Pages 1--30 from medic

Health Plan of Nevada Inc 2000
A Health Maintenance Organization

Serving Clark Nye Mineral and Lyon Counties and parts of Washoe County in
Nevada and Mohave County Arizona

Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
NM1 Self Only
NM2 Self and Family

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www sierrahealth com

Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service

RI 73 129 1
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Health Plan of Nevada 2000
Table of Contents
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18
Section 8 FEHB facts 20
Non FEBH Benefits 24
Inspector General Advisory Stop Healthcare Fraud 25
Summary of benefits 26
Premiums Back cover

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Health Plan of Nevada 2000
Introduction

Health Plan of Nevada
P O Box 15645
Las Vegas NV 89119 5645

This brochure describes the benefits you can receive from Health Plan of Nevada under its contract CS 1942 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is 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

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 3 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Health Plan of Nevada as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not rewritten the Benefits section of this brochure You will find new benefits language next year

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Health Plan of Nevada 2000
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Health Plan of Nevada 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and
injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services or point of service benefits POS 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 Our providers follow generally accepted medical practice when prescribing any course of
treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3
How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate relevant or complete If the physician does not amend your record you may add a
brief statement to it If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to this Your share of the non postal premium will increase by 0.9 for Self Only or 12.3 for Self and Family
Plan Co payments for prescriptions have changed for this plan Members will now pay a 6 co payment for

generic drugs a 12 co payment for brand name formulary drugs and a 25 co payment for nonformulary
drugs See page 14

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Health Plan of Nevada 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our
Plan's service service area is
area The Nevada counties of Clark Nye Mineral and Lyon and the Arizona county of Mohave Portions of

Washoe County in Nevada are also within the service area as indicated by the zip codes 89431 89432
89433 89434 89435 89436 89442 89501 89502 89503 89504 89505 89506 89507 89509 89510
89511 89512 89513 89515 89520 89523 89533 89570

Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care or point of service benefits 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

How much do I You must share the cost of some services This is called either a co payment a set dollar amount or
pay for coinsurance a set percentage of charges Please remember you must pay this amount when you receive
services services There are no co payments or coinsurance for the following services when provided under the HMO benefit provisions laboratory tests x rays home visits by nurses and health aids short term

rehabilitation therapy inpatient sessions entereal formulas and special food products outpatient hospice
services and the first 30 days of inpatient mental health and or substance abuse care

After you pay 3,320 in co payments or coinsurance for one family member or 7,084 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However co payments or coinsurance for your prescription
drugs dental services and services provided under your Point of Service POS benefit do not count
toward these limits and you must continue to make these payments If you decide to use your POS
benefits your maximum benefit is 1,500 per member and 4,500 per family each year

Be sure to keep accurate records of your co payments and coinsurance since you are responsible for
informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't contract with us or you use point of service benefits If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the

year after the year you received the service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time

Who provides This plan has been approved as a mixed model prepayment plan This means that doctors who practice in
my health care medical centers groups or in individual offices provide your care You must choose a primary care doctor when you choose this plan This plan has a provider directory which lists primary care doctors

with their locations and phone numbers Primary care doctors generally include family practitioners
pediatricians OB GYN's and internists

What do I do if Call us We will help you select a new one
my primary
care physician
leaves the Plan

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Health Plan of Nevada 2000
Section 3 How to get benefits continued
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will
I need to go into make the necessary hospital arrangements and supervise your care All hospitalizations which are
the hospital planned or are not emergency admissions require prior authorization from the plan If you need to be admitted to the hospital because of an emergency prior authorization may not be required Please refer

to page 12 for more information on benefits for emergency situations

What do I do if First call our customer service department at 702 242 7300 or toll free 800 777 1840 If you are
I'm in the new to the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
hospital when I Program and are switching to us your former plan will pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or

The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will arrange your referral to a specialist The plan requires that the referral
specialty care be made to the specialists listed in the plan's directory A woman may see her Plan Obstetrician Gynecologist directly with no need to be referred by her Primary Care Doctor Referrals to

specialty providers not listed in the plan's directory must be arranged by your PCP and will only be
allowed if services are not available through plan providers You must also seek the plan's authorization
for the following services

All non emergency hospital admissions
Admissions to skilled nursing facilities and inpatient hospice facilities
All non emergency inpatient and outpatient surgeries
Many diagnostic services refer to page 9 for additional information
Physical occupational and speech therapy
Inpatient and outpatient mental health and substance abuse services
Home health care services
Prosthetic devices and durable medical equipment

It is best to contact your plan physician before you seek any services Failure to follow the requirements
of the referral process will result in higher out of pocket costs to you

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 plan has dedicated clinical staff to work with you and your
provider to provide an assessment of your medical needs and assist you with planning your care Please
contact your plan physician or member services at 702 242 7300 or toll free 800 777 1840 if you
have any questions

What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a
I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when us you must receive treatment from a specialist who does Generally we will not pay for you to see a
I enroll specialist who does not participate with our Plan

What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive
my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan

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Health Plan of Nevada 2000
Section 3 How to get benefits continued
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue
have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy
provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
Plan leaves the you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
Program condition or are in your second or third trimester Your new plan will pay for or provide your care for

up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in
your second or third trimester your new plan will pay for the OB GYN care you receive from your
current provider until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize recommending follow up care Before giving approval we consider if the service is medically necessary
medical and if it follows generally accepted medical practice Our decisions are based only on reviews of
services appropriateness of the requested care and or service The plan uses nationally accepted guidelines which are reviewed on an annual basis and take into consideration the individual circumstances and needs of

each case The plan does not pay clinical staff conducting reviews based upon the outcome of the
review

How do you The plan regularly evaluates for possible coverage new medical technologies and new application of
decide if a existing technologies including medical procedures drugs and devices The evaluation includes a
service is review of information on the proposed service from appropriate government regulatory bodies as well as
experimental or published scientific evidence
investigational

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM
OPM to review will determine if we correctly applied the terms of our contract when we denied your claim or request for
a denial service

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Health Plan of Nevada 2000
Section 4 What to do if we deny your claim or request for service continued
What if I have a Call us at 702 242 7300 or 800 777 1840 and we will expedite your review
serious or life
threatening
condition and
you haven't
responded to my
request for
service

What if you If we expedite your review due to a serious medical condition and deny your claim we will inform OPM
have denied my so they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
request for care Contract Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions
and my are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as
condition is possible
serious or life
threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional

information

What do I send Your request must be complete or OPM will return it to you You must send the following information
to OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in

this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to which
claim

Who can make Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's
representative They must send a copy of the person's specific written consent with the review
request

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Health Plan of Nevada 2000
Section 4 What to do if we deny your claim or request for service continued
Where should I Send your request for request for review to Office of Personnel Management Office of Insurance
mail my Programs Contract Division 3 P O Box 436 Washington D C 20044
disputed claim
to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third

year after the year in which you received the disputed services or supplies

What laws Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
apply if I file a review on the record that was before OPM when OPM made its decision on your claim You may
lawsuit recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure described

above

Your records Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us
and the Privacy to determine if our denial of your claim is correct The information OPM collects during the review
Act process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the

disputed claim decision If you file a lawsuit this information will become part of the court record

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Health Plan of Nevada 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services provided by Plan doctors and other Plan providers This includes all necessary office visits where you pay a 10 office visit copayment
but no additional co payment for laboratory tests and X rays Within the service area house
calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you
pay a 20 co payment for a doctor's house call nothing for home visits by nurses and health aides

Co payments for surgery are shown under the section labeled limited benefits
The following services are included and are subject to the office visit co payment unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during
these five years for women age 40 through age 49 one mammogram every one or two years for
women age 50 through age 64 one mammogram every year and for women age 65 and above one
mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Fecal occult blood test for members age 40 and over Sigmoidoscopy screening every 5 years
starting at age 50
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be
provided after coverage under the Plan has ended Ordinary nursery care of the newborn child
during the covered portion of the mother's hospital confinement for maternity will be covered under
either a Self Only or Self and Family enrollment other care of an infant who requires treatment will
be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants 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
Related medical and hospital expenses of the donor are covered when the recipient is covered by this
Plan
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Prosthetic devices such as artificial limbs breast prosthesis and surgical bras as well as their
replacement Lenses following cataract removal initial device covered only
Home health services of nurses and health aides including intravenous fluids and medications when
prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS 9 11
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
What is covered All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and continued other Plan providers at no additional cost to you
Chiropractic services
Blood and blood derivatives

Limited benefits Surgical procedures are subject to a 50 per outpatient procedure copayment for all procedures except those performed in the doctor's office which alone are subject to a 5 copayment per procedure in
addition to the office visit copayment however sterilizations performed in a doctor's office are subject
to the 50 outpatient surgical procedure copayment Surgery performed in an outpatient surgical facility
is also subject to a 50 facility copayment for each visit Inpatient surgical procedures are subject to a
100 per procedure copayment

Oral and maxillofacial surgery is provided for nondental surgical procedures for congenital defects
such as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent to
the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and
cysts All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including shortening of the mandible or maxillae for cosmetic purposes and correction of malocclusion
Dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome is
covered at 50 of eligible medical expenses and limited to a 2,500 maximum per member per calendar
year

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis for up to two months per condition if significant improvement can be expected within
two months Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist you to achieve and maintain self care and improved
functioning in other activities of daily living For these services you pay nothing for inpatient sessions
and a 10 co payment per outpatient session

Diagnosis and treatment of infertility is covered you pay 10 per visit The following types of
artificial insemination are covered intracervical insemination ICI and intrauterine insemination IUI
you pay 10 per visit cost of donor sperm is not covered Fertility drugs are not covered Other assisted
reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not
covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided at a Plan facility for up to 30 days you pay 10 per visit

Enteral formulas and special food products are covered when prescribed by a physician and authorized
by the Plan for the treatment of an inherited metabolic disease Special food products are limited to a
combined HMO POS maximum benefit of 2,500 per member per calendar year You pay nothing under
the HMO benefit

Medication equipment supplies and appliances used for the treatment of type I and type II
diabetes and gestational diabetes are covered Covered services include training and education for the
care and management of diabetes after the member is initially diagnosed with diabetes You pay a 5
copay per visit and per therapeutic supply and a 20 copay per unit for diabetic equipment

Durable Medical Equipment DME is covered at 50 of the EME and is subject to a combined
HMO POS maximum benefit of 4,000 per member per calendar year

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE 10
STANDARD HMO BENEFITS 12
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance attending school or camp or travel Reversal of voluntary surgically induced sterility

Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Orthopedic devices such as braces and foot orthotics
Long term rehabilitative therapy
Transplants not listed as covered

Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay a 100 co payment per day not to exceed 200 for

each admission and a 100 co payment per surgical procedure All necessary services are covered
including

Semiprivate room accommodations When a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate Such
care must be recommended by a Plan doctor and approved by the Plan You pay a 100 co payment per
day not to exceed 200 per admission 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

Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling Services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life
expectancy of approximately six months or less For inpatient hospice services you pay a 100
copayment per day not to exceed 200 per admission Outpatient bereavement counseling for each
family member upon the death of a terminally ill member is covered for either 5 group therapy visits or a
maximum of 500 in benefits per calendar year whichever is less You pay a 20 copayment per visit
Respite care for family members of a terminally ill patient is also covered You pay nothing for
outpatient respite services with a maximum benefit of 1,000 per calendar year You pay 100 per day
not to exceed 200 per admission for inpatient respite services with a maximum benefit of 1,500 per
calendar year

Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a
service 25 co payment per trip See page 12 for Emergency Benefits

Limited benefits
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 14 for

nonmedical substance abuse benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS 11 13
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
What is not Personal comfort items such as telephone and television
covered Dental hospitalization Custodial care rest cures domiciliary or convalescent care

Emergency
Benefits

What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
medical endangers your life or could result in serious injury or disability and requires immediate medical or
emergency 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 the Plan may determine are medical
emergencies what they all have in common is the need for quick action

Emergencies If you are in an emergency situation please call your primary care doctor In extreme emergencies if you
within the are unable to contact your doctor contact the local emergency system e g the 911 telephone system or
service area 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 must notify the Plan within 48 hours

unless it was 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 was 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

You may also receive care at the Plan's 24 hr Urgent Care Center at 888 South Rancho Drive Las Vegas
NV 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 except as covered under POS benefits

Plan pays Customary and reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay 25 per hospital emergency room visit waived if admitted as an inpatient or 15 per urgent care center visit for emergency services that are covered benefits of this Plan 25 per ambulance trip co payments
as shown on page 10 for outpatient inpatient surgical procedures and outpatient surgical facility visits and
inpatient admissions 25 per non Plan doctor's office visit except 15 per urgent care center and all
charges for services which are not a covered benefit of this Plan

Emergencies Benefits are available for any medically necessary health service that is immediately required because of
outside the injury or unforeseen illness If you need to be hospitalized the Plan must be notified within 48 hours or
service area on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be

transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by
the Plan or provided by Plan providers except as covered under POS benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE 12
STANDARD HMO BENEFITS 14
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 25 per hospital emergency room visit waived if admitted as an inpatient or 15 per urgent care center visit for emergency services that are covered benefits of this Plan 25 per ambulance trip co payments
as shown on page 10 for outpatient inpatient surgical procedures and outpatient surgical facility visits and
inpatients admissions 25 per non Plan doctor's office visit except 15 per urgent care center all
charges for services which are not a covered benefit of this Plan

What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan

What is not Elective care or nonemergency care except as covered under POS benefits
covered Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area except as covered under POS benefits

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service
area except as covered under POS benefits

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
non plan receipt of their claims Physician claims should be submitted on a HCFA 1500 claim form If you are
providers required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card Payment will be sent to

you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with the Plan's decision you may request reconsideration in
accordance with the disputed claims procedure described on page 6

Mental
Conditions
Substance
Abuse Benefits

Mental For services you must contact Behavioral Healthcare Options Inc at 800 873 2246 prior to services
conditions being rendered

What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year For these services you pay a 20 co payment per visit for each covered visit you pay 10 co payment
per group therapy visit You pay for all charges for visits after you have reached the benefit limit

Inpatient care You pay nothing for the first 30 days of hospitalization each calendar year You pay for all charges thereafter

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS 13 15
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
Covered significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless

determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition

Substance This Plan provides medical and hospital services such as acute detoxification services for the medical
Abuse non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other illness or condition Services for diagnosis and rehabilitative treatment are covered under the

mental conditions benefits as shown above and in addition to the extent shown below

What is covered
Outpatient care Treatment for individual group and family counseling is covered to a maximum of 2,500 per calendar year You pay a 20 co payment per visit for individual counseling and 10 per group therapy visit

Inpatient care Treatment is covered up to a maximum of 9,000 per calendar year and you pay nothing
What is not Treatment that is not authorized by the Plan
covered

Prescription
Drug Benefits

What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay a 6 copay per prescription unit or refill for generic drugs
You pay a 12 copay per prescription unit or refill for name brand drugs If a name brand is chosen but
is not required specified by your doctor you pay a 12 copay and the difference in cost between the
name brand and the generic drug If a name brand is required specified by your doctor you pay a 12
copay You pay a 25 copay per prescription unit or refill for non formulary drugs

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary A
formulary is a list of drugs covered by the Plan and this list is updated on a regular basis The Plan's
formulary is determined by reviewing pertinent medical literature provider feedback and changes or
improvements in medical technology A copy of this Plan's current drug formulary is available by
contacting the Plan

Mail Order A mail order program is available for up to a 90 day supply of covered maintenance medications for the
Pharmacy treatment of long term conditions such as diabetes arthritis heart disease and high blood pressure if
Option authorized by a Plan provider You pay two prescription co payments for up to a 90 day supply

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE 14
STANDARD HMO BENEFITS 16
16 Page 17 18
Health Plan of Nevada 2000
Section 5 BENEFITS continued
Covered Drugs for which a prescription is required by law
medications and Insulin with a co payment charge applied to each whole vial up to 40 ml
accessories Diabetic supplies including insulin syringes needles blood glucose measuring strips and urine
include checking reagents Nitroglycerin phenobarbital or Thyroid U S P When prescribed in quantities of 100 a single copayment

charge will apply
Vitamins which require a prescription
Disposable needles and syringes needed to inject covered prescribed medication
Contraceptive devices injectable implantable and oral contraceptive drugs which require a
prescription contraceptive diaphragms
Smoking cessation drugs and medication including nicotine patches
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under the requirements of Medical and Surgical Benefits

Limited Benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available
covered Drugs obtained at a non Plan pharmacy except for out of area emergencies Vitamins and nutritional substances that can be purchased without a prescription

Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Injectable and oral prescription drugs to treat infertility

Other Benefits
Dental Care
Accidental
Injury Benefit

What is covered Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must directly result from an accidental injury You pay 25 per emergency room
visit and 5 per doctor's office visit The outpatient inpatient surgery admissions co payments noted on
pages 10 and 11 also apply

What is not Other dental services not shown as covered
covered

Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye exams which include the written lens prescriptions for eyeglasses may be obtained from
Plan providers You pay a 10 copayment

What is not Eye exercises
covered Eyeglasses frames contact lenses including the fitting of the lenses

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS 15 17
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
Point of Service Facts about Health Plan of Nevada's Point of Service Benefits
POS Benefits At your option you may choose to obtain services from non Plan doctors and hospitals except for the

benefits listed below under the heading What is not covered You may still be eligible for coverage
under the conditions of this POS benefit Some services must be received from or arranged by Plan
doctors and cannot be obtained under the POS benefit When you obtain non emergency care and from a
non Plan doctor or without a referral from a Plan doctor your coverage under this POS benefit is subject
to the deductible coinsurance and maximum benefit stated below

Your calendar year deductible is 250 per member and 750 per family After the deductible is met you
pay 20 of the plan's Eligible Medical Expenses for all covered POS services except Durable Medical
Equipment DME DME is covered at 50 of EME After satisfying the calendar year deductible your
coinsurance maximum is limited to 1,500 of EME per member per calendar year or 4,500 per family in
any calendar year

What is covered Physician Services Non specialist Office visit Inpatient visit Specialist visit
after satisfying Preventive Healthcare well child care routine physical exams and pap smear routine diagnostic
your deductible subject to a maximum benefit of 100 per calendar year Manual Manipulation Chiropractor D O Physical Therapist subject to a maximum benefit of

500 per calendar year and 5,000 maximum lifetime benefit
Physician Consultations Non specialist Office Visit Specialist Office Visit
Inpatient Hospital Services
Outpatient Hospital and Ambulatory Surgical Facility Services
Skilled Nursing Services subject to a maximum benefit of 12 days per calendar year
Inpatient and Outpatient Physician Services
Inpatient and Outpatient Oral Surgical Physician Services
Surgical Assistant Services
Anesthesia Services
Ambulance Services non emergent
Laboratory Services
Routine Radiological and Non radiological Diagnostic Imaging Services Outpatient
Other Diagnostic and Therapeutic Services including Chemotherapy Dialysis Therapeutic
Radiology Allergy testing and Serum Injection Otologic Evaluations complex diagnostic imaging
vascular diagnostic and therapeutic services pulmonary diagnostic services neurological or
psychiatric testing
Home Health Care Services with a maximum benefit of 30 visits or 5,000 per calendar year
whichever is less
Prescription Drugs prescription drug fee
Durable Medical Equipment is covered at 50 of the EME and subject to a combined HMO POS
maximum benefit of 4,000 per member per calendar year
Enteral Formulas and special food products special food products are subject to a combined
HMO POS maximum benefit of 2,500 per member per calendar year
Self Management and treatment of Diabetes
Short Term Inpatient and Outpatient Rehabilitation Services subject to a combined HMO POS
calendar year maximum of two months per condition
Prosthetic and Orthotic Devices subject to a combined HMO POS maximum benefit of 10,000
including repairs
Mental Health and Substance Abuse Services

16 18
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Health Plan of Nevada 2000
Section 5 BENEFITS continued
What is not Examples Include
covered Hospice Care Services Temporomandibular Joint dysfunction Treatment

Sterilization
Organ or Tissue Transplants
Care or treatment of an Illness or Injury caused by or arising out of riots war insurrection rebellion
armed invasion or aggression
No payment shall be made on any claim which is not received within 12 months after the date
Covered Services are provided

Covered under the in plan benefit

PriorAuthorization In order for certain services to be covered prior authorization must be obtained from the plan Failure to comply with the prior authorization requirements may result in a reduction of benefits Benefits payable
for services which are not authorized as will be reduced to 50 up to a maximum penalty 500 of
coverage you would have received if the services had been properly authorized

Benefits which require Prior Authorization under the Point of Service benefits include
All elective inpatient admissions and extensions of stay beyond the original certified length of stay to
a Hospital or Skilled Nursing Facility
All outpatient surgery provided in any setting if the charges exceed 200
All outpatient tests including technical and professional services if the charges exceed 200
All outpatient courses of treatment including but not limited to allergy testing treatment
angioplasty chemotherapy dialysis manual manipulation radiation therapy rehabilitation therapy
physical occupational speech

Eligible Medical Means the maximum allowable amount the Plan will pay for a particular service as determined in
Expenses EME accordance with the Plan Reimbursement Schedule

Plan Means the level of payment for EME as defined by the Plan with reference to
Reimbursement
Schedule the amount most consistently paid to the Provider or the amount paid to other Providers of similar qualifications or

is relative to the value or worth of other allowances for similar services comparable in severity and
nature as determined by the Plan with reference to other industry and governmental sources

Lifetime These Point of Service benefits are limited to a Plan payment maximum of 2,000,000 per member per
Maximum lifetime

For additional information write or call
Health Plan of Nevada Inc
P O Box 15645
Las Vegas Nevada 89114 5645
702 871 0999

17 19
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Health Plan of Nevada 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred
services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and 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
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with
us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan 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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan offered
by this Plan see page 24

Other group When anyone has coverage with us and with another group health plan it is called double coverage You
insurance must tell us if you or a family member has double coverage You must also send us documents about
coverage other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

18 20
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Health Plan of Nevada 2000
Section 7 Limitations Rules that affect your benefits continued
Other group If we pay second we will determine what the reasonable charge for the benefit should be After the first
insurance plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
coverage less We will not pay more than the reasonable charge If we are the secondary payer we may be continued entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not
file a claim with your other plan you must still tell us that you have double coverage

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

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries 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

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers

Compensation Programs OWCP or a similar Federal or State agency determine they must provide
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 the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or
Government indirectly pays for
Agencies

19 21
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Health Plan of Nevada 2000
Section 8 FEHB FACTS
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
to information information about your health plan its networks providers and facilities You can also find out about
about your care management which includes medical practice guidelines disease management programs and how
HMO we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make available to you

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

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information Employees Health Benefits Plans brochures for other plans and other materials you need to make an
about enrolling informed decision about
in the FEHB When you may change your enrollment
Program 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
The next Open Season for enrollment

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

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums premiums begin January 1
effective

What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
when I retire the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is

described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage for a
family and me 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 you
give birth or add the child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
family member

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

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan

20 22
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Health Plan of Nevada 2000
Section 8 FEHB Facts continued
Are my medical We will keep your medical and claims information confidential Only the following will have access to
and claims it
records
confidential OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of Workers

Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity
or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809
cards or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible
under my old
plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment
in this Plan Your enrollment ends unless you cancel your enrollment or
ends You are a family member no longer eligible for coverage

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

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
coverage spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC 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 TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect
TCC if you are fired from your Federal job due to gross misconduct

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

21 23
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Health Plan of Nevada 2000
Section 8 FEHB FACTS continued
What is TCC Key points about TCC continued
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from
the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC You
in TCC must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60
days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage
or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline

How can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
coverage pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or

You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You must
apply in writing to us within 31 days after you are no longer eligible for coverage

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

22 24
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Health Plan of Nevada 2000
Section 8 FEHB FACTS continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of
Plan Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well

23 25
25 Page 26 27
Health Plan of Nevada 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles POS maximum benefits or outof
pocket maximums These benefits are not subject to the FEHB disputed claims procedure

Supplemental Dental Health Plan of Nevada Inc is pleased to offer a Supplemental Dental program to FEHBP
Care Services members with Dentists who have agreed under contract to participate in HPN's Dental Program and provide Dental Care Services to members Procedures not listed are not

covered You are required to re enroll every year into the supplemental dental plan during
the open enrollment period Please refer to the supplemental dental information for further
information on this program including premiums what is covered under the supplemental
program and limitations and exclusions

Medicare Choice This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare Annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop
their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their
area They may then later reenroll in the FEHB Program Most Federal annuitants have
Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but
will probably have to pay for hospital coverage in addition to the Part B premium Before
you join the plan ask whether the plan covers hospital benefits and if so what you will
have to pay Contact your retirement system for information on dropping your FEHB
enrollment and changing to a Medicare prepaid plan Contact us at 702 821 2301 or
800 650 6232 for information on the Medicare prepaid plan and the cost of that enrollment
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored
by this Plan without dropping your enrollment in this Plan's FEHB plan call 702 821 2301
or 800 650 6232 for information on the benefits available under the Medicare HMO

Benefits on this page are not part of the FEHB contract
24 26
26 Page 27 28
Health Plan of Nevada 2000
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 702 242 7300 or 800 777 1840 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 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 they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

25 27
27 Page 28 29
Health Plan of Nevada 2000
Summary of Benefits for Health Plan of Nevada 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE AND SERVICES AVAILABLE AS POS BENEFITS ARE COVERED ONLY WHEN PROVIDED OR
ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care private room

and private nursing care if medically necessary diagnostic tests drugs and medical
supplies use of operating room intensive care and complete maternity care You pay 100 per day not to exceed 200 per admission 100 per surgical procedure 11

Extended All necessary services no dollar or day limit You pay 100 per day not to exceed
Care 200 per admission 11

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient
Conditions care per year You pay nothing 13

Substance Coverage under mental conditions benefits and in addition rehabilitative care up to
Abuse 9,000 per calendar year You pay nothing 14

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic

check ups and routine immunizations laboratory tests and x rays complete maternity
care You pay 10 copay per office visit 20 per house call by a doctor 50 per
surgical procedure 50 per outpatient surgical facility visit 9 10

Home Health All necessary visits by nurses and health aids You pay nothing 9
Care

Mental Up to 20 visits per calendar year You pay a 20 copay per visit you pay 10 copay
Conditions per group therapy visit 13

Substance Coverage under mental conditions benefits an in addition counseling up to 2,500
Abuse per calendar year You pay a 20 copay per visit you pay 10 per group therapy visit 14

Emergency Care Customary and reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each emergency room

visit and any non Plan doctor's office visit and ambulance trip 15 per urgent care
center visit surgery admission copayments as shown and any charges for services
that are not covered by this plan 12 13

Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 6 copay per prescription unit or refill If a name brand is chosen but is not

required specified by your doctor you pay the 12 copay and the difference in cost
between the name brand and the generic If a name brand is required specified by
your doctor you pay a 12 copay If a non formulary drug is prescribed by a Plan
doctor and obtained at a Plan pharmacy you pay a 25 copay per prescription unit
or refill A Mail Order is available for up to a 90 day supply of maintenance
medications You pay two prescription copayments 14 15

Dental Care Accidental injury benefit You pay a 10 per doctor's visit and a 25 for an emergency room visit and surgery admission copayments as shown 15

Vision Care One refraction annually You pay a 10 per visit 15
Point of Service Benefits Services of non Plan doctors and hospitals Not all benefits are covered You pay deductibles and coinsurance and a maximum benefit applies 16

Out of Pocket Limit Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 3,30 per Self Only or 7,804 per Self and Family enrollment per
calendar year under standard HMO benefits 1,500 per member or 4,500 per family for POS benefits benefits will be provided at 100 This copay maximum does not

include prescription drugs 16

26 28
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Health Plan of Nevada 2000
Notes

27 29
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Health Plan of Nevada 2000
2000 Rate Information for
Health Plan of Nevada Inc

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for
United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans

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

Self Only NM1 55.95 18.65 121.22 40.41 66.21 8.39 66.21 8.39
Self and Family NM2 143.22 47.74 310.31 103.44 169.48 21.48 169.48 21.48

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