For GroupsUnderstanding Your

Health Care Coverage

1

Contents

For Your Information

The Understanding YourHealth Care Coveragebrochure contains high-lights about how yourHMO coverage works. In it you will find helpfulinformation about HMOsand tips on how to accessyour BlueCare coverageand benefits. Also, visit ourwebsite at www.bcbsfl.com.Please remember that thisis not a contract, nor is it a summary of the benefitsavailable under your con-tract. In this regard, youwill find it helpful to referto your Member Handbook.

Welcome to BlueCare from Health Options 2

What is Health Options? 3

What is an HMO? 4

What Does “Managed Care” Mean? 5

Choosing Your Primary Care Physician 6

Arranging Office Visits 8

When You Need to See a Specialist 9

Handling an Emergency 10

Going Into the Hospital 11

Membership in Health Options 12

How Health Options Makes a Coverage Decision Regarding Medical Necessity 14

Time-Saving Health Resources 15

Complaint and Grievance Process 16

About Confidentiality 21

Coverage for You and Your Family 22

A Brief Description of Covered Services 23

Working to Control Health Care Costs 25

Members’ Rights and Responsibilities 26

Advance Directives 28

Terms to Understand 29

Questions and Answers 31

Please remember that yourMember Handbook defines:• the benefits available

under your coverage• what is covered• what is not covered; and• any limits or exclusions

applicable to your coverage

The words “you” or “your”in this brochure refer to thepeople who are covered byHealth Options. The words“us,” “we” and “our” referto Health Options, Inc.

We can serve you bestwhen our records are keptup-to-date. So, if youraddress or telephone number changes, or if youhave any questions, pleasecall us as soon as possibleat the number listed on your Health Optionsmembership card.

The more you know aboutyour health care and howyour coverage works, theeasier it will be for you tomaximize the value of yourbenefits. We want you tobe a well-informed healthcare consumer.

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Welcome to BlueCare from Health Options

You’ve chosen BlueCarefrom Health Options1

because you want the best health care coveragepossible. We want the bestfor you too. That is why wehave dedicated ourselvesto providing Floridians like you with affordable, reliablehealth care coverage.

And because stayinghealthy is just as importantas getting well, we put anemphasis on preventivecare and wellness benefitsfor you and each of yourfamily members. Pleasesee your MemberHandbook for full details.

Since we know everyonehas different needs, eachfamily member can choosehis or her own personaldoctor, called a Primary CarePhysician (PCP), from our list of PCPs. Our networkcontains some of the samecommunity physicians withwhom you are familiar. YourPCP will get to know youand your medical historyand will help you coordinateyour medical services.

You’ll find most of the medical services coveredby BlueCare have low, predetermined copaymentamounts. This helps you to know beforehand whatyour out-of-pocket costswill be.

Please refer to your

Schedule of Copayments

for a detailed list of

copayments.

The National Committee forQuality Assurance (NCQA)is an independent, non-profit organization locatedin Washington, DC thatassesses the quality ofmanaged care organizations.NCQA evaluates how well

a health plan manages itsnetwork of physicians, hos-pitals, and other providersin order to continuallyimprove the health carecoverage experience for itsmembers. Health Optionsmeets NCQA’s rigorous standards foraccreditation. Please take a few minutes now to read the following pages.We want to help you learnmore about the health carecoverage and value webring to you and your family.

1Health Options, Inc. is the HMO subsidiary of Blue Cross and Blue Shield of Florida, Inc.

What is Health Options?

Health Options, Inc., is acombination IndividualPractice Association (IPA)/Network model HealthMaintenance Organization(HMO) and a wholly-ownedsubsidiary of Blue Crossand Blue Shield of Florida,Inc. For more than 60years, Floridians like youhave looked to the stabilityand experience of BlueCross and Blue Shield ofFlorida to provide the security and peace of mindthat come with affordableand reliable health carecoverage. Following in thistradition, Health Options continually works to makesure that coverage is bothaffordable and reliable.

As an IPA/Network modelHMO, Health Options isresponsible for making coverage and payment deci-sions based on the termsof your Member Handbook.Health Options does notprovide medical care ortreatment nor does it makecare or treatment decisions.

As a member of HealthOptions you, your family,and most importantly, yourphysician or health careprovider are responsible for all care and treatmentdecisions regarding thecare you and your familymembers receive.

Health Options Uses

Provider Financial

Incentives

In order to keep the premiums you pay for your coverage affordable, HealthOptions attempts to holddown the cost of healthcare. Health Options doesthis in several ways. One of the ways that may beused by Health Options to help hold down the costof health care is offering financial incentives tophysicians and other healthcare providers, through oneor more kinds of compen-sation arrangements (e.g.,capitation, and participationin “risk pools” and fee“withhold” arrangements),to deliver cost-effectivemedically appropriatehealth care services.Financial incentives in com-pensation arrangementswith physicians and otherhealth care providers is one method by whichHealth Options (and otherHMOs) attempt to reduceand control the costs of health care. Otherapproaches include effortsto assist members to stayhealthy through educationand the offering of certainpreventive health benefitssuch as mammograms.

The use of financial incen-tives by Health Options isintended to encouragephysicians and other healthcare providers to minimizethe provision of unneces-sary services, reduce wastein the application of medicalresources, and to eliminateinefficiencies which maylead to the artificial inflationof health care costs. Theseincentives are also intendedto improve doctor-patientrelationship satisfaction.

Health Options wants youand your family membersto know that your physician’sor health care provider’sdecisions regardingwhether or not to providemedical care and treatmentmay affect the amount ofmoney your physician orhealth care provider earns.For example, Health Optionsmay prepay your physicianor health care provider aset amount per month tocover the cost of providingservices to you and yourfamily members whetheror not he or she actuallyrenders care during thatmonth. This form ofprovider payment is calledcapitation. If this predeter-mined amount of moneypaid to your physician isless than what it actually

costs your physician to provide care to you or yourfamily members, yourphysician may lose money.Of course, Health Optionswants and expects that your physician will recommend treatmentalternatives that are medically appropriate foryou. However, if you have concerns in this regard, we strongly encourage you to discuss with yourphysicians and other healthcare providers how theiracceptance of financial riskmay affect your medicalcare or treatment.

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A Health MaintenanceOrganization (HMO) is analternative health carefinancing and/or deliveryorganization that either pro-vides directly, or througharrangements made withother persons or entities,comprehensive health carecoverage and benefits orservices, or both, inexchange for prepaid percapita or prepaid aggregatefixed sum. HMOs often useprovider financial incentivesand apply so called “man-aged care” principles andtechniques to coverage andbenefit decisions in order topromote the delivery ofcost-effective medicallyappropriate health care serv-ices. See the section, “WhatDoes ‘Managed Care’Mean?”

HMOs have grown increas-ingly popular because typically there are nodeductibles to satisfy andmembers are covered for awide range of health careservices with little or no out-of-pocket costs.Additionally, many HMOsput a special emphasis onpreventive care benefits forperiodic health assess-ments and immunizations.

Types of HMOs

While some HMOs are sim-ilar, not all HMOs operate orare organized in the sameway. For example, an HMOcan be organized and operate as a Staff model, aGroup model, an IndividualPractice Association (IPA)model or a Network model.Here are a few importantways these types ofHMOs differ:

Staff and Group

Model HMOs

In a Staff model HMO, thedoctors and other providersproviding care are usuallysalaried employees of theHMO and generally providecare in a clinic setting ratherthan in their own personaloffices. Group modelHMOs, on the other hand,contract with large medicalgroup practices to provideor arrange for most healthcare services. Typically, the HMO is owned by the doctors in the medicalgroups. In both these models, the HMO’s doctorsand other providers typicallydo not see patients coveredby other third party payers ormanaged care organizations.

IPA and Network

Model HMOs

In an IPA model HMO, theHMO typically contractswith individual, independentdoctors and/or a physicianorganization, which may inturn contract services withadditional doctors andproviders. Unlike the Staffor Group model HMOs, the IPA model HMO doesnot provide health care services itself. Instead, itpays independent, qualifiedproviders to provide healthcare to its members. Thedoctors in an IPA modelHMO are not the agents or employees of the HMO;they typically practice intheir own personal offices,and continue to see patientscovered by other third partypayers or managed careorganizations.

In a Network model HMO,the HMO contracts withindividual, independentdoctors, IPAs, and/or med-ical groups to make up ahealth care network. Unlikethe Staff or Group modelHMOs, the Network modelHMO does not providehealth care services itself.Instead, it pays independent,qualified providers to

provide health care. Thedoctors in a Networkmodel HMO are not theemployees of the HMOand typically practice intheir own personal offices.Like the IPA model HMO,doctors under contract with a Network modelHMO usually continue tosee patients covered by other third party payers ormanaged care organizations.

Please note: This descrip-tion is not intended to bean exhaustive listing of allHMO organizational modelsin use in the United States.

Health Options is a combination of an IPA anda Network model HMO. It is not a Staff or Groupmodel HMO. This meansthat the doctors and otherproviders with whom itcontracts are independentcontractors and not theemployees or agents, actualor ostensible, of HealthOptions. Rather, theseindependent doctors andproviders typically continueto see their own patients intheir own personal officesor facilities and continue to see patients covered by other third party payers ormanaged care organizations.

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What is an HMO?

The term “managed care”is used to describe theprocesses or techniquesgenerally used by someHMOs and other third partypayers to promote thedelivery of cost effectivemedically appropriate healthcare services. Managed caretechniques can be used withservices performed by doc-tors or other providers ofhealth care. They most ofteninclude one or more of thefollowing: prior and concur-rent review, for coverageand payment purposes, ofthe medical necessity ofservices or site of services;financial incentives or disin-centives related to the useof specific providers,services,or service sites; coordi-nated access to medicalcare, and coordination ofservices by a case manageror primary care physician;and payer efforts to identifytreatment alternatives andmodify benefit restrictionsfor high-cost patient care.

These managed care tech-niques can help offset therising cost of health careand provide relief in the wayof limiting out-of-pocketcosts to consumers.

Does Health Options use

managed care techniques?

Health Options uses managed care techniquesincluding prior and concur-rent review, for coverageand payment purposes, of the medical necessity of services or site of services. Health Optionsalso uses provider financialincentives. For additionalinformation, see “HealthOptions Uses ProviderFinancial Incentives” on page 3 and “HowHealth Options Makes a Coverage DecisionRegarding MedicalNecessity” on page 14 inthis booklet.

What Does “Managed Care” Mean?

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Choosing Your Primary Care Physician

We want you to be com-fortable with your doctor.It’s important to have adoctor who knows yourmedical history to coordi-nate your care and help youmake informed decisions.Your Primary Care Physician(PCP), chosen from our network of health careproviders, should be some-one you trust and can talkwith easily. Take time to get to know your PCP.

To make sure your wholefamily receives the individualcare and attention theyneed, each family membermay choose a PCP fromour network of providers.Or if you prefer, one PCPcan coordinate care foryour entire family.

A Provider Directory is

Part of Your Enrollment

Package

You should refer to theprovider directory that ispart of your enrollmentpackage for a list of thehealth care providers whoare part of the HealthOptions network and areavailable in the area where you live. You mayalso visit our website atwww.bcbsfl.com. Our online provider directorygives you the most up-to-date information about ourproviders, including theircontracting status. Even so, always confirm yourproviders’ contracting statuswith Health Options or whenmaking an appointment.

If you wish to check aprovider’s education, licens-ing credentials, or boardcertification, you may callthe Department of Healthat (850) 488-0595. Shouldyou wish to file a complaintagainst a provider or checkthe status of a disciplinaryaction against a provider,you may call the Agency forHealth Care Administration(AHCA) Information Centerat (888) 419-3456 andpress 2 after the prompts.

Transfer Your Medical

Records

If the PCP you’ve chosen isnot your current physician,you should contact your current doctor and ask tohave your medical recordstransferred to your new PCP.

Get to Know Your PCP

You don’t have to wait untilyou are sick to meet yournew doctor. It’s a good ideato make an appointment to meet your new doctorand go over your medical history. Ask your doctorquestions if you don’tunderstand his or herinstructions for your treat-ment. You should also bringany medications you arecurrently taking to yourPCP to obtain updated prescriptions. Your PCP willprovide and help you coor-dinate your medical care.

By taking the time to meetyour new doctor, you andyour PCP can build a soundrelationship, which is thefirst step in assuring yourgood health.

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Get to Know Your PCP

Follow the proceduresbelow to get started:

1. Make it a point toknow your PCP for yourself and each of your dependents.

2. Call your PCP for yourinitial visit and any health care needs.

3. Always show yourmembership card beforeyou receive health careservices and supplies.

Changing Your PCP

We encourage you to maintain a relationship witha PCP you can trust withyour health care concerns.We understand there maystill be instances when youmay want to change to anew PCP.

You may change your PCPby selecting a new onefrom your provider directory.Simply call the CustomerService telephone numberon your Health Optionsmembership card to makethe change. If you call tomake the change beforethe 15th of the month, theeffective date will be thefirst day of the followingmonth. For example, if youcall on October 10, theeffective date of changewill be November 1. If youcall after the 15th, thechange will not be effectiveuntil the second monthfrom the date you call. For example, if you call onOctober 20, the effectivedate of change will beDecember 1. Until thechange is effective, youmust continue to receivemedical services from yourcurrent PCP.

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Arranging Office Visits

For routine office visits,call your PCP’s office andschedule your appointment.Make sure you inform yourdoctor’s office that you area Health Options memberand take your membershipcard with you to yourappointment.

If you need to cancel a visit to your doctor, please give the office atleast 24 hours notice.

Please remember these

important TIPS:

• At enrollment you wererequired to select a PrimaryCare Physician (PCP). Seekcare from your PCP for yourprimary health care needs.However, you are notrequired to obtain a referralfrom your PCP to visit aparticipating Health OptionsSpecialist.

• You don’t have to wait untilyou’re sick to get to knowyour new PCP. If youhaven’t already done so,make an appointment withyour PCP so he or she canget to know you and yourmedical history. This wayyou and your PCP can builda sound relationship whichis the first step in assuringyour good health.

• Services rendered outsideof the service area, thataren’t an emergency, mustbe authorized in advance byHealth Options in order tobe covered services.

When Your Doctor’s Office

Is Closed—After Hours

Medical Care

You may need medical carewhen your PCP’s office isclosed. If you have an emer-gency medical condition, goto the nearest hospital orclosest emergency room or call 911.

If your medical condition is not an emergency, youshould call your PCP. Yourcall will be answered by your PCP’s answering service. The answeringservice will ask you ques-tions that may include yourdoctor’s name and a briefdescription of the reasonfor your call. The answeringservice will then call yourPCP, who will call you backand give you instructions.

In the event of an

emergency, always go

to the nearest hospital

emergency room or

call 911.

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When You Need to See a Specialist

BlueCare covers office visits to your PCP and tospecialist offices with onlya small copayment formost plans. Please refer toyour Member Handbook fordetailed information aboutyour benefits and costsharing.

Please remember these

important TIPS:

• Having your PCP coordinateyour medical care can saveyou time and money.

• You are not required toobtain a referral from yourPrimary Care Physician toseek care from a HealthOptions participating specialist, or when a specialist refers you toanother participating specialist.

• Authorizations are stillrequired for certain medicalservices including, but notlimited to hospitalization,rehabilitation services,home care, select DME,and certain office-basedservices such as CT scans,MRI/MRAs, cardiac nuclearmedicine studies, andselect injectables.

Behavioral Health

Providers

Mental health and/or substance abuse treatmentmay be covered under yourBlueCare plan. Please referto your Member Handbookfor detailed information onany mental health and/orsubstance abuse treatmentcoverage you may have and whether these servicesmust be coordinated byyour PCP.

Additional information,regarding Behavioral HealthProviders, can also be foundin your provider directory.

Getting a Second Opinion

You may get a second medical opinion from alicensed physician in yourservice area under certaincircumstances.

• You may get a second medical opinion if you dis-agree with Health Options,your PCP, or a contractingspecialist’s opinion aboutthe necessity of surgicalprocedures.

• You may get a second med-ical opinion if you are subjectto a serious injury or illness.

• You may also request a second medical opinion if you feel you are notresponding satisfactorily to treatment.

• Health Options may require you to get a second medical opinion.

Please refer to your MemberHandbook for details.

In the event of an

emergency, go to

the nearest hospital

emergency room

or call 911.

With BlueCare, you havecoverage for emergencyservices 24 hours a day, 7 days a week. So whetheryou’re at home or on theroad, your benefits work toget you the care you need.

If you have an emergency,go to the nearest emer-gency room for treatment.After you receive treatment,call your PCP or havesomeone call for you assoon as possible. You do not have to be referred byyour PCP when you receiveemergency services and care. However, pleaseremember that it is yourresponsibility to let HealthOptions know as soon as possible about youremergency services andcare and/or any admissionto a hospital that may be needed because of your emergency condition.

Follow up care for youremergency condition mustbe coordinated by your PCPor treating participatingspecialist. If follow-up careis not provided by or coordinated by your PCP or participating treating

specialist, coverage for thatcare may be denied andyou may be responsible forthe costs of that care.

In the Emergency Room

If you go to the emergencyroom for services and careand it is determined that anemergency does not exist,you will be responsible forall charges.

Emergencies Out of

Your Service Area

If you go to an emergencyroom while you are out ofthe Health Options servicearea, present your mem-bership card. Depending on the hospital’s billing policy, the bill for emer-gency services and carewill be sent directly to Health Options or to you. If you receive a bill foremergency services andcare, send the unpaid bill to Health Options with anexplanation regarding thenature of the emergency.You’ll find our address on your Health Optionsmembership card.

Please refer to your Schedule of Copaymentsfor the emergency servicesand care copayment.

Your Health Care

Coverage Goes With You

As a Health Options HMOmember, you have accessto certain health care serv-ices across the country. Tomeet the different healthcare needs of membersand dependents who areaway from home, HealthOptions offers separateprograms for short tripsand long-term stays.

For shorter trips, theBlueCard® Program givesyou access to doctors andhospitals almost every-where, giving you thepeace of mind that you'llalways find the care youneed. Non-emergencyservices rendered outsidethe Health Options ServiceArea must be authorized inadvance by Health Optionsin order to be covered serv-ices.

For longer trips (90 consec-utive days or longer), theAway From Home Care®

Guest Membership pro-gram may be available foryou and your covereddependents in most statesand the District ofColumbia. For eligibilityinformation and specificlocations where the GuestMembership program isavailable, please contactthe customer service num-

ber indicated on yourHealth Options ID card.

This program is designedto bring you peace of mindif you have a dependentattending school out-of-state, have family mem-bers living in different serv-ice areas, or have a long-term work assignment inanother state. Coverage islimited to another Plan’sHMO service area.

What to do for Guest

Membership

You may call the CustomerService number listed onyour HMO ID card to verifyif your travel location isavailable for coverage. Ifavailable, an Away FromHome Care enrollmentapplication will be forward-ed to you for completion.Once you have returnedthe completed enrollmentapplication and arrive atyour new travel destination,you will receive informationfrom the host HMO onhow to access medical cov-erage.

Note:The above services

may not be available to

all Blue Cross and Blue

Shield of Florida/Health

Options group plans or

members at this time.

Handling an Emergency

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Going Into the Hospital

When you need hospitalcare or surgery, your PCPor specialist will arrangeyour hospital admission andcoordinate your care.

Some hospital benefitsrequire copayments. Pleaserefer to your Schedule ofCopayments for detailedinformation on hospitalcopayments. Coordinatingyour care through your PCPwill ensure that you receivethe maximum benefit.

Important Tip: Remember,your PCP or contractingspecialist must coordinateyour admission to a contracting Health Optionshospital for non-emergencycare, or you will be respon-sible for all hospital charges.

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Your Membership Card

Your membership cardshows you are a HealthOptions member withBlueCare coverage. Yourcard is recognized through-out the medical communityand serves as your key tonetwork services. Keepyour membership card withyou at all times and show itto your providers any timeyou receive health care.Your membership card listsimportant telephone num-bers such as the numberfor your PCP and your localCustomer Service office.

If you lose your member-ship card, please callHealth Options right awayto get another card.

Prescription Drug

Coverage

Your employer may havepurchased a prescriptiondrug endorsement. If so,simply take your prescrip-tions to a contracting phar-macy on the list included in your enrollment package.

For your convenience, ourpharmacy network includesneighborhood and nationalcompanies, so you can getyour prescriptions filledclose to home or near yourworkplace. All you need to

do is show your member-ship card and pay theamount required.

Some prescription drugbenefits may be subject toa Preferred Medication List.The Preferred MedicationList is simply a list of med-ications that have beenselected and reviewed by a panel of doctors and pharmacists. If your plan is subject to a PreferredMedication List, detailedinformation is included inyour enrollment package.Please note that HealthOptions reserves the rightto change the PreferredMedication List at any time.

Filing Claims

When you receive coveredmedical services and useproviders who contractwith Health Options, youwill not have to file anyclaim forms. Contractingproviders have eitheralready been paid for theirservices or will file claimsfor you. Always be sure to show your membershipcard when you receivehealth care services.

If you receive emergencymedical services and carefrom a provider who doesnot contract with HealthOptions, you will need to

send your bill to HealthOptions at the address onyour membership card.

Continually Looking at

New Technology

The types of treatments,devices and drugs coveredby BlueCare are extensive.In light of the rapid changesin medical technology, it is important to continuallylook at new medicaladvances and technology to determine which will be covered by your healthcare benefit package.

Before covering new medical technology, welook at a number of factors. Procedures anddevices must be provento be safe and effective by meeting certain criteria, among them:

• Approval by an appropriategovernment regulatoryagency, such as the Foodand Drug Administration(FDA)

• Scientific evidence ofimproved patient outcomewhen used in the usualmedical setting, not just a research setting

Membership in Health Options

• Benefit for patients is equalto established alternatives.To aid in decision-making,expert sources such as clinical studies published inrespected scientific journalsand physicians from variousspecialty medical organiza-tions are consulted

Because we strive to coveronly treatments which havebeen proven to be safe andeffective for a particular dis-ease or condition, BlueCaredoes not cover experimentalor investigational services.Experimental or investiga-tional services are treat-ments that have not beenproven safe and effective.Also, we try to determine,for coverage and paymentpurposes, if any new medical technology issuperior to the treatmentsalready in use.

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Medical necessity meansthat, for coverage and pay-ment purposes, a medicalservice or supply is requiredto identify, treat, or managea condition. To decide if amedical service or supply is medically necessary forcoverage and payment purposes, Health Optionsmay consider one or moreof the following:

• information provided by you or your physicians con-cerning your health status

• reports in medical literatureconcerning your conditionor status or similar conditions and status

• reports or guidelines published by nationally recognized health careorganizations and recog-nized by local physicians

• professional standards ofsafety and effectiveness

• the opinion of health careprofessionals in the healthspecialty involved

• the opinion of the attending physician(s)

• other information considered relevant byHealth Options

A decision by Health Optionsthat a medical service orsupply is not medically necessary does not meanthat you cannot get thetreatment you want or thatis recommended; it simplymeans that Health Optionswill not cover or pay for theservice based on one or all the factors noted above.You are always free to getthe service or supply andpay for it yourself. Pleaserefer to your MemberHandbook for detailed information on how medicalnecessity decisions aredetermined for coverageand payment purposes.

How Health Options Makes a CoverageDecision Regarding Medical Necessity

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As part of our ongoingcommitment to bringingexpanded choices andgreater value to your healthplan, we are pleased tooffer a program of discounted products andvalue-added services calledBlueComplements.

BlueComplements is avail-able to you automatically asa plan member at no additional premium cost.And you can access theservices throughout Floridaand, where available,nationwide. This programincludes:

MyBlueServiceSM* givesyou access to online healthcare information, forms anddirectories 24 hours a day,seven days a week. Toaccess, go towww.bcbsfl.com and clickon MyBlueService to checkclaims, review benefits,request an ID card, updateother insurance, change anaddress and much more.

BlueComplementsSM pro-vides members with significant discounts* onvision care, hearing examsand hearing aids, contact lenses, bicycle helmets, fitness centers, weightmanagement programs,massage therapy and complementary alternativemedicine.

e-Medicine* allows you to communicate withtheir doctor’s office onlinethrough a secure and confidential website. Someof the services that may beavailable include schedulingan appointment, refillingprescriptions and consulting with your physician for non-urgenthealth care needs. Toaccess e-Medicine, visitwww.bcbsfl.com and clickon Members and then e-Medicine.

Care Decision Support

through Health Dialog®* provides you with healthinformation, health coach-ing and other health-related programs tohelp guide treatment choices and decisionsabout health care. HealthDialog is available to youwhenever you need it, 24hours a day, either byphone or online.

Health Coaches are themost personal aspect ofour support programs, providing you with relevanton-the-spot information andhealth-related videos andwritten materials if needed.Health Coaches arelicensed, experiencedhealth care professionals,including registered nurses,dietitians and respiratorytherapists available 24hours a day, seven days aweek.

The Online Provider

Directory allows you andyour employees to findproviders by visitingwww.bcbsfl.com. Just clickon Provider Directory tofind a provider throughQuick Search or by plan,specialty and hospital affiliation through AssistedSearch. Custom directoriescan even be printed byplan, region and specialty.

*Blue Cross and BlueShield of Florida, Inc.(BCBSF) has arrangementswith third-party vendors toprovide our members withthese services. BCBSFdoes not endorse and isnot responsible for theproducts, services or information provided andcannot guarantee or beheld responsible for thequality of services providedby these vendors.

Time-Saving Health Resources

Introduction

Health Options has estab-lished a process for review-ing Member Complaintsand Grievances. The pur-pose of this process is tofacilitate review of, amongother things, the Member’sdissatisfaction with HealthOptions, Health Options’administrative practices,coverage, benefit or pay-ment decisions, or with theadministrative practicesand/or the quality of careprovided by any independ-ent Contracting Provider.The Complaint andGrievance Process also per-mits the Member, or his orher Physician, to expediteHealth Options’ review of certain types ofGrievances. The processdescribed below must befollowed if the Member hasa Complaint or Grievance.

Under the Complaint andGrievance Process, aComplaint will be handledinformally in accordancewith the Informal Reviewsubsection set forth below.

A Grievance will be handledformally in accordance withthe Formal Review subsec-tion described below. Arequest to review an Ad-verse Benefit Determi-nation of a Pre-ServiceClaim, Post-Service Claim,

or a Concurrent CareDecision will be handled inaccordance with the termsof this section.

Health Options encouragesthe Member to first attemptinformal resolution of anydissatisfaction by calling us.If Health Options is unableto resolve the matter on aninformal basis, the Membermay submit his or her formalrequest for review in writing.

Informal Review –

Complaints

To advise Health Options ofa Complaint, the Membershould first contact an Health Options CustomerService Representative atthe local Health Optionsoffice, either by telephoneor in person. The telephonenumber is listed on theMembership Card, and theaddress of the local officeis listed in the TelephoneNumbers and Addressessubsection. The CustomerService Representative,

working with appropriatepersonnel, will review theComplaint within a reason-able time after its submis-sion and attempt to resolveit to the Member’s satisfac-tion. If the Memberremains dissatisfied withHealth Options’ resolutionof the Complaint, he or shemay submit a Grievance inaccordance with the FormalReview subsection below.

Important Note:

The Member must provideto the Customer ServiceRepresentative all of thefacts relevant to theComplaint. The Member’sfailure to provide anyrequested or relevant infor-mation may delay HealthOptions’ review of theComplaint. Consequently,the Member is obliged tocooperate with HealthOptions in our review ofthe matter.

Formal Review -

Grievances

The Member, a provideracting on his or her behalf,a state agency, or anotherperson designated by theMember, may submit aGrievance. To submit or pur-sue a Grievance on behalfof a Member, a healthcareprovider must previouslyhave been directly involvedin his or her treatment ordiagnosis. The form or let-ter must be mailed to theaddress listed in theTelephone Numbers andAddresses subsection.

How To Obtain Forms:Health Options will providethe Member the form nec-essary to initiate aGrievance. A form will alsobe sent with each writtendecision letter or uponrequest. The Member mayobtain the necessary formby contacting a CustomerService Representative atthe local office number listed

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Complaint and Grievance Process

17

on the Membership Card.

While the Member is not

required to use Health

Options’ preprinted form,

Health Options strongly

urges that the Grievance

be submitted on such a

form in order to facilitate

logging, identification,

processing, and tracking

of the Grievance through

the formal review

process.

If the Member needsassistance in preparing theGrievance, he or she maycontact Health Options forsuch assistance. Hearingimpaired Members maycontact Health Options viaTDD.

1. Local Office Review:

a) Standard Grievances

In order to begin the for-mal review process, theMember must completea form or write a letterexplaining the facts andcircumstances relatingto the Grievance. TheMember should provideas much detail as possi-ble and attach copies ofany relevant documenta-tion. The Local OfficeGrievance Committeewill review theGrievance in accordancewith the standardGrievance procedureand advise the Memberof its decision in writing.If the Grievance involvesa Pre-Service Claim,Health Options’ decisionregarding the Grievancewill be made within 15days of receipt of theGrievance. If the

Grievance involves aPost-Service Claim,Health Options’ decisionregarding the Grievancewill be made within 30days. If the Memberremains dissatisfiedwith the decision of theLocal Office, he or shemay request a reconsid-eration of the decisionby Health Options’Corporate Office asdescribed in theCorporate Office Reviewprovision.

b) Internal Review Panel

Grievance

In the event of aGrievance involving anAdverse BenefitDetermination where acoverage determinationby Health Options thatan admission, availabilityof care, continued stay,or other Health CareService has beenreviewed and, basedupon the informationprovided, does not meetHealth Options’ require-ments for MedicalNecessity, appropriate-ness, health care set-ting, level of care oreffectiveness, and cov-erage for the requestedService is thereforedenied, reduced, or ter-minated, the Member

may request that theGrievance be reviewedby an Internal ReviewPanel. For the Memberto have such anAdverse BenefitDeterminationGrievance reviewed bythe Internal ReviewPanel, Health Optionsmust receive thereview request within30 calendar days fromthe date that theMember received adenial decision. Torequest this type ofreview, send a written

request and support-

ing documentation

within the 30-day timelimit to the addresslisted in the TelephoneNumbers andAddresses subsection.

If Health Options doesnot receive therequest for review bythe Internal ReviewPanel within 30 calen-dar days, the denialdecision will bereviewed by the LocalOffice GrievanceCommittee in accor-dance with the stan-dard Grievance proce-dure. If the Grievanceinvolves a Pre-ServiceClaim, Health Options’decision regarding theGrievance will bemade within 15 days

18

of receipt of theGrievance. If theGrievance involves aPost-Service Claim,Health Options’ deci-sion regarding theGrievance will bemade within 30 days.

The Internal ReviewPanel will review theGrievance and maymake a decision basedon medical records,additional information,and input from healthcare professionals inthe same or similarspecialty as typicallymanages theCondition, procedureor treatment underreview. The LocalOffice will advise theMember of its deci-sion in writing.

If the Memberremains dissatisfiedwith the decision ofthe Local Office, he orshe may request areconsideration of thedecision by theCorporate Office asdescribed in theCorporate OfficeReview provision.

c) Expedited Review of

Urgent Grievances

In the event of aGrievance involving an

Adverse BenefitDetermination, theMember, or a personacting on his or herbehalf, may requestthat the review of theGrievance be expedit-ed. In order for aGrievance to be eligi-ble for expeditedreview (i.e., a ClaimInvolving UrgentCare), it must meetthe following criteriaas determined byHealth Options:

1) The Member mustbe dissatisfied with an HealthOptions AdverseBenefit Determination;

2) As determined byHealth Options, adelay in the provisionof Health CareServices for thelength of time permit-ted under the stan-dard Grievance proce-dure time frames(approximately 30-60working days) couldseriously jeopardizethe Member’s life orhealth, or theMember’s ability toregain maximum func-tion, or in the opinionof a Physician withknowledge of theMember’s Condition,

would subject theMember to severepain that cannot beadequately managedwith the care of treat-ment that is the sub-ject of the claim; and

3) The health careprovider involved hasrefused to or will notprovide the neededmedical Service with-out a guarantee ofcoverage or paymentfrom the Member orHealth Options.

The Member, or aprovider acting on his orher behalf, must specifi-cally request an expedit-ed review. For example,this request may bemade by saying: “I wantan expedited review.”Only the followingServices that have yet tobe rendered are subjectto this Expedited Reviewprocess: (1) Pre-ServiceClaims; or (2) requestsfor extension of concur-rent care Services madewithin 24 hours prior tothe termination ofauthorization for suchServices.

Information necessary toevaluate a ClaimInvolving Urgent Caremay be transmitted by

telephone, facsimiletransmission, or suchother expeditiousmethod as is appropriateunder the circumstances.

A Claim Involving UrgentCare will be evaluated bya health care professionalwho was not involved inthe initial decision andwho is in the same orsimilar specialty, if any,as typically manages theCondition, process, ortreatment which you orthe provider are request-ing be reviewed.

Health Options will makea decision and notify theMember, or the provideracting on his or herbehalf, as expeditiouslyas the Conditionrequires, but in no eventlonger than 72 hoursafter receipt of therequest for expeditedreview. If additional infor-mation is necessary,Health Options will notifythe provider and theMember within 24 hoursof receipt of the ClaimInvolving Urgent Careand Health Options mustreceive the requestedadditional informationwithin 48 hours ofrequest. After receipt,Health Options will makeits determination within

an additional 48 hours.

If the Member’s requestfor expedited review aris-es out of a utilizationreview determination byHealth Options that acontinued hospitalizationor continuation of acourse of treatment isnot Medically Necessary,coverage for the hospital-ization or course of treat-ment will continue untilthe Member has beennotified of the determina-tion.

Health Options will pro-vide written confirmationof its decision concern-ing Claim InvolvingUrgent Care within twoworking days after pro-viding notification of thatdecision. If the Memberis not satisfied with thedecision, he or she maysubmit the Grievance tothe Statewide Providerand SubscriberAssistance Panel.

2. Corporate Office

Review:

In order to appeal theLocal Office’s decision toHealth Options’Corporate Office, HealthOptions must receive,within 30 days of theLocal Office’s decision, aform or a letter explain-

ing why the Memberfeels that the LocalOffice’s decision waswrong or not appropriateand what he or shewould like HealthOptions to do to remedythe matter.

Health Options’Corporate Office willreview the Local Officedecision as quickly aspossible and advise theMember of its decisionin writing.

Statewide Provider and

Subscriber Assistance

Panel

The Member always hasthe right, at any time, tohave a Complaint or aGrievance reviewed bythe Florida Departmentof Insurance or theAgency for Health CareAdministration or theStatewide Provider andSubscriber AssistancePanel. The Member maysubmit the Grievance tothe Statewide Providerand SubscriberAssistance Panel within365 days of theCorporate Office’s deci-sion. Telephone numbersand addresses are listedin the TelephoneNumbers and Addresssubsection. The Membermust complete the entireComplaint and Grievance

Process and receive afinal disposition fromHealth Options beforepursuing review by theStatewide Provider andSubscriber AssistancePanel.

Time Frames for

Resolution of a

Grievance

Health Options willresolve Grievances in atimely manner. In resolv-ing Grievances, timeframes may vary depend-ing on the circum-stances, between theLocal Office andCorporate Office review.Health Options will, how-ever, resolve theMember’s Grievancewithin 30 days afterreceipt for Pre-ServiceClaims, or within 60 daysfor Post-Service Claims.

General Rules

General rules regardingHealth Options’Complaint and GrievanceProcess include the fol-lowing:

1. The Member mustcooperate fully withHealth Options in itseffort to promptly reviewand resolve a Complaintor Grievance. In theevent the Member doesnot fully cooperate withHealth Options, he or

she will be deemed tohave waived his or herright to have theComplaint or Grievanceprocessed within thetime frames set forthabove.

2. Health Options willoffer to meet with theMember if he or shebelieves that such ameeting will help HealthOptions resolve theComplaint or Grievanceto the Member’s satis-faction. For theMember’s convenience,and at his or her option,he or she may elect tomeet with HealthOptions’ representativesin person, by telephoneconference call, or byvideo-conferencing (iffacilities are available).Health Options will notreimburse the Memberfor travel or lodging inconnection with any suchmeeting. Appropriatearrangements will bemade to allow telephoneconferencing or videoconferencing to be heldat Health Options’ admin-istrative offices withinthe Service Area. HealthOptions will make thesetelephone or videoarrangements with noadditional charge to you.The Member must notifyHealth Options that he or 19

she wishes to meet withHealth Options’ represen-tatives concerning theComplaint or Grievance.

3. The time frames setforth herein may be mod-ified by the mutual con-sent of Health Optionsand the Member, howev-er, any mutually agreedtime frame extensiondoes not preclude theMember from havingHealth Options’ decisionsreviewed by theStatewide Provider andSubscriber AssistancePanel at any time.

4. Health Options will nothonor a request for expe-dited review that relatesto Services that havealready been performed,rendered, or provided toyou or a request that isnot eligible for expeditedreview in accordancewith the criteria set forthin the Expedited Reviewof a Claim InvolvingUrgent Care provision.Health Options willprocess any suchGrievance, however, inaccordance with thestandard Grievance pro-cedure.

5. Health Options mustreceive all Grievanceswithin one year of thedate of the occurrencethat initiated the

Grievance.

6. If the Grievanceinvolves a determinationthat the Services did notmeet Health Options’Medical Necessity guide-lines for coverage of aService or that theService is excludedbecause it meets thedefinition of anExperimental orInvestigational Service ora similar exclusion or limi-tation, then the Membermay request an explana-tion of the scientific orclinical judgment reliedupon, if any, for thedetermination, thatapplies the terms of theMember Handbook tothe Member’s medicalcircumstances.

7. During the reviewprocess, the Services inquestion will be reviewedwithout regard to thedecision reached in theinitial determination.

8. The Member mayrequest to review perti-nent documents, such asany internal rule, guide-line, protocol, or similarcriterion relied upon tomake the determination,and submit issues orcomments in writing.

Telephone Numbers and

Addresses

The Member may contactan Health OptionsGrievance Coordinator atthe number listed on theMembership Card or thenumbers listed below. If aGrievance is unresolved,the Member may, at anytime, contact an agency atthe telephone numbers andaddresses listed below.

Agency for Health Care

Administration

Bureau of Managed Care

2727 Mahan DriveBldg.1, Room 311Tallahassee, FL 323081-850-487-0640

Department of

Financial Services

Office of InsuranceRegulation200 East Gaines StreetTallahassee, Florida32399-03221-800-342-2762

Statewide Provider and

Subscriber Assistance Panel

2727 Mahan Drive,Building 1, Room 339,Mail Stop-27ATallahassee, Florida 323081-850-921-54581-888-419-3456

Local Office Locations

Phone: (877) 352-2583TTY/TDD - Florida Relay 711

Health Options, Inc.

Attention: GrievanceDepartment4800 Deerwood CampusParkway DCC4-1Jacksonville, Florida32246-8273

Health Options, Inc.

Attention: GrievanceDepartment4350 West Cypress Street,Suite 400Tampa, Florida 33607

Health Options, Inc.

Attention: GrievanceDepartment8400 NW 33rd Street,Suite 100Miami, Florida 33122-1932

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21

About Confidentiality

Health Options respectsyour privacy and has poli-cies and proceduresdesigned to safeguard yourpersonal information, in allforms – spoken, writtenand electronic. You havealready been provided witha copy of our Notice ofPrivacy Practices. If youwish to view or obtainanother copy, you may visitus at www.bcbsfl.com orcall us at the number listedon your HMO MembershipID card.

22

Your benefits weredesigned with you and yourfamily in mind. Prenatalcare, well-child care, immu-nizations, periodic healthassessments and eye andear screenings are a part of your coverage. Othercovered preventive healthservices include familyplanning counseling and services and healtheducation programs.

Women’s Health Needs

Women’s annual exams are very important for goodhealth. Your plan allows you to go directly to a contracting gynecologistwithout a referral from your PCP for your annualexam. Please refer to your Member Handbook for details of your plan.

Because of the importanceof early detection, regularmammograms are alsopart of your BlueCare coverage. Mammogramsare covered based on thefollowing schedule:

• A baseline mammogramfor any woman who is 35 years of age or older,but younger than 40 yearsof age.

• A mammogram every twoyears for any woman whois 40 years of age or older,but younger than 50 yearsof age, or more oftenbased on a physician’s recommendation.

• A mammogram every yearfor any woman who is 50years of age or older.

• A mammogram every yearbased on a physician’s recommendation for anywoman who is at risk forbreast cancer because ofpersonal or family history.

Pregnancy testing is alsocovered by your plan.

Maternity Care

Your health care coverageplan is designed to takecare of both routine anddifficult pregnancies.

If you become pregnant, ourHealthy Addition programprovides prenatal counsel-ing and education to helpexpectant mothers havehealthier, full-term pregnan-cies to reduce the numberof premature births.

High-risk cases that areidentified are monitored toreduce the potential forexpensive neonatal carethat results from many

problem pregnancies.Healthy Addition helps morewomen deliver healthybabies with fewer prob-lems and complications.

For information aboutHealthy Addition, call (800) 955-7635 and press 6 after the prompts.

Just for Kids

Health Options takes careof your children’s healthcare coverage needs from the moment of birth.

Your newborn will have aPCP that you choose fromamong our contractingproviders. The PCP youchoose will help coordinate your child’s care.

Because growing up isn’talways easy, it helps tohave a health care coverageplan for routine develop-mental care and checkups.

If potential problems areidentified, your child’s PCPcan counsel you regardingchoices, so you’ll have theinformation you need tomake decisions about yourchild’s continuing medicalcare or treatment.

Your Family Members

are Covered

When you enroll, your familymembers may also be eligible to join. For example,family members eligible toenroll in BlueCare include:

• Your spouse

• Your children, stepchildren,legally adopted children, orchildren for whom you are alegal guardian. Note: Fosterchildren may or may not be covered. Please refer toyour Member Handbook formore details.

Your spouse and depend-ents may enroll:

• when you or your depend-ents are first eligible forBlueCare,

• during a subsequent openenrollment period, or

• during a special enrollmentperiod.

Please refer to your

Member Handbook for

details about enrollment.

Coverage for You and Your Family

23

Not all health care servicesand supplies which may becovered under your BlueCareplan are listed below.

Please check your

Member Handbook for a

complete list and details

of covered services.

Hospital Care

Inpatient or outpatient hos-pital services such as roomand board in a semi-privateroom, intensive care units,operating and recovery oremergency rooms, drugsand medicines, intravenoussolutions, casts, anesthet-ics, transfusion supplies,and chemotherapy.

Physician Care

Physician services such asdoctor visits when you arean inpatient, your outpatientoffice visits, surgical proce-dures, diagnostic services,and consultations.

Ambulatory Surgical

Center Care

Ambulatory surgical cen-ter care such as use ofoperating and recoveryrooms, oxygen, drugs andmedicines, and other sup-plies or services.

Preventive Health Services

Preventive health servicesmay include: periodic healthassessments, instruction inpersonal health care meas-ures, immunizations andinoculations, eye and earscreenings, family planningcounseling and services,health education programs,and one annual gynecolog-ical examination per calen-dar year.

Ambulance Services

Ambulance transportationto the nearest medical facil-ity which can provide requir-ed emergency services andcare is a covered service ifthe use of an ambulance ismedically necessary.

Maternity Care

Prenatal, delivery and postnatal care.

Newborn Care

Newborn assessment andcoverage for injury or sick-ness, including the care ortreatment of birth abnor-malities and prematurity.

Please Note: Coverage forthe newborn child of adependent will automaticallyterminate 18 months afterthe date of birth.

Well-Child Care

Up to the child’s 17th birth-day, he or she may receiveperiodic examinations,immunizations, and labtests normally performedfor a well-child.

Accidental Dental Care

Dental care provided as a result of an accident which damaged sound natural teeth.

Prescription Drugs

If your employer purchaseda prescription drug endorse-ment, drugs that are prescribed by a physicianand dispensed by a phar-macist may be covered.Your prescription coveragemay or may not be subjectto a Preferred MedicationList (PML). The PML is simply a list of medicationsthat have been selectedand reviewed by a panel ofdoctors and pharmacists forcoverage by Health Options.The prescription drugendorsement included withyour Member Handbook

will give you informationabout your prescriptiondrug program.

Other Covered Services

The following are also covered. Always refer toyour Member Handbook fordetails and any limitationson services covered by your BlueCare plan.

• Skilled nursing facility care

• Home health care

• Prosthetic and orthoticdevices

• Durable medical equipment

• Short-term rehabilitationservices

• Diabetes treatment services

• Osteoporosis screening

Exclusions

Please refer to your

Member Handbook for

the specific exclusions

related to your coverage.

• Any service not listed in the covered services sectionor in any endorsement

• Any services rendered by aprovider who does not participate in theHealthOptions network andthat has not been author-

A Brief Description of Covered Services

24

ized by the member’sPCP, except in cases ofemergency as describedpreviously

• Any services orsupplies that are notmedically necessary

• Custodial, domiciliary,convalescent, and restcare

• Personal comfort items,services, and supplies

• Cosmetic surgery that isnot medically necessary

• Dental care

• Vision care

• Hearing aids

• Complementary and alter-native healing methods

• Prescription drugs(unless your employerpurchased a prescriptiondrug endorsement)

• Experimental or investigationaltreatment

24

25

Working to Control Health Care Costs

We know how hard youwork to provide for yourfamily. At Health Options,we work just as hard tomake sure your family’shealth care coverageremains affordable.Together we can work tocontrol the increasing costof health care coverage and medical care.

Coordination of Benefits

If you are covered byanother group plan or anykind of insurance that also provides health carebenefits, please let HealthOptions know. When applicable, this allows us

to coordinate your healthcare benefits with the otherinsurance company andpossibly help minimize yourout-of-pocket expenses.

Subrogation

If you are injured or become ill due to anotherperson’s intentional act or negligence, the personresponsible for your injuryor illness should pay foryour medical care. If yourecover money from anotherperson to compensate youfor your damages, HealthOptions should be paid back for payments made on your behalf. This is calledsubrogation. You must contact Health Options withdetails of your accident orsickness and cooperate withHealth Options.

Case Management

This program may be made available to you byHealth Options, in its sole discretion, if you have acatastrophic or chronic condition. Under this voluntary program, HealthOptions may elect (but is

not required) to offer alter-native benefits or paymentfor cost-effective healthcare services. These alter-native benefits or pay-ments may be made avail-able by Health Options on acase-by-case basis if youmeet Health Options’ casemanagement program cri-teria then in effect. Suchalternative benefits or pay-ments, if any, will be madeavailable in accordancewith a treatment plan withwhich you, or someonerepresenting you who isacceptable to HealthOptions, and your doctoragree to in writing. The factthat Health Options offersto provide any alternativebenefits or paymentsunder this program to youdoes not mean that HealthOptions is obligated to con-tinue to provide such bene-fits or payments or to pro-vide them to you or anoth-er person in the future. Fordetailed information, pleaserefer to your MemberHandbook, its terms prevail.

26

Members’ Rights and Responsibilities

As a Member you have

the following rights and

responsibilities.

Rights

1. To be provided with infor-mation about HealthOptions, our services,coverage and benefits,the contracting practition-ers and providers deliver-ing care, and members’rights and responsibili-ties.

2. To receive medical careand treatment fromContracting Providerswho have met our cre-dentialing standards.

3. To expect health careproviders who contractwith Health Options to:a) discuss appropriate orMedically Necessarytreatment options foryour condition, regard-less of cost or benefitcoverage; and b) permityou to participate in themajor decisions aboutyour health care, consis-tent with legal, ethical,and relevant patient-provider relationshiprequirements.

4. To expect courteousservice from HealthOptions and consideratecare from contractingproviders with respectand concern for your dig-nity and privacy.

5. To voice your complaintsand or appeal unfavor-able medical or adminis-trative decisions by fol-lowing the establishedappeal or grievance pro-cedures found in theMember Handbook orother procedures adopt-ed by Health Options forsuch purposes.

6. To inform contractingproviders that you refusetreatment, and to expectto have such providershonor your decision ifyou choose to acceptthe responsibility andthe consequences ofsuch a decision.

7. To have access to yourrecords and to have con-fidentiality of your med-ical records maintained inaccordance with applica-ble law.

8.To call or write to us anytime with helpful com-ments, questions, andobservations whetherconcerning somethingyou like about our plan orsomething you feel is aproblem area. You mayalso make recommenda-tions regarding HealthOptions’ members’rights and responsibilitiespolicies. Please call thenumber or write to us atthe address on yourHMO membership IDcard.

Responsibilities

1. To seek all non-emer-gency care through yourassigned PCP or aContracting Physicianand to cooperate with allpersons providing yourcare and treatment.

2. To be respectful of therights, property, comfort,environment and privacyof other individuals andnot be disruptive.

3. To take responsibility forunderstanding yourhealth problems and par-ticipate in developingmutually agreed upontreatment goals, as bestas possible, then follow-ing the plans and instruc-tions for care that youhave agreed upon withyour Health Optionsprovider.

4. To provide accurate andcomplete informationconcerning your healthproblems and medicalhistory and to answer allquestions truthfully andcompletely.

5. To be financially respon-sible for any copaymentsand non-covered servic-es, and to provide cur-rent information con-cerning your enrollmentstatus to any HealthOptions-affiliatedprovider.

6. To follow establishedprocedures for filing a

grievance concerningmedical or administrativedecisions that you feelare in error.

7. To request your medicalrecords in accordancewith Health Options rulesand procedures andapplicable law.

8. To follow the CoverageAccess Rules estab-lished by Health Options.

What Happens if Your

BlueCare Coverage Ends

The following are reasonswhy BlueCare health carecoverage may end:

• You are no longer a full-time employee

• You no longer meet eachof the full-time employeerequirements

• You leave your presentemployer

• Your employer no longeroffers Health Options’health care coverage

• Premiums or copaymentsare not paid

• You move away from theHealth Options servicearea

• You knowingly commitfraud, make a misrepre-sentation, or give falseinformation

• You are disruptive, unruly,abusive, or uncooperative

• You willfully misuse yourmembership card

27

Please refer to yourMember Handbook fordetailed information.

Florida Health Insurance

Coverage Continuation

Act (FHICCA) Provisions

(For employers with one

to 19 employees)

Effective January 1, 1997,Florida Statutes 627.6692,known as the FloridaHealth Insurance CoverageContinuation Act, requiresthat a Small Employer withfewer than 20 employeeswho does not qualify forthe Consolidated OmnibusReconciliation Act of 1985(COBRA), offer to CoveredEmployees and theirCovered Dependents theopportunity for a temporaryextension of health cover-age (called "continuation ofcoverage") in certaininstances where coveragewould otherwise end. TheCovered Person has certainrights and obligations underthe continuation of cover-age provision of the law.

You May Choose to

Continue Coverage

Under COBRA

If you lose your healthcare coverage, you may beable to continue coverageunder the ConsolidatedOmnibus Budget

Reconciliation Act of 1985(COBRA). There are certainevents that qualify a per-son to continue coverageunder COBRA. If a personqualifies, then he or shemust choose continuationof their group coverageunder COBRA within 60days of the date of thequalifying event. Youremployer is responsible forgiving you informationabout COBRA.

Please refer to yourMember Handbook fordetailed information aboutevents that qualify a per-son for coverage underCOBRA.

Conversion Options

If your Health Optionsmembership ends, youmay qualify to change yourBlueCare coverage to anindividual plan unless youbecome covered underanother group plan within31 days after coverageends. You won't need amedical examination toqualify for the individualplan, and family membersthat qualify may get cover-age on the same basis.

Health Options offers twoconversion options.Conversion Option A cov-ers medical, hospital, andother health care services.Conversion Option B cov-

ers other benefits such asprescription drugs.

To apply for continuouscoverage, we must receiveyour application and anyrequired premium within63 days after your groupmembership ends. Youmay call Health Options toget forms if you need toapply for a conversionoption.

Care Without

Discrimination

Members have a right toexpect that health careproviders who contractwith Health Options’ net-work will not discriminateagainst members in thedelivery of health careservices, consistent withthe benefits covered intheir policy, based on race,ethnicity, national origin,religion, sex, age, mentalor physical disability, sexu-al orientation, geneticinformation or source ofpayment.

Translation Services

Health Options’ policy is toprovide prompt customerservice to all of our mem-bers. We employ manySpanish-speaking cus-tomer service representa-tives and internal serviceassociates to serve thelarge number of Floridianswho speak Spanish. We

also employ many multilin-gual people to meet theneeds of members whospeak other languages.

Non-English-speakingmembers can obtain helpat any Health Optionsoffice. We have multilingualstaff available throughoutthe company. There is nocharge when we provideservice in a language otherthan English.

When a non-English-speaking member callsHealth Options, we ask forthe member’s languagepreference. An internalservice associate assiststhe member in that lan-guage whenever the serv-ice capability exists.Sometimes a membercannot communicate a lan-guage preference. In thosecases, we ask the mem-ber to have an English-speaking friend or relativehelp. The member and theEnglish-speaking friend orrelative can call HealthOptions at their conven-ience. We will respond tothe member’s inquiry atthat time.

If you have any furtherquestions concerning thismatter or need additionalassistance, please call thecustomer service numberon your Health Optionsmembership card.

28

Advance Directives

At Health Options, wealways want your coverageto meet your changinghealth needs. However,there are a few special circumstances in which youmay want to communicateyour wishes in advance,using an Advance Directive.An Advance Directive is awitnessed oral or writtenstatement made while youare still of sound mind that gives your wishes formedical care. An AdvanceDirective includes yourwishes as to whether life-prolonging proceduresshould be applied, whetherto apply for Medicare,Medicaid or other healthbenefits, and with whomthe health care providershould consult in makingtreatment decisions. The following is an overviewonly. Please refer to yourMember Handbook formore information. There arethree types of AdvanceDirective documents thatare used most often inFlorida: a Living Will, aHealth Care SurrogateDesignation, and a DurablePower of Attorney forHealth Care. A generaldescription of each follows:

Living Will

A Living Will is a documentthat explains your wishesas to whether life-prolongingprocedures should be given,not given, or stopped if youare suffering from a terminalcondition and are not able toexpress your own wishes.

Health Care

Surrogate Designation

This Advance Directive givesauthority to an appointedperson of your choice, calleda surrogate, to make healthcare decisions for youaccording to your wishes.The surrogate can makedecisions only if you are notable to do so on your own.If it is necessary for the surrogate to make healthcare decisions for you,these decisions must bethose that you would want,or make, if you were able to do so yourself.

There are some health caredecisions that a surrogatecannot make, by law, on your behalf, such asagreeing that you have anabortion, or agreeing toelectroshock therapy. Thisdocument must be specificas to what limits apply to your surrogate’s power to make health care decisions on your behalf.

Durable Power of

Attorney for Health Care

This Advance Directive documents the person youappoint to be your attorney-in-fact to arrange and toagree to medical, therapeu-tic, and surgical proceduresfor you if you are not able to do so for yourself.

You Have a Choice

Whether to Have an

Advance Directive

You are not required tohave an Advance Directive.However, if you choose notto have one, Florida lawsays the following personscan make decisions onbehalf of a patient who isnot able to do so. They arelisted below in order of priority, based on this law:

• a legal guardian

• a spouse

• an adult child or children

• a parent

• sister(s) and/or brother(s)

• an adult relative who is familiar with your activities, health, and religious beliefs

• a close friend, who is an adult, familiar with your activities, health and religious beliefs

Deciding to have anAdvance Directive is animportant and complexdecision. It may be helpfulfor you to discuss AdvanceDirectives with yourspouse, family, friends, religious or spiritual advisoror attorney. The goal for making an AdvanceDirective should be for aperson to clearly state hisor her wishes to ensure the health care facility,physician and whoever elsewill be faced with carryingout those wishes knowwhat you would want. We also recommend thatyou give a copy of yourAdvance Directive to yourPCP and family members.

If you believe your providerhas not complied with yourAdvance Directive, you oryour representative mayfile a complaint by writingto the following address:

Agency for Health CareAdministration, Bureauof Managed Care2727 Mahan DriveBldg. 1, Room 311Tallahassee, FL 32308

29

Here are some terms thatwill help you understandyour health care coverage.

Adverse Benefit

Determination means anydenial, reduction or termination of coverage,benefits, or payment (inwhole or in part) under thisMember Handbook withrespect to a Pre-ServiceClaim or a Post-ServiceClaim. Any reduction or termination of coverage,benefits, or payment inconnection with aConcurrent Care Decision,as described in this section, shall also constitute an AdverseBenefit Determination.

Case Management is amutually agreed uponarrangement for the payment or coverage ofapproved health care services on a case-by-casebasis.

Claim Involving Urgent

Care means any request orapplication for coverage orbenefits for medical care ortreatment that has not yetbeen provided to theMember with respect towhich the application oftime periods for makingnon-urgent care

determinations: (1) couldseriously jeopardize theMember's life or health orhis or her ability to regainmaximum function; or (2) inthe opinion of a Physicianwith knowledge of theMember’s Condition, wouldsubject the Member tosevere pain that cannot beadequately managed without the proposedServices being rendered.

Coinsurance is the sharing of health careexpenses for coveredServices between BCBSFand you. This is a percentage of the allowedamount for covered services. Most BlueCareHMO plans have a copay-ment for covered services,not a coinsurance.

Complaint means an oral(i.e., non-written) expres-sion of dissatisfaction,whether or not such dissatisfaction was made inperson, by telephone, or onthe Member's behalf.

Concurrent Care Decision

means a decision by HealthOptions to deny, reduce, orterminate coverage, benefits, or payment (inwhole or in part) withrespect to a course of

treatment to be providedover a period of time, or aspecific number of treatments, if HealthOptions had previouslyapproved or authorized inwriting coverage, benefits,or payment for that courseof treatment or number oftreatments.

As defined herein, aConcurrent Care Decisionshall not include any decision to deny, reduce, orterminate coverage, benefits, or payment underthe Case Management subsection as described inthe Coverage Access Rulessection of this MemberHandbook.

Contracting Provider

means any health careprovider who provideshealth care services or supplies to you and has an agreement with Health Options to participate in the HMO network at the time the services or supplies are rendered.

Coordination of Benefits

is a method by whichHealth Options attempts to avoid duplicate paymentfor expenses coveredunder more than onehealth insurance plan orhealth care policy.

Copayment means the pre-established dollar amount you pay for covered services.

Terms to Understand

30

Coverage Access Rules

Coinsurance is the sharingof health care expenses forCovered Services betweenBCBSF and you. This is apercentage of the allowedamount for covered services. Most BlueCareHMO plans have a copay-ment for covered services,not a coinsurance.

Credentialing means the process used to verifythat a provider is properlylicensed and has obtainedthe appropriate profession-al, technical or educationalcertifications.

Deductible is the amountyou pay before coveragebegins for services requiring a deductible.Most BlueCare HMO planshave a copayment structure and do notrequire a deductible.

Experimental orInvestigational generallymeans any service or procedure that has not, inthe opinion of HealthOptions, been proven tobe safe and effective.

Grievance means a writ-ten expression of dissatis-faction. The Member, a

provider acting on his orher behalf, or a stateagency may submit aGrievance.

Health Care Service(s) or

Service(s) means evaluations, treatments,therapies, devices, procedures, techniques,equipment, supplies,products, remedies,

vaccines, biological products, drugs, pharma-ceuticals, chemical compounds and otherservices rendered or supplied, by or at thedirection of, providers.

Internal Review Panel

means a panel establishedby Health Options toreview Grievances relatedto Adverse BenefitDeterminations made byHealth Options that anadmission, availability ofcare, continued stay, orother Health Care Servicehas been reviewed and,based upon the informa-tion provided, does notmeet the Health Options'requirements for MedicalNecessity, appropriate-ness, health care setting,level of care, or efficacy.This panel consists ofPhysicians who have

appropriate expertise, andwho were not previouslyinvolved in the initialAdverse BenefitDetermination.

Medically Necessary orMedical Necessity meansthat for coverage and payment purposes, a medical service or supplyis, in the opinion of HealthOptions, required for theidentification, treatment, ormanagement of aCondition.

Non-Contracting Provider

means any health careprovider with whom HealthOptions does not have anagreement to participate inits HMO network at thetime a service or supply isrendered. If you go to anon-contracting provider,you may be balance billed.

Premium is the amountyou are required to pay in order to have health care coverage.

Primary Care Physician

(PCP) is a doctor who hasagreed with HealthOptions to act as a PrimaryCare Physician and whogenerally coordinates ordirectly provides most ofyour medical care. YourPCP must participate withHealth Options as a PCP.

Service Area is thegeographic area describedin your MemberHandbook.

31

Q.What if I have an acci-

dent and am taken to a

non-participating hospital?

A. In an emergency, youare covered for all neces-sary care administered byany provider. You, or amember of your family,must contact your PCP or Health Options after receipt of such emergencyservices and care toarrange for follow-up care.

Q. What happens if l have

an emergency?

A. Go to the nearest hospi-tal or call 911. Your BlueCarebenefits extend worldwidein an emergency. It isimportant for you, or amember of your family, tocontact your PCP or HealthOptions as soon as possibleafter receipt of emergencyservices and care, toarrange for follow-up care.If you receive a bill, send itto Health Options.

Q. What if l require the

services of a specialist

and/or consultant?

A. As a Health Optionsmember you have accessto specialists and/or consultants in every majorfield of medicine.

Q.What happens if

I have been seeing a

health care provider who

is not a Health Options

participant?

A. You will not be covered ifyou see a non-contractinghealth care provider withouta referral from your PCP.Health Options is associatedwith specialists and/or consultants in every majorfield of medicine. Your PCPwill arrange for your care to be continued with a specialist and/or a consult-ant, if necessary.

Q. What should l do if l

become ill in the middle

of the night?

A. Call your PCP and discuss the nature of yourcondition. Your PCP willthen advise you about when and where to seektreatment. In an emergency, call 911.

Q. If l have single member

coverage and marry

or have a child, may I

add a dependent to my

coverage?

A. Newly acquired depend-ents may be added withoutwaiting for open enrollment,provided application is madeaccording to the require-ments described. You must

add newly acquired depend-ents to your coverage within30 days or during the nextOpen Enrollment Period.Please see your MemberHandbook for completeinformation.

Q. May I convert to indi-

vidual coverage if l leave

my group employer?

A. If your coverage ends asa result of leaving the group,you may convert to individ-ual coverage without regardto health status within 63 days after receipt ofnotice of termination ofcoverage under the group.

Q. Will I have to fill out

forms for any insurance

and pay deductibles and

the customary fee for

office visits?

A. With Health Options,there are no claim forms to fill out or deductibles tomeet when you receivecare from your PCP. You may see your PCPwhenever necessary, butmay be required to make a copayment at the timeservices are rendered.

Q. What if I have a non-

medical question about

my coverage?

A. Call our CustomerService number on yourmembership card duringregular business hours.

Remember, care mustbe received from, or coordinated by, yourPrimary Care Physician.

Questions and Answers

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