For GroupsUnderstanding Your

Health Care Coverage

1

Contents

For Your Information

This brochure containshighlights 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

Complaint and Grievance Process 15

About Confidentiality 18

Coverage for You and Your Family 19

A Brief Description of Covered Services 20

Working to Control Health Care Costs 22

Members’ Rights and Responsibilities 24

Advance Directives 26

Terms to Understand 27

Questions and Answers 28

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.

2

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.

Health Options North andSouth has been accreditedby the National Committeefor Quality Assurance(NCQA), an independent,non-profit organizationlocated in Washington, DC,that assesses the quality of

managed care organizations.Health Options has receivedCommendable accreditationin its North GeographicBusiness Unit and has anExcellent status in its SouthGeographic Business Unit.NCQA evaluates how wella 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 50years, 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.

3

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?”

In recent years, HMOs havegrown increasingly popularbecause there are nodeductibles to satisfy andmembers are covered for awide range of health careservices with little or no out-of-pocket costs. Additionally,many HMOs put a specialemphasis on preventive care benefits for periodichealth assessments andimmunizations.

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.

4

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?

5

6

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 1-850-488-0595. 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 1-888-419-3456 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.

7

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.

7

8

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:

• 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.

• Make sure to have yourPCP provide or refer all yourmedical care. If you receivemedical care without goingthrough your PCP, you areresponsible for the costs ofany care provided except incase of emergency.

• Services rendered outsideof the service area, thataren’t an emergency, must

be 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.

9

When You Need to See a Specialist

If you need to see a specialist, call your PCP. Types of specialistsyou may be referred to include Cardiologists,Orthopedists,Obstetriciansand many others.

BlueCare covers office visits to your PCP and tospecialist offices with onlya small copayment. Pleaserefer to your MemberHandbook for detailed information about your benefits and copayments.

Please remember these

important TIPS:

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

• If additional services or visits are suggested by the specialist, you must first callyour PCP to get a referral.

• If you go to a specialist with-out a referral from your PCP,you are responsible for thecosts of any care provided.

When You Don’t Need

a Referral from Your PCP

A contracting provider is ahealth care provider whohas entered into a contractwith Health Options and ispart of the Health Optionsnetwork at the time you are

seen by that provider. Thereare certain contractingproviders that you can seewithout a referral from yourPCP. They are:

Chiropractors and

Podiatrists: You may visit a contracting Chiropractor or a Podiatrist, within theservice area, who is listed in your provider directorywithout being referred byyour PCP.

Dermatologists: You may visit a contractingDermatologist, within theservice area, for up to fivevisits per calendar year foroffice visits, minor proce-dures, and testing withoutbeing referred by your PCP.

Gynecologists: Womenmay visit a contractingGynecologist, within theservice area, for an annualroutine examination withoutbeing referred by their PCP.

Refer to your provider directory for a listing of contracting providers, or call Health Options.

Behavioral Health

Providers

Mental health and/or substance abuse treatmentmay be covered under yourBlueCare plan. Please refer

to your Member Handbookfor detailed information onany mental health and/orsubstance abuse treatmentcoverage you may have and whether these servicesmust be coordinated byyour PCP.

Getting a Second Opinion

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

• 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.

10

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 to youremergency condition mustbe coordinated by your (oryour family member’s) PCP.If follow-up care is not provided by or coordinatedby your PCP, coverage forthat care may be deniedand you may be responsiblefor the 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.

Handling an Emergency

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.

11

12

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 thecopayment or otheramount 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 Health

Options, you will need tosend 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.

13

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

14

Health Options has aComplaint and GrievanceProcess in place for you sothat any concerns you haveabout your health care coverage can be resolved.These concerns mayinvolve coverage, benefit,or payment decisions. Youmay also have concernsabout the quality of carethat you receive from acontracting provider. If youdo have a complaint orgrievance, you must followthe process that is outlinedin your Member Handbook.The information below is a summary of how thecomplaint and grievanceprocess outlined in yourMember Handbook works.

Verbal Complaints

If you have a verbal complaint, you may:

• call the Health OptionsCustomer Service area atthe telephone number thatis on your membershipcard, or

• go to your local HealthOptions office in person(the address is in yourMember Handbook underthe Complaint andGrievance section) to fileyour verbal complaint.

The Customer Service areawill review your verbal com-plaint with other HealthOptions staff if necessary.Your verbal complaint will be resolved within areasonable amount of time.

Written Grievances

If you don’t agree with ourresponse to your verbalcomplaint, you may file awritten grievance. Pleasecontact the Customer Ser-vice number listed on youridentification card to verifythe current mailing address.

1. Local Office Review

Standard Grievances—To file a written grievancewith your local HealthOptions office, please fillout a pink HOI GrievanceForm (form number 16297R1299 SR). You should havea copy of this form in yourmember package, or youmay get the form by callingthe Customer Service tele-

phone number on yourHealth Options membershipcard. If you don’t have aform, you may also write aletter telling Health Optionsabout the facts concerningyour grievance. If you needhelp, our Customer ServiceRepresentatives can assistyou in preparing the griev-ance. Hearing impairedmembers can contactHealth Options via TDD.Please be sure to includeas much detail as possibleabout your grievance. Send or take the letter toyour local Health Optionsoffice. (Addresses and telephone/TDD numbersare listed on page 17.)

We strive to resolve griev-ances in a timely manner.Although time frames varybetween circumstances,Health Options will resolveyour grievance within 30-60 working days ofreceipt, or within 90 work-ing days if the grievanceinvolves the collection of

information from outsidethe service area.

Adverse Determination

Grievances—HealthOptions sometimes deniescoverage and/or benefits for particular treatments,services, procedures orsupplies based on a lack of medical necessity.

When coverage is denied inthese instances, referred toas “adverse determination,”you or a provider acting on your behalf can requestfurther review of the deci-sion by the Health Options Internal Review Panel.Health Options promptlyand fairly considers andreviews all adverse determination grievances,which are governed by special rules.

15

Complaint and Grievance Process

16

Health Options’ Internal Review Panel, which reviewsadverse determinations, con-sists primarily of physicianswith appropriate expertise.

For your adverse determi-nation to be reviewed bythe Internal Review Panel,Health Options must receivethe review request within 30days from the date that youor your provider received adenial decision. To requestthis type of review, you oryour provider must send a request in writing with supporting documentationwithin the 30-day time limit.

If Health Options does notreceive your request forreview by the InternalReview Panel within 30days, the denial decisionwill be reviewed by thelocal Grievance Committeein accordance with thestandard grievance proce-dure. Normally, localGrievance Committeereview under the standardprocedure takes approxi-mately 30 working days.

For all other grievances youhave one year from thedate of your denied healthcare coverage to file.

2. Corporate Office Review

If you are not satisfied withthe decision of your HealthOptions local officeGrievance Committee, youmay appeal to our Board ofDirectors Grievance Com-mittee by sending a secondgrievance request in writingto the Health Options localoffice within 30 days of thelocal office decision. Just fillout the green HOI GrievanceAppeal Form (form number16298 R1299 SR). Youshould have a copy of thisform in your member pack-age, or you may get a copyof this form by calling theCustomer Service telephonenumber on your member-ship card. You may alsosend a detailed letter to theHealth Options local officeGrievance Coordinator.

The Health Options localoffice Grievance Coordinatorwill forward your grievanceto the Corporate Office inJacksonville, Florida. TheHealth Options Board ofDirectors GrievanceCommittee will review yourgrievance and give you ananswer in writing as quicklyas possible.

3. Statewide Provider

and Subscriber

Assistance Panel

If you are not satisfied with the second review ofyour grievance by theHealth Options corporateoffice, you may send your grievance in writing to theStatewide Provider andSubscriber AssistancePanel within 365 days ofreceiving the Health Optionscorporate office decision.However, you must com-plete the entire HealthOptions Complaint andGrievance process—andreceive a final dispositionfrom Health Options—before pursuing review bythe Statewide Provider andSubscriber Assistance Panel.

Send your grievance to the Statewide Provider and Subscriber AssistancePanel at the address listed below.

Statewide Provider &Subscriber Assistance Panel2727 Mahan Drive Bldg. 1, Room 339 Tallahassee, FL 32308

17

Grievance Telephone

Numbers and Addresses

If a grievance is notresolved, you may contactan agency at the telephonenumbers and addresseslisted below at any time.

Department of Insurance

Division of Insurance

Consumer Services

200 East Gaines StreetTallahassee, FL 32399-03221-800-342-2762

Agency for Health Care

Administration

Bureau of Managed Care

2727 Mahan DriveBldg. 1, Room 311Tallahassee, FL 323081-850-922-64811-800-226-1062

Statewide Provider &

Subscriber Assistance Panel

2727 Mahan DriveBldg. 1, Room 339Tallahassee, FL 323081-850-921-54581-800-226-1062

Health Options’ Local

Office Addresses and

Telephone Numbers

You may contact a HealthOptions Grievance Coord-inator at the Customer Ser-vice number listed on yourmembership card or thenumbers listed below.

Central Florida

Health Options, Inc.Attn: Grievance Department4904 Eisenhower BlvdSuite 200Tampa, FL 33634-63301-800-583-9072TDD 1-813-882-7681

South Florida

Health Options, Inc.Attn: Grievance Department8400 NW 33rd Street Suite 100Miami, FL 33122-19321-800-964-6595TDD 1-800-818-4521

North Florida

Health Options, Inc.Attn: Grievance Department4800 Deerwood Campus PkwyJacksonville, FL 32246-82731-800-734-6656TDD 1-800-955-1339

Expedited Review

of Urgent Grievances

You may request a recon-sideration of a denied serv-ice or benefit that you havenot yet received. If youbelieve your life, health, orability to regain maximumfunction could be seriouslythreatened if a service isnot received, you mayrequest a 72-hour review,called an expedited review.A provider acting on yourbehalf may also ask for anexpedited review.

You or a provider acting onyour behalf, must specifi-cally request an expeditedreview. For example, thisrequest may be made bysaying: “I want an expedit-ed review.”

Health Options will determine whether areview request meetscertain criteria before handling it as an expeditedreview. If the criteria aremet, Health Options willmake a decision within 72 hours after receipt ofthe request. If your requestdoes not meet the criteriafor an expedited grievance,you may have the denieddecision reviewed throughthe standard grievance procedure. A denial of pay-ment for services alreadyreceived does not qualifyfor an expedited review.

If you are not satisfied withHealth Options’ decision,you may send your griev-ance in writing to theStatewide Provider andSubscriber AssistancePanel, 2727 Mahan Drive,Bldg. 1, Room 339,Tallahassee, FL 32308.

Please refer to yourMember Handbook fordetailed information aboutthe Complaint andGrievance Process. If youneed help or informationafter you have reviewed theComplaint and GrievanceProcess, call the CustomerService number listed onyour Health Options mem-bership card.

18

About Confidentiality

You’ve entrusted us withyour health care coverage.It is important to us thatyou know and understandwe keep your records private as mandated by lawand Health Options’ (HOI)policy. We also require thatproviders contracting withHOI maintain the confiden-tiality of your medicalrecords held by them.

When you enrolled withus, you agreed to letproviders give us the infor-mation we need to makecoverage and benefits decisions for you. The information we need fromyour providers includes thediagnosis and history of your health care. Ourcontracts with providersrequire them to complywith confidentiality laws.

When you applied for coverage, you also author-ized us to share records ofyour health when neededto administer your coverage.

We may share your records with:

• medical reviewers and consultants

• a utilization review board or entity

• any other health benefitplan with which you have coverage

• any other insurance company with which youhave coverage

We respect your privacy,and have policies and procedures designed tosafeguard confidential information we receivefrom providers.

If you’d like a summary ofour policy and procedures,feel free to call us at thetoll-free Customer Servicenumber on your member-ship card.

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. Any other exams or careyou may need will be coordinated by your PCP.

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 to

reduce the potential forexpensive neonatal carethat results from manyproblem pregnancies.Healthy Addition helps morewomen deliver healthybabies with fewer prob-lems and complications.

For information aboutHealthy Addition, call 1-800-955-7635 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 coordinate all of 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 PCPwill 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

19

20

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. All other ambulance or trans-portation services must beauthorized by Health Optionsor ordered by your PCP.

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 service that has notbeen authorized by themember’s PCP, except incases of emergency asdescribed previously

A Brief Description of Covered Services

21

• 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 investi-gational treatment

22

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 you

recover 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 isnot required) to offer alter-native benefits or paymentfor cost-effective healthcare services. These alter-native benefits or paymentsmay be made available byHealth Options on a case-by-case basis if you meetHealth Options’ case man-agement program criteriathen in effect. Such alterna-tive benefits or payments,if any, will be made availablein accordance with a treat-

ment plan with which you,or someone representingyou who is acceptable toHealth Options, and yourdoctor agree to in writing.The fact that HealthOptions offers to provideany alternative benefits or payments under this program to you does notmean that Health Optionsis obligated to continue to provide such benefits or payments or to providethem to you or anotherperson in the future. Fordetailed information, pleaserefer to your MemberHandbook, its terms prevail.

23

24

Members’ Rights and Responsibilities

You Have the Right:

1. To be given informationabout Health Options, itscoverage and benefits,contracting providers and practitioners, andmembers’ rights andresponsibilities.

2.To get health care fromproviders who meet Blue Cross and Blue Shieldof Florida and HealthOptions’ credentialingstandards and who con-tract with Health Options.

3.To participate in majordecisions about yourhealth care with yourproviders.

4.To have a frank discussionwith your provider aboutthe best treatment optionsfor you no matter whatthe cost of the treatment oryour benefit coverage.

5.To be treated with courtesy, respect, andconcern for your dignityand privacy by providersand other patients.

6.To appeal unfavorablemedical or administrativedecisions by followingestablished appeal orgrievance procedures.

7. To refuse treatment if you choose to accept the responsibility andconsequences of such a decision.

8.To have access to yourmedical records.

9.To call or write to us any time with helpfulcomments, questionsand observations whetherconcerning somethingyou like about our plan orsomething you feel is aproblem area. Please callthe number or write tous at the address on your membership card.

You Have the

Responsibility:

1. To follow the coverageaccess rules in yourMember Handbook.

2.To seek all non-emergencycare through your PCP.

3.To get referrals for spe-cialist care from your PCP.

4. To understand and followinstructions for yourtreatment and ask yourPCP questions if youdon’t understand.

5. To give accurate andcomplete informationabout your health problems and medicalhistory and to answer all questions truthfullyand completely.

6. To pay copayments to your provider at the time of service.

7. To follow applicable com-plaint and/or grievanceprocedures when youdisagree with HealthOptions’ decisions.

8. To respect the rights,property, comfort, environment, and privacy of other patients.

9. To ask for your medicalrecords according toapplicable law and Health Options’ rules.

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 meeteach of the full-timeemployee requirements

• You leave yourpresent employer

• Your employer no longeroffers Health Options’health care coverage

• Premiums or copaymentsare not paid

• You move away fromthe Health Optionsservice area

• You knowinglycommit fraud, make a misrepresentation, orgive false information

• You are disruptive, unruly,abusive, or uncooperative

• You willfully misuse yourmembership card

Please refer to yourMember Handbook fordetailed information.

25

You May Choose to

Continue Coverage

Under COBRA

If you lose your health carecoverage, you may be ableto continue coverage underthe Consolidated OmnibusBudget Reconciliation Actof 1985 (COBRA). There are certain events thatqualify a person to continuecoverage under COBRA. If a person qualifies, thenhe or she must choosecontinuation of their groupcoverage under COBRAwithin 60 days of the dateof the qualifying event. Youremployer is responsible for giving you informationabout COBRA.

Please refer to yourMember Handbook fordetailed information aboutevents that qualify a personfor coverage under COBRA.

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 to

qualify for the individualplan, and family membersthat qualify may get cover-age on the same basis.

Health Options offers two conversion options.Conversion Option A coversmedical, hospital, and other health care services.Conversion Option B coversother benefits such as prescription drugs.

To apply for continuouscoverage, we must receiveyour application and anyrequired premium within 63 days after your group membership ends. You maycall Health Options to getforms if you need to applyfor a conversion option.

26

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

27

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

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

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.

Coverage Access Rules

are rules for getting healthcare coverage and benefitsthrough Health Options.They explain the role ofHealth Options and thePCP, how to get specialtycare, and what to do ifemergency services andcare are needed. Pleaserefer to your MemberHandbook for details on the coverage access rules.

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

Experimental orInvestigational generallymeans any service or pro-cedure that has not, in theopinion of Health Options,been proven to be safe and effective.

Medically Necessary orMedical Necessity meansthat for coverage and pay-ment purposes, a medicalservice or supply is, in theopinion of Health Options,required for the identifica-tion, treatment, or manage-ment of a Condition.

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 Health Optionsto act as a Primary CarePhysician and who generallycoordinates or directly provides most of your medical care. Your PCPmust participate withHealth Options as a PCP.

Service Area is thegeographic area describedin your Member Handbook.

Terms to Understand

28

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, throughreferral by your PCP.

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 mustadd 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

19713-0901R SR