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Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely,    Kay Coles James    Director

2
M-CARE HMO Health Plan
M-CARE 2003 www. mcare. org
A Health Maintenance Organization
Serving: Mid and Southeastern Michigan
Enrollment in this Plan is limited. You must live in our Geographic service area to enroll. See page 7 for requirements.

Enrollment code:
EG1 Self Only
EG2 Self and Family

RI 73-445

For changes
in benefits,
see page 8.

This Plan has an Excellent accreditation
from the NCQA. See the 2003 Guide for
more information on NCQA.

Authorized for distribution by the:
United States
Office of Personnel Management

Retirement and Insurance Service
http:// www. opm. gov/ insure 1.
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2.
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2003 M-CARE
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:

For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:

See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical

information. 3.
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2003 M-CARE
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized
OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
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2003M-Care 2 Table of Contents
Table of Contents
Introduction........................................................................................................................................................................................ 4
Plain Language....................................................................................................................................................................................... 4
Stop Health Care Fraud! ........................................................................................................................................................................ 5
Section 1. Facts about this HMO plan................................................................................................................................................... 6
How we pay providers ......................................................................................................................................................... 6
Your Rights .......................................................................................................................................................................... 6
Service Area......................................................................................................................................................................... 7
Section 2. How we change for 2003 ..................................................................................................................................................... 8
Program-wide changes ......................................................................................................................................................... 8
Changes to this Plan ............................................................................................................................................................. 8
Section 3. How you get care ................................................................................................................................................................ 9
Identification cards............................................................................................................................................................... 9
Where you get covered care ................................................................................................................................................. 9

Plan providers ................................................................................................................................................................ 9
Plan facilities ................................................................................................................................................................. 9
What you must do to get covered care ................................................................................................................................. 9

Primary care................................................................................................................................................................... 9
Specialty care................................................................................................................................................................. 9
Hospital care ................................................................................................................................................................ 10
Circumstances beyond our control ..................................................................................................................................... 11
Services requiring our prior approval................................................................................................................................. 11
Section 4. Your costs for covered services.......................................................................................................................................... 12

Copayments ................................................................................................................................................................. 12
Deductible.................................................................................................................................................................... 12
Coinsurance ................................................................................................................................................................. 12
Your catastrophic protection out-of-pocket maximum ...................................................................................................... 12
Section 5. Benefits .............................................................................................................................................................................. 13
Overview............................................................................................................................................................................ 13
(a) Medical services and supplies provided by physicians and other health care professionals ................................... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals................................ 25
(c) Services provided by a hospital or other facility, and ambulance services.............................................................. 29
(d) Emergency services/ accidents ................................................................................................................................. 31
(e) Mental health and substance abuse benefits ............................................................................................................ 33
(f) Prescription drug benefits........................................................................................................................................ 35 5.
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2003M-Care 3 Table of Contents
(g) Special features ....................................................................................................................................................... 37
Flexible benefits option
Services for the deaf and hearing impaired
Health Management Program
(h) Dental benefits......................................................................................................................................................... 38
(i) Non-FEHB benefits available to Plan members ..................................................................................................... 39
Section 6. General exclusions --things we don't cover....................................................................................................................... 40
Section 7. Filing a claim for covered services..................................................................................................................................... 41
Section 8. The disputed claims process............................................................................................................................................... 42
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 44
When you have other health coverage. 44
What is Medicare........................................................................................................................................................ 44
Medicare managed care plan ...................................................................................................................................... 47
TRICARE and CHAMPVA.. 48
Worker's Compensation 48
Medicaid 48
Other Government Agencies...................................................................................................................................... 48
When others are responsible for injuries ..................................................................................................................... 48
Section 10. Definitions of terms we use in this brochure..................................................................................................................... 49
Section 11. FEHB facts ....................................................................................................................................................................... 51
Coverage information....................................................................................................................................................... 51
No pre-existing condition limitation ........................................................................................................................ 51
Where you get information about enrolling in the FEHB Program.......................................................................... 51
Types of coverage available for you and your family .............................................................................................. 51
Children's Equity Act............................................................................................................................................... 51
When benefits and premiums start ........................................................................................................................... 52
When you retire........................................................................................................................................................ 52
When you lose benefits .................................................................................................................................................... 52

When FEHB coverage ends ..................................................................................................................................... 52
Spouse equity coverage........................................................................................................................................... 52
Temporary Continuation of Coverage (TCC) ......................................................................................................... 52
Converting to individual coverage .......................................................................................................................... 53
Getting a Certificate of Group Health Plan Coverage ............................................................................................. 53
Long term care insurance is still available ............................................................................................................................................ 54
Index ..................................................................................................................................................................................................... 55
Summary of benefits ............................................................................................................................................................................. 56
Rates........................................................................................................................................................................................ Back cover 6.
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2003 M-CARE 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of M-CARE under our contract CS 2341 with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for M-CARE's administrative offices is:

M-CARE
2301 Commonwealth Boulevard
Ann Arbor, MI 48105

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is you responsibility to be informed about your health benefits

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we"
means M-CARE.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel
Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2003 M-CARE 5 Stop Health Care Fraud!
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of
the agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:

Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at (800) 658-8878 and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

CALL --THE HEALTH CARE FRAUD HOTLINE
202-418-3300

OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 8.
8 Page 9 10
2003 M-CARE 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. The Plan is soley responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent provider directory.

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

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

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

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

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

M-CARE is licensed by the State of Michigan to operate as an HMO and has been in existence since 1986.
M-CARE is a non-profit organization.
M-CARE's Commercial HMO has an Excellent accreditation from the NCQA.
If you want more information about us, call (800) 658-8878, TDD (800) 649-3777, or write to M-CARE, Customer Service, 2301
Commonwealth Boulevard, Ann Arbor MI 48105. You may also contact us by fax at (734) 332-2027 or visit our website at
www. mcare. org. 9.
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2003 M-CARE 7 Section 1
Service Area
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is:
The entire Michigan counties of:

Clinton, Eaton, Genesee, Ingham, Livingston, Macomb, Oakland, Shiawassee, Washtenaw, and Wayne.
And portions of the following counties:

Jackson: Jackson City, Parma Village, Blackman, Columbia, Grass Lake, Henrietta, Leoni, Liberty, Napoleon, Norvell, Parma, Rivers,
Sandstone, Spring Arbor, Springport, Summit, Tompkins, and Waterloo Townships.

Lapeer: Almont, Arcadia, Attica, Deerfield, Dryden, Elba, Hadley, Imlay, Lapeer, Marathon, Mayfield, Metamora, Oregon, Rich
Townships, Lapeer City, and Imlay Village.

Monroe: Ash, Berlin, Frenchtown, London, and Milan Townships.

St. Clair: Berlin and Ira Townships.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our Service Area, we will pay
only for emergency care benefits. We will not pay for any other health care services out of our Service Area unless the services have
prior plan approval.

If you or a covered family member move outside of our Service Area, you can enroll in another plan. If your dependents live out of
the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an
HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season
to change plans. Contact your employing or retirement office. 10.
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2003 M-CARE 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002

Changes to this Plan
Your share of the non-Postal premium will increase by 17.4% for Self Only or 17.4% for Self and Family.
The copay for durable medical equipment and prosthetic & orthopedic items will increase from zero to 50% coinsurance per item. (Section 5 (a))

Under the Emergency Benefits, the hospital emergency room copay will increase from $25 to $50 and the urgent care center copay will increase from $10 to $20. (Section 5 (d))
The prescription drug copays have changed to $10 generic, $20 preferred brand-name, and $30 non-preferred brand-name drugs for up to a 34-day supply of covered medication. Previously, members paid $5 for generic drugs and $10 for brand-name drugs.
(Section 5 (f))
The copay for M-CARE approved maintenance drugs will be $20 generic, $40 preferred brand-name, and $60 non-preferred brand-name maintenance drugs per 90-day supply. (Section 5( f))

We cover prescription drugs for the purpose of weight loss with a 50% copay for members who qualify under M-CARE's morbid obesity treatment plan. (Section 5 (f)) 11.
11 Page 12 13
2003 M-CARE 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at (800) 658-8878.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. Our M-CARE provider
network recruitment process is a very selective process. Our physician screening and
credentialing is rigorous and comprehensive. For credentialing, we verify state licensure,
hospital privileges, board certification, and whether there is adequate malpractice
coverage.

We list Plan providers in the provider directory, which we update periodically. The list is
also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our website.
It depends on the type of care you need. First, you and each family member must choose
a primary care physician. This decision is important since your primary care physician
provides or arranges for most of your health care. You must choose a primary care
physician from the primary care physicians listed in the M-CARE Provider Directory.
You can select a primary care physician from M-CARE's Provider Directory or by
calling us at (800) 658-8878 for help with choosing or changing your primary care
physician.

Primary care Your primary care physician can be a family practitioner, internist, or pediatrician. Your primary care physician will provide most of your health care, or give you a referral
to see a specialist. If you have not chosen a M-CARE pediatrician to be your child's PCP
and want to take your child to a M-CARE pediatrician for routine services, you can
without a referral. M-CARE may assign that pediatrician to be your child's PCP.

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

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, a female member may see her
M-CARE OB/ GYN for routine services, without referral.

What you must do
to get covered care 12.
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2003 M-CARE 10 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with us and plan specialists
to develop a treatment plan that allows you to see your specialist for a certain number
of visits without additional referrals. Your primary care physician will use our criteria
when creating your treatment plan (the physician may have to get an authorization or
approval beforehand).

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

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at (800) 658-8878. If you are new to the FEHB
Program, we will arrange for you to receive care.

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

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 13.
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2003 M-CARE 11 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.

Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally-accepted
medical practice.

We call this review and approval process pre-authorization. Your physician must obtain
pre-authorization for the following services:

All non-emergency inpatient hospitalization
Outpatient/ ambulatory surgery
Skilled nursing facility admissions
Home health care services
Hospice
Durable medical equipment
Orthopedic and prosthetic devices
Selected medications

Our pre-authorization process is as follows:

Your primary care physician determines a need for an elective admission or other medically necessary service that requires pre-authorization.
Your primary care physician contacts M-CARE's Authorization Department.
Your primary care physician, or specialist with the primary care physician's approval, notifies a participating hospital or facility of the need for this

procedure.
If there are any questions related to admission, care setting, benefit, coverage, or medical necessity, M-CARE's Utilization Management Department will contact

your primary care physician or treating physician directly.

You are responsible for obtaining authorization for mental health and substance
abuse services from the Central Diagnostic and Referral (CDR) unit assigned to you before seeking treatment. Your CDR authorizes and coordinates all of your mental

health and substance abuse care. Simply call the CDR phone number that is listed on the
front of your M-CARE identification card. You do not need a referral from your primary
care physician. M-CARE will not cover unauthorized care. If you need additional
information or the phone number of your CDR, please call M-CARE Customer Service.

Services requiring our
prior approval 14.
14 Page 15 16
2003 M-CARE 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per
office visit.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care. For example, you pay 50% of the allowable charges for durable medical equipment.

After your copayments total $4, 000 per person or $8, 000 per family enrollment in any
calendar year, you do not have to pay any more for covered services. However,
copayments for prescription drugs do not count toward your out-of-pocket maximum,
and you must continue to pay copayments for them.

Be sure to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum.

Your catastrophic procection out-of-pocket maximum for
deductibles, coinsurance, and
copayments 15.
15 Page 16 17
2003 M-CARE 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and page 56 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning
of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits, contact us at (800) 658-8878 or at our website at
www. mcare. org.

(a) Medical services and supplies provided by physicians and other health care professionals........................................................ 14-24
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies

Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................................ 25-28

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

(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 29-30

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

(d) Emergency services/ accidents.................................................................................................................................................. 31-32
Medical emergency Ambulance

(e) Mental health and substance abuse benefits............................................................................................................................. 33-34
(f) Prescription drug benefits ........................................................................................................................................................ 35-37
(g) Special features ............................................................................................................................................................................. 37
Flexible benefits option

Services for the deaf and hearing impaired
Health management program
(h) Dental benefits ............................................................................................................................................................................. 38
(i) Non-FEHB benefits available to Plan members .......................................................................................................................... 39
Summary of benefits ............................................................................................................................................................................ 56 16.
16 Page 17 18
2003 M-CARE 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office

Office medical consultations
Second surgical opinion

$10 per office visit

Professional services of physicians
During a hospital stay

In an urgent care center
In a skilled nursing facility

Nothing

At home
Note: We cover house calls within the service area if your doctor
determines that such care is necessary and appropriate.

$10 per house call

Diagnostic and treatment services --continued on next page 17.
17 Page 18 19
2003 M-CARE 15 Section 5( a)
Diagnostic and treatment services (continued) You pay
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these services
during your office visit; otherwise, $10 per
office visit

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including

. Fecal occult blood test
. Sigmoidoscopy, screening every five years starting at age 50
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older

$10 per office visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$10 per office visit

Preventive Care -Adult --continued on next page 18.
18 Page 19 20
2003 M-CARE 16 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram covered as follows:
From age 35 through 39, one during this five-year period
From age 40-64, one every calendar year
At age 65 and older, one every two consecutive calendar years

$10 per office visit

Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, travel, or to obtain
a marriage license.

All charges

Routine immunizations such as:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine-annually, age 50 and over
Pneumococcal vaccines-annually, age 65 and over

$10 per office visit

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

Well-child care charges for routine examinations, immunizations and care
Examinations, such as:
. Eye exams through age 17 to determine the need for vision correction.

. Ear exams through age 17 to determine the need for hearing correction
. Examinations done on the day of immunizations

Nothing for well-child care visits through
age 6

$10 per office visit after age 6 19.
19 Page 20 21
2003 M-CARE 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

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

Surgery benefits (Section 5b).
We cover one routine ultrasound per low-risk pregnancy.

Nothing

Not covered: Multiple sonograms to determine fetal age, size or sex. All charges.
Family planning
A broad range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Genetic counseling
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization. All charges 20.
20 Page 21 22
2003 M-CARE 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
. intravaginal insemination (IVI)
. intracervical insemination (ICI)
. intrauterine insemination (IUI)

$10 per office visit

Fertility drugs
Note: We typically cover injectable fertility drugs under medical benefits
and oral fertility drugs under the prescription drug benefit. However,
there are some self-injected infertility drugs covered under the
prescription drug benefit.

50% copay per prescription unit or refill for
fertility drugs to induce ovulation

Not covered:
Assisted reproductive technology (ART) procedures, such as:
. in vitro fertilization
. embryo transfer, gamete GIFT and zygote ZIFT
. Zygote transfer

Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment
Allergy injection

$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization.
All charges 21.
21 Page 22 23
2003 M-CARE 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 27.

Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we pre-authorize the treatment
and it is documented that the member has a growth hormone deficiency.
Call (800) 658-8878 for prior authorization. We cover GHT under the
plan's prescription drug benefit. See Services requiring our prior
approval in Section 3.

Nothing if you receive these treatments
during your visit; otherwise, $10 copay
per office visit

Physical and occupational therapies
60 visits per condition per calendar year for the services of each of the following:
. qualified physical therapists, and
. occupational therapists Note: We only cover therapy to restore bodily function when there has

been a total or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or
a myocardial infarction is provided for up to six consecutive weeks.

Nothing

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges 22.
22 Page 23 24
2003 M-CARE 20 Section 5( a)
Speech therapy You pay
20 visits per condition per calendar year for medically necessary speech therapy services with qualified speech pathologists. Nothing.

Not covered:
Evaluations and treatments covered in a school program or public agency.
Foreign accent reduction or English as a second language spoken at home.
Maintenance therapy, i. e., treatment that does not require the use of a qualified speech therapist to perform.
Treatment for disorders that are self-correcting as determined by the member's PCP/ specialist and speech therapist.

All charges

Hearing services (testing, treatment, and supplies)
Hearing testing $10 per office visit

Not covered:
All other hearing testing
Hearing aids and hearing aid evaluations

All charges.

Vision services (testing, treatment, and supplies)
In addition to the medical and surgical benefits provided for the
diagnosis and treatment of diseases of the eye, we cover an annual
refraction (to provide a written lens prescription) by a plan provider.

Nothing

Not covered:
Eyeglasses or contact lenses (except immediately following cataract surgery)

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges 23.
23 Page 24 25
2003 M-CARE 21 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

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

$10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above.
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open-cutting surgery).

All charges

Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant

following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See 5( b)
for coverage of the surgery to insert the device.

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

Limited to one per member per lifetime.

50% coinsurance per item

Externally-worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
Note: Your plan physician must write the prescription and we must
authorize the equipment. We base our decision on medical necessity.
You must obtain authorized equipment from a plan contracted provider. We reserve the right to require use of the least costly

medically-effective device.

Nothing

Orthopedic and prosthetic devices -Continued on next page 24.
24 Page 25 26
2003 M-CARE 22 Section 5( a)
Orthopedic and prosthetic devices (continued) You pay
Not covered:
Orthopedic and corrective shoes,
Arch supports
Foot orthotics
Heel pads and heel cups
Wigs, prosthetic hair, or hair transplants
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than three years after the last one we covered

All charges

Durable medical equipment (DME)
We cover rental or purchase, at our option, including repair and
adjustment, of durable medical equipment prescribed by your Plan
physician, such as oxygen and dialysis equipment. Under this benefit, we
also cover:

Hospital beds;
Wheelchairs; {the type depends on your illness);
Crutches;
Walkers

50% coinsurance per item

Blood glucose monitors;
Insulin pumps;
Diabetic supplies including glucose test tablets and test tape,
Benedict's solution or equivalent, and acetone test tablets
Note: Your plan physician must write the prescription and we must
authorize the equipment. We base our decision on medical necessity.
You must obtain authorized equipment from a plan contracted DME provider. We reserve the right to require use of the least costly

medically-effective device.

Nothing

Not covered:
Over-the-counter medical supplies such as gauze, bandages, tape, and dressings

Over-the-counter or custom-fitted braces
Bathroom items
Athletic or exercise equipment
Personal convenience items
Air conditioner, humidifiers, etc.

All charges 25.
25 Page 26 27
2003 M-CARE 23 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.

$5 per home health visit

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

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.

All charges

Chiropractic
No benefit. All charges 26.
26 Page 27 28
2003 M-CARE 24 Section 5( a)
Alternative treatments You pay
No Benefit. We do not cover services such as:
Naturopathic services
Hypnotherapy
Biofeedback
Acupuncture

All charges

Educational classes and programs
Coverage is limited to:

Health education classes including childbirth preparation, breastfeeding nutrition, CPR, first aid, and smoking cessation classes
are limited to one per category per calendar year. Classes must be
provided at a plan provider.

Free access to the University of Michigan Health System's Health Education Resource Center to borrow a variety of health-related
videos, audiotapes, and books.

Asthma, heart failure, and diabetes management programs.
A limited number of visits for nutritional counseling provided by a registered dietician are covered when ordered by the member's PCP
for the following medical diagnoses:

. Hyperlipidemia, Hypertension, Heart Failure, and Previously diagnosed diabetes (four visits per year);

. Newly diagnosed diabetes (six visits the first year following diagnosis);
. Gestational diabetes (four visits per pregnancy).

Nothing 27.
27 Page 28 29
2003 M-CARE 25 Section 5( b)
Surgical procedures continued on next page.

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

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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

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

surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure

which services require precertification and identify which surgeries require precertification.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal weight

according to current underwriting standards; eligible members must
be age 18 or over

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

$10 per office visit or nothing if performed
in a hospital 28.
28 Page 29 30
2003 M-CARE 26 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit or nothing if performed
in a hospital

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

All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

. The condition produced a major effect on the member's appearance and

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

$10 per office visit or nothing if performed
in a hospital

All stages of breast reconstruction surgery following a mastectomy, such as:
. Surgery to produce a symmetrical appearance on the other breast;
. Treatment of any physical complications, such as lymphedemas;
. Breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

$10 per office visit or nothing if performed
in a hospital

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges 29.
29 Page 30 31
2003 M-CARE 27 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and

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

$10 per office visit or nothing if performed
in a hospital

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival, and alveolar bone)

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach,

and pancreas

Note: The Plan's providers participate with the United Network Organ
Sharing (UNOS) and the National Marrow Donor Program.

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

Nothing 30.
30 Page 31 32
2003 M-CARE 28 Section 5( b)
Organ/ tissue transplants (continued) You pay
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered
Travel and lodging expenses

All charges

Anesthesia
Professional services provided in
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Physician's office

Nothing 31.
31 Page 32 33
2003 M-CARE 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge

(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
Semi-private, or intensive care accommodations;
General nursing care; and
Meals and special diets

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

Nothing

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

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

Private nursing care

All charges 32.
32 Page 33 34
2003 M-CARE 30 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

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

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
We cover up to 100 days of skilled nursing facility care per calendar
year when full-time skilled nursing care is medically necessary and
arranged and authorized by M-CARE. All necessary services are
covered, including:

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

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care
Personal comfort items, such as telephone and television

All charges

Hospice care
We cover supportive and palliative care for a terminally ill member in
the home or a hospice facility. Services include inpatient and outpatient
care, and family counseling. All services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less. Hospice services must be arranged and authorized by M-CARE.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate. Non-emergent ambulance service must be pre-authorized by
M-CARE

Nothing 33.
33 Page 34 35
2003 M-CARE 31 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

What to do in case of emergency:
Emergencies within or outside of our service area:
If you consider your condition to be so serious or life-threatening that delay might cause death, severe injury, or serious
impairment, you should call 911 or seek help from the nearest medical facility as soon as possible.

If possible, we also recommend that you attempt to contact your PCP for medical advice. If you are unable to reach your
PCP, you may contact the M-CARE After Hours Line for assistance at (800) 658-8878, extension 6. We strongly
recommend that you contact your PCP within 48 hours after seeking emergency services (or as soon as possible if
circumstances make 48 hours impossible) to arrange for follow-up medical care. Your PCP must arrange all of your follow-up
care after an emergency in order for us to cover it. 34.
34 Page 35 36
2003 M-CARE 32 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care as an outpatient at a hospital, including doctors' services $50 per emergency room visit
Note: We waive the copay if you area
admitted to the hospital

Emergency care at an urgent care center $20 per visit

Emergency care at a doctor's office $10 per visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care as an outpatient at a hospital, including doctors' services $50 per emergency room visit
Note: We waive the copay if you are
admitted to the hospital

Emergency care at an urgent care center $20 per visit

Emergency care at a doctor's office $10 per visit
Not covered:

Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

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

All charges

Ambulance
Professional ambulance service when medically appropriate. Air ambulance service is also covered when medically appropriate.

See 5( c) for non-emergency service.

Nothing

Not covered: Ambulance transportation for care that was not
necessitated by a need for emergency services.
All charges 35.
35 Page 36 37
2003 M-CARE 33 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
YOU MUST GET PRE-AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

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

Your cost-sharing responsibilities are no
greater than for other illness or conditions

Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

$10 per visit

Mental health and substance abuse benefits --continued on next page 36.
36 Page 37 38
2003 M-CARE 34 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests Nothing if you receive these services
during your office visit; otherwise, $10
per office visit

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

Nothing

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

All charges

Pre-authorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
Before seeking treatment, you must call the phone number of the Central Diagnostic
and Referral (CDR) unit listed on the front of your M-CARE identification card. Your
CDR authorizes and coordinates all of your mental health and substance abuse care.
You do not need a referral from your PCP. M-CARE will not cover unauthorized
care. You may also call M-CARE Customer Service for information and the phone
number of your CDR.

Limitation We may limit you benefits if you do not obtain a treatment plan. 37.
37 Page 38 39
2003 M-CARE 35 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

We do not have a calendar year deductible.
Certain drugs require our prior authorization.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

I M
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There are important features you should be aware of. These include:
Who can write your prescription. A plan contracted physician must write the prescription.

Where you can obtain them. M-CARE contracts with a network of pharmacies that includes most large chains and independent pharmacies operating nationwide. If you need help in locating a contracted pharmacy, please
call M-CARE Customer Service at (800) 658-8878.

We use a formulary. We have a preferred list of cost-effective drugs. We encourage Plan physicians to prescribe medications listed in the therapeutic selection guide but we do not require it. We have an "open" or
"voluntary" prescription drug formulary because we cover non-formulary drugs when your doctor prescribes
them.

Our doctors prescribe from that list as appropriate for your condition. When your doctor prescribes a drug that is
not on the preferred list, your pharmacist may contact your doctor to check whether a preferred drug is right for
you. To view M-CARE's list of preferred drugs, visit www. mcare. org, or call M-CARE Customer Service at
(800) 658-8878 for more information.

These are the dispensing limitations. Plan pharmacies dispense prescription drugs for up to a 34-day supply or one commercially prepared unit such as one inhaler, one vial ophthalmic medication or one vial of insulin.

Generally, the Plan pharmacy will dispense a generic drug that meets the equivalency standards of the Food and
Drug Administration. If you request a name brand drug when a generic drug is available, you must pay the price
difference between the name brand and generic drug, unless your doctor writes "Dispense as Written" on the
prescription. Additionally, M-CARE retains the right to place prior authorization requirements or a maximum
supply limit on certain prescriptions.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They contain the same active ingredients and must be equivalent in strength and
dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U. S.
Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand-name drugs. To maximize your prescription drug benefit and avoid
paying any cost difference, ask your prescribing physician to help you decide whether a generic alternative is
available and appropriate for you.

When you have to file a claim. If you are a new member of M-CARE and have not yet received your M-CARE identification card, you may be asked to pay for your prescriptions until you get your card. You can request a
prescription drug claim form by calling M-CARE Customer Service at (800) 658-8878. Customer Service will
then send you the appropriate claim form and provide instructions on submitting the form and receipt for
reimbursement. 38.
38 Page 39 40
2003 M-CARE 36 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those
listed as Not covered

Disposable needles and syringes for the administration of covered medications other than insulin

Contraceptive drugs and devices
Smoking cessation drugs and medications, including nicotine patches

$10 per generic prescription unit or refill
$20 per preferred brand-name prescription
unit or refill.

$30 per non-preferred brand-name
prescription unit or refill

Note: If there is no generic equivalent
available, you will still have to pay the
brand-name copay

Drugs for sexual dysfunction have dispensing limitations (contact M-CARE for details), and require prior authorization for males
under the age of 35.

50% copay per prescription unit (six pills
per month) or refill for generic or brand-name
drugs

Insulin and disposable needles and syringes used for its injection. Nothing

Fertility drugs to induce ovulation
Drugs used for the purpose of weight loss for those members who qualify under M-CARE's morbid obesity treatment plan

50% copay per prescription unit or refill
50% copay per presription unit or refill

Maintenance drugs
Note: You may receive up to a 90-day or 100 unit supply (whichever is
greater) of M-CARE approved maintenance drugs. Please contact us if
you would like a copy of M-CARE's maintenance drug list.

$20 for generic maintenance drugs
$40 for brand-name maintenance drugs
$60 for non-formulary brand-name drugs

Covered medications and supplies --continued on next page 39.
39 Page 40 41
2003 M-CARE 37 Section 5( g)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs used for the purpose of weight loss (unless you qualify for our morbid obesity plan)

Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients, food and liquid supplements, and infant formula even if a physician prescribes or administers them
Nonprescription medicines
Medical supplies such as dressing and antiseptics

All charges

Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

Services for deaf and hearing impaired Hearing impaired members may contact M-CARE at (800) 649-3777 TDD.

Health management program M-CARE's Lifelong Health Management Program includes the following programs for you at no charge: member newsletter, health survey, health
management programs, and personal health risk assessments. You may call
(888) 448-3865 or email lifelong@ mcare. med. umich. edu. for more information. 40.
40 Page 41 42
2003 M-CARE 38 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan providers must provide or arrange your care.
We do not have a calendar year deductible.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is

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

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound, natural teeth. The need for these services must
result from an accidental injury. We do not cover injuries to the teeth
caused by chewing.

Nothing

Dental benefits
We have no other dental benefits. 41.
41 Page 42 43
2003 M-CARE 39 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

Lifelong Health Management Program
As part of M-CARE's Lifelong Health Management Program, M-CARE offers health education classes to all of its
members. M-CARE pays 100% of the fee for approved classes in the following categories: Childbirth preparation,
CPR, first aid, and smoking cessation. Classes are limited to one per category per year. If you would like more
information on these classes, or would like a class listing, please contact M-CARE's Lifelong Health Management
Program at (888) 448-3865 or via email at lifelong@ mcare. med. umich. edu. 42.
42 Page 43 44
2003 M-CARE 40 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.

We do not cover the following:

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

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service. 43.
43 Page 44 45
2003 M-CARE 41 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

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

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at (800) 658-8878.
When you must file a claim --such as for services you receive outside of the Plan's
service area --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: M-CARE Customer Service Department, 2301 Commonwealth
Boulevard, Ann Arbor, MI 48105-2945.

Prescription drugs If you are a new member of M-CARE and have not yet received your M-CARE identification card, you may be asked to pay for your prescriptions until you get your
card. You can request a prescription drug claim form by calling M-CARE Customer
Service at (800) 658-8878. Customer Service will then send you the appropriate claim
form and provide instructions on submitting the form and receipt for reimbursement.

Submit your claims to: M-CARE Customer Service Department, 2301 Commonwealth
Boulevard, Ann Arbor, MI 48105-2945.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 44.
44 Page 45 46
2003 M-CARE 42 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies including a request for pre-authorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within six months from the date of our decision; and
(b) Send your request to us at: M-CARE Member Appeals Coordinator, 2301 Commonwealth Boulevard, Ann Arbor, MI
48105-2945; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this
brochure; and

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

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request go to
step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We
will base our decision on the information we already have.
We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, 1900 E Street, NW,
Washington, DC 20415-3630. 45.
45 Page 46 47
2003 M-CARE 43 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must include a copy of your specific written consent with the review request.

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

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against
OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline that may not
be extended.

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

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

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

(a) We haven't responded yet to your initial request for care or pre-authorization/ prior approval, then call us at (800) 658-8878
and we will expedite our review; or

(b) We denied your initial request for care or pre-authorization/ prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment, too, or

You can call OPM's Health Benefits Contracts Division 3 at (202) 606-0755 between 8 a. m. and 5 p. m. eastern time. 46.
46 Page 47 48
2003 M-CARE 44 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary
plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance. We will apply any copayments or limitations on your
M-CARE coverage. We must receive the primary carrier's Explanation of Payment with
the claim so that we can determine your M-CARE benefits.

When an M-CARE member receives treatment for injuries during a motor vehicle
accident, we need a statement that tells us the type of medical coverage that the injured
member carries on the automobile insurance. This statement will help us determine
coverage.

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

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you

should be able to qualify for premium-free Part A insurance. (Someone who was a
Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for
more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement

check.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare + Choice is the term used to describe the various health plan choices available
to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan
you have. 47.
47 Page 48 49
2003 M-CARE 45 Section 9
The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription
drugs.

When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. Your M-Care primary care physician
must still coordinate your care and seek our prior approval for certain services. We do
not waive your M-CARE copays.

Claims process when you have the Original Medicare Plan --You probably will never
have to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will pay the
balance of covered charges. You will not need to do anything. To find out if you
need to do something about filing your claims, call us at (800) 658-8878 or visit our
website at www. mcare. org.

We do not waive any costs when you have the Original Medicare Plan.

(Primary payer chart begins on next page.)

The Original Medicare Plan (Part A or Part B) 48.
48 Page 49 50
2003 M-CARE 46 Section 9
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.

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

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

2) Are an annuitant,

3) Are a re-employed annuitant with the Federal government when
a) The position is excluded from FEHB, or

b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

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

5) Are enrolled in Part B only, regardless of your employment status, (for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and
the Office of Workers' Compensation Programs has determined that
you are unable to return to duty,

(except for claims
related to Workers'
Compensation.)

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

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

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

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

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

If your doctor does not participate with Medicare, you will have to file a claim with Medicare. 49.
49 Page 50 51
2003 M-CARE 47 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like HMOs)
in some areas of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE
(1-800-633-4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to you:
This Plan and another plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even
out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.

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

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

If you do not enroll in Medicare Part A or Part B 50.
50 Page 51 52
2003 M-CARE 48 Section 9
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If both
TRICARE, or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about TRICARE these
programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.

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

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

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

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these State programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may
do so only at the next Open Season unless you involuntarily lose coverage under the State
program.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care for injuries for injuries or illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures. 51.
51 Page 52 53
2003 M-CARE 49 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care is considered custodial whether it is provided in a hospital, skilled nursing facility, or your home through a home care agency when it is primarily for the purpose of meeting
your personal needs and can be provided by persons without professional skills or
training. Such care would include, but is not limited to, help in walking, bathing, taking
medication, as well as getting in and out of bed. Please note that custodial care that lasts
90 days or more is sometimes known as Long Term Care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 12.
A drug, device, treatment or procedure meeting one or more of the following criteria:
It cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use
or proposed use or;
It is the subject of a current investigational new drug or new device application on file with the FDA; or

It is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental research arm of a Phase III clinical trial;
It is being provided pursuant to a written protocol which describes among its objectives the determination of safety, efficacy, or efficiency in comparison to
conventional alternatives; or
It is described as experimental, investigational or research by informed consent or patient information documents; or

It is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations,
particularly those of the FDA or the Department of Health and Human Services or
successor agencies, or of a human subjects (or comparable) committee; or

The predominant opinion among experts as expressed in the published authoritative medical or scientific literature is that usage should be substantially confined to

experimental, investigational, or research settings; or
The predominant opinion among experts as expressed in the published authoritative medical or scientific literature is that further experiment, investigation, or research is

necessary in order to define safety, toxicity, effectiveness, or efficiency compared
with conventional alternatives. Antineoplastic drug therapy shall be provided in
accordance with Michigan law.

Experimental or
investigational services 52.
52 Page 53 54
2003 M-CARE 50 Section 10
Group health coverage An employer group is the employer with which M-CARE has contracted to provide services to eligible employees who choose M-CARE for themselves and their eligible
dependents.

Medical necessity A service or supply is considered to be medically necessary to the extent that M-CARE's Medical Director determines they satisfy all of the following criteria:
They are medically appropriate for the diagnosis and treatment of your illness or injury,
They are consistent with professionally recognized standards of health care,
They do not involve costs that are excessive in comparison with alternative services that would be effective for the diagnosis and treatment of your illness

and injury,
Please note, the fact that a physician may have prescribed, ordered, recommended, or approved the provision of certain services to you does not

necessarily mean that such services satisfy the above criteria.

Us/ We Us and we refer to M-CARE.
You You refers to the enrollee and each covered family member. 53.
53 Page 54 55
2003 M-CARE 51 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office can answer your about enrolling in the questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures
FEHB Program for other plans, and other materials you need to make an informed decision about your FEHB coverage. These material tell you:

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

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot change your
enrollment status without information from your employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.

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

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

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

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a
court or administrative order requiring you to provide health benefits for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you involuntarily as
follows: 54.
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2003 M-CARE 52 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option;
If you have a Self Only enrollment in a fee-for-service plan or in an HMO