For changes benefits in
page 4 see
Serving Southern California
Enrollment in this Plan is limited see page 5 for locality requirements
Enrollment codes
C41 Self Only
C42 Self and Family
This service area has accreditation
with commendation from the
JCAHO See the 2000 Guide for
information on JCAHO
Visit the OPM website at http www opm gov insure
and
UHP HEALTHCARE's website at http www uhphealthcare com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance
RI 73 269
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UHP HEALTHCARE 2000
Table of Contents
Introduction .3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB facts 18
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits 23
Premiums 24
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UHP HEALTHCARE 2000
Introduction
UHP HEALTHCARE
3405 W Imperial Highway
Inglewood CA 90303
This brochure describes the benefits you can receive from UHP HEALTHCARE under its contract CS2032 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is 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
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 4 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to UHP HEALTHCARE as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs
and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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UHP HEALTHCARE 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services 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 Our providers follow generally accepted medical practice when prescribing any course of
treatment
Section 2 How we change for 2000
To keep premium as low as possible OPM has set a minimum copay of 10 for primary care office visits
Program wide This year you have a right to more information about this Plan care management our networks facilities
changes and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the second
or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of
your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3 How
to Get Benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical
records ask your health care provider for them You may ask that a physician amend a record that is
not accurate not relevant or incomplete If the physician does not amend your record you may add a
brief statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Your share of the non postal premium will increase by 4.1 for Self Only or 2.4 for Self and Family
Changes to this Plan
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UHP HEALTHCARE 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our
service area service area is
Los Angeles County
90001 08 90240 42 90601 08 90846 91340 91612
90010 29 90245 90631 91001 91343 45 91702
90031 42 90247 50 90637 40 91006 91356 91706
90056 59 90254 55 90650 91010 91364 91722 24
90061 69 90260 62 90660 91016 91367 91731 33
90071 90266 90670 91024 91401 03 91740
90074 90270 90701 91030 91405 06 91744 48
90077 90274 90706 91010 08 91411 91754
90079 90277 78 90710 91125 91423 91765
90089 90280 81 90712 17 91302 07 91436 91770
90201 90291 93 90732 91311 91501 02 91775 77
90203 90301 05 90744 48 91316 91504 06 91789 92
90210 13 90308 10 90801 15 91324 26 91509 91801
90220 22 90401 05 90822 91330 31 91601 02 91803
90230 31 90501 06 90840 91335 91604 08 93063
Orange County
90620 23 90742 43 92626 28 92670 92799 92825
90630 92601 92631 33 92683 84 92087 92895
90680 92605 92635 92686 87 92812
90720 92615 92640 49 92701 08 92814
90740 92621 22 92655 92728 92716
Riverside County
92324
San Bernardino County
91739 92318 92336 92354 92376 92427
92316 92324 92345 46 92369 92401 18
Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care We will not pay for any other health care services
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 another family member move outside our service area you do not have to wait until
Open Season to change plans Contact your employing or retirement office
How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance
for services a set percentage of charges Please remember you must pay this amount when you receive services
Your out of pocket expenses for benefits covered under UHP HEALTHCARE are limited to the stated
copayments which are required for a few benefits
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UHP HEALTHCARE 2000
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider
claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service
Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented
you from filing on time
Who provides my UHP HEALTHCARE is a non profit federally qualified and state licensed health maintenance organization
health care It has a combination group practice and IPA health care delivery system serving members in parts of Los Angeles Orange Riverside and San Bernardino counties Each member must live or work within UHP's
Service Area to enroll and may choose his or her own primary care doctor from the staff of the medical
group or IPA office selected
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will
need to go into the make the necessary hospital arrangements and supervise your care
hospital
What do I do if I'm First call our customer service department at 800 544 0088 If you are new to the FEHB Program we
in the hospital when will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
I join this Plan your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist
care If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals Your primary care physician will use our criteria when
creating your treatment plan The physician may have to get an authorization or approval beforehand
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a specialist
seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us you
when must receive treatment from a specialist who does Generally we will not pay for you to see a specialist
I enroll who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive services
specialist leaves the from your current specialist until we can make arrangements for you to see someone else
Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
serious illness and your provider for up to 90 days after we notify you that we are terminating our contract with the provider
my provider leaves unless the termination is for cause If you are in the second or third trimester of pregnancy you may
the Plan or this Plan continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition
or are in your second or third trimester Your new plan will pay for or provide your care for up to
90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second
or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care
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UHP HEALTHCARE 2000
How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice UHP will provide benefits for covered services only when the services are medically necessary to prevent diagnose or treat your illness or condition
How do you decide The determination that a service is experimental or investigational is based on 1 reference to relevant
if a service is federal regulations such as those contained in Title 42 Code of Federal Regulations Chapter IV Health
experimental or Finance Administration and Title 21 Code of Federal Regulations Chapter I Food and Drug
investigational Administration 2 consultation and provider organizations academic and professional specialists pertinent to the specific service and 3 reference to current medical literature
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that
you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM
OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service
What if I have a serious Call us at 800 544 0088 and we will expedite our review
or life threatening
condition and
you haven't responded
to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform OPM
denied my request so that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
for care and my condition Contract Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are
is serious or ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
life threatening
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UHP HEALTHCARE 2000
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send to Your request must be complete or OPM will return it to you You must send the following information
OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in this
brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical
records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which
claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's
representative They must send a copy of the person's specific written consent with the review
request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contract Division 3 P O Box 436 Washington D C 20044
OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds your only recourse is to sue
the Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services
supplies or drugs covered by us until you have completed the OPM review procedure described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
Privacy Act determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of
Information Act and the Privacy Act OPM may disclose this information to support the disputed claim
decision If you file a lawsuit this information will become part of the court record
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UHP HEALTHCARE 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered
A comprehensive range of preventive diagnostic and treatment services is provided by UHP doctors and other UHP providers This
includes all necessary office visits you pay 10.00 for office visits but no additional copay for laboratory tests and X rays Within
the service area house calls will be provided if in the judgement of the UHP doctor such care is necessary and appropriate a 10
copay for a doctor's house call and nothing for home visits by nurses and health aides
The following services are included with your copay
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women
age 40 through 49 one mammogram every one or two years for age 50 through 64 one mammogram every year and for
women age 65 and above one mammogram every two years In addition to routine screening mammograms are also covered
when prescribed by the doctor as medically necessary to diagnose or treat the member illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a UHP doctor
The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery Inpatient stays will be extended if medically necessary If enrollment in UHP HEALTHCARE is terminated during
pregnancy benefits will not be provided after coverage under UHP HEALTHCARE has ended Ordinary nursery care of the newborn
child during the covered portion of the mother's hospital confinement for maternity will be covered under either a Self
Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant
is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of disease of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney lung single double and liver transplants 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 Transplants are covered when approved by the Medical Director Related medical and
hospital expenses of the donor are covered when the recipient is covered by UHP HEALTHCARE
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in
the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces
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UHP HEALTHCARE 2000
Prosthetic devices such as artificial limbs and lenses following cataract removal breast protheses including the surgical bra
for an external prosthesis following a mastectomy and necessary replacement prostheses and bras
Durable medical equipment such as wheelchairs and hospital beds
Chiropractic and acupuncture office visits
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your UHP
doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from UHP doctors and other UHP providers
Limited benefits
Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft
lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including but
not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas
surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain
dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has
produced a major effect on the member's appearance and if the condition can reasonably be expected to be corrected by such
surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational therapy is provided on an inpatient or outpatient basis for up to
two consecutive months per condition if significant improvement can be expected within two months you pay nothing per outpatient
session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 10.00 per office visit Artificial insemination intravaginal insemination
IVI intracerival insemination ICI and intrauterine insemination IUI is covered you pay 10.00 per office visit cost of donor
sperm is not covered Fertility drugs are covered Other assisted reproductive technology ART procedures such as in vitro fertilization
and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a UHP approved facility
you pay 10.00 per office visit
What is not covered
Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment
or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Refractions including lens prescriptions and corrective eyeglasses and frames or contact lenses including the fitting of contact
lenses
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UHP HEALTHCARE 2000
Hospital Extended Care Benefits
What is covered
Hospital care
UHP HEALTHCARE provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care
of a UHP doctor You pay nothing All necessary services are covered including
Semiprivate room accommodations when a UHP doctor determines it is medically necessary the doctor may prescribe private
accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care
UHP HEALTHCARE provides a comprehensive range of benefits for up to 30 days per calendar year when full time skilled nursing
care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a UHP doctor and approved
by UHP HEALTHCARE You pay nothing 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 UHP doctor
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and
outpatient care and family counseling these services are provided under the direction of a UHP doctor who certifies that the patient
is in the terminal stages of illness with a life expectancy of approximately six months or less
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a UHP doctor
Limited benefits
Inpatient dental procedures
Hospitalization for certain dental procedures is covered when a UHP doctor determines there is a need for hospitalization for reasons
totally unrelated to the dental procedure UHP HEALTHCARE will cover the hospitalization but not the cost of the professional dental
services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of medical conditions
and medical management of withdrawal symptoms acute detoxification if the UHP doctor determines that outpatient management
is not medically appropriate See page xx for nonmedical substance abuse benefits
What is not covered
Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
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UHP HEALTHCARE 2000
Emergency Benefits
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 UHP HEALTHCARE may determine are medical emergencies what they all have in common is
the need for quick action
Emergencies within the service area
If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are unable to contact your
doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure
to tell the emergency room personnel that you are a UHP member so they can notify UHP HEALTHCARE You or a family member
must notify UHP HEALTHCARE within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that
UHP HEALTHCARE has been timely notified
If you need to be hospitalized UHP HEALTHCARE must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify UHP HEALTHCARE within that time If you are hospitalized in non UHP facilities
and a UHP doctor believes care can be better provided in a UHP hospital you will be transferred when medically feasible with any
ambulance charges covered in full
Benefits are available for care from non UHP providers in a medical emergency only if delay in reaching a UHP provider would
result in death disability or significant jeopardy to your condition
To be covered by UHP HEALTHCARE any follow up care recommended by non UHP providers must be approved by UHP
HEALTHCARE or provided by a UHP provider
UHP HEALTHCARE pays
Reasonable charges for emergency services to the extent the services would have been covered if received from UHP providers
You pay
Nothing for emergency room or urgent care center visits for emergency services that are covered benefits of UHP HEALTHCARE and
are received from UHP facilities a 50 copay or 50 of charges whichever is less for emergency services that are covered benefits
of UHP HEALTHCARE and are received from non UHP facilities If the emergency results in admission to a hospital any applicable
copay is waived
Emergencies outside the service area
Benefits are available for any medically necessary health service that is immediately required because of injury or unforseen illness
If you need to be hospitalized UHP HEALTHCARE must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify UHP HEALTHCARE within that time If a UHP doctor believes care can be better
provided in a UHP hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by UHP HEALTHCARE any follow up care recommended by non UHP providers must be approved by UHP
HEALTHCARE or provided by a UHP provider
UHP HEALTHCARE pays
Reasonable charges for emergency care services to the extent the services would have been covered if received from UHP providers
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UHP HEALTHCARE 2000
You pay
A 50 copay or 50 of charges whichever is less for emergency room visit or urgent care center visit for emergency services that
are covered benefits of UHP HEALTHCARE If the emergency results in admission to a hospital the copay is waived
What is covered
Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by UHP HEALTHCARE
What is not covered
Elective care or nonemergency 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
Filing claims for non UHP providers
With your authorization UHP HEALTHCARE will pay benefits directly to the providers of your emergency care upon receipt of their
claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit
itemized bills and your receipts to UHP HEALTHCARE along with an explanation of the services and the identification information
from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based If you disagree
with UHP's decision you may request reconsideration in accordance with the disputed claims procedure described on page 7
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered
To the extent shown below UHP HEALTHCARE provides the following services necessary for the diagnosis and treatment of acute
psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care
Up to 20 outpatient visits to UHP doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay per
visit for each covered visit all charges thereafter
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UHP HEALTHCARE 2000
Inpatient care
Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
What is not covered
Care for psychiatric conditions which in the professional judgement of UHP doctors are not subject to significant improvement
through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a UHP doctor
to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse
What is covered
UHP HEALTHCARE provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric
aspects of substance abuse including alcoholism and drug addiction the same as for any other illness or condition and to the extent
shown below the services necessary for diagnosis and treatment
Outpatient care
Up to 20 outpatient visits to UHP providers for treatment each calendar year you pay a 10 copay for each covered visit all charges
thereafter
The substance abuse benefit may be combined with the outpatient mental conditions benefit shown above provided such treatment is
necessary as a mental health care service and is approved by UHP HEALTHCARE to permit an additional 20 outpatient visits per calendar
year with the applicable mental conditions benefit copayments
Inpatient care
Up to 30 days each calendar year for elective detoxification is provided in an alcohol
detoxification or rehabilitation center approved by UHP HEALTHCARE you pay nothing during the benefit period all charges thereafter
What is not covered
Treatment that is not authorized by a UHP doctor
Prescription Drug Benefits
What is covered
Prescription drugs prescribed by a UHP or referral doctor and obtained at a UHP pharmacy will be dispensed for up to a 30 day supply
or 100 unit supply whichever is less or one commercially prepared unit i e one inhaler one vial ophthalmic medication or
insulin You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not
permissible When generic substitution is permissible i e a generic drug is available and the prescribing doctor does not require the
use of a name brand drug but you request the name brand drug you pay the price difference between the generic and the name
brand drug as well as the 5 copay per prescription unit or refill
Drugs are prescribed by UHP doctors and dispensed in accordance with UHP HEALTHCARE's drug formulary Nonformulary drugs
will be covered when prescribed by a UHP doctor UHP HEALTHCARE must arrange for the nonformulary drug to be dispensed when
requested to do so by the prescribing doctor
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UHP HEALTHCARE 2000
UHP HEALTHCARE's Formulary Pharmacy Therapeutics Advisory Committee determines which drugs are to be included in UHP's
drug formulary The Committee is an advisory group consisting of medical pharmacy and other professionals This committee
serves as the governing body for the Formulary system and currently includes the UHP Medical Director contracted Medical Group
Prescribers the UHP Pharmacy Director contracted Pharmacy Provider Pharmacists and the UHP Utilization Management Director
The primary purposes of the UHP Formulary Pharmacy Therapeutics Advisory Committee are to develop UHP's medication formulary
and to provide members cost effective and quality drug therapy
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs contraceptive diaphragms
Implanted contraceptive devices you pay nothing for device implantation and removal is provided by UHP HEALTHCARE
Insulin a copay charge applies to each vial
Intrauterine devices
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent and
acetone test tablets
Disposable needles and syringes needed to inject covered prescribed medication
Fertility drugs and injectables are covered under the Medical and Surgical Benefits
Drugs to treat sexual dysfunction
What is not covered
Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non UHP pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Non prescription contraceptive drugs and devices
Smoking cessation drugs and medication including nicotine patches
Implanted time release medications except Norplant
Other Benefits
Dental care
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural
teeth are covered The need for these services must result from an accidental injury you pay
nothing
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UHP HEALTHCARE 2000
Non FEHB Benefits Available to UHP Members
The benefits on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all
enrollees and family members of UHP HEALTHCARE The cost of the benefits described on this page is not included in the FEHB premium
and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits are
not subject to the FEHB disputed claims procedures
Medicare prepaid plan enrollment UHP HEALTHCARE offers Medicare recipients the opportunity to enroll in UHP HEALTHCARE
through Medicare As indicated on Page 17 annuitants and former spouses with FEHB coverage and Medicare Parts A and B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later reenroll
in the FEHB program Contact your retirement system for information on dropping your FEHB enrollment and changing to a
Medicare prepaid plan Contact us at 1 800 544 0088 for information on UHP's Medicare prepaid plan and the cost of that enrollment
Benefits on this page are not part of the FEHB contract
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UHP HEALTHCARE 2000
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 or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred
services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and 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
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with
us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan 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
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in
the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits
will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan offered
by this Plan call 1 800 540 0088
Other group When anyone has coverage with us and with another group health plan it is called double coverage You
insurance coverage must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first
plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is less
We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to
receive payment from your primary plan
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UHP HEALTHCARE 2000
We will always provide you with the benefits described in this brochure Remember even if you do not
file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that another
responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of
injuries 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
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the primary
payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation
Programs OWCP or a similar Federal or State agency determine they must provide
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 the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or indirectly
Agencies pays for
If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it
malpractice must go to binding arbitration Contact us about how to begin our binding arbitration process
claim
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
information about information about your health plan its networks providers and facilities You can also find out about care
your HMO management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific
types of information that we must make available to you
If you want specific information about us call 800 544 0088 or write to UHP HEALTHCARE 3405 West
Imperial Highway Inglewood CA 90303 You may also contact us by fax at 310 412 1288 or visit our
website at www uhphealthcare com
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UHP HEALTHCARE 2000
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about
FEHB Program 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
The next Open Season for enrollment
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
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums
premiums effective begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
I retire the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is
described later in this section
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried
are available for dependent children under age 22 including any foster or step children your employing or retirement
me and my family office authorizes coverage for Under certain circumstances you may also get 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 you
give birth or add the child to your family The benefits and premiums for your Self and Family enrollment
begin on the first day of the pay period in which the child is born or becomes an eligible family
member
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
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the following will have access to it
claims records
confidential OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
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UHP HEALTHCARE 2000
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809
cards or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends You or a family member are no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can receive
TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if
you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing or
retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from
the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel
your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
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UHP HEALTHCARE 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You
TCC must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer
an eligible family member That office will send you information about enrolling in TCC You must
enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is
later
Former spouses You or your former spouse must notify your employing or retirement office within 60
days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage
or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline
How can I convert You may convert to an individual policy if
to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a family
member who is losing coverage the employing or retirement office will not notify you You must apply
in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage due to
pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Certificate of how long you have been enrolled with us You can use this certificate when getting health insurance
Group Health or other health care coverage You must arrange for the other coverage within 63 days of leaving this
Plan Coverage Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well
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UHP HEALTHCARE 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital 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 800 544 0088 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate
anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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UHP HEALTHCARE 2000
Summary of Benefits for UHP HEALTHCARE 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by UHP HEALTHCARE If you wish to enroll or
change your enrollment in UHP be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of
this brochure ALL SERVICES COVERED UNDER UHP HEALTHCARE WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY UHP DOCTORS
Benefits UHP pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital care doctor care room and board general nursing care private room and private nursing care if medically
necessary diagnostic tests drugs and medical supplies use of operating room intensive care
and complete maternity care You pay nothing .11
Extended All necessary services up to 30 days per calendar year You pay nothing for up to 30 days all
care charges thereafter .11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year
conditions You pay nothing .14
Substance Up to 30 days each calendar year in an alcohol detoxification or rehabilitation center You pay nothing
abuse .14
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care care preventive care including well baby care periodic check ups and routine immunizations
laboratory tests and X rays complete maternity care You pay 10 per office visit a 10
copay per house call by a doctor .9 10
Mental Up to 20 outpatient visits per year You pay a 10 copay per visit .13
conditions
Substance Up to 20 outpatient visits per year You pay a 10 copay per visit .13
abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay nothing if emergency care services are received from UHP facilities a 50 copay or 50 of charges
whichever is less if received from non UHP facilities and nothing if emergency results in admission
to a hospital and any charges for services that are not covered benefits of UHP HEALTHCARE 12 13
Prescription drugs Drugs prescribed by a UHP doctor and obtained at a UHP pharmacy You pay a 5 copay per prescription unit or refill when generic substitution is not possible If member requests a non formulary
drug member pays difference between formulary and non formulary plus the 5 copay .14 15
Dental care Accidental injury benefit You pay nothing .15
Vision care No current benefit
Out of pocket Your out of pocket expenses for benefits covered under UHP HEALTHCARE are limited to the stated maximum copayments which are required for a few benefits .5
CARE MUST BE RECEIVED FROM OR ARRANGED BY UHP DOCTORS
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UHP HEALTHCARE 2000
2000 Rate Information for
UHP HEALTHCARE
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category
or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees but do not apply to non career Postal employees Postal retirees certain
special Postal employment categories or associate members of any Postal employee organization If you are in a special Postal
employment category refer to the FEHB Guide for that category
Non postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Code Govt Your Govt Your USPS Your
Enrollment Share Share Share Share Share Share
Self Only C40 50.85 16.95 110.18 36.72 60.17 7.63
Self and Family C42 108.35 36.12 234.77 78.25 128.22 16.25
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