Pages 1--24 from Untitled

Universal Care Healthcare you can feel good about Universal Care 2000
A Health Maintenance Organization

For changes
to benefitssee page 3

Serving Southern California
Enrollment in this Plan is limited see page 4 for requirements

Enrollment code
6Q1 Self Only
6Q2 Self and Family

Visit the OPM website at http www opm gov insure
and this Plan's website at http www universalcare com

Special Notice This plan is being offered for the first time under the Federal
Employee Health Benefits Program during the 1999 open season

Authorized for distribution by the
UNITED
STATES

United States Office of Federal Employees OFFICE Personnel Management
Health Benefits Program OF

MANAGEMENT
Retirement and Insurance PERSONNEL RI 73 796 1
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Universal Care 2000
Table of Contents

Introduction 1
Plain Language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4 6
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 8 13
Section 6 General Exclusions Things we don't cover 15
Section 7 Limitations Rules that affect your benefits 15 16
Section 8 FEHB FACTS 16 19
Inspector General Advisory Stop Healthcare Fraud 20
Summary of Benefits 21
Premiums 22

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Universal Care 2000
Introduction
Universal Care 1600 East Hill Street

Signal Hill California 90806 3682 800 635 6668

This brochure describes the benefits you can receive from Universal Care under its contract CS2855 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 3 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 Universal Care 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 written 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

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Universal Care 2000
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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Universal Care 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
Program wide This year you have a right to more information about this Plan care management our networks changes facilities 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

Changes to This Plan is new to the FEHB Program for 2000 this Plan

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Universal Care 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is Los Angeles Orange Riverside San Bernardino San Diego Kern and parts of
area Ventura county
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 services 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 the new area 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

How much do You must share the cost of some services This is called either a copayment a set dollar amount I pay for or coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 1,000 in copayments or coinsurance for one family member or 3,000 for two or more family members you do not have to make any further payments for certain services for the

rest of the year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs and mental health do not count toward these limits and you must continue to
make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider 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 Universal Care provides covered services through the Universal Care Contracted Medical Groups my health and Primary Care Physicians The location telephone number and hours of service of the
care Contracted Medical Groups and Primary Care Physicians are listed in the Universal Care Provider Directory accompanying this Brochure Emergency Services are available on a 24 hour basis seven
7 days a week

What do I do if Call us We will help you select a new one my 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 need to go into the specialist will make the necessary hospital arrangements and supervise your care
hospital
What do I do if First call our Member Services Department at 800 635 6668 If you are new to the FEHB I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and are
hospital when switching to us your former plan will pay for the hospital stay until I join this
Plan 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

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Universal Care 2000
Section 3 How to get benefits continued
How do I get Your primary care physician will arrange your referral to a specialist specialty care
Your Primary Care Physician is responsible for directing and coordinating all of your health care needs for Covered Services Your Primary Care Physician will arrange for laboratory tests x rays
referrals to specialists hospitalization and any other Medically Necessary Covered Services In order to be covered under this health plan all referrals to specialists must be coordinated by your
Primary Care Physician
If your Primary Care Physician determines that you need to see a specialist your Primary Care Physician will make an appropriate referral to a specialist Generally your Primary Care Physician
will refer you to a specialist within your Contracted Medical Group If you require services that are not available within your Contracted Medical Group the Primary Care Physician will arrange
for a referral to a Contracted Provider within Universal Care's network
To order certain services the Primary Care Physician will give you a written referral authorizing such services For certain specialty services the referral is submitted by the Primary Care
Physician for review for Prior Authorization to Universal Care or to the Contracted Medical Group's Utilization Review Committee

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

What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a if I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you I enroll to see a specialist who does not participate with our Plan

What do I do Call your primary care physician who will arrange for you to see another specialist You may if my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and seeing your provider for up to 90 days after we notify you that we are terminating our contract with
my provider leaves the provider unless the termination is for cause If you are in the second or third trimester of the Plan or this Plan pregnancy you may 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
How do you Your physician must get our approval before sending you to a hospital referring you to a specialist authorize medical or recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows generally accepted medical practice
Certain health care services require Prior Authorization in order to be covered Prior Authorization means that your Primary Care Physician must contact Universal Care or in some cases the
Contracted Medical Group with which your Primary Care Physician is affiliated to request that the service be approved for coverage before services are rendered Requests for Prior Authorization
will be denied if the requested services are determined to be not Medically Necessary Requests for Prior Authorization of coverage for services by non Contracted Providers will also be denied if
Universal Care determines that comparable or more appropriate services are available through Universal Care's Contracted Providers

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Universal Care 2000
Section 3 How to get benefits continued
How do you The majority of requests for Prior Authorization of coverage are responded to within 72 hours of authorize medical their receipt and urgent matters are expedited Those requests which require investigation and or
services physician review sometimes take longer as there may be need for additional information and continued communication with the requesting Primary Care Physician or specialist Requests for coverage
that are approved by Universal Care are communicated directly to you and your Primary Care Physician and the referral specialist along with an authorization number Requests for Prior
Authorization of coverage that are denied by Universal Care are communicated in writing to your Primary Care Physician and you

In the event that Prior Authorization of coverage has been denied by Universal Care or in some cases the Utilization Review Committee of your Contracted Medical Group you or your Primary
Care Physician on your behalf may appeal the denial by following the appeals process outlined on page 7 of this brochure If you would like a more detailed description of Universal Care's Criteria
for Authorizing or Denying Health Care Services you may contact Universal Care's Member Services Department at 800 635 6668

How do you For Universal Care to determine if a service or supply is experimental or investigational we refer decide if a service to evidence from the national medical community which may include one or more of the following
is experimental sources or investigational
National Centers for Health Services Research Peer reviewed medical and scientific literature Publications from organizations such as the American Medical Association Professionals
specialists and experts and written protocols and consent forms used by the proposed treating facility or other facility administering substantially the same drug device or medical treatment

In addition the service or supply must meet all of the following criteria
If it is a drug or device which cannot be lawfully marketed without the approval of the United States Food and Drug Administration FDA final approval must have been obtained at the time
the drug or device is furnished Interim FDA approvals for a Phase I II or III trial pre market approval applications and investigational exemptions are not sufficient

The evidence must show conclusively that the service or supply is safe effective and medically appropriate for use in the treatment of the illness injury or condition at issue as compared to the
conventional means of treatment or diagnosis
The service or supply must be recognized or approved in accordance with generally accepted professional medical standards Any required approval of any federal government or agency or any
state government or agency must have been obtained prior to the time of use
To obtain additional information concerning how we determine whether a particular service or treatment is experimental or investigational or to obtain information on how to appeal our decision
to deny a service or treatment as Experimental or Investigational please call our Member Services Department at 800 635 6668

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Universal Care 2000
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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal ask OPM to OPM will determine if we correctly applied the terms of our contract when we denied your claim
review a denial or request for service
What if I Call us at 800 635 6668 and we will expedite our review have a serious
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 denied my request OPM so that they can give your claim expedited treatment too Alternately you can call OPM's
for care and my health benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial 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 Your request must be complete or OPM will return it to you You must send the following to OPM information

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
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Universal Care 2000
Section 4 What to do if we deny your claim or request for service continued
Who can make Those who have a legal right to file a disputed claim with OPM are the 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 Send your request for review to Office of Personnel Management Office of Insurance Programs I mail my Contract Division III P O Box 436 Washington D C 20044
disputed claim to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the decision your only recourse is to sue
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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and the and us to determine if our denial of your claim is correct The information OPM collects during
Privacy Act 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

Section 5 Medical and Surgical Benefits
What is A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors covered and other Plan providers This includes all necessary office visits you pay a 10 office visit copay
but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a
5 copay for a doctor's house call and 5 for home visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care periodic check ups and routine eye and hearing examinations for members under the age of nineteen 19
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 women 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
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness Routine immunizations and boosters
Consultations by specialists Diagnostic procedures such as laboratory tests and X rays you pay nothing

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Universal Care 2000
Section 5 Medical and Surgical Benefits continued
What is Complete obstetrical maternity care for all covered females including prenatal delivery and covered postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48
continued hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan 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 All FDA approved contraceptive
prescription drugs or devices are covered you pay 100 copay for vasectomy male sterilization or tubal ligation female sterilization you pay 30 copay per injection for
Depo Provera Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum you pay nothing for allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints Cornea heart heart lung kidney 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 this Plan 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 you pay nothing Surgical treatment of morbid obesity
Medical formulas and low protein foods for certain inherited Diseases of amino acids and organic acids
Orthopedic devices such as braces you pay nothing Prosthetic devices such as artificial limbs and lenses following cataract removal breast
prostheses and surgical bras following mastectomies as well as their replacement you pay nothing
Durable medical equipment such as wheelchairs and hospital beds wigs are covered only for members undergoing chemotherapy or radiation treatment you pay nothing
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need you pay 5 Injectable Medication excluding Depo Provera you pay nothing
Cardiac rehabilitation following a heart transplant bypass Surgery or a myocardial infarction is provided at a Plan Facility
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental 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

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Universal Care 2000
Section 5 Medical and Surgical Benefits continued
Limited benefits Short term rehabilitative therapy physical speech and occupational is provided on an inpatient continued or outpatient basis for up to two months per condition if significant improvement can be expected
within two months you pay 10 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 50 of charges Embryo transplants in vitro fertilization and the following types of artificial insemination are covered intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay 50 of charges cost of donor sperm is not covered Injectable Fertility drugs are covered you pay
50 of charges Other assisted reproductive technology ART procedures are not covered
Induced interruption of pregnancy abortion and related procedures services drugs and supplies are not covered 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 These services are covered up to 20 weeks of gestation you pay 150

What is not Physical examinations that are not necessary for medical reasons such as those required for covered 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
Shoes or foot orthotics Chiropractic services
Blood and blood derivatives not replaced by the member Corrective eyeglasses frames and contact lenses including the fitting of contact lenses except
as necessary for the first pair of corrective lenses following cataract surgery Refractions including lens prescriptions
Dental benefits

Section 5 Hospital Extended Care Benefits
What is covered

Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan 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 Subacute care is provided in either a designated area of an acute care hospital in a comprehensive Skilled Nursing free standing rehabilitation facility or in a specially designed unit within a skilled nursing facility
Care and Subacute care is considered a lower level of care in terms of nursing and physician contact time Subacute Care with the patient and yet is still a comprehensive level of care for patients whose condition is likely
Benefits to continue to improve and who
1 Have had an acute illness or injury for which acute care is no longer medically necessary 2 Have experienced a recurrence of a chronic disease process for which acute care is no longer
necessary and 3 Though stable may still require some diagnostic and or invasive procedures and nursing care
and or monitoring

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Universal Care 2000
Section 5 Hospital Extended Care Benefits continued
Extended care The Plan provides a comprehensive range of benefits with no dollar limit for up to 100 days per continued calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a Plan doctor and approved by the Plan 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 Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility Services include inpatient and outpatient care and family counseling these 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 Services must be authorized
by a Plan doctor and approved by the Plan You pay nothing
Ambulance care Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay nothing

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan 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 Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 13 for nonmedical substance abuse benefits

What is not Personal comfort items such as telephone and television covered Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care

Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical believe endangers your life or could result in serious injury or disability and requires immediate
emergency 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 the Plan may

determine are medical emergencies what they all have in common is the need for quick action
Emergencies If you are in an emergency situation please call your primary care doctor In extreme emergencies within the if you are unable to contact your doctor contact the local emergency system e g the 911

service area telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member
must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the
Plan within that time If you are hospitalized in non Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any
ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
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Universal Care 2000
Section 5 Emergency Benefits continued
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay 25 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay
is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the because of injury or unforeseen illness
service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred
when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay
is waived
What is Emergency care at a doctor's office or an urgent care center covered Emergency care as an outpatient or inpatient at a hospital including doctors services

Ambulance service approved by the Plan
What is not Elective care or nonemergency care covered 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 With your authorization the Plan will pay benefits directly to the providers of your emergency care for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
providers If you are required to pay for the services submit itemized bills and your receipts to the Plan 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 the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 7

Section 5 Mental Conditions Substance Abuse Benefits
Mental conditions
What is To the extent shown below the Plan provides the following services necessary for the diagnosis and covered treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation Psychological testing
Psychiatric treatment including up to 50 minutes of individual and group therapy Hospitalization including inpatient professional services

Outpatient Up to 20 outpatient visits office visits or by telephone to Plan doctors or other psychiatric care personnel each calendar year you pay a 10 copay for each covered visit all charges thereafter

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Universal Care 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Inpatient Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all care
charges thereafter

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject covered 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 Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is This Plan provides medical and hospital services such as acute detoxification services for the covered medical non psychiatric 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 Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 10 copay care
for each covered visit all charges thereafter

Inpatient Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in care an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the benefit
period all charges thereafter
What is not Treatment that is not authorized by a Plan doctor covered

Section 5 Prescription Drug Benefits
What is Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan contracted covered pharmacy will be dispensed for up to a one month supply You pay a 5 copay generic drugs or
name brand drugs per prescription unit or refill for up to a one month supply Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary

Nonformulary drugs will be covered when prescribed by a Plan doctor
Universal Care approved maintenance drugs for chronic conditions can be ordered through the mail You pay 7.50 for a 90 day supply

Covered medications and accessories include Drugs for which a prescription is required by Federal law
Oral contraceptive drugs Non injectable Fertility drugs
Insulin a copay charge applies to each vial Disposable needles and syringes needed to inject covered prescribed medication
Insulin syringes needles and blood glucose monitoring strips Prenatal Vitamins
Vitamins with fluoride for infants up to one year of age Intravenous fluids and medication for home use implantable drugs such as Norplant and
some injectable drugs such as Depo Provera are covered under Medical and Surgical Benefits
What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered available
Drugs obtained at a non Plan 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 Diabetic supplies except for insulin syringes needles and blood glucose monitoring strips
Smoking cessation drugs and medication

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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Universal Care 2000
Non FEHB Benefits Available to Plan Members
The benefits described 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 this Plan 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 procedure You must enroll in
Universal Care's Medical Benefit Plan to be eligible for these benefits
You and your family can receive both Dental and Vision benefits for an annual fee payable to Universal Care
Subscriber 48.84 Subscriber and Dependent 72.84
Subscriber and Family 96.84
To obtain these additional benefits you must enroll in Universal Care's medical benefit plan
Dental Benefits
As a Universal Care member you and each covered member of your family are entitled to enrollment in our Dental Plan You must enroll in Universal Care's medical benefit plan to receive these additional benefits The following
sample copayments apply
Adult Oral Examination No charge Child Oral Examination No charge
Adult Cleaning 20.00 Child Cleaning 15.00

The Dental Plan is currently available to members in Los Angeles Orange San Bernardino Riverside and part of Ventura Counties Universal Care is currently seeking regulatory approval in San Diego and Kern Counties To receive
further information and enroll in Universal Care's Dental Plan please call 800 257 3087
Vision Benefits
As a Universal Care member you and each covered member of your family are entitled to enrollment in our Vision Plan You must enroll in Universal Care's medical benefit plan to receive these additional benefits The following sample
discounts will apply when you obtain services from the Eye Care Network ECN
Routine Eye Examinations 20 Discount Lenses 20 Discount
Frames 20 Discount Contact Lenses 20 Discount
Photochromatic Lenses 20 Discount Tints and coatings 20 Discount

To receive further information and enroll in Universal Care's Vision Plan please call 800 257 3087
This document is intended to be used as a summary only The supplemental benefit booklets for these benefits should be consulted for a detailed description of covered benefits and limitations Other charges may apply

Benefits on this page are not part of the FEHB contract

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Universal Care 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 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 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 reenroll 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
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage You must tell us if you or a family member has double coverage You must also send us
coverage 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

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

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Universal Care 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care

control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries 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
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 Agencies indirectly 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 malpractice claim it must go to binding arbitration Contact us about how to begin our binding arbitration process

Section 8 FEHB FACTS
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the to information right to information about your health plan its networks providers and facilities You can also find

about your HMO out about care 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 800 635 6668 or write to 1600 E Hill St Signal Hill CA 90806 You may also contact us by fax at 562 490 9419 or visit our website at
www universalcare com
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
enrolling in the an 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
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Universal Care 2000
Section 8 FEHB FACTS continued
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1

premiums effective Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorizes coverage for Under certain circumstances you may also get family and me 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 We will keep your medical and claims information confidential Only the following will have and claims access to it
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

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 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 conditions you enrolled in this Plan solely because you had the condition before you enrolled

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Universal Care 2000
Section 8 FEHB FACTS continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member 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 spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage

under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get 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 You can pick a new plan about TCC 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
How do I If you leave Federal service your employing office will notify you of your right to enroll under enroll in TCC TCC You 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

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Universal Care 2000
Section 8 FEHB FACTS continued
How can I convert to You may convert to an individual policy if individual coverage

Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you 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 Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of Coverage leaving this 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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Universal Care 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 1 800 635 6668 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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Universal Care 2000
Summary of Benefits for Universal Care Health Benefit Plan 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 the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pay provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit
Care Includes in hospital 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 10 11

Extended Care All necessary services no dollar limit for up to 100 days You pay nothing 10 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient Conditions care per year You pay nothing 12 13

Substance Up to 30 days per year in a substance abuse treatment program You pay nothing 13 Abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
Care including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care

You pay 10 copay per office visit 5 per house call by a doctor 8

Home Health All necessary visits by nurses and health aids You pay a 5 copay per visit 9 Care

Mental Up to 20 outpatient visits per year You pay a 10 copay per visit 12 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 a 25 copay to the hospital for each emergency room visit and any charges for
services that are not covered by this Plan 11 12

Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan contracted pharmacy You pay a 5 copay per prescription unit or refill for up to a one month supply 13

Dental Care No current benefit
Vision Care No current benefit
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses
Maximum reach a maximum of 1,000 per Self Only or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not

include charges for prescription drugs or mental health 4

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Universal Care 2000
2000 Rate Information for
Universal Care

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 In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career postal employees If you are a
career employee but not a member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which
rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

Southern California

Self Only 6Q1 54.58 18.19 118.25 39.42 64.58 8.19 64.58 8.19
Self and Family 6Q2 131.00 43.66 283.82 94.61 155.01 19.65 155.01 19.65

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