolled in this Plan solely because you had the condition before you
enrolled.

Where you can get information
about enrolling in the FEHB
Program

See www. opm. gov/ insure. Also, your employing or retirement office can answer your
questions, and give you a Guide to Federal Employees
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 for
you and your family

Self Only coverage is for you alone. Self and Family coverage is for
you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren for whom your employing or retirement office
authorizes coverage for. Under certain circumstances, you may also continue coverage
for a disabled child 22 years of age or older who is incapable of self-support.

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

Your employing or retirement office will not notify you when a family member is no
longer eligible to receive health benefits, nor will we. Please tell us immediately when
you add or remove family members from your coverage for any reason, including
divorce, or when your child under age 22 marries or turns 22. If you or one of your
family members is enrolled in one FEHB plan, that person may not be enrolled in or
covered as a family member by another FEHB plan.

When benefits and premiums start The benefits in this brochure are effe tive on January 1. If you joined this Plan during Open Season, your overage 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 offi e will yell you the effe tive date of coverage.

Your medical and claims records
are confidential

We will keep your medical and claims information confidential. Only
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 46
46 Page 47 48
2002 AultCare HMO 47 Section 11
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 laim or defending litigation about a laim.
When you retire When you retire, you an 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 overage, 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 ( TCC) .

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse s enrollment. But, you may be
eligible for your own FEHB coverage under the spouse equity law. If you are recently
divorced or are anticipating a divorce, contact your ex-spouse s employing or
retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees , or
other information about your coverage choices.

Temporary continuation 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.

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 individual coverage You may convert to a non-FEHB individual policy if:
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 overage 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 47
47 Page 48 49
2002 AultCare HMO 48 Section 11
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 offers limited Federal protections for health coverage availability and continuity to
people who lost employer group coverage. If you leave the FEHB Program, we will give
you a Certifi ate of Group Health Plan Coverage that indi ates 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 ex lusions for health
related onditions based on the information in the ertifi ate, as long as you enroll within 63 days

of losing overage 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. gove/ 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. 48
48 Page 49 50
2002 AultCare HMO 49 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:

What is long term care
( LTC) insurance?
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 .

I m healthy. I won t need
long term care. Or, will I?
Welcome to the club!
76% of Americans believe they will never need long term care, but the facts are that about half of them will. And it s not just the old folks. About 40% of people needing

long term care are under age 65. They may need chronic care due to a serious accident,
a stroke, or developing multiple sclerosis, etc. Many people now consider long term
care insurance to be vital to their financial and retirement planning.
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.
Is long term care expensive? 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.

But won t my FEHB plan,
Medicare or Medicaid cover
my long term care?

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

100 day limit.
Medicaid covers long term care for those who meet their state s poverty guidelines, but has restrictions on covered services and where they can be received. Long term care

insurance can provide choices of care and preserve your independence.
When will I get more information
on how to apply for this new
insurance coverage?

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.
How can I find out more about the
program NOW?
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.

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. 49
49 Page 50 51
2002 AultCare HMO 50 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

A ccidental injury 34 Allergy tests 17
Alternative treatment 22 Ambulance 27
Anesthesia 25Autologous bone marrow transplant 25
B iopsies 23 Blood and blood plasma 27
C asts 27 Changes for 2002 8
Chemotherapy 18 Childbirth 16
Chiropractic 21 Cholesterol tests 15Claims
37 Coinsurance 12
Colorectal cancer screening 15Congenital anomalies 23
Contra eptive devi es and drugs 16, 31 Coordination of benefits 40
Covered charges 9 Covered providers 9
Crutches 21
D eductible 12 Definitions 44

Dental care 34 Diagnostic services 14
Disputed claims review 38 Donor expenses ( transplants) 25Dressings
26 Durable medical equipment ( DME) 21
Effective date of enrollment 46 Emergency 28
Experimental or investigational 36, 44 Eyeglasses 19
F amily planning 16 Fecal occult blood test 15
G eneral Exclusions 36 H earing services 19

Home health services 21 Home nursing care 21
Hospice care 27 Hospital 26
I mmunizations 15Infertility 17
In-hospital physician care 14 Inpatient Hospital Benefits 26
Insulin 31
L aboratory and pathological services 14

M achine diagnostic tests 14 Magnetic Resonance Imagings
( MRIs) 14 Maintenance Prescription Drugs
31 Mammograms 15Maternity
Benefits 16 Medicaid 43
Medically necessary 44 Medicare 40
Members 45Mental Conditions/ Substance
Abuse Benefits 30
N ewborn care 16 Non-FEHB Benefits 35Nurse

Anesthetist 26 Nursery charges 16
O bstetrical care 16 Occupational therapy 18
Ocular injury 19 Office visits 14
Oral and maxillofacial surgery 24 Orthopedic devices 20
Out-of-pocket expenses 12 Outpatient facility care 27
Oxygen 21, 26
P ap test 15Physical examination 15

Physical therapy 18 Physician 9
Precertification 11 Preventive care, adult 15Preventive
care, hildren 15Prescription drugs 31
Preventive services 15Prior approval 10
Prostate cancer screening 15Prosthetic devices 20
Psychologist 30
R adiation therapy 18 Renal dialysis 18

Room and board 26 S econd surgical opinion 14
Skilled nursing fa ility care 27 Smoking cessation 31
Speech therapy 18 Splints 26
Sterilization procedures 16, 23 Subrogation 43
Substance abuse 30 Surgery 23
Anesthesia 25 Oral 24
Outpatient 27 Reconstructive 24
Syringes 31
T emporary continuation of coverage 47

Transplants 25Treatment therapies 18
V ision services 19 W ell child care 15Wheelchairs
21 Workers Compensation 43
X -rays 14 50
50 Page 51 52
2002 AultCare HMO 51
NOTES: 51
51 Page 52 53
2002 AultCare HMO 52 Summary
Summary of benefits for the AultCare 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. . . . . . . . . . . . . . . . . . . . $ 10 per office visit 14

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

Nothing
26
27

Emergency benefits:
In-area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nothing

Nothing
28
29

Mental health and substance abuse treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular cost sharing 30
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5 generic, $ 10 brand 31
Dental care:
Accidental injury benefit
Preventive dental care
Nothing
30% 34 34

Vision care:
One exam every two years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Eyewear
$ 10 per office visit
Various payments
19

19

Special features:
Aultman Healthline
I Can Cope
Common Ground

33 52
52 Page 53
2002 AultCare HMO 53 Rates
2002 Rate Information for
AultCare HMO

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

Stark, Carroll, Holmes, Tuscarawas and Wayne counties and Canton metropolitan area in Ohio

Self Only 3A1 $ 71.42 $ 23.81 $ 154.75 $ 51.58 $ 84.52 $ 10.71

Self and Family 3A2 $ 178.91 $ 59.63 $ 387.63 $ 129.21 $ 211.70 $ 26.84 53

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