Pages 1--48 from Heart of America HMO

Enrollment codes for this Plan:
RU1 Self Only
RU2 Self and Family

For changes
in benefits, see
page 7.

RI 73-543

A Health Maintenance Organization 1
1 Page 2 3
2002 Heart of America HMO 2 Table of Contents
Introduction .............................................................................................................................................................. 4
Plain Language ......................................................................................................................................................... 4
Inspector General Advisory...................................................................................................................................... 4
Section 1. Facts about this HMO plan ................................................................................................................... 5
How we pay providers .......................................................................................................................... 5
Your rights ............................................................................................................................................. 5
Service area ........................................................................................................................................... 6
Section 2. How we change for 2002............................................... ....................................................................... 7
Program-wide changes .......................................................................................................................... 7
Changes to this Plan .............................................................................................................................. 7
Section 3. How you get care ............... .................................................................................................................. 8
Identification cards ................................................................................................................................ 8
Where you get covered care.................................................................................................................. 8
Plan providers .................................................................................................................................. 8
Plan facilities ................................................................................................................................... 8
What you must do to get covered care.................................................................................................. 8
Primary care..................................................................................................................................... 8
Specialty care................................................................................................................................... 9
Hospital care .................................................................................................................................... 9
Circumstances beyond our control...................................................................................................... 10
Services requiring our prior approval ................................................................................................. 10
Section 4. Your costs for covered services........................................................................................................... 11
Copayments ................................................................................................................................... 11
Deductible...................................................................................................................................... 11
Coinsurance ................................................................................................................................... 11
Your out-of-pocket maximum ............................................................................................................. 11
Section 5. Benefits................................................................................................................................................ 12
Overview ............................................................................................................................................. 12
(a) Medical services and supplies provided by physicians and other health care professionals ..... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals.. 21
(c) Services provided by a hospital or other facility, and ambulance services................................ 24
(d) Emergency services/ accidents..................................................................................................... 26
(e) Mental health and substance abuse benefits ............................................................................... 28
(f) Prescription drug benefits ........................................................................................................... 30
(g) Dental benefits ............................................................................................................................ 32
Section 6. General exclusions things we don't cover ....................................................................................... 33
Section 7. Filing a claim for covered services ..................................................................................................... 34
Section 8. The disputed claims process................................................................................................................ 35

Table of Contents 2
2 Page 3 4
2002 Heart of America HMO 3 Table of Contents
Section 9. Coordinating benefits with other coverage ......................................................................................... 37
When you have
Other health coverage.................................................................................................................... 37
Original Medicare.......................................................................................................................... 37
Medicare managed care ................................................................................................................ 39
TRICARE/ Workers' Compensation/ Medicaid.................................................................................... 39
Other Government agencies ................................................................................................................ 40
When others are responsible for injuries ............................................................................................ 40
Section 10. Definitions of terms we use in this brochure ...................................................................................... 41
Section 11. FEHB facts .......................................................................................................................................... 42
Coverage information.......................................................................................................................... 42
No pre-existing condition limitation ............................................................................................. 42
Where you get information about enrolling in the FEHB Program.............................................. 42
Types of coverage available for you and your family................................................................... 42
When benefits and premiums start ................................................................................................ 43
Your medical and claims records are confidential ........................................................................ 43
When you retire ............................................................................................................................. 43
When you lose benefits ....................................................................................................................... 43
When FEHB coverage ends .......................................................................................................... 43
Spouse equity coverage ................................................................................................................. 43
Temporary Continuation of Coverage (TCC) ............................................................................... 43
Converting to individual coverage ................................................................................................ 44
Getting a Certificate of Group Health Plan Coverage .................................................................. 44
Long term care insurance is coming later in 2002................................................................................................. 45
Index ....................................................................................................................................................................... 46
Summary of benefits .............................................................................................................................................. 47
Rates ......................................................................................................................................................... Back cover 3
3 Page 4 5
2002 Heart of America HMO 4 Introduction/ Plain Language
Heart of America HMO
810 South Main
Rugby, ND 58368

This brochure describes the benefits of Heart of America HMO under our contract (CS 2606) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for
Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2002, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and are
summarized on page 7. Rates are shown at the end of this brochure.

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

Except for necessary technical terms, we use common words. For instance, "you" means the enrolle or family
member; "we" means Heart of America HMO.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov. insure or e-mail us at fehbwebcomments@ opm. gov.

Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, phar-macy,
or hospital has charged you for services you did not receive, billed you twice for the same service, or misrep-resented
any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 701-776-5848 or 800-525-5661 and explain the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE at 202-418-3300 or write to:
The United States Office of Personnel Management, Office of the Inspector General Fraud Hotline, 1900 E
Street, NW, Room 6400, Washington, DC 20415.

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

Introduction
Plain Language
Inspector General Advisory 4
4 Page 5 6
2002 Heart of America HMO 5 Section 1
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services.

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

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

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

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

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the required information is listed below.

We are Federally qualified
We have been in existence for 19 Years
We are a non-profit organization

If you want more information about us, call 701-776-5848 or 1-800-525-5661, or write to Heart of America HMO,
810 South Main. You may also contact us by fax at 701-776-5425.

Section 1. Facts about this HMO plan 5
5 Page 6 7
2002 Heart of America HMO 6 Section 1
Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is:
All of Pierce, Rolette, Bottineau, McHenry, Towner, Ward, and Renville counties in North Dakota and the portions
of Benson, Wells, Sheridan, McLean, Mountrail, and Burke Counties represented by the following zip codes:

58310 58339 58365 58450 58754 58741 58763 58782
58313 58341 58366 58451 58722 58744 58768 58783
58316 58343 58367 58540 58723 58746 58769 58784
58317 58346 58368 58701 58725 58747 58770 58785
58318 58348 58369 58704 58731 58750 58772 58787
58320 58353 58384 58705 58733 58752 58773 58789
58324 58356 58385 58710 58734 58756 58775 58790
58325 58357 58386 58711 58735 58758 58776 58792
58329 58359 58418 58712 58736 58759 58778 58793
58331 58360 58422 58713 58737 58760 58779
58332 58362 58423 58716 58739 58761 58781
58337 58363 58438 58718 58740 58762

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service
area, we will pay only for emergency care. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you 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. 6
6 Page 7 8
2002 Heart of America HMO 7 Section 2
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure, any language change not shown here is a
clarification that does not change benefits.

Program-wide changes
We removed the requirement that services must be needed to restore functional speech from the speech therapy
benefit

Changes to this Plan
Your share of the non-Postal premium will increase by 0.5 % for Self Only or 7.3 % for Self and Family.
We now cover certain intestinal transplants (Section 5 (b))

Section 2. How we change for 2002 7
7 Page 8 9
2002 Heart of America HMO 8 Section 3
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider. Until you
receive your ID card, use your copy of the Health Benefits Election
Form, SF-2809, your health benefits enrollment confirmation (for
annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
701-776-5848.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or coinsurance, and you will not have to

file claims.
Plan providers Plan providers are physicians and other health care professionals in
our service area that we contract with to provide covered services to
our members.

We list Plan providers in the provider directory, which we update
periodically. All doctors of the Johnson Clinic Professional
Corporation and Trinity Medical Group and affiliated clinics are
available to HAHMO members. The doctors of the Johnson Clinic,
P. C. are available to provide health care from offices located in
Leeds, Towner, Maddock, Dunseith and Rugby, North Dakota. The
doctors of the Trinity Medical Group are available to provide health
care from offices located in Minot, Velva, New Town, Kenmare,
Parshall, Westhope, Garrison and Mohall, North Dakota. Your plan
doctor will coordinate your health care needs including referrals to
specialists when necessary. Services of specialists other than
Johnson Clinic and Trinity Medical Group primary care doctors are
covered only when there has been a referral by the member's prima-ry
care doctor with the following exception: a woman may see her
plan gynecologist for an annual routine examination without a refer-ral.

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

What you must do to It depends on the type of care you need. First, you and each family get covered care member must choose a primary care physician. This decision is

important since your primary care physician provides or arranges for
most of your health care. Provider directories are available at the
time of enrollment or upon request by calling the Heart of America
HMO office at 701-776-5848 or 1-800-525-5661.

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

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

Section 3. How you get care 8
8 Page 9 10
2002 Heart of America HMO 9 Section 3
Specialty care Your primary care physician will refer you to a specialist for needed
care. When you receive a referral from your primary care physician,
you must return to the primary care physician after the consultation,
unless your primary care physician authorized a certain number of
visits without additional referrals. The primary care physician must
provide or authorize all follow up care. Do not go to the specialist for
return visits unless your primary care physician gives you a referral.
However, a woman may see her plan gynecologist for her annual rou-tine
examination without a referral.

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

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

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admis-sion
to a skilled nursing or other type of facility. 9
9 Page 10 11
2002 Heart of America HMO 10 Section 3
If you are in the hospital when your enrollment in our Plan begins,
call our customer service department immediately at 701-776-5848 or
1-800-525-5661. If you are new to the FEHB Program, we will
arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center;
or

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

These provisions apply only to the hospital benefit of the hospitalized
person; we cover your other non-hospital care.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide

them. In that case, we will make all reasonable efforts to provide you
with the necessary care.

Services requiring prior approval Your physician must get our approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care. Before

giving approval, we consider if the service is medically necessary, and
if it follows generally accepted medical practice. 10
10 Page 11 12
2002 Heart of America HMO 11 Section 4
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay when you receive
services.

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

Deductible A deductible is a fixed expense you must incur for certain covered
services and supplies before we start paying benefits for those services.
Copayments do not count toward any deductible.

We have a $600 per member calendar year deductible for prescription
drugs.

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

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

Your out-of-pocket maximum The copayment and coinsurance maximum is 50% of your for deductibles, coinsurance, annual premium per calendar year. When the copayment and
and copayments coinsurance maximum applicable to your contract has been fulfilled, copayment and coinsurance will no longer be applied to the following
services:
Emergency room services
Outpatient hospital services
Inpatient hospital services
Outpatient mental health services
Outpatient chemical dependency services
Inpatient mental health services
Inpatient chemical dependency services
Durable equipment and prosthetic devices
Referral services provided by non participating providers

Section 4. Your costs for covered services 11
11 Page 12 13
2002 Heart of America HMO 12 Section 5
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the fol-lowing
subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at
701-776-5848 or at 1-800-525-5661.

(a) Medical services and supplies provided by physicians and other health care professionals ...................... 13 20
Diagnostic and treatment services Speech therapy
Lab, X-ray, and other diagnostic tests Hearing services (testing, treatment, and supplies)
Preventive care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and occupational therapies Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals................... 21 23
Surgical procedures Oral and maxillofacial surgery
Reconstructive surgery Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services.................................................. 24 25
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory facility benefits
surgical center Hospice care|
Ambulance

(d) Emergency services/ accidents...................................................................................................................... 26 27
Medical emergency Ambulance
(e) Mental health and substance abuse benefits ................................................................................................. 28 29
(f) Prescription drug benefits .............................................................................................................................. 30 31
(g) Dental benefits........................................................................................................................................................ 32
Summary of benefits.............................................................................................................................................................. 47

Section 5. Benefits OVERVIEW (See page 7 for how our benefits changed this year and page 47 for a benefits summary.) 12
12 Page 13 14
2002 Heart of America HMO 13 Section 5 (a)
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

Professional services of physicians $10 per visit
In physician's office No copayment for visits to a
plan specialist.

Professional services of physicians Nothing
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations by a specialist
Second surgical opinion by a specialist

At home -doctor's house call Nothing

Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description

Diagnostic and treatment services

You pay
After the calendar year deductible

Note: When you receive authorized services from a non-Plan specialist, you pay 20% of charges up to a maximum
coinsurance of $1,000 per year. 13
13 Page 14 15
Laboratory tests, such as: Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Routine screenings such as: Nothing
Total Blood Cholesterol -once every three years
Colorectal Cancer Screening, including
Fecal occult blood test -yearly after age 50

Sigmoidoscopy, screening -every five years starting at age 50

Prostate Specific Antigen (PSA test) -one annually for men age 40 and older

Routine pap test
Note: There is a $10 copay for an office visit with a pap test.

Routine mammogram -covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

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

Routine Immunizations, limited to: Nothing
Tetanus-diphtheria (Td) booster -once every 10 years, ages19 and over
(except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

Lab, X-ray and other diagnostic tests You Pay
Preventive care, adult

2002 Heart of America HMO 14 Section 5 (a) 14
14 Page 15 16
2002 Heart of America HMO 15 Section 5 (a)
Childhood immunizations recommended by the American Nothing
Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and care
(up to age 22) $10 per visit

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (up to age 22)

Complete maternity (obstetrical) care, such as: $10 copay on first prenatal visit
Prenatal care only
Delivery
Postnatal care

Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 25 for other
circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend your inpatient stay if
medically necessary.

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

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

Not covered: Routine sonograms to determine fetal age, size or sex All charges

Preventive care, children
Maternity care
You Pay 15
15 Page 16 17
2002 Heart of America HMO 16 Section 5 (a)
A broad range of voluntary family planning services, limited to: $10 per visit
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
For covered medications and accessories, you pay 50% of charges after a $600 deductible.

Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.

Diagnosis and treatment of infertility, such as: $10 per visit
Artificial insemination:
intrauterine insemination (IUI)

Not covered: All charges
Intracervical insemination (ICI)
Intravaginal insemination (IVI)
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote
zygote transfer
Services and supplies related to excluded ART procedures
Fertility drugs
Cost of donor sperm
Cost of donor egg

Testing and treatment $10 per visit
Allergy injection

Allergy serum Nothing

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

Family planning
Infertility services

Allergy care

You Pay 16
16 Page 17 18
2002 Heart of America HMO 17 Section 5 (a)
Chemotherapy and radiation therapy $10 per office visit
Note: High dose chemotherapy in association with autologous bone marrow
transplants are limited to those transplants listed under Organ/ Tissue Transplants
on page 23.

Respiratory and inhalation therapy
Dialysis -Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: We cover growth hormone under the prescription drug benefit.
Note: -We will only cover GHT when we preauthorize the treatment. Call your
plan physician to get a referral for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will only cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically necessary, we will not cover the GHT or related
services and supplies. See Services requiring our prior approval in Section 3.

Up to two consecutive months per condition for the services of each of the $10 per visit
following:
qualified physical therapists; Nothing per visit during covered
occupational therapists inpatient admission

Note: We only cover therapy to restore bodily function or speech when there
has been a total or partial loss of bodily function due to illness or injury.

We Cover cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, for up to three (3) sessions per week up to three (3)
months. Any sessions beyond three (3) months require authorization by
HAHMO Medical Director.

We cover long-term rehabilitative therapy (physical and occupational) after the
short-term therapy benefit has been exhausted. Benefits are provided for one
supervisory physical therapy visit per month and one supervisory occupational
therapy visit per month.

Not covered: All charges
exercise programs

. Up to two consecutive months per condition. $10 per outpatient visit
NOTE: We cover speech therapy in all situations where it is medically necessary. Nothing per visit during
covered inpatient admission

Treatment therapies
Physical and occupational therapies
You Pay

Speech therapy 17
17 Page 18 19
2002 Heart of America HMO 18 Section 5 (a)
Hearing testing for children through age 17 (see Preventive care, children) Nothing
Not covered: All charges
all other hearing testing
hearing aids, testing and examinations for them

Eye exam to determine the need for vision correction for children through age Nothing
17 (see Preventive care, children)

Not covered: All charges
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Routine foot care when you are under active treatment for a metabolic or Nothing
peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe inserts.

Not covered: All charges
Cutting, trimming or removal of corns, calluses, or the free edge of toenails,
and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability, imbalance or subluxation of the foot (unless the treatment is by
open cutting surgery)

Hearing services (testing, treatment, and supplies)
Foot care
Vision services (testing, treatment, and supplies)
You Pay 18
18 Page 19 20
2002 Heart of America HMO 19 Section 5 (a)
Artificial limbs, lenses following cataract surgery
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers and cochlear
implants. Note: See 5( b) for coverage of the surgery to insert the device.

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

Note: There is a maximum benefit of $3,500 per member per calendar year for
orthopedic and prosthetic devices and durable equipment combined.

Not covered: All charges
Orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, and other supportive devices

Rental or purchase, at our option, including repair and adjustment, of durable
medical equipment prescribed by your Plan physician, such as oxygen and dialy-sis
equipment. Under this benefit, we also cover:

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

Note: There is a maximum benefit of $3,500 per member per calendar year for
orthopedic and prosthetic devices and durable equipment combined.

Not covered: All charges
Motorized wheel chairs

Orthopedic and prosthetic devices
Durable medical equipment (DME)
You Pay
20% coinsurance on items
which exceed $25.00 up to a
maximum coinsurance of $500
per contract per calendar year.

20% coinsurance on items
which exceed $25.00 up to a
maximum coinsurance of $500
per contract per calendar year. 19
19 Page 20 21
2002 Heart of America HMO 20 Section 5 (a)
Home health care ordered by a Plan physician and provided by a registered Nothing
nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home health aide. Services include oxygen therapy, intravenous
therapy and medications.

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

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

Manipulation of the spine and extremities $10 per visit
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application

No benefit for services such as: All charges
naturopathic services
hypnotherapy
biofeedback
acupuncture

Coverage is limited to: $10 per visit
Diabetes self-management which includes: individual instruction by primary
care physician, diabetic course up to five days, diabetic camps for children
up to age 16 and dietary instruction by a dietician

Home health services
Alternative treatments
Educational classes and programs

You Pay
Chiropractic 20
20 Page 21 22
2002 Heart of America HMO 21 Section 5 (b)
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.

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

A comprehensive range of services, such as: ` $10 per office visit
Operative procedures (nothing for hospital visits)
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedure
Biopsy procedure
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an individual
weighs 100 pounds or 100% over his or her normal weight according to
current underwriting standards; eligible members must be age 18 or over

Insertion of internal prosthetic devices. See 5( a) -Orthopedic braces and
prosthetic devices for device coverage information.

Voluntary sterilization Nothing
Treatment of burns

Note: When you receive authorized services from a non-Plan specialist, you pay 20% of charges up to a maximum
coinsurance of $1,000 per year.

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

Section 5 (b) Surgical and anesthesia services provided by physicians and other
health care professionals

I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description

Surgical procedures
You pay 21
21 Page 22 23
2002 Heart of America HMO 22 Section 5 (b)
Surgery to correct a functional defect Nothing
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant
deviation from the common form or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as: Nothing
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.

Not covered: All charges
Cosmetic surgery -any surgical procedure (or any portion of a procedure)
performed primarily to improve physical appearance through change in bodily
form, except repair of accidental injury

Surgeries related to sex transformation

Oral surgical procedures, limited to: Nothing
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and

Other surgical procedures that do not involve the teeth or their supporting
structures.

Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodntal membrane, gingiva, and alveolar bone)

Reconstructive surgery
Oral and maxillofacial surgery
You Pay 22
22 Page 23 24
2002 Heart of America HMO 23 Section 5 (b)
Limited to: Nothing
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine)
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer is subject to approval by the Plan's medical
director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when
we cover the recipient.

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

Implants of artificial organs
Transplants not listed as covered

Professional services provided in -Nothing
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office

Organ/ tissue transplants
Anesthesia
You Pay 23
23 Page 24 25
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in
a Plan facility.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.

The amounts listed below are for the charges billed by the facility (i. e., hospital or
surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

Room and board, such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.

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

Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines given in the hospital
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home

Note: When you receive authorized services at a non-Plan facility, you pay 20% of charges up to a maximum
coinsurance of $1,000 per year.

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

Section 5 (c) Services provided by a hospital or other facility,
and ambulance services

I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description
Inpatient hospital
You pay

2002 Heart of America HMO 24 Section 5 (c) 24
24 Page 25 26
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines given in the outpatient hospital or
ambulatory surgical center
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment. We do not cover
the dental procedures.

Extended care benefit: Nothing
The Plan provides a comprehensive range of benefits for up to sixty (60) days
per calendar year, unless such limitation is waived by the Medical Director,
when full-time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor and
approved by the Plan. All necessary services are covered, including:

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

Not covered: custodial care All charges

Supportive and palliative care for a terminally ill member is covered in the Nothing
home or hospice facility. Services include inpatient and outpatient care and
family counseling. These services are provided under the care of a plan doctor
who certifies that the patient is in the terminal stages of illness, with a life
expectancy of approximately six months or less.

Not covered: Independent nursing, homemaker services All charges

Local professional ambulance service when medically appropriate Nothing

Outpatient hospital or ambulatory surgical center You Pay
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance
2002 Heart of America HMO 25 Section 5 (c) 25
25 Page 26 27
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

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

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In
extreme emergencies, if you are unable to contact your doctor, contact the local emergency 911 system or go to the
nearest hospital emergency room. There are physicians on call 24 hours a day at our contracted hospitals at Heart of
America Medical Center, Rugby, ND at 701-776-5261 or Trinity Hospital in Minot, ND at 701-857-5260. Be sure to
tell the emergency room personnel that you are a Plan member so that they can notify the Plan. You or a family mem-ber
must notify the Plan within 48 hours if medically feasible.

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

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

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

Emergencies outside our service area: Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission unless it was not reasonably possible to notify the plan within that time. If a Plan doctor believes that care
can better be 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.

Section 5 (d) Emergency services/ accidents
I M
P O
R T
A N
T

I M
P O
R T
A N
T

2002 Heart of America HMO 26 Section 5 (d) 26
26 Page 27 28
Benefit Description
Emergency within our service area
You pay

2002 Heart of America HMO 27 Section 5 (d)
Emergency care at a doctor's office Nothing
Emergency care at an urgent care center

Emergency care at a hospital, including doctors' services. $30 per visit
Note: If emergency results in admission, we waive the copayment.

Not covered: Elective care or non-emergency care All charges

Emergency care at a doctor's office Nothing
Emergency care at an urgent care center

Emergency care at a hospital, including doctors' services. $30 per visit
Note: If emergency results in admission, we waive the copayment.

Not covered: All charges
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery
of a baby outside the service area

Professional ambulance service when medically appropriate. Nothing
We cover air ambulance when medically appropriate.

See 5( c) for non-emergency service.

Emergency outside our service area
Ambulance 27
27 Page 28 29
When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.

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

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

All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may include
services, drugs, and supplies described elsewhere in this brochure.

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

Professional services, including individual or group therapy by providers such Nothing
as psychiatrists, psychologists, or clinical social workers

Medication management

Mental health and substance abuse benefits -Continued on next page
2002 Heart of America HMO 28 Section 5 (e)

Section 5 (e) Mental health and substance abuse benefits
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
Your cost sharing
responsibilities are no greater
than for other illness or
conditions. 28
28 Page 29 30
Diagnostic tests Nothing
Services provided by a hospital or other facility Nothing
Services in approved alternative care settings such as partial hospitalization,
residential treatment (under 21 years of age) and full-day hospitalization.

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

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the following authorization processes:
Inpatient service and outpatient therapy services must be directed by
your primary care physician and approved by the HAHMO Medical
Director. Available providers for Mental Health and Substance
Abuse Benefits are listed on your Provider Directory that you
receive when you enroll or you may call the HAHMO office at
701-776-5848 or 1-800-525-5661 to obtain one.

2002 Heart of America HMO 29 Section 5 (e)

Mental health and substance abuse benefits (Continued) You pay 29
29 Page 30 31
2002 Heart of America HMO 30 Section 5 (f)
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on
the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure
and are payable only when we determine they are medically necessary.

The calendar year deductible is: $600 per member. The calendar year deductible
applies to almost all benefits in this Section.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription
Where you can obtain them. You may fill the prescription at any pharmacy. We do
not have a network pharmacy.

Why use generic drugs. To reduce your out-of-pocket expenses! A generic drug is
the chemical equivalent of a corresponding brand name drug. Generic drugs are less
expensive than brand name drugs; therefore, you may reduce your out-of-pocket costs
by choosing to use a generic drug.

When you have to file a claim. See Section seven (7) Filing a claim for covered
services. We cover the following medications and supplies
prescribed by a Plan physician:

We cover the following medications and supplies prescribed by a Plan physician.
Drugs for which a prescription is required by law
Diabetic supplies, including insulin syringes, needles, glucose test tablets and
test tape, Benedict's solution or equivalent, glucose monitors and acetone test
tablets

Insulin
Disposable needles and syringes for the administration of covered medications
Drugs for sexual dysfunction
Contraceptive drugs and devices for birth control that are FDA approved.

Note: We cover intravenous fluids and medication for home use, implantable
drugs, and some injectable drugs under Medical and Surgical Benefits.

Section 5 (f) Prescription drug benefits
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Benefit Description You pay After the calendar year deductible
Covered medications and supplies
50% of charges per
prescription unit or refill, after
you meet your $600 per
member deductible. 30
30 Page 31 32
2002 Heart of America HMO 31 Section 5 (f)
Not covered: All Charges
Drugs and supplies for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a
prescription

Nonprescription medicines
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Fertility drugs
Smoking cessation drugs and medication

Covered medications and supplies (Continued) You pay 31
31 Page 32 33
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.

Plan dentists must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.

We cover restorative services and supplies necessary to promptly repair Nothing
(but not replace) sound natural teeth. The need for these services must result
from an accidental injury.

We have no other dental benefits.

2002 Heart of America HMO 32 Section 5 (g)

Section 5 (g) Dental benefits
I M
P O
R T
A N
T

I M
P O
R T
A N
T

Accidental injury benefit You pay

Dental benefits 32
32 Page 33 34
2002 Heart of America HMO 33 Section 6
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your
illness or condition.

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.

Section 6. General exclusions things we don't cover 33
33 Page 34 35
2002 Heart of America HMO 34 Section 7
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, or
coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital and drug benefits
In most cases, providers and facilities file claims for you. Physicians
must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 701-776-5848.

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

Covered member's name and ID number;
Name and address of the physician or facility that provided the
service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from
any primary payer such as the Medicare Summary Notice
(MSN); and

Receipts, if you paid for your services.
Submit your claims to: Heart of America HMO
810 South Main
Rugby, ND 58368

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 administra-tive
operations of Government or legal incapacity, provided the claim
was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

Section 7. Filing a claim for covered services 34
34 Page 35 36
2002 Heart of America HMO 35 Section 8
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies -including a request for preauthorization:

Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: Heart of America HMO, 810 South Main, Rugby, ND 58368; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

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

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your medical provider for more information. If we ask your provider, we will send you a
copy of our request go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E. Street NW, Washington, D. C. 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;

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

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representa-tive,
such as medical providers, must provide a copy of your specific written consent with the review request.

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

Section 8. The disputed claims process 35
35 Page 36 37
2002 Heart of America HMO 36 Section 8
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received

the disputed services or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

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

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

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
701-776-5848 or 1-800-525-5661 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your
claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time. 36
36 Page 37 38
When you have other health You must tell us if you are covered or a family member is covered coverage under another group health plan or have automobile insurance that pays
medical expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the sec-ondary

payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guide-lines.

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

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A.

If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insur-ance.
(Someone who was a Federal employee on January1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be
able to buy it. Contact 1-800-MEDICARE for more information
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have. {RV 5/ 12}
The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States. It is the way everyone used to get their Medicare benefits, and is the way most

people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this plan, you still need to follow the rules in this brochure for us to cover your care. Your care
must continue to be directed by your Primary Care Physician and referrals for specialty care must be approved by the HAHMO Medical Director in
order for us to pay our share.
We do not waive any of our copayments when you have original Medicare.

(Primary payer chart begins on next page.)

Section 9. Coordinating benefits with other coverage

2002 Heart of America HMO 37 Section 9 37
37 Page 38 39
2002 Heart of America HMO 38 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.

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

1) Are an active employee with the Federal government (including when you 4
or a family member are eligible for Medicare solely because of a disability),

2) Are an annuitant, 4
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB 4
b) Or, the position is not excluded from FEHB 4
Ask your employing office which of these applies to you.

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge
who retired under Section 7447 of title 26, U. S. C. (or if your covered spouse 4
is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, 4 4
(for Part B services) (for other services)

6) Are a former Federal employee receiving Workers' Compensation and the 4
Office of Workers' Compensation Programs has determined that you are (except for claims
unable to return to duty, related to
Workers' Compensation.)

B. When you or a covered family member have Medicare
based on end stage renal disease (ESRD) and

1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD, 4

2) Have completed the 30-month ESRD coordination period and are still eligible
for Medicare due to ESRD, 4

3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision, 4

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability,
a) And are an annuitant 4
b) And are an active employee 4
c) Are a former spouse of an annuitant 4
b) Are a former spouse of an active employee 4

Original Medicare This Plan 38
38 Page 39 40
2002 Heart of America HMO 39 Section 9
Claims Process You must tell us if you or a family member is enrolled in Part A or B. Medicare will determine who is responsible for paying for medical services
and we will coordinate the payments. On occasion, you may need to file
Medicare claim forms.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in a Medicare
managed care plan. These are health care choices (like HMOs) in some
areas of the country. In most Medicare managed care plans, you can only go
to doctors, specialists, or hospitals that are part of the plan. Medicare man-aged
care plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescription drugs. To learn more about enrolling in a
Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-
800-633-4227) or at www. medicare. gov. If you enroll in a Medicare man-aged
care plan, the following options are available to you:

This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area (if you use our Plan providers), but we will not
waive any of our copayments or coinsurance.

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

If you do not enroll in If you do not have one or both parts of Medicare, you can still be
Medicare Part A or Part B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can't get premium-free Part A, we will not ask
you to enroll in it.

TRICARE TRICARE is the health care program for eligible dependents of military per-sons, and retirees of the military. TRICARE includes the CHAMPUS pro-gram.

If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

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

Once OWCP or similar agency pays its maximum benefits for your treat-ment,
we will cover your eligible care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first. 39
39 Page 40 41
2002 Heart of America HMO 40 Section 9
When other Government We do not cover services and supplies when a local, State, or Federal agencies are responsible Government agency directly or indirectly pays for them.
for your care
When others are responsible When you receive money to compensate you for medical or hospital for injuries care for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment that
exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 40
40 Page 41 42
2002 Heart of America HMO 41 Section 10
Calendar year January 1 through December 31 of the same year. For new enrollees, the calen-dar year begins on the effective date of their enrollment and ends on December
31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you receive covered ser-vices. See page 11.

Coinsurance Coinsurance is the percentage of our reasonable charge that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care what HAHMO determines is essential to assist the patient in meeting the activities of daily living and is not primarily provided for thera-peutic

treatment of an illness, disease, injury or condition.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.

See page 11.
Experimental or A drug, device or medical treatment or procedure is experimental or
investigational services investigational:
If the drug or device does not have required Food and Drug Administration (FDA) approval.

If reliable reports (in respected medical and scientific literature) show that the opinion of experts determine that further study is needed to decide how
a drug, device or medical treatment or procedure compares with the standard method of treatment or diagnosis.

Group health coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that pro-vides
payment for hospital, medical, or other health care services or supplies.
Medical necessity Services, supplies or treatment rendered by a hospital physician, skilled nursing facility, home health agency, or other provider to treat an illness or injury which

is:
Consistent with the symptoms or diagnosis of the condition, disease, ailment or injury;

Appropriate and accepted according to good medical practice standards;
Not primarily for the convenience of the member or the provider of care;
The most appropriate supply or level of service which can safely be provided to a member. When a member receives inpatient care, it further

means that the member's medical symptoms or condition could not safely be treated on an outpatient basis.

Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:
Our payment is based on usual, customary and reasonable charges. Usual, Customary, and Reasonable means the usual charge made by a physician or other
supplier of services, medicines or supplies. The charge cannot exceed the general level of charges made by other suppliers within the area in which the charge is
incurred for injury or sickness comparable in severity and nature to the injury and sickness being treated.

Us/ We Us and we refer to Heart of America HMO.
You You refers to the enrollee and each covered family member.

Section 10. Definitions of terms we use in this brochure 41
41 Page 42 43
2002 Heart of America HMO 42 Section 10
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal

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

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age

22, including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circum-stances,
you may also continue coverage for a disabled child 22 years
of age or older who is incapable of self-support.

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

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

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

Section 11. FEHB facts 42
42 Page 43 44
2002 Heart of America HMO 43 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this Plan during Open Season, your coverage begins on the first day of your
first pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when

coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

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

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage
(TCC).
When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premi-um, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage.

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

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary

Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement
office or from www. opm. gov/ insure. 43
43 Page 44 45
2002 Heart of America HMO 44 Section 11
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot
convert;

You decided not to receive coverage under TCC or the spouse
equity law; or

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

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

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

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for health

coverage availablity and continuity to people who lose employer group cov-erage.
If you leave the FEHB Program, we will give you a Certificate of
Group Health Plan Coverage that indicates how long you have been enrolled
with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting peri-ods,
limitations, or exclusions for health related conditions based on the
information in the certificate, as long as you enroll within 63 days of losing
coverage under this Plan.

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

For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opom. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked question. These highlight HIPAA rules, such as
the requirement that Federal employees must exhaust any TCC eligibility as
one condition for guaranteed access to individual health coverage under
HIPAA and have information about Federal and State agencies you can con-tact
for more information. 44
44 Page 45 46
2002 Heart of America HMO 45 Long Term Care Insurance
The Office of Personnel Management (OPM) will sponsor a high-quality long term care insurance program effective in October 2002. As part of its educational effort, OPM asks you to consider these questions:
What is long term care (LTC) It's insurance to help pay for long term care services you may need if insurance? you can't take care of yourself because of an extended illness or injury,
or an age-related disease such as Alzheimer's. LTC insurance can provide broad, flexible benefits for nursing home
care, care in an assisted living facility, care in your home, adult day care, hospice care, and more. LTC insurance can supplement care provided by
family members, reducing the burden you place on them.
I'm healthy. I won't need Welcome to the club! long term care. Or, will I? 76% of Americans believe they will never need long term care, but the
facts are that about half of them will. And it's not just the old folks. About 40% of people needing long term care are under age 65. They
may need chronic care due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan just in case. Many people now consider long term care insurance to
be vital to their financial and retirement planning.
Is long term care expensive? Yes, it can be very expensive. A year in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And that's before inflation! Long term care can easily exhaust your savings. Long term care
insurance can protect your savings.
But won't my FEHB plan, Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of Medicare or Medicaid cover your FEHB brochure. Health plans don't cover custodial care or a stay in
my long term care? an assisted living facility or a continuing need for a home health aide to help you get in and out of bed and with other activities of daily living.
Limited stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit. Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be received. Long term care insurance can provide choices of care and
preserve your independence. {RV: 7-26}
When will I get more information Employees will get more information from their agencies during the LTC on how to apply for this new open enrollment period in the late summer/ early fall of 2002.
insurance coverage? Retirees will receive information at home.
How can I find out more about the Our toll-free teleservice center will begin in mid-2002. In the meantime, program NOW? you can learn more about the program on our web site at
ww. opm. gov/ insure/ ltc.

Long Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long term care insurance. 45
45 Page 46 47
2002 Heart of America HMO 46 Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Index

Accidental injury....................... 32
Allergy tests .............................. 16
Alternative treatment ................ 20
Ambulance ................................ 25
Anesthesia ................................. 21
Autologous bone marrow
transplant ................................ 23
Biopsies ..................................... 21
Birthing centers......................... 15
Blood and blood plasma ........... 25
Breast cancer screening ............ 14
Casts.................................. 24 25
Catastrophic protection............. 47
Changes for 2002........................ 7
Chemotherapy ........................... 17
Childbirth .................................. 15
Cholesterol tests ........................ 14
Claims ............................... 34 36
Coinsurance............................... 11
Colorectal cancer screening...... 14
Congenital anomalies................ 21
Contraceptive devices and
drugs ....................................... 16
Coordination of benefits ........... 37
Covered charges........................ 47
Covered providers....................... 8
Crutches..................................... 19
Deductible ................................. 11
Definitions ........................ 41 42
Dental care ................................ 32
Diagnostic services........... 13 14
Disputed claims review .... 35 36
Donor expenses (transplants) ... 23
Dressings ................................... 24
Durable medical equipment
(DME)..................................... 19
Educational classes and
programs ................................. 20
Effective date of enrollment ..... 43
Emergency ........................ 26 27
Experimental or
investigational......................... 33

Eyeglasses ................................. 18
Family planning........................ 16
Fecal occult blood test .............. 14
General Exclusions ................... 33
Hearing services........................ 18
Home health services................ 20
Hospice care.............................. 25
Home nursing care.................... 20
Hospital ....................................... 9
Immunizations .................. 14 15
Infertility.................................... 16
Inhospital physician care .......... 13
Inpatient Hospital Benefits ....... 24
Insulin.................................. 19, 30
Laboratory and pathological
services ................................... 14
Machine diagnostic tests .......... 14
Magnetic Resonance Imagings
(MRIs) .................................... 14
Mail Order Prescription
Drugs .............................. 30 31
Mammograms ........................... 14
Maternity Benefits .................... 15
Medicaid.................................... 39
Medically necessary.................. 10
Medicare.................................... 37
Members.................................... 43
Mental Conditions/ Substance
Abuse Benefits ............... 28 29
Neurological testing.................. 14
Newborn care............................ 15
Nursery charges ........................ 15
Obstetrical care ......................... 15
Occupational therapy ................ 17
Office visits ............................... 13
Oral and maxillofacial
surgery .................................... 22
Orthopedic devices ................... 19
Ostomy and catheter
supplies ................................... 19
Out-of-pocket expenses ............ 11
Outpatient facility care ............. 25

Oxygen ...................................... 19
Pap test ...................................... 14
Physical examination ................ 14
Physical therapy ........................ 17
Physician ................................... 13
Preventive care, adult................ 14
Preventive care, children .......... 15
Prescription drugs ............. 30 31
Preventive services ........... 14 15
Prior approval............................ 10
Prostate cancer screening.......... 14
Prosthetic devices...................... 19
Psychologist .............................. 28
Psychotherapy ........................... 28
Radiation therapy...................... 17
Rehabilitation therapies ............ 17
Renal dialysis ............................ 17
Room and board........................ 24
Second surgical opinion............ 13
Skilled nursing facility care...... 25
Smoking cessation .................... 31
Speech therapy .......................... 17
Splints........................................ 24
Sterilization procedures ............ 16
Subrogation ............................... 40
Substance abuse................ 28 29
Surgery ...................................... 21
Anesthesia............................... 23
Oral ......................................... 22
Outpatient ............................... 25
Reconstructive ........................ 22
Syringes..................................... 30
Temporary continuation of
coverage.................................. 43
Transplants ................................ 23
Treatment therapies................... 17
Vision services .......................... 18
Well child care.......................... 15
Wheelchairs............................... 19
Workers' compensation............. 39
X-rays ........................................ 14 46
46 Page 47 48
2002 Heart of America HMO 47
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.

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

We only cover services provided or arranged by Plan physicians, except in emergencies.
Below, an asterisk (*) means the item is subject to the $xx calendar year deductible.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office Office visit copay: $10 primary 13
care; $ 0 specialist

Services provided by a hospital:
Inpatient Nothing 24
Outpatient 25
Emergency benefits:
In-area $30 copay for each emergency 27
room visit

Out-of-area $30 copay for each emergency 27
room visit.

Mental health and substance abuse treatment Regular cost sharing. 28, 29
Prescription drugs $600 deductible and 50% of 30, 31
charges thereafter.

Dental Care No benefit. 32
(Accidental injury benefit only)

Vision Care No benefit.
Protection against catastrophic costs Nothing after you have met the
(your out-of-pocket maximum) maximum of 50% of your annual 11
premium per calendar year.

Some costs do not count toward
this protection

Summary of benefits for the Heart of America HMO -2002 47
47 Page 48
2001 Heart of America HMO 48 Summary
2002 Rate Information for
Heart of America HMO Health Plan

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

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United
States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB guides are published for
Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG) employees
(see RI 70-2IN).

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

Non-Postal Premium Postal Premium
Biweekly Monthly

Type of Enrollment Code Gov't Share Your Share Your Share Your Share Gov't Share USPS Share
Biweekly

Self Only
Self and Family
RU1
RU2
$26.54
$68.21
$79.63
$204.64
$172.53
$443.39
$94.23
$242.15
$57.51
$147.79
$11.94
$30.70 48

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