**Enclosure 2B - HMO brochure examples**

This is the key for the \"Print size\" and \"Print style\". Follow the
visual in making text: **bold, *bold-italicized,*** and *italicized*,
and for shading degrees.

Times New Roman, 32-point

Times New Roman, 14-point

Times New Roman, 16-point

Times New Roman, 13-point

Times New Roman, 10 point

{{Use Graphic for logo AND it\'s text}}

Times New Roman, 11-point

Times New Roman, 12-point

Tahoma, 14-point (or equivalent)

**HMO name**

[http://www.planAddress.org](http://www.planAddress.org/)

**2001**

**A Health Maintenance Organization**

**with a point of service product**

![](media/image2.png){width="1.1881944444444446in"
height="1.2145833333333333in"}![](media/image2.png){width="1.1881944444444446in"
height="1.2145833333333333in"}

**Serving:** *{insert general service area }*

**Enrollment in this Plan is limited; see page 5 for requirements.**

**Enrollment codes for this Plan:**

**001 Self Only**

**002 Self and Family**

![](media/image3.png){width="1.2868055555555555in"
height="0.9159722222222222in"}

![](media/image4.png){width="3.848611111111111in"
height="0.7222222222222222in"}

  -----------------------------------------------------------------------
  Table of Contents
  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

Introduction............................................................................
xx

Plain
Language........................................................................
xx

Section 1. Facts about this HMO plan xx

We also have point-of service (POS) benefits xx

How we pay providers xx

Who provides my health care? *{Add ONLY if you have the header in text.*
xx

Patients\' Bill of Rights xx

Service Area xx

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

Program-wide changes xx

Changes to this Plan xx

Section 3. How you get care ............\... xx

Identification cards xx

Where you get covered care xx

Plan providers xx

Plan facilities xx

What you must do to get covered care xx

Primary care xx

Specialty care xx

Hospital care xx

Circumstances beyond our control xx

Services requiring our prior approval xx

Section 4. Your costs for covered services xx

Copayments xx

Deductible xx

Coinsurance xx

Your out-of-pocket maximum xx

Section 5.
Benefits..................................................................
xx

Overview xx

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

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

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

(d) Emergency services/accidents xx

(e) Mental health and substance abuse benefits xx

(f) Prescription drug benefits xx

(g) Special features xx

(h) Dental benefits xx

(i) Point of service product *{OPTIONAL; if none, delete & change (i) to
    (j)} xx*

(j) Non-FEHB benefits available to Plan members xx

*{delete above entry if you do not have a non-FHEB page)*

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

Section 7. Filing a claim for covered services xx

Section 8. The disputed claims process xx

Section 9. Coordinating benefits with other coverage xx

When you have...

Other health coverage xx

Original Medicare xx

Medicare managed care plan xx

TRICARE/Workers\' Compensation/Medicaid xx

Other Government agencies xx

When others are responsible for injuries xx

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

Section 11. FEHB facts xx

Coverage information xx

No pre-existing condition limitation xx

Where you get information about enrolling in the FEHB Program xx

Types of coverage available for you and your family xx

When benefits and premiums start xx

Your medical and claims records are confidential xx

When you retire xx

When you lose benefits xx

When FEHB coverage ends xx

Spouse equity coverage xx

Temporary Continuation of Coverage (TCC) xx

Converting to individual coverage xx

Getting a Certificate of Group Health Plan Coverage xx

Inspector General Advisory *\[RV 8-7}* xx

Department of Defense/FEHB Demonstration Project xx

Index xx

Summary of benefits xx

Rates..........................................................................................................................Back
cover

  -----------------------------------------------------------------------
  **Section 2. How we change for 2001**

  -----------------------------------------------------------------------

**Program-wide changes**

-   The plain language team reorganized the brochure and the way we
    describe our benefits. We hope this will make it easier for you to
    compare plans.

```{=html}
<!-- -->
```
-   This year, the Federal Employees Health Benefits Program is
    implementing network mental health and substance abuse parity. This
    means that your coverage for mental health, substance abuse,
    medical, surgical, and hospital services from providers in our
    *{HMOs insert \"plan network\", and FFS insert \"our PPO network\"}*
    will be the same with regard to deductibles, coinsurance, copays,
    and day and visit limitations when you follow a treatment plan that
    we approve. Previously, we placed *{insert \"higher patient cost
    sharing\" or \"shorter day or visit limitations\"}* on mental health
    and substance abuse services than we did on services to treat
    physical illness, injury, or disease.

```{=html}
<!-- -->
```
-   Many healthcare organizations have turned their attention this past
    year to improving healthcare quality and patient safety. OPM asked
    all FEHB plans to join them in this effort. You can find specific
    information on our patient safety activities by calling *{insert
    plan phone number and contact}*, **or** checking our website
    *{insert plan website}*. You can find out more about patient safety
    on the OPM website, www.opm.gov/insure. To improve your healthcare,
    take these five steps:

> Speak up if you have questions or concerns.
>
> Keep a list of all the medicines you take.
>
> Make sure you get the results of any test or procedure.
>
> Talk with your doctor and health care team about your options if you
> need hospital care.
>
> Make sure you understand what will happen if you need surgery.

-   We clarified the language to show that anyone who needs a mastectomy
    may choose to have the procedure performed on an inpatient basis and
    remain in the hospital up to 48 hours after the procedure.
    Previously, the language referenced only women.

    **Changes to this Plan**

```{=html}
<!-- -->
```
-   Your share of the non-Postal premium will \[decrease\]\[increase\]
    by xx% for Self Only or xx% for Self and Family.

-   

  -----------------------------------------------------------------------
  Section 3. How you get care
  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**Identification cards** We will send you an identification (ID) card.
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
xxx.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, deductibles, and/or
coinsurance, *{Plan specific*} and you will not have to file claims.
{*POS, if any, make plan specific*:} If you use our point-of-service
program, you can also get care from non-Plan providers, or from
participating providers without a required referral, but it will cost
you more.

**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. *{Plan specific to modify entire paragraph, and
add primary/specialist/etc}*

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. *{Plan specific to modify
entire paragraph, and add primary/specialist/etc}*

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

**What you must do** It depends on the type of care you need. First, you
and each family member must choose a primary care physician. This
decision is important since your primary care physician provides or
arranges for most of your health care. *{insert information here about
how to select the physician.}*

**Primary care** Your primary care physician can be a *{insert types,
i.e. -- 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. However, you may see *{insert
types/circumstances}* without a referral. *{text/list from 2000
brochure}*

Here are other things you should know about specialty care:

+-----------------------------------------------------------------------+
| **Section 5. Benefits \-- OVERVIEW**                                  |
|                                                                       |
| ***(See page xx for how our benefits changed this year and page xx    |
| 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. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us at *{phone number}* or at our
website at [www.]() *{insert web address}.*

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

+---------------------------------+------------------------------------+
| Diagnostic and treatment        | Hearing services (testing,         |
| services                        | treatment, and supplies)           |
|                                 |                                    |
| Lab, X-ray, and other           | Vision services (testing,          |
| diagnostic tests                | treatment, and supplies)           |
|                                 |                                    |
| Preventive care, adult          | Foot care                          |
|                                 |                                    |
| Preventive care, children       | Orthopedic and prosthetic devices  |
|                                 |                                    |
| Maternity care                  | Durable medical equipment (DME)    |
|                                 |                                    |
| Family planning                 | Home health services               |
|                                 |                                    |
| Infertility services            | Alternative treatments             |
|                                 |                                    |
| Allergy care                    | Educational classes and programs   |
|                                 |                                    |
| Treatment therapies             |                                    |
|                                 |                                    |
| Rehabilitative therapies        |                                    |
+---------------------------------+------------------------------------+

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

+---------------------------------+------------------------------------+
| Surgical procedures             | Oral and maxillofacial surgery     |
|                                 |                                    |
| Reconstructive surgery          | Organ/tissue transplants           |
|                                 |                                    |
|                                 | Anesthesia                         |
+---------------------------------+------------------------------------+

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

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

(d) Emergency services/accidents xx-xx

> Medical emergency Ambulance *{Note, if you STET Accidental injury in
> the text, add it back here}}*

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

(f) Prescription drug benefits xx

(g) Special features xx

*{list your special features}*

(h) Dental benefits xx

(i) Point of service benefits *{If you don\'t have POS, remove t his and
    renumber j}* xx

(j) Non-FEHB benefits available to Plan members xx

Summary of benefits xx

*{insert page \# for summary at back of brochure}*

+---+---+-------------------------+-------------------+--------+---+----+
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+---+---+-------------------------+-------------------+--------+---+----+
|   | * | **Here are some         |                   |        | * |    |
|   | * | important things to     |                   |        | * |    |
|   | I | keep in mind about      |                   |        | I |    |
|   | * | these benefits:**       |                   |        | * |    |
|   | * |                         |                   |        | * |    |
|   |   | -   Please remember     |                   |        |   |    |
|   | * |     that all benefits   |                   |        | * |    |
|   | * |     are subject to the  |                   |        | * |    |
|   | M |     definitions,        |                   |        | M |    |
|   | * |     limitations, and    |                   |        | * |    |
|   | * |     exclusions in this  |                   |        | * |    |
|   |   |     brochure and are    |                   |        |   |    |
|   | * |     payable only when   |                   |        | * |    |
|   | * |     we determine they   |                   |        | * |    |
|   | P |     are medically       |                   |        | P |    |
|   | * |     necessary.          |                   |        | * |    |
|   | * |                         |                   |        | * |    |
|   |   | -   Plan physicians     |                   |        |   |    |
|   | * |     must provide or     |                   |        | * |    |
|   | * |     arrange your care.  |                   |        | * |    |
|   | O |                         |                   |        | O |    |
|   | * | -   The calendar year   |                   |        | * |    |
|   | * |     deductible is:      |                   |        | * |    |
|   |   |     *{plan specific}*   |                   |        |   |    |
|   | * |     \$275 per person    |                   |        | * |    |
|   | * |     (\$550 per family). |                   |        | * |    |
|   | R |     The calendar year   |                   |        | R |    |
|   | * |     deductible applies  |                   |        | * |    |
|   | * |     to almost all       |                   |        | * |    |
|   |   |     benefits in this    |                   |        |   |    |
|   | * |     Section. We added   |                   |        | * |    |
|   | * |     "(No deductible)"   |                   |        | * |    |
|   | T |     to show when the    |                   |        | T |    |
|   | * |     calendar year       |                   |        | * |    |
|   | * |     deductible does not |                   |        | * |    |
|   |   |     apply. . *{If you   |                   |        |   |    |
|   | * |     want, you can say,  |                   |        | * |    |
|   | * |     "We added           |                   |        | * |    |
|   | A |     asterisks - \* - to |                   |        | A |    |
|   | * |     show when the       |                   |        | * |    |
|   | * |     calendar year       |                   |        | * |    |
|   |   |     deductible does not |                   |        |   |    |
|   | * |     apply."}*. *{If HMO |                   |        | * |    |
|   | * |     -- if you don't     |                   |        | * |    |
|   | N |     have deductible,    |                   |        | N |    |
|   | * |     remove this check   |                   |        | * |    |
|   | * |     mark or say "We     |                   |        | * |    |
|   |   |     have no calendar    |                   |        |   |    |
|   | * |     year deductible.}*  |                   |        | * |    |
|   | * |                         |                   |        | * |    |
|   | T | ```{=html}              |                   |        | T |    |
|   | * | <!-- -->                |                   |        | * |    |
|   | * | ```                     |                   |        | * |    |
|   |   | -   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 pay**       |        |   |    |
|   |   |                         |                   |        |   |    |
| * |   |                         | **After the       |        |   |    |
| * |   |                         | calendar year     |        |   |    |
| B |   |                         | deductible...**   |        |   |    |
| e |   |                         |                   |        |   |    |
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| * |   |                         |                   |        |   |    |
| * |   |                         |                   |        |   |    |
+---+---+-------------------------+-------------------+--------+---+----+
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| * |   |                         |                   |        |   |    |
+---+---+-------------------------+-------------------+--------+---+----+
| # |   |                         | **You pay -       | **You  |   |    |
| # |   |                         | Standard Option** | pay -  |   |    |
| # |   |                         |                   | High   |   |    |
|   |   |                         |                   | Op     |   |    |
| * |   |                         |                   | tion** |   |    |
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| * |   |                         |                   |        |   |    |
+---+---+-------------------------+-------------------+--------+---+----+
| > |   |                         | \$10 per visit    |        |   |    |
|   |   |                         |                   |        |   |    |
| P |   |                         | ***{Minimum copay |        |   |    |
| r |   |                         | for primary care  |        |   |    |
| o |   |                         | office visit is   |        |   |    |
| f |   |                         | \$10 per 2000     |        |   |    |
| e |   |                         | negotiations.}*** |        |   |    |
| s |   |                         |                   |        |   |    |
| s |   |                         | *{{When you have  |        |   |    |
| i |   |                         | different copay   |        |   |    |
| o |   |                         | for primary care  |        |   |    |
| n |   |                         | and specialty     |        |   |    |
| a |   |                         | care, say:*       |        |   |    |
| l |   |                         |                   |        |   |    |
| > |   |                         | \$10 per visit to |        |   |    |
|   |   |                         | your primary care |        |   |    |
| s |   |                         | physician         |        |   |    |
| e |   |                         |                   |        |   |    |
| r |   |                         | \$5 per visit to  |        |   |    |
| v |   |                         | a specialist      |        |   |    |
| i |   |                         |                   |        |   |    |
| c |   |                         | *{Change copay    |        |   |    |
| e |   |                         | descriptions to   |        |   |    |
| s |   |                         | fit your          |        |   |    |
| > |   |                         | circumstances}*   |        |   |    |
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|   |   |                         |                   |        |   |    |
| - |   |                         |                   |        |   |    |
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| ' |   |                         |                   |        |   |    |
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|   |   |                         |                   |        |   |    |
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| c |   |                         |                   |        |   |    |
| e |   |                         |                   |        |   |    |
+---+---+-------------------------+-------------------+--------+---+----+

+-----------------------------------------------------------------------+
| > 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.**
>
> *\[\[Alternate ending for plans with precertification/prior
> approval:\]\]* . . . or condition and we agree, as discussed under
> *What Services Require Our Prior Approval* on page xx.
>
> 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
    {*plan specific---can vary; discuss with contract specialist }*;

-   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.

*{{Insert other "**Genera**l Exclusions" from your 2000 brochure---your
contract specialist will help you edit for plain language and necessity
-- BE SURE TO PUT "; or" after the next to last entry and then a period
after the last entry}}*

  -----------------------------------------------------------------------
  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, coinsurance, or deductible.

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 and hospital 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 xxx.

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 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;

```{=html}
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```
-   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: {{*insert Plan address}}***

**Prescription drugs** {*Insert Plan-specific process; if same as above,
change the header in the above to "Medical, Hospital and Drug
benefits"*}

> **Submit your claims to:** *{{insert plan address}}*

**Other supplies or services** {*Insert Plan-specific process, such as
dental, DME, vision, chiropractic; if same as above, don't put this
header in}*}

> **Submit your claims to: {{***insert plan address}}*

**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.

  -----------------------------------------------------------------------
  Section 8. The disputed claims process

  -----------------------------------------------------------------------

*{NOTE: For step numbers below, sample below is 16pt Tahoma. But as long
as the numbers stand out and look balanced, it won\'t matter what type
face you use.}*

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:

+------+---------------------------------------------------------------+
| **St | **Description**                                               |
| ep** |                                                               |
+------+---------------------------------------------------------------+
| *    | Ask us in writing to reconsider our initial decision. You     |
| *1** | must:                                                         |
|      |                                                               |
|      | (a) Write to us within 6 months from the date of our          |
|      |     decision; and                                             |
|      |                                                               |
|      | (b) Send your request to us at: {{Plan address}}; 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. |
+------+---------------------------------------------------------------+
| *    | We have 30 days from the date we receive your request to:     |
| *2** |                                                               |
|      | (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 medical provider for more information. If |
|      |     we ask your provider, we will send you a copy of our      |
|      |     request---go to step 3.                                   |
+------+---------------------------------------------------------------+
| *    | You or your provider must send the information so that we     |
| *3** | 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.                       |
+------+---------------------------------------------------------------+
| *    | If you do not agree with our decision, you may ask OPM to     |
| *4** | 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 xx, P.O. Box 436,      |
|      | Washington, D.C. 20044-0436.                                  |
+------+---------------------------------------------------------------+