Resolution No. 7929I
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RESOLUTION NO. 7929
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING AND AUTHORIZING THE EXECUTION OF A
NEW UNIVERSAL CARE LARGE GROUP SUBSCRIBER AGREEMENT
(PREMIER 100 PLAN) BY AND BETWEEN THE CITY OF
VERNON AND UNIVERSAL CARE AND RATIFYING THE PAYMENT
OF HEALTH PLAN PREMIUMS
WHEREAS, on December 15, 1998, the City Council of the City
of Vernon adopted Resolution No. 7252 approving Universal Care Group
Subscriber Agreement M10 Plan (90-100) ("M10 Plan Agreement"); and
WHEREAS, the M10 Plan Agreement took effect on January 1,
1999, and has been renewed each calendar year either by resolution or
minute order; and
WHEREAS, the M10 Plan Agreement was not renewed and expired
Ilas of December 31, 2001; and
WHEREAS, in order to meet the urgent need for a new HMO
plan, Joan Francone, Risk Manager, administratively approved the
payment of Health Plan Premiums to Universal Care for a Premier 100
Plan for the months of January (January 8, 2002), February (February
4, 2002) and March (February 27, 2002), subject to ratification by the
City Council; and
WHEREAS, Universal Care has presented the City with a Large
Group Subscriber Agreement effective January 1, 2002, for the new
Premier 100 Plan under which employees are charged a co -payment for
office visits, prescription drugs and emergency room treatment; and
WHEREAS, the City Council desires to approve and ratify the
payment of Health Plan Premiums for the new Premier 100 Plan; and
WHEREAS, on March 11, 2002, the Finance Committee recommended
that the City Council approve the recommendation of Bruce V.
w r ! ,f; p.:
1 Malkenhorst, the Director of Finance, dated March 7, 2002, that the new
2 HMO Plan (Premier 100 Plan) with Universal Care be approved and an
3 agreement executed.
4 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
5 CITY OF VERNON AS FOLLOWS:
6 SECTION 1: The City Council of the City of Vernon hereby
7 finds and determines that the recitals contained hereinabove are true
8 and correct.
9 SECTION 2: The City Council of the City of Vernon hereby
10 approves and ratifies the January through March payments of Health
11 Plan Premiums for the new Premier 100 Plan.
12 SECTION 3: The City Council of the City of Vernon hereby
13 approves the Large Group Subscriber Agreement (Premier 100) with
14 Universal Care, a copy of which is attached hereto as Exhibit "A" and
15 made a part hereof.
16 SECTION 4: The City Council of the City of Vernon hereby
17 authorizes the Mayor and the City Clerk to execute said Agreement for,
18 and on behalf of, the City of Vernon.
19 SECTION 5: The City Council of the City of Vernon hereby
20 directs the City Clerk, or his designee, to send one fully executed
21 Agreement to:
22 Universal Care
Attn: Jay B. Davis, Executive Vice President
23 1600 E. Hill Street
24 Signal Hill, CA 90806-3682
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SECTION 6: The City Clerk of the City of Vernon shall
certify to the passage of this resolution, and thereupon and
thereafter the same shall be in full force and effect.
APPROVED AND ADOPTED this 20th day of March, 2002.
FATTEST:
BRUCE V. MALKENHORST, City Clerk
EONIS C. MA BURG, Nayor
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STATE OF CALIFORNIA )
ss
COUNTY OF LOS ANGELES )
I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do
hereby certify that the foregoing Resolution, being Resolution No.
7929, was duly adopted by the City Council of the City of Vernon at a
regular meeting of the City Council duly held on Wednesday, March 20,
2002, and thereafter was duly signed by the Mayor of the City of
Vernon.
(SEAL)
BRUCE V. MALKENHORST, City Clerk
- 4 -
EXHIBIT
Ain
UNIVERSAL CARE
LARGE GROUP SUBSCRIBER AGREEMENT
Group's Minimum Number of Eligible Employees is 51
THIS LARGE GROUP SUBSCRIBER AGREEMENT (the "Agreement") is
entered into between CITY OF VERNON (the "Group") and Universal Care, a California
corporation (hereinafter sometimes referred to as the "Health Plan" or "Universal Care Health
Plan") which operates a health care service plan licensed and regulated by the Department of
Managed Health Care of the State of California under the Knox -Keene Health Care Service Plan
Act of 1975, as amended.
To the extent herein limited and defined, this Agreement provides for
comprehensive health services provided through the Health Plan. Upon payment of Health Plan
Premiums (the amount paid by Group to Universal Care in consideration for the benefits
provided under the Health Plan) in the amount and manner provided for in this Agreement,
Universal Care HEREBY AGREES to furnish services and benefits as defined in this Agreement
to the eligible employees and their eligible Dependents of:
Group's Name: CITY OF VERNON
Group's Minimum Number of Eligible Employees is: 51.
Group's ID Number: 10010A
Group's Benefit Plan ID Code: Premier 100 (P100MRX4)
Group's Effective Date: January 1, 2002
Documents Incorporated by Reference into this Group Subscriber Agreement:
1. Combined Evidence of Coverage and Disclosure Form for the Group's Benefit Plan
(includes Benefit Plan and Exclusions and Limitations)
2. Premium Rate Schedule
3. Available Riders (as applicable): Point of Service (POS); Dental; Vision; Chiropractic
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed at Signal Hill, California on this 7TH day of February, 2002.
NIVERSAL CARE
By: �+ r
Jay ( Davis
Executive Vice President
Date.
CITY OF VERNON
LEONIS C. MALBURG, Mayor
Date:
ATTEST:
BRUCE V. MALKENHORST, City Clerk
APPROVED AS TO FORM:
E DUA 0 OLIVO, City Attorney
Universal Care Large Group GSA (R5) DMHC Approva Pen ing
DOCUMENTS INCORPORATED BY REFERENCE
The application for the Group Subscriber Agreement, and any duly executed addenda,
amendments, applicable Combined Evidence of Coverage and Disclosure Form[s] and Schedules
are incorporated by this reference herein.
TERM AND TERMINATION OF AGREEMENT
This Agreement becomes effective on the Effective Date noted at the beginning of this
Group Subscriber Agreement at 12:01 a.m., Pacific Time, (the "Effective Date") and will remain
in effect for a term of twelve consecutive months, subject to amendments by Universal Care (see
section titled Amendments to Agreement) and the payment of Health Plan Premiums (see section
titled Health Plan Premiums and Copayments). This Agreement will automatically renew from
year to year on the anniversary of the Effective Date (the "Renewal Date"), unless terminated or
not renewed as set forth herein. This Agreement may be terminated by the Group with a 30-day
prior written notice to Universal Care. Universal Care may terminate or not renew this
Agreement for good cause as set forth in the Combined Evidence of Coverage and Disclosure
Form under the Section titled "Ending Coverage (Termination of Benefits)." Termination of this
Agreement by Universal Care for good cause, other than for not paying Health Plan Premiums
(See section below titled "Health Plan Premiums and Copayments") shall become effective with
a 30-day prior written notice to the Group.
If this Agreement is terminated by either Universal Care or the Group, the Group shall
promptly mail or hand deliver to each covered Subscriber, a notice of cancellation of this
Agreement. The group shall, upon request by Universal Care, provide Universal Care with a
copy of the notification, a written statement that the notice of cancellation was mailed or hand
delivered to each Subscriber, and the date of mailing or hand delivery.
Members who are hospitalized on the date coverage under this Agreement ends, may be
eligible for continuation of coverage. See Combined Evidence of Coverage and Disclosure Form
under the Section titled 'Extension of Benefits for Totally Disabled Members upon Termination
of Agreement Between Employer Group and Universal Care."
Universal Care shall give the group 30 days notice if the group does not meet the
Minimum Participation Requirements as stated on the signature page and in Section 1 of this
Agreement. Such notice period shall begin 30 days prior to the renewal date. If the group does
not increase its participation to the minimum requirements during the notice period, this
Agreement may not be renewed.
Universal Care shall give the group 30 days notice if the group is not contributing a
minimum of 50% of the employee only premium cost. Such notice period shall begin 30 days
prior to the renewal date. If the group does not increase its contribution to the minimum
requirements during the notice period, this Agreement may not be renewed.
2
Universal Care Large Group GSA (R5) DMHC Approval Pending
AMENDMENTS TO AGREEMENT
If the Plan proposes any amendment to this Agreement, including a change in the
prepayment fees or benefits or copayments, and gives the Subscriber Group written notice of the
amendment at least thirty (30) days in advance, the amendment shall become effective on the
date identified in the plan's thirty (30) day written notice, unless the Subscriber terminates this
Agreement in accord with its terms. With at least thirty (30) days notice, the Plan may also
propose amendments to this Agreement (including a change in the prepayment fees, premiums,
benefits, copayments, or the documents incorporated by reference into this Agreement) that result
from legislation or regulations imposed by any regulatory agency that has authority over the Plan
and its Agreements.
The Plan may propose one or more amendments to this Agreement to go into effect no
sooner than thirty (30) days after the Plan has given written notice of the proposal to the
Subscriber Group. An amendment may include increases or other changes in prepayment fees
and copayments and reductions or other changes in benefits. Each such amendment shall go into
effect on the date specified in the notice unless the Subscriber Group gives the Plan at least thirty
(30) days written notice of its rejection of such amendment(s). If the Subscriber group rejects
any such amendments, this Agreement may not be renewed at the Renewal Date.
HEALTH PLAN PREMIUMS AND COPAYMENTS
The Group must pay Health Plan Premiums in exchange for coverage for the health care
benefits, services, and supplies. The Health Plan Premiums for the Health Plan's supplemental
benefits, if any, are set forth in the supplemental benefit rider(s) for those benefits.
The Health Plan Premiums for the first month of coverage must be paid to Universal Care
on or before the Effective Date of this Agreement. Subsequently, all Health Plan Premiums must
be received by Universal Care by the 25'h day of the month preceding the month for which the
Health Plan Premium fee applies. Universal Care may unilaterally, at any time[s] during the term
of this Agreement and with thirty days written notice to the Group, increase all subsequent
Health Plan Premiums that are due from the Group to continue this Agreement in full force and
effect. Payment of any portion of the increased Health Plan Premium shall constitute acceptance
of this modification.
Non-payment of Premiums
The Plan may terminate this Agreement if the Subscriber Group fails to pay the monthly
premium within fifteen (15) days after receiving notice of delinquency. The termination shall be
effective retroactively to the last day of the last month for which full payment has been made by
the Subscriber Group. Services obtained by Subscribers or Members during the retroactive
period will not be covered by Plan and the Subscriber Group shall assume financial responsibility
for payment of such services.
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Universal Care Large Group GSA (R5) DMHC Approval Pending
If this Agreement is terminated for any reason, the Group shall be liable for all Health
Plan Premiums for any time this Agreement is in force during a grace period and any notice
period. Only Members for whom the stipulated Health Plan Premium fee is actually received by
Universal Care shall be eligible for Covered Services under this Agreement and only for the
period covered by such payment.
Reinstatement
If, after giving notice of termination of this Agreement for non-payment of the
prepayment fees, the Plan receives full payment of those fees from the Subscriber Group before
the due date of the next months prepayment fees, this Agreement shall be reinstated, unless; (1)
the Plan's notice of termination states that if payment is not received within fifteen (15) days after
issuance of the notice or such longer period as it may allow, the Plan will require a new
application and impose conditions on a new Agreement or reinstatement of this Agreement, or
(2) the payment is received more than fifteen (15) days after issuance of this notice and the Plan
refunds the payment within twenty (20) business days after receipt, or (3) the payment is received
more than fifteen (15) days after issuance and within twenty (20) business days of receipt the
Plan issues a new Agreement and a statement of the ways the new Agreement differs from this
Agreement. Individual Subscribers or other members have no right to renew or reinstate this
Agreement.
Any late payment, whether partial or full, which is received and accepted by Plan after
Plan serves a Notice of Termination upon Subscriber Group, shall accrue an interest penalty of
eighteen percent (18%) per annum, effective from the original due date of the payment. Plan
may, at its discretion upon acceptance of such payment, apply it, first, to such interest owed, and
then to the principle balance due.
Partial Payment
Plan may, at its sole discretion and without waiving its right to terminate this Agreement
or to assess an interest penalty, accept partial payment of any amount owed by Subscriber Group.
Plan may accept such partial payment and apply it, first, to interest owed thereon, and then to the
principle balance due, but such acceptance of a partial payment shall not automatically operate as
a renewal or continuation of this Agreement. Plan shall have the sole authority to determine
whether a partial payment shall be sufficient to renew or continue this Agreement.
SOLICITATION AND ENROLLMENT
The Group shall cooperate with the Health Plan with respect to soliciting and enrolling
persons eligible to enroll hereunder and in obtaining authorized payroll withholdings from such
persons to the extent the applicable Health Plan Premiums exceed the Group's contribution on
their behalf. The Group will promptly send the Health Plan copies of all signed enrollment forms
and enrollment change forms. The Health flan may inspect the Group's records pertinent to
eligibility, enrollment and Health Plan Premiums hereunder, and make copies thereof, at
reasonable times upon reasonable prior notice to the Group.
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Universal Care Large Group GSA (R5) DMHC Approval Pending
The Health Plan Premiums will be calculated by Universal Care from current records as
to the number of Members enrolled. Within ten (10) days after the commencement of the term of
this Agreement, and on the first day of each month thereafter, the Group will deliver to Universal
Care an alphabetized list of the names and social security numbers of all persons who enroll
hereunder and whose enrollment has not terminated pursuant to the provisions hereof. Universal
Care may rely upon the latest information received from Group as correct without further
verification.
Retroactive payment adjustments will be made in subsequent billings for any additions or
terminations of Members not currently reflected in Universal Care's records at the time of
calculation of Health Plan Premiums. However, in no event will the effective date of an addition
or termination be more than sixty (60) days prior to the date of the receipt by Universal Care of
the written notice of the addition or termination from the Group, and Universal Care will not
refund any Health Plan Premiums to the Group paid for an ineligible Member if the request for
such refund is made later than sixty (60) days after the receipt of payment by Universal Care for
said ineligible Member.
When a Member is being retroactively terminated, the effective date of retroactive
termination cannot be prior to any date on which services or supplies were provided to the
Member under this Agreement. In such instances, the date of termination will be the first day of
the calendar month following the month in which Covered Services were provided, and any
applicable credit of Health Plan Premiums will be calculated from that date.
In addition to the Health Plan Premiums, each individual Member is required to pay
Copayments for some Covered Services provided. These Copayments are payable to the
Provider at the time the Covered Services are provided. The Copayments are specified in the
Benefit Schedule portion of the Combined Evidence of Coverage and Disclosure Form next to
the applicable Covered Services.
BINDING ARBITRATION
(a) Except as provided in Subsection 9(c) below, any controversy or dispute between
any of the following interested parties -- the Subscriber Group; an agent, trustee, affiliate or
assignee of the Subscriber Group; a Subscriber; a Dependent; or an heir at law or personal
representative of a Subscriber or Dependent -- on the one hand, and any of the following parties -
- the Plan, its employees or agents, or its Contracting Providers or their agents or employees, --
on the other, whether involving a claim in tort, contract or otherwise, including disputes
pertaining to this Agreement or the care or other benefits rendered pursuant hereto or refused as
not covered hereunder, and including disputes which are not adequately resolved by the Plan's
grievance procedures, shall be submitted to binding arbitration.
(b) Arbitration may be initiated by any interested party, but if the matter in dispute is
one which is subject to review under the Plan's grievance procedures, arbitration may not be
initiated until the completion of such procedures. The arbitration shall follow in accordance with
the applicable rules of the Judicial Arbitration and Mediation Services (JAMS). The arbitration
5
Universal Care Large Group GSA (R5) DMHC Approval Pending
process may be initiated by calling the American Arbitration Association and requesting a form
used to demand arbitration. The demand for arbitration must be served personally or by
recognized messenger service or by certified mail, return receipt requested, on or before the last
date it would have to be filed in a court of law under the applicable statute of limitations.
(c) If a Subscriber, a Dependent, or an heir at law or personal representative of a
Subscriber or Dependent asserts an arbitration claim and the amount in dispute is less than
$200,000, the claimant and Universal Care shall agree to a single neutral person to render a
decision in arbitration. The single neutral arbitrator must be selected from the JAMS panel of
arbitrators and the arbitration will be conducted under the rules of the JAMS.
(d) In the event the claimant and Universal Care cannot agree on a single neutral
arbitrator, the JAMS shall appoint a default arbitrator according to its rules and procedures.
(e) Contracting Physicians, Contracting Hospitals and/or Contracting Providers may
bring legal actions to collect copayments for covered services or fee -for -service rates for non -
covered services. The Plan may seek declaratory relief regarding the interpretation of this
Agreement or seek judicial remedies to collect prepayment fees.
(f) The costs of the arbitration shall be borne equally by both parties; however, for
purposes of this Agreement, the costs of arbitration are limited to fees and expenses of the
arbitrators and charges for arbitrators' transcripts of the proceedings, and the room where the
arbitration is conducted. The arbitrator may require the submission of pleadings, briefs and other
memoranda and documents and may compel discovery from the parties, shall hold a hearing
within a reasonable time and shall set forth his decision in writing, with his reasons and authority
therefore. Any judgment or award rendered by the arbitrator may be entered into any court
having jurisdiction thereof. The arbitration procedure established by this Agreement is the sole
and exclusive means for the settlement of any such controversy or dispute.
(g) Beginning with arbitration claims served on or after August 1, 1997, extreme
hardship provisions will apply for Subscribers and Dependents or their heirs or personal
representatives seeking arbitration. Upon request, Universal Care will provide the Subscriber,
Dependent, heir or personal representative with either an application for relief from arbitration
costs or information on how to obtain such an application from JAMS. The approval or denial of
the application for hardship will be made by JAMS. Procedures established by JAMS for
handling such hardship requests will be followed. Information on how to file an application for
hardship relief may be obtained from Universal Care's Member Services Department by calling
800-635-6668 or 562-424-6200.
INDEMNIFICATION OF PARTIES
The Parties agree to save, hold harmless, defend and indemnify each other from and
against all claims, demands, liabilities, actions or causes of action of any kind or nature which
may arise out of, in connection with, or related to any act, omission, negligence, malpractice or
lack of due care caused or alleged to have been caused by either party, any subcontractor of either
party, or any of their employees, Contracting Physicians, Contracting Hospitals, Contracting
6
Universal Care Large Group GSA (R5) DMHC Approval Pending
Physicians, consulting doctors, agents or partners in the performance of the services, duties and
obligations under this Agreement, except as may result from a breach of either party's obligations
hereunder.
RELATIONSHIP BETWEEN PARTIES
The relationship between Plan and the physicians, hospitals and other health care
Providers who are its Contracting Physicians, Contracting Providers, Contracting Hospitals is
that of an independent contractor relationship (except for the employees of Universal Care who
provide services at the medical offices owned and operated by Universal Care); they are not
agents or employees of Universal Care, and this Plan and its employees are not employees or
agents of those Contracting Providers.
Each physician, Hospital or other Provider of health care services is to maintain a direct
physician. -patient, hospital -patient or other such relationship with Universal Care members to
whom it provides services, and is solely responsible for its decisions as to what health care
diagnostic, treatment or other services are required.
MODIFICATION OF AGREEMENT / HEALTH PLAN PREMIUMS
Universal Care may modify this Agreement at any time by providing a 30-day written
notice to the Group prior to the effective date of such modification. Universal Care may
unilaterally, at any time[s] during the term of this Agreement and with thirty days written notice
to the Group, increase all subsequent Health Plan Premiums that are due from the Group to
continue this Agreement in full force and effect. Payment of any portion of the increased Health
Plan Premium shall constitute acceptance of this modification.
In addition, if a government authority (a) imposes a tax or fee that is computed on Health Plan
Premiums or (b) requires a change in coverage or administrative practice that increases Universal
Care's costs. Universal Care may amend this Agreement and increase the Health Plan Premiums
sufficiently to cover the tax, fee, or costs. The effective date of such increase shall be the date set
forth in a written notice from Universal Care to the Group. The effective date shall not be earlier
than the date the tax, fee, or required change in coverage or administrative practice is imposed by
the governmental authority.
UNDERWRITING REQUIREMENTS
Underwriting requirements are incorporated by reference in the Large Group Health
Proposal which is created for each large group.
GENERAL PROVISIONS
1. Form or Content of Agreement
7
Universal Care Large Group GSA (R5) DMHC Approval Pending
No agent or employee of Universal Care is authorized to change the form or content of
this Agreement. Any changes can be made only through a written amendment authorized and
signed by an officer of Universal Care.
2. Notice of Certain Events
Universal Care will give the Group written notice, within a reasonable time, of any
termination or breach of contract, or inability to perform services, by any Contracting Provider, if
the Group may be materially and adversely affected thereby.
3. Assignment
The Health Plan may assign this Agreement and its rights hereunder, and delegate its
duties hereunder, to any entity which is a licensed health care service plan into which it is merged
or which acquires substantially all of its assets, upon the approval of the Department of Managed
Health Care. The Group may not assign this contract without the prior written consent of the
Health Plan. Neither party may otherwise assign this Agreement unless such assignment is
required by law. Any purported assignment in violation hereof shall be void and unenforceable.
4. Applicable Law and Interpretation
This Agreement shall be construed and interpreted in accordance with the laws of the
State of California and so as to effectuate its purpose in accordance with the Medical Practice
Act, the ethics of the medical profession, the Knox -Keene Health Care Service Plan Act of 1975,
as amended ("Knox -Keene Act") and any other applicable laws and regulations. Any provision
required to be in this Agreement by the Knox -Keene Act (Health & Safety Code Section 1340 et
sec .) or regulations promulgated thereunder (Title 28, Section 1300.43 et SeMc . of the California
Code of Regulations) shall bind the parties whether or not contained in this Agreement.
5. Acceptance of Contract
The Group may accept this Agreement either by execution of the face sheet or by making
the required Health Plan Premium payments to Universal Care, and such acceptance shall render
all terms and provisions hereof binding on the Health Plan and Group.
6. Contract Binding on Members
By this Agreement the Group makes the Health Plan coverage available to eligible
persons; however, this Agreement shall be subject to amendment or modification in accordance
with the provisions hereof or by mutual agreement between Universal Care and the Group
without the consent or concurrence of the Members.
7. Applications and Other Required Information
Members or those persons applying for membership shall complete and submit to the
Health Plan such applications, forms or statements as the Health Plan may reasonably request.
8
Universal Care Large Group GSA (R5) DMHC Approval Pending
Members warrant that all material information contained in such applications, questionnaires,
forms or statements submitted to the administration hereof are true, correct and complete, and all
rights to benefits hereunder are subject to the condition that all such information is true, correct
and complete.
8. Notices
Any notice under this Agreement may be given personally, by a recognized messenger
service such as Federal Express or by United States mail, postage prepaid, addressed as follows:
To the Health Plan: Universal Care
ATTN: President
1600 E. Hill Street
Signal Hill, CA 90806
To the Member: To the latest address provided for the Member on the enrollment or
change of address forms actually delivered to Universal Care.
To the Group: To the latest address provided by the Group in connection with
Health Plan Premium payments.
Notice of material matter sent to the Group by Universal Care shall be disseminated to Members
by the Group in its regular communication to Members, but in no case later than thirty (30) days
after receipt of such notice.
9. Discrimination Prohibited
The Health Plan shall not cancel this Agreement, nor decline to renew or reinstate this
Agreement, nor shall the terms of this Agreement be modified and the benefits or coverage be
subject to any limitations, exceptions, exclusions, reductions, copayments, coinsurance,
deductibles, reservations, premiums, price change differentials or other modifications because of
the race, color, national origin, ancestry, religion, sex, marital status, sexual orientation or, age of
any Member or applicant for membership, except that Health Plan Premiums, price or charge
differentials because of the sex or, age of any such individual and based on objective, valid and
up-to-date statistical, underwriting or actuarial data shall not be prohibited.
The Health Plan will not deny or limit coverage or charge higher Health Plan Premiums
for an enrollee solely because of a physical or mental impairment, except when the refusal,
limitation or rate differential is based on sound actuarial or underwriting principles or practices.
However, if the Health Plan has requested a Member or applicant for membership to disclose a
physical or mental impairment in enrollment application materials and that person fails to
disclose or misrepresents such an impairment, the Health Plan may terminate that person's
enrollment as set forth in the Combined Evidence of Coverage and Disclosure Form under the
Section titled "Ending Coverage (Termination of Benefits)."
10. Entire Agreement
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Universal Care Large Group GSA (R5) DMHC Approval Pending
This Agreement, the application of the Group, and the individual applications of
employees shall constitute the entire Agreement between the parties.
11. Recordkeeping
The Group is responsible for keeping records relating to this Agreement. Universal Care
has the right to inspect and audit those records.
COBRA CONTINUATION COVERAGE
With regard to COBRA, Universal Care is committed to the following:
A. Providing continuation coverage to Health Plan Members upon the request of a Group
when such requests are consistent with the Group's obligations under the law.
B. Sharing knowledge regarding COBRA with the Group as it experiences problems;
however, Universal Care will not give legal advice on these matters.
HEALTH PLAN BENEFITS AND COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM
Universal Care will issue and deliver to each Member a Combined Evidence of Coverage
and Disclosure Form (including a Benefit Schedule) which will set forth a statement of services
and benefits to which Members are entitled, along with an Identification Card.
As noted above, the services and benefits of this Health Plan are set forth in the attached
Combined Evidence of Coverage and Disclosure Form and are incorporated by reference herein.
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Universal Care Large Group GSA (RS) DMHC Approval Pending
41
1I
PO_4LE P100MRX4
Universal Care
Healthcare you can feel good about.
PREMIER 100 PHARMACY OPTION 4
LARGE GROUP
Section 1
Table of Contents
Welcome to Universal Care
Glossary of Terms
P100MRX4 PO 4LE
2
Tff-'Atv
Universal Care
t»`''' Healthcare you can feel good about.
Section 1
WELCOME TO UNIVERSAL CARE . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... . 4
GLOSSARY OF TERMS .............................................. 6
Section 2
BENEFIT SCHEDULE ................................................ 14
Section 3
CONFIDENTIALITY................................................. 42
ELIGIBILITY, ENROLLMENT & BEGINNING DATE OF COVERAGE . . . . .
. . . . . . . . . . .. . 42
Coverage for Dependents ............................................
42
New Family Members ...............................................
43
Enrollment......................................................44
Special Enrollment .................................................
44
When Your Coverage Begins ..........................................
44
Your Universal Care Member Identification Card ...............................
45
CHOICE OF PHYSICIANS AND PROVIDERS - ACCESSING CARE . . . ..
. . . . . . .. . . . . . 46
Facilities - Provider Locations ..........................................
46
Relationship Between Universal Care and Providers .............................
46
Choosing a Primary Care Physician . . . . . .. . . . . . . . . . . . . . . . . ..
. . . . . . . . . . . . . . 46
Using the Primary Care Physician . .. . . .. . . . . . . . . . . . .. . . . . ..
.. . . . . . . . .. . . . 47
Scheduling Appointments .............................................
47
Initial Health Assessment .............................................
48
Referrals to Specialists ...............................................
48
Prior Authorization - Approval, Modification,
or Denial of Health Care Services ........................................
48
Standing Referrals to Specialists .........................................
50
Extended Referral for Coordination of Care by Specialist ..........................
51
Access to OB/GYN Physician Services and Women's Routine
and Preventive Health Care Services ......................................
51
Continuity of Care for New Members ......................................
52
Terminated Providers - Continuity of Care for an Acute Conditions,
Serious Chronic Condition, and Certain Pregnancies ............................
52
Second Medical Opinions .............................................
53
Cancer Clinical Trials...........................................................
55
Changing Your Primary Care Physician .....................................
55
Service Area ..... ............... ..........................
. 56
EMERGENCY SERVICES AND URGENTLY NEEDED SERVICES . . . . . . . . . . . . . . . . . .. . . 56
Emergency Services ................................................ 56
What to do When You Require Emergency Services ............................. 56
Urgently Needed Services . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 57
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What to do When You Require Urgently Needed Services .......................... 57
Post -Stabilization Care ............................................... 57
Non -Qualifying Services . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Extraordinary Circumstances .......................................... 58
HEALTH PLAN PREMIUMS (PREPAYMENT FEES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
COPAYMENTS....................................................
59
Annual Copayment Maximum .........................................
59
Your Protection and Liability ..........................................
59
Claims Procedures (Reimbursement) ... ...................... ...........
60
CHANGES IN COVERAGE OR ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
61
Notifying Us of any Change in Your Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
61
Ending Coverage (Termination of Benefits) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
61
Notifying You of Changes in Your Plan ....................................
64
Renewal or Reinstatement ............................................
64
Continuing Coverage ..............................................
64
COBRA.......................................................
65
Individual Conversion ..............................................
65
REIMBURSEMENT OF THIRD PARTY LIABILITY .. . . . . . . . . . . .. . . . . . . . . . . . . . . . .
66
COORDINATION OF BENEFITS . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .
68
NON -DUPLICATION OF BENEFITS WITH CHAMPUS . . . . . . .. . . . . . . . . . . . .. . . . . .
68
NON -DUPLICATION OF BENEFITS WITH WORKERS' COMPENSATION . . . . . . . . . . . . . .
69
NON -DUPLICATION OF BENEFITS WITH MEDICARE . . . . . . . . . . .. . . . . . . . . . . . . . .
69
HOW UNIVERSAL CARE PARTICIPATING PROVIDERS ARE COMPENSATED . . . . . . . . . . .
70
MEMBER SERVICES . .. . . . . . . . . . . . . . .. . . . . ... . . . . . . . . . . . . . . . . . . . . . . .
71
Member Services Department & Multi -Lingual Services ..........................
71
24 Hour Nurse AdviceLine...........................................
71
Grievance Process ................................................
72
Quality of Care Complaints . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
Benefit Coverage, Reimbursement and Other Complaints Not
Involving the Quality of Care Rendered by a Provider . . . .. . . . . . . . . . . . . . . . . . . . . . .
73
Binding Arbitration ................................................
80
PUBLIC POLICY COMMITTEE . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
81
YOUR RIGHTS & RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Your Responsibilities............................................... 82
IMPORTANT INFORMATION ABOUT ORGAN AND TISSUE DONATION . . . . . . . . . . . . . 83
How to Learn More ............................................... 83
Section 4
SERVICE AREA ................................................... 86
3
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a_ ....... E _u_I_ D_E__N.._ C _E_ ....O _._F___C___OLu_ E WR._A.
AND DISCLOSURE FORM
Universal Care
Healthcare you can feel good about.
WELCOME TO UNIVERSAL CARE
This Combined Evidence of Coverage and Disclosure Form, including the accompanying Benefit
Schedule, summarizes your medical plan from Universal Care. These documents explain your rights
and responsibilities as a Universal Care Member. They also explain Universal Care's responsibilities to
you. This Combined Evidence of Coverage and Disclosure Form contains important information.
Please keep it in a safe place, available for quick reference.
Universal Care is a prepaid health care service plan licensed by the California Department of Managed
Health Care. Medical and hospital care is arranged by Universal Care through physicians, nurses, and
other health care professionals who work together to deliver the health care you need in a coordinated
manner.
NOTE. This Combined Evidence of Coverage and Disclosure Form discloses the terms
and conditions of coverage with Universal Care and all applicants have a right to view
this document prior to enrollment. This Form should be read completely and carefully.
Individuals with special health needs should carefully read those sections that apply to
them. You may receive additional information about the benefits of the Universal Care
health plan by calling 1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired.
Primary Care Physicians are available at Contracting Medical Groups. Contracting Medical Groups
include medical facilities owned and operated by Universal Care and independent physician groups
which contract with Universal Care to provide Covered Services to our Members. The locations and tele-
phone numbers for all Contracting Medical Groups are in the Universal Care Provider Directory fur-
nished to you at the time of enrollment. Universal Care also arranges for the availability of Physicians in
all major medical and surgical specialties at Contracting Medical Groups or by referral from the Member's
Contracting Medical Group or Primary Care Physician. Universal Care Contracting Hospitals provide a
full range of hospital inpatient services, as well as 24-hour a day emergency services, seven (7) days a
week.
Benefits may only be obtained from Contracting Medical Group physicians or Contracting Hospitals.
Universal Care will not reimburse you for services secured from Non -Contracting Providers except as
specified in this Combined Evidence of Coverage and Disclosure Form for Emergency or Urgently
Needed Services or when you are referred to a Non -Contracting Provider by your Universal Care
Primary Care Physician with the prior, written authorization of the Universal Care Medical Director.
Please read this booklet carefully so you will know your benefits and responsibilities as a Universal Care
Member. Please give extra attention to those sections that explain how to choose a Primary Care
Physician, the Covered Services that are available to you, how and where to obtain the Covered Services
you may need, and what to do in the event of a medical emergency. Your Primary Care Physician will be
responsible for providing and coordinating all your medical and hospital care.
PO_4LE
P100MRX4
L
To help you understand some of the terms used in this Evidence of Coverage, the
following words and phrases are defined as set forth below:
Benefit Year is the twelve (12) month period
commencing January 1st of each year at 12:01 a.m.
Contracting Hospital is a duly licensed general
acute care hospital or other health care facility that
has a written agreement with Universal Care to
provide medical, diagnostic and surgical facilities
for the care and treatment of Members on an inpa-
tient and outpatient basis, and which provides
such facilities under the supervision of a staff of
physicians and 24-hour a day nursing service, and
which is utilized by Contracting Medical Groups
for the provision of Hospital Services to Members.
Contracting Medical Groups are: (1) the out-
patient facilities and medical offices owned and
operated by Universal Care that provide Covered
Services to Members through Physicians employed
by Universal Care at these facilities and (2) the
independent medical groups or independent prac-
tice associations that have written agreements with
Universal Care to provide Covered Services to
Members at their offices. The Universal Care
Contracting Medical Groups are listed in the
Universal Care Provider Directory.
Contracting Pharmacy is a pharmacy that has
a contract to provide medication(s) prescribed to
Universal Care members by their Contracting
Providers in accordance with the terms and condi-
tions of the Health Plan.
Contracting Physician is a Physician who is
either employed by or under contract with
Universal Care or a Contracting Medical Group to
provide Covered Services to Members.
Contracting Providers are duly licensed
Physicians, surgeons, osteopaths, medical groups,
hospitals, skilled nursing facilities, extended care
PO_4LE
facilities, home health agencies, paramedical per-
sonnel, alcoholism and drug abuse centers, mental
health professionals and any other licensed health
care professionals or facilities which are owned or
employed by Universal Care or have a written
agreement with Universal Care to provide Covered
Services to Members.
Copayments are additional fees that a Member
must pay to a Contracting Provider at the time
Covered Services are provided and which are in
addition to the Health Plan Premium fees paid by
an Employer and any payroll contribution required
by your Employer. Copayments are either (i) a
fixed cost for each service provided; or (ii) a per-
centage of the discounted charges Universal Care
has negotiated with the Provider, sometimes called
"coinsurance". All Copayments have been
approved by the Department of Managed Health
Care and are disclosed in the Benefit Schedule.
Coverage Decision means the approval or
denial of health care services by Universal Care, or
by one of its Contracting Providers, substantially
based on a finding that the provision of a particu-
lar service is included or excluded as a Covered
Benefit under the terms and conditions of the
Universal Care Health Plan contract.
Covered Services are the Medically Necessary
Medical, Hospital and other health care services,
including Emergency and Urgently Needed
Services, arranged or paid for by Universal Care or
Contracting Medical Groups as set forth in the
Benefit Schedule and subject to the exclusions and
limitations set forth in the Principal Exclusions and
Limitations on Benefits and Principal Limitations
and Reductions in Services. The Group Subscriber
Agreement between Universal Care and your
P100MRX4
4, I.
__ G. l.__O_ S.__S _ A,R_X__-- CQ _ E
Employer must be consulted to determine the exact exists, and if it does, the care, treatment, and/or
terms and conditions of coverage.
Dependent means the Subscriber's spouse and/or
unmarried dependent children who are enrolled
and meet all the eligibility requirements of the
Group Subscriber Agreement and for whom
applicable health plan premiums have been
received by Universal Care.
Disputed Health Care Service means any
health care service eligible for coverage and pay-
ment under a Universal Care Health Plan contract
that has been denied, modified, or delayed by a
decision of Universal Care, or by one of its
Contracting Providers, in whole or in part due to a
finding that the service is not Medically Necessary.
Emergency Medical Condition means a med-
ical condition manifesting itself by acute symp-
toms of sufficient severity (including severe pain)
such that the absence of immediate medical atten-
tion could reasonably be expected by the Member
to result in any of the following:
• Placing the Member's health in serious jeopardy;
• Serious impairment to bodily functions;
• Serious dysfunction of any bodily organ or part; or
• Active labor, meaning labor at a time that either
of the following would occur:
(1) There is inadequate time to effect safe transfer
to another hospital prior to delivery; or
(2) A transfer poses a threat to the health and
safety of the Member or unborn child.
Emergency Services are Medically Necessary
ambulance, and ambulance transport services pro-
vided through the "911" emergency response sys-
tem, and medical screening, examination and eval-
uation by a physician, or other appropriate person-
nel under the supervision of a physician, to deter-
mine if an Emergency Medical Condition, includ-
ing a psychiatric emergency medical condition,
surgery by a physician necessary to relieve or elim-
inate the Emergency Medical Condition, including
psychiatric emergency medical condition, within
the capabilities of the facility.
Employer is your employer who has entered
into the Group Subscriber Agreement with
Universal Care.
Exclusion is any provision of this Agreement
whereby coverage for a specified injury, illness
or method of diagnosis or treatment is entirely
eliminated.
Experimental or Investigational Treatment
means any procedure, treatment, therapy, drug,
biological product, facility, equipment, device or
supply which Universal Care has determined not
to have been demonstrated as safe, effective and
medically appropriate for use in the treatment of
the illness, injury or condition at issue, as com-
pared with the conventional means of treatment or
diagnosis.
For Universal Care to determine 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 with conventional
treatment or diagnosis, 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 exemp-
tions are not sufficient.
7
P100MRX4 PO 4LE
8
• 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.
Evidence will not be considered conclusive if the
service or supply is the subject of ongoing Phase I,
II or III clinical trials; or if it is under study to
determine maximum tolerated dose, toxicity, safety
or medical appropriateness as compared with the
conventional treatment or diagnosis; or if its safety,
effectiveness or medical appropriateness is the sub-
ject of substantial debate within the national med-
ical community.
• The service or supply must be recognized or
approved in accordance with generally accepted
professional medical standards in the national
medical community as being safe, effective and
medically appropriate for use in the treatment of
the illness, injury or condition at issue. 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 determine whether a particular treatment is
experimental or investigational, Universal Care
shall refer to evidence from the national medical
community, which may include one or more of the
following sources:
• Evidence from national medical organizations,
such as the 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.
Upon referral to a clinical cancer trial by the
member's treating physician, Universal Care will
PO_4LE
cover the routine patient care costs for the mem-
ber's participation in a cancer clinical trial, sub-
ject to the specific requirements of Section 1370.6
of the California Health and Safety Code.
Fee -For -Service Rates means the non -dis-
counted fees or charges Contracting Providers rea-
sonably and customarily charge to individuals who
are not Members of this Health Plan or any other
health coverage plan.
Formulary is a list of the prescribed medications
that are covered by Universal Care. It is prepared
by Universal Care with participation by practicing
physicians and is regularly reviewed and revised to
meet the medical needs of Universal Care
Members.
Group Subscriber Agreement is the agree-
ment entered into by Universal Care and your
Employer under which you receive the benefits
and services summarized in this Evidence of
Coverage and Disclosure Document.
Health Plan/Universal Care Health Plan
refers to Universal Care, Inc., a California
Corporation, which operates a health care service
plan licensed by the State of California under the
Knox -Keene Health Care Service Plan Act of 1975,
as amended, and the terms and conditions set
forth in this combined Subscriber Agreement,
Evidence of Coverage and Disclosure Form, and
the Benefit Schedule.
Health Plan Premiums are amounts paid to
Universal Care by your Employer on your behalf
in consideration of the benefits provided under the
Health Plan.
Health Statement means a report of an individ-
ual's health history and conditions that may be
required for each person applying for enrollment.
Hospital Services are Medically Necessary ser-
vices and supplies performed or supplied by a
Contracting Hospital on an inpatient or outpa-
tient basis.
P100MRX4
Limitation means any provision other than an
Exclusion which restricts coverage under this
Agreement for an otherwise Covered Service.
Medically Necessary refers to Medical or
Hospital Services which are determined by
Universal Care or the Contracting Medical Group's
Utilization Review Process to be:
• Rendered for the treatment or diagnosis of any
injury or illness;
• Appropriate for the symptoms, consistent with
diagnosis, and otherwise in accordance with
generally accepted medical practice and
professionally recognized standards;
• Not furnished primarily for the convenience of
the Member, the attending physician or other
provider of services; and
• Furnished in the most economically efficient
manner, which may be provided safely and
effectively to Member. Inpatient Hospital
Services are Medically Necessary only if they
require the acute bed -patient (overnight)
setting and could not be provided in a physi-
cian's office, the outpatient department of a hos-
pital or in another appropriate facility without
adversely affecting the Member's condition or
the quality of care rendered.
Medical Services (Physician Services)
are Medically Necessary professional services of
Physicians, surgeons and paramedical personnel,
including medical, surgical, diagnostic and thera-
peutic services and preventive health services,
which are provided, directed or authorized by your
Primary Care Physician or Contracting Medical
Group, except as otherwise specified in this
Evidence of Coverage booklet.
Member is the Subscriber or any Dependent who
is enrolled, covered and eligible for Universal Care.
Member Services Department is a depart-
ment of Universal Care dedicated to answering
your questions concerning your membership, ben-
efits, grievances and appeals. A Universal Care
Member Services representative is available to
assist you during regular business hours by calling
1-800-635-6668 or TTY 1-866-321-5955 for the
hearing impaired, Monday through Friday from
8:00 a.m. to 6:00 p.m., or by writing to Universal
Care Member Services Department, 1600 East Hill
Street, Signal Hill, California 90806-3682.
Non -Contracting Pharmacy is a pharmacy
that does not have a contract to provide medica-
tion(s) prescribed to Universal Care members by
their Contracting Providers in accordance with the
terms and conditions of the Health Plan.
Non -Contracting Providers are licensed
physicians, surgeons, osteopaths, medical groups,
hospitals, skilled nursing facilities, extended care
facilities, home health agencies, paramedical per-
sonnel, alcoholism and drug abuse centers, mental
health professionals and any other licensed health
care professionals or facilities that do not have a
written agreement with Universal Care, or any of
its sub -contractors, to provide Covered Services to
Members and are not part of the Universal Care
health care delivery network.
Open Enrollment Period is a time period, of
not less than thirty (30) days, as determined by
Universal Care and your Employer during which
all eligible group employees and their Dependents
may enroll.
Out -of -Area Coverage is coverage while a
Member is anywhere outside Universal Care's
Service Area, and shall also include coverage for
Emergency and Urgently Needed Services.
Physician is a medical, allopathic or osteopathic
doctor duly licensed to practice in the State of
California.
P 100MRX4 PO4LE
9
�e V
10
Prescription Unit is the maximum amount
(quantity) of medication that may be dispensed
per single Copayment. For most oral medications
the Prescription Unit represents a thirty (30) day
supply of medication. The Prescription Unit for
other medications will represent a single container,
inhaler unit, package, or course of therapy. For
drugs that could be habit-forming, the Prescription
Unit is set at a smaller quantity for Member pro-
tection and safety.
Primary Care Physician or PCP is a
Contracting Physician who is specially trained in
internal medicine, family practice, general practice,
pediatrics or obstetrics/gynecology, and who is
chosen by the Member to be primarily responsible
for providing and managing all primary medical
care, maintaining the continuity of medical care,
and coordinating and authorizing referrals for hos-
pital services and specialty medical care.
Primary Residence is the home or address at
which the Member actually lives most of the time.
A residence will no longer be considered a Primary
Residence if (1) the Member moves without intent
to return, (2) the Member is absent from the resi-
dence for ninety (90) consecutive days, or (3) the
Member is absent from the residence for more
than one hundred (100) days in any six (6) month
period. The Subscriber shall notify Universal Care
of a change in Primary Residence of the Subscriber
or any Dependent of the Subscriber. A change in
Primary Residence shall result in disenrollment of
the Member if the Member's Primary Residence is
not within the Service Area.
Primary Workplace is the facility or location at
which the Member works most of the time and to
which the Member regularly commutes. If the
Member does not regularly commute to one loca-
tion then the Member does not have a Primary
Workplace.
PO_4LE
Prior Authorization or Pre -Authorization
or Pre -Certification is the requirement that
your Primary Care Physician requests approval of
coverage from Universal Care or the Contracting
Medical Group with which the Primary Care
Physician is affiliated prior to your obtaining cer-
tain Covered Services.
Qualifying Prior Coverage means any public
or privately sponsored individual or group policy,
contract or program, that is written or adminis-
tered by a disability insurer, non-profit hospital
service plan, health care service plan, fraternal
benefits society, the Federal Medicare Program or
the Medicaid Program, in this state or elsewhere,
and that arranges or provides medical, hospital,
and surgical coverage not designed to supplement
other private or governmental plans. The term
does not include accidental only, credit, disability
income, Medicare supplement, long term care,
dental, vision, coverage issued as a supplement to
liability insurance, workers' compensation, auto-
mobile medical payment insurance, or insurance
under which benefits are payable with or without
regard to fault and that is statutorily required to be
contained in any liability insurance policy.
Religious Employer is an entity for which each
of the following is true:
1. The inculcation of religious values is the
purpose of the entity.
2. The entity primarily employs persons who
share the religious tenets of the entity.
3. The entity serves primarily persons who share
the religious tenets of the entity.
4. The entity is a nonprofit organization as
described in Section 6033 (a) (2) (A) i or iii, of
the Internal Revenue Code of 1986, as amended.
P100MRX4
♦ f r
Service Area means the geographic area in the
State of California designated by Universal Care
and approved by the California Department of
Managed Health Care in which the Health Plan
provides and arranges for Covered Services. A zip
code list of the Universal Care Service Area is
located at the end of this Agreement.
Skilled Nursing Care refers to skilled nursing
services or physical therapy services which are
Medically Necessary, ordered by the Member's
Contracting Medical Group, required to be pro-
vided by a licensed nurse or a licensed physical
therapist and above the level of custodial care.
Skilled Nursing Care must be authorized under
the Health Plan.
Skilled Nursing Facility is a skilled nursing
facility or skilled nursing unit of a legally operated
Hospital certified under Titles XVIII and XIX of
the Social Security Act.
Spouse is the Subscriber's legally recognized hus-
band or wife under the laws of the State of
California.
Subscriber is the person who enrolls in
Universal Care and meets all the applicable eligi-
bility requirements of the employer group and
Universal Care, and for whom health plan premi-
ums have been received by Universal Care, and
whose enrollment or other status, except family
dependency, is the basis for eligibility for member-
ship in Universal Care.
Universal Care is a California corporation that
is licensed under the Knox -Keene Health Care
Service Plan Act of 1975.
Universal Care Medical Group or Medical
Group means: (i) medical offices owned and
operated by Universal Care and (h) independent
medical groups that contract with the Health Plan
to provide primary care or "first contact" medical
services to Universal Care Members at their offices.
Each Subscriber is to select a Universal Care
Medical Group and the Subscriber and his or her
Dependents should each select an individual
physician within that Medical Group as his or her
primary physician.
Universal Care Provider Directory is the
listing of the names and locations of all the
Contracting Medical Groups and Primary Care
Physicians and Contracting Hospitals, which was
furnished to Members at the time of enrollment in
Universal Care and which may be updated from
time to time by Universal Care
Urgently Needed Services are Medically
Necessary services required outside of the Service
Area to prevent serious deterioration of the
Member's health resulting from an unforeseen
illness, injury or condition manifesting itself by
acute symptoms of sufficient severity, which may
include severe pain, such that treatment cannot
be delayed until the Member returns to the
Service Area.
Utilization Review Committee is a commit-
tee utilized by Universal Care or a Contracting
Medical Group to promote the efficient use of
resources and to maintain the quality of health
care. If necessary, this committee will review and
determine if particular services are Medically
Necessary Covered Services.
11
P100MRX4 PO 4LE
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z' Universal Care!
Healthcare you can feel good about.
Section 2
I Benefit Schedule
PIOOMRX4 PO 4LE
14
THIS BENEFIT SCHEDULE SUMMARIZES THE GROUP PREPAID MEDICAL
CARE PLAN BEING OFFERED BY UNIVERSAL CARE. KEEP IT IN A SAFE
PLACE FOR FUTURE REFERENCE.
THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM CONSTITUTES
ONLY A SUMMARY OF THE PLAN. THE GROUP SUBSCRIBER AGREE-
MENT MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND
CONDITIONS OF COVERAGE. IF YOU WOULD LIKE A COPY OF THE
ACTUAL CONTRACT, ONE WILL BE FURNISHED UPON REQUEST.
THE SERVICES OF THIS PLAN ARE PROVIDED WHEN PERFORMED, PRE-
SCRIBED, DIRECTED OR AUTHORIZED AS MEDICALLY NECESSARY BY A
PHYSICIAN OR MEDICAL DIRECTOR IN THE UNIVERSAL CARE MEDICAL
GROUP THAT THE MEMBER HAS SELECTED.
Please see the Universal Care Large Group Plan Disclosure booklet for the Universal Care Benefit Plan
Matrix. This referenced Matrix is used to compare coverage benefits and is a summary only.
1. INTRODUCTION TO BENEFITS
You will receive health care services directly from your Primary Care Physician and from other health
care professionals upon referral by your Primary Care Physician and upon Prior Authorization by
your Contracting Medical Group. Obstetrical and gynecological services may also be received directly
from an OB/GYN or Family Practice Physician affiliated with your Contracting Medical Group.
Hospital Services will be coordinated by your Primary Care Physician, who will arrange for the provi-
sion of Medically Necessary inpatient or outpatient hospital care at a Contracting Hospital upon the
Prior Authorization of your Medical Group. The following description of your benefits explains
health services provided to you on an outpatient basis, health services provided to you on an inpa-
tient basis, what you should do in an emergency, your prescription drug benefit, and the exclusions
and limitations on benefits provided by this Health Plan.
PO_4LE
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New Technologies
Universal Care has a standardized process for evaluating new technology to keep pace with develop-
ing health technology and to help ensure that members have access to safe and effective care.
Advances in medical technology are evaluated and may be approved for coverage if:
• they provide a demonstrable benefit for a particular illness or disease
• they are scientifically proven to be safe and efficacious
• there is no equally effective or less costly alternative
Additional information on the process for evaluating new technology can be obtained by calling the
Universal Care Member Services Department at 1-800-635-6668 or TTY 1-866-321-5955 for the hear-
ing impaired.
Some hospitals and other providers do not provide one or more of the following
services that may be covered under your plan contract and that you or your family
member might need: family planning; contraceptive services, including emergency
contraception; sterilization, including tubal ligation at the time of labor and deliv-
ery; infertility treatments; or abortion. You should obtain more information before
you enroll. Call your prospective doctor, medical group, independent practice asso-
ciation, or clinic, or call the health plan at 1-800-635-6668 or TTY 1-866-321-5955
for the hearing impaired to ensure that you can obtain the health care services that
you need.
1s
PIOOMRX4 PO 4LE
16
ON AN OUTPATIENT BASIS
COPAYMENTS
$20 per visit I A. Physician Services - Medically Necessary diagnostic and treatment ser-
vices provided by Member's Primary Care Physician, as well as services provided
by other licensed health professionals upon the Prior Authorization of the
Member's Contracting Medical Group, including preventive services, surgical pro-
cedures, consultation and treatment. The Member may obtain obstetrical and
gynecological Physician services by self -referring directly to an OB/GYN or Family
Practice Physician affiliated with the Member's Contracting Medical Group.
$20 per visit
B. Periodic Health Evaluations - Physician, laboratory, radiology and
related services as recommended by the American Academy of Pediatrics and the
U.S. Preventive Health Task Force and authorized through Member's Contracting
Medical Group to determine Member's health status. Adult male examinations
may include screening and diagnosis for prostate cancer (including but not limit-
ed to prostate -specific antigen testing and digital rectal examination) when
Medically Necessary and consistent with good professional practice. Provides
coverage for all generally medically accepted cancer screening tests. For women,
refer to Well -Woman Care benefit. For children under two (2) years old, refer to
Well -Baby Care benefit.
$20 per visit
C. Well -Baby Care - Preventive health services, including immunizations, pro-
vided by the Member's Contracting Medical Group, up to age two (2) .
$20 per visit
D. Well -Woman Care - Examinations for women include Papanicolaou (pap)
smear, manual breast examination, and pelvic examination by a Contracting
Medical Group OB/GYN or Family Practice Physician affiliated with the
Member's Contracting Medical Group and upon referral by the Contracting
Medical Group for screening Mammography as recommended by the U.S.
Preventative Health Services Task Force.
$20 per visit
E. Immunizations - Immunizations for children are covered consistent with
the most current version of both of the following: (a) the recommendations for
preventive pediatric health care, as adopted by the American Academy of
Pediatrics and (b) the most current version of the recommended Childhood
Immunization Schedule /United States, jointly adopted by the American Academy
of Pediatrics, the Advisory Committee in Immunization Practices, and the
American Academy of Family Physicians. The following immunizations may be
covered: DPT, DP, Tetanus Toxoid, Oral Polio, Measles, Mumps, Rubella,
Hepatitis B, Haemophilus, influenza type b and Varicella. Covered for children
under two (2) years of age.
P0_41,E
P100MRX4
r
ON AN OUTPATIENT BASIS
COPAYMENTS
Immunizations for adults are covered consistent with the most current recom-
mendations of the U.S. Preventive Task Force. Travel Immunizations that are rec-
ommended and approved by the Centers for Disease Control and Prevention (the
"CDC") for the country you are visiting are covered.
No charge for
F Health Education Services - Counseling and educational material on a
regular plan pro-
variety of health subjects, such as prenatal care, family planning, nutrition and
grams. Reasonable
appropriate use of Health Plan services and instructions on achieving and main -
charges for special
taining good health. Includes general health education services not addressed to
programs made
specific medical conditions such as weight -control, smoking cessation, etc.
available to Plan
members.
$20 per visit
G. Maternity Care, Tests and Procedures - Physician visits, laboratory,
including the California Department of Health Services expanded Alpha-Feto
Protein (AFP) program, and radiology services are covered for complete prenatal
and postpartum outpatient maternity care.
H. Family Planning - The following services are covered when authorized by
Member's Contracting Medical Group:
$150 per procedure
1. Vasectomy (male sterilization)
$150 per procedure
2. Tubal ligation (female sterilization)
$150 per procedure
3. Voluntary interruption of pregnancy when not Medically Necessary
(through twenty (20) weeks). Voluntary interruption of pregnancy after
the twentieth (20th) week is covered only when the mother's life is in
jeopardy.
$150 per procedure
4. Induced interruption of pregnancy when Medically Necessary.
No charge
5. Information and instruction on methods of birth control.
6. Insertion, removal or injection of the following are covered:
$20 copayment
• Intra-Uterine Device (IUD) (device not covered)
$20 copayment
• Norplant (device not covered)
$20 copayment
• Diaphragm (device not covered)
$20 copayment
• Cervical cap (device not covered)
$20 copayment
• Depo-Provera Injection (medication not covered)
17
P100MRX4 PO 4LE
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18
ON AN OUTPATIENT BASIS
COPAYMENTS
The following family planning devices, supplies or medications are not covered:
• IUD
• Norplant device
• Diaphragm
• Cervical cap
• Depo-Provera Medication
1. Infertility Service - Universal Care provides coverage for the following
infertility benefits. Universal Care's infertility benefit is limited to a lifetime max-
imum of $15,000 per member. Male infertility treatment is not covered.
Procedures consistent with established medical practices in the treatment of
infertility are covered, including diagnosis, diagnostic tests, medication, and
surgery. However, In -Vitro Fertilization ("IVF"), as well as procedures related to
IVF, are not covered.
Infertility is defined as either: (1) the presence of a demonstrated condition rec-
ognized by a Contracting Medical Group as a cause of infertility, or (2) documen-
tation in the patient's medical record reflecting the inability to conceive a preg-
nancy or to carry a pregnancy to live birth after a year or more of regular sexual
relations, without contraception.
49% of charges 1. Physiologic infertility studies including sperm count; hysterosalpingogra-
phy; endometrial biopsy; clomid therapy; estrogen level; prolactin serum
level; blood studies to rule out systemic diseases such as anemia, dia-
betes, hyperthyroidism or hypothyroidism.
49% of charges 2. Physiologic infertility treatment, including surgery, artificial insemina-
tion, and embryo transplants if determined to be medically necessary by
the Universal Care Medical Director.
49% of charges 3. Embryo transplants (limited to Gamete Intrafallopian Transfer (GIFT))
will be considered for women who have failed infertility treatment guide-
lines of Universal Care. The GIFT benefit is limited to a lifetime benefit
of one procedure authorized by Universal Care's Medical Director.
49% of charges 4. Prescription drugs for infertility treatment include including "GIFT".
$20 per visit J. Allergy Testing and Treatment - Testing for the determination of proper
allergy treatment and services necessary for the treatment of allergies, including
allergy antigen.
P0_4LE P100MRX4
ON AN OUTPATIENT BASIS
COPAYMENTS
$20 per visit
K. Hearing Screening - Routine hearing screening to determine the need for
hearing correction through age eighteen (18).
$20 per visit
L. Vision Screening - Routine eye health assessment and screening to deter-
mine the need for vision correction through age eighteen (18).
No charge
M. Outpatient Surgery - Short -stay, day care or other similar outpatient
surgery facility when provided as a substitute for inpatient care as described
below under the section titled "Benefits while Hospitalized as an Inpatient", and
the subsections titled "Inpatient Hospital Benefits/Acute Care" and
"Reconstructive Surgery". Professional Physician services included as part of
inpatient Physician care benefit.
$20 per visit
N. Therapy and Rehabilitative Treatments - Physical therapy, speech
therapy, occupational therapy and other outpatient rehabilitative treatments are
limited to thirty (30) sessions for any injury, illness or congenital abnormality.
An additional thirty (30) sessions, up to a maximum of sixty (60) sessions total,
will be covered if, in the opinion of the participating physician and Medical
Director of Universal Care or Contracting Medical Group, significant improve-
ment will result from such treatment.
$50 copayment
O. Ambulance - Ambulance (land or air) and ambulance transport services
provided to a Member as a result of a "911 " emergency response system request
for assistance are covered, without prior authorization, if either: (1) the request
for assistance is made for a medical condition that requires Emergency Services
and ambulance transport services are required or (2) the Member reasonably
believes that the medical condition requires ambulance transport services. It is
appropriate for Members to use the "911 " emergency response system for assis-
tance when the Member has a medical condition that the Member reasonably
believes requires ambulance services to transport the Member to the nearest hos-
pital. Use of an ambulance for non -emergency Medically Necessary transport is
covered when specifically authorized by Member's Primary Care Physician or
Member's Contracting Medical Group.
$20 per visit
R Breast Cancer Screening, Diagnosis and Treatment - Services neces-
sary for screening, diagnosis of and treatment for breast cancer are covered.
Screening and diagnosis will be covered consistent with generally accepted med-
ical practice and scientific evidence, upon referral by the Member's Contracting
Physician. Mammography for screening or diagnostic purposes is covered as
19
P100MRX4
PO 4LE
r
4, •r
20
l I,.._ E_N_ A 1 t A _
ON AN OUTPATIENT BASIS
COPAYMENTS
authorized by your Contracting Nurse Practitioner, Contracting Certified
Midwife, or Contracting Physician, providing care to the Member and operating
within the scope of practice provided under California law. Treatment for breast
cancer is covered as authorized by the Member's Primary Care Physician,
Contracting Medical Group or Universal Care, as applicable.
$20 per visit
Q. Dental Treatment Anesthesia - General anesthesia and associated facili-
ty charges are covered for dental procedures rendered in a hospital or ambulatory
surgery center, as prior authorized and directed by the Member's Contracting
Medical Group, when any of the following criteria are met: (i) the Member is
under seven (7) years of age; or (ii) the Member is developmentally disabled,
regardless of age; or (iii) the Member's health is compromised and general anes-
thesia is Medically Necessary.
$20 per visit
R. Diabetes Management and Treatment - Diabetes management and
No charge for
treatment are covered as prescribed by the Member's Contracting Medical Group.
supplies for the
Services include outpatient self -management training, education and medical
management and
nutrition therapy services, and additional diabetes outpatient self -management
treatment of
training, education and medical nutrition therapy upon the direction or prescrip-
diabetes that are
tion of those services by the Member's Contracting Physician as Medically
provided in Your
Necessary. The diabetes outpatient self -management training, education, and
provider's office.
medical nutrition therapy services covered under this benefit shall be provided
Supplies obtained
by appropriately licensed or registered health care professionals as prescribed by
from a Contracted
a Contracting Provider legally authorized to prescribe the service.
Pharmacy are subject
Universal Care covers specified equipment and supplies for the management and
to the applicable
treatment of insulin -dependent diabetes, non -insulin dependent diabetes, and
copayment charge
gestational diabetes as Medically Necessary, even if the items are available with -
under Your pharmacy/
out a prescription. Covered equipment and supplies include: (1) blood glucose
drug coverage.
monitors and blood glucose testing strips; (2) blood glucose monitors designed
to assist the visually impaired; (3) insulin pumps and all related necessary sup-
plies; (4) ketone urine testing strips, (5) lancets and lancet puncture devices; (6)
pen delivery systems for the administration of insulin; (7) podiatric devices to
prevent or treat diabetes -related complications; (8) insulin syringes; and (9) visu-
al aids, excluding eyewear, to assist the visually impaired with proper dosing of
insulin. Additionally, the following prescription items are covered if they are
determined to be Medically Necessary: (1) insulin; (2) prescription medications
for the treatment of diabetes; and (3) glucagon.
PO_4LE
P100MRX4
to V 3 44 x1
.__Ii BENEFITS AVAI4ABI._E
O N AN OUTPATIENT BASIS
COPAYMENTS
No charge
No charge
No charge
$20 per visit
S. Durable Medical Equipment, Corrective Appliances and Prosthetics
1. Durable Medical Equipment - Medically Necessary durable medical equip-
ment is covered when it is designed to assist an injury or illness of the
Member and is appropriate for use in the home. Durable medical equipment
is medical equipment which does not easily deteriorate for a reasonable
period of time. Examples of covered durable medical equipment include
glucose monitoring devices, wheelchairs, manually operated hospital beds
and oxygen machines.
2. Corrective Appliances - Medically Necessary corrective appliances are cov-
ered as determined by Member's Primary Care Physician as authorized by
Member's Contracting Medical Group. Corrective appliances are devices,
such as crutches, trusses, braces or orthotics, which are designed to support
a weakened body part.
3. Prosthetics - Medically Necessary prosthetics are covered as authorized by
Member's Contracting Medical Group. Prosthetics are durable, custom-made
devices designed to replace all or part of a permanently inoperative or mal-
functioning body part or organ. Examples of covered prosthetics include:
removable non -dental prosthetic devices such as false eyes or limbs that do
not require surgical connection to nerves, muscles or other tissue.
Corrective appliances, prosthetics and durable medical equipment purchase
or rental is limited to initial placement, repair or adjustment, and replace-
ment due to normal wear and tear or because of a significant change in the
Member' physical condition (as determined by Member's Contracting
Medical Group).
T. Home Health Care - Medically Necessary part-time or intermittent skilled
home care is covered, up to a maximum of one hundred (100) visits per benefit
year, when authorized by Member's Contracting Medical Group. If extensive
home care is required, Member may be required to transfer to an alternative care
setting such as a Skilled Nursing Facility. Temporary private duty Skilled
Nursing Care is covered to train family members willing and capable of provid-
ing care in the home. Unsuccessful training of the family members may result in
placement in an alternative care setting.
21
P100MRX4 PO 4LE
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22
ON AN OUTPATIENT BASIS
COPAYMENTS
No charge
U. Hospice Care - Hospice services authorized by Member's Contracting
Medical Group are covered in a facility or on an outpatient basis when Member:
(i) has been determined to have six (6) months of life expectancy or less; and (ii)
no longer wishes to pursue aggressive medical treatment, but instead chooses
supportive nursing care and counseling during the terminal phase of an illness
and bereavement services following the death of the member. Hospice care bene-
fit includes hospice nursing care, social services evaluation, counseling and home
health aide services.
$20 per visit
V. Phenylketonuria (PKU) Testing and Treatment - Testing for
Please see
Phenylketonuria (PKU) is covered when Medically Necessary to prevent the
applicable copay-
development of serious physical or mental disabilities or to promote normal
ment under Your
development or function as a consequence of PKU.
Prescription Drug
Coverage includes FDA approved special low protein formulas specifically
Benefit for approved
approved for PKU and food products that are specially formulated to have less
formulas and spe-
than one gram of protein per serving. Food products naturally low in protein are
cial food products.
not covered.
W. Mental Health Services - Diagnosis and Medically Necessary treatment of
severe mental illness and/or serious emotional disturbances of a child are provid-
ed when referred by a Universal Care Contracting Physician. The benefit
includes outpatient services, inpatient hospital services, partial hospital services,
and prescription drugs. The mental health benefit is subject to the same maxi-
mum lifetime benefit limitations, annual maximums, copayments, and individual
and family deductibles as benefits for physical illnesses. Mental health benefits
may be provided by Universal Care through a subcontract (or by your Employer
through a contract) with a health plan that specializes in mental health services.
For purposes of the mental health benefit, a "severe mental illness" means: (a)
Schizophrenia; (b) Schizoaffective disorder; (c) Bipolar disorder (manic-depres-
sive illness); (d) Major depressive disorders; (e) Panic disorder; (f) Obsessive -
compulsive disorder; (g) Pervasive developmental disorder or autism; (h)
Anorexia nervosa; and (i) Bulimia nervosa.
PO_4LE
P100MRX4
N
11 _B...._�..NEFITS AVAILABI F
ON AN OUTPATIENT BASIS
COPAYMENTS
For purposes of the mental health benefit, a "serious emotional disturbance
(SED) of a child" means a minor under the age of eighteen (18) years who has at
least one disorder, as identified in the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders (other than a primary substance abuse dis-
order or developmental disorder), that results in behavior inappropriate to the
child's age according to expected developmental norms. In addition, the child
shall meet at least one of the following sets of criteria set forth in subsections
(a) through (c) below.
Due to a mental disorder either:
(a) the child manifests psychotic features, risk of suicide or risk of violence;
OR
(b) the child has substantial impairment in at least two of the following
areas: self -care, school functioning, family relationships, or ability to func-
tion in the community AND either the child is at risk of removal from home
or has already been removed from home, or the mental disorder and impair-
ments have been present for more than six (6) months or are likely to con-
tinue for more than one (1) year without treatment;
OR
(c) the child meets special education eligibility requirements under Division
7 of Title 1 of the California Government Code.
Upon referral by a PCP, the initial evaluation by a licensed psychiatrist, licensed
psychologist, licensed marriage, family therapist ("MFT"), or licensed clinical
social worker ("LCSW"), as well as continuing treatment is subject to an office
visit copayment.
$20 per visit 1. Mental Health Consultation by a Primary Care Physician.
$20 per visit 2. Initial Evaluation by a licensed psychiatrist, licensed psychologist, MFT, or
LCSW if required.
$20 per visit 3. Treatment for severe mental illness for Members with confirmed diagnoses
Inpatient services of schizophrenia, schizoaffective disorder, bipolar disorder, major depressive
copayment is equal
to the inpatient disorders, panic disorder, obsessive -compulsive disorder, anorexia nervosa,
hospital benefit as bulimia nervosa, pervasive developmental disorder or autism and serious
set forth under emotional disturbances of children.
"Benefits while
Hospitalized as an
Inpatient".
P100MRX4 PO 4LE
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24
11 B�NEFIT� A1[AILA�I �
ON AN OUTPATIENT BASIS
COPAYMENTS
$40 per visit 4. Treatment, other than for severe mental illness or serious emotional distur-
bances of a child, by a psychiatrist (M.D.), psychologist (Ph.D.), or licensed
therapist with a Master's degree for crisis intervention and/or the evaluation
of an acute mental health condition is limited to twenty (20) outpatient ses-
sions for short term evaluation or crisis intervention in the Benefit Year.
Each session consists of up to fifty (50) minutes in person or by telephone
with a psychiatrist (M.D.), psychologist (Ph.D.) or licensed therapist with a
Master's degree.
$20 per visit X. Alcohol, Drug and Other Substance Abuse - Treatment for detoxifica-
tion (limited to 72 hours per occurrence and a maximum of eighteen (18) days
per Benefit Year) is covered when authorized by Member's Contracting Medical
Group. Rehabilitation for alcohol, drug or other substance abuse is not covered.
$50 copayment Y. Emergency Treatment - Emergency services for necessary medical ser-
vices are covered. (For additional information with regard to Emergency
Treatment, please see the sections of this document titled "Emergency Services
and Urgently Needed Services" and "Coverage of Emergency or Urgently Needed
Services").
$20 per visit Z. Diagnostic Tests - X-ray and laboratory tests for diagnostic purposes,
and other diagnostic, radiological services, electrocardiography and electroen-
cephalography
PO_4LE P100MRX4
M
AS AN INPATIENT
COPAYMENTS
No charge
A. Inpatient Hospital Benefits/Acute Care - Medically Necessary inpa-
tient hospital services authorized by Member's Contracting Medical Group are
covered in a semi -private room (where available).
No charge
B. Inpatient Physician Care - The services of Physicians while Member is
hospitalized as an inpatient are covered, including the services of Member's
Contracting Medical Group Physicians, surgeons, assistant surgeons, anesthesiol-
ogists, and any other specialty Physician.
No charge
C. Maternity Care - Inpatient Hospital Services for maternity care, including
Inpatient services
labor and delivery room and recovery room, delivery by Cesarean section, mis-
copayment is equal
carriage, involuntary abortion and any complications of pregnancy or childbirth.
to the inpatient
Educational classes on lactation, childcare and/or child bearing (Lamaze) are not
hospital benefit as
covered.
set forth under
A minimum 48 hour inpatient stay for normal vaginal delivery and a minimum 96
"Benefits while
hour inpatient stay following delivery by Cesarean section is covered. The inpa-
tient hospital stay may be for a time period less than 48 or 96 hours if the decision
Inpatient".
to discharge the mother and newborn before the 48 or 96 hour time period is
made by the treating Physician in consultation with the mother. In addition, if the
mother and newborn are discharged prior to the 48 or 96 hour time period, a post -
discharge follow-up visit for the mother and newborn must be provided within 48
hours of discharge, when prescribed by the treating Physician.
No charge
D. Newborn Care - Complete prenatal and post -natal Hospital Services.
Coverage for newborn children of the Subscriber begins at birth. In order for
coverage to continue beyond thirty-one (31) days after the date of birth, an
enrollment form for the Dependent must be submitted to Universal Care within
thirty-one (31) days from the date of birth.
No charge
E. Inpatient Rehabilitation/Subacute Care - Medically Necessary ser-
vices, as determined by Member's Contracting Medical Group or Universal Care's
Medical Director, which are provided in an inpatient rehabilitation facility to
train or retrain a Member disabled by disease or injury to Member's highest level
of functional ability are covered. Inpatient rehabilitation services include room
and board, physical, speech and occupational therapy and other services custom-
arily provided in an inpatient rehabilitation facility, when Medically Necessary.
P100MRX4
PO 4LE
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26
AS AN INPATIENT
COPAYMENTS
Coverage for subacute care includes Medically Necessary inpatient services
authorized by the Member's Contracting Medical Group provided in an acute
care hospital, or a comprehensive freestanding rehabilitation facility. Members
may call Universal Care's Member Services Department to obtain a list of con-
tracting subacute or transitional inpatient care facilities. Members may also call
the Member Services Department to request a copy of Universal Care's utilization
review and prior authorization processes that apply to care provided in subacute
care, transitional inpatient care and skilled nursing facilities.
No charge F. Mastectomy/Breast Reconstruction after Mastectomy and
Complications from Mastectomy - Surgery to perform a Medically
Necessary mastectomy and lymph node dissection is covered, including prosthet-
ic devices or reconstructive surgery to restore and achieve symmetry for the
Member incident to the mastectomy. The length of a hospital stay associated
with a Medically Necessary mastectomy and lymph node dissection is deter-
mined by the attending physician and surgeon in consultation with the Member,
consistent with sound clinical principles and processes. Coverage includes any
initial and subsequent reconstructive surgeries or prosthetic devices for the dis-
eased breast on which the mastectomy was performed and for a healthy breast if,
in the opinion of the attending physician and surgeon, this surgery is necessary
to achieve normal symmetrical appearance. Medical treatment for any complica-
tions from a mastectomy, including lymphedema, is covered.
No charge G. Reconstructive Surgery - Pre -Authorized Reconstructive Surgery is cov-
ered when performed to correct or repair abnormal structures of the body caused
by congenital defects, developmental abnormalities, trauma, infection, tumors, or
disease to do either of the following: (i) to improve function; or (ii) to create a
normal appearance, to the extent possible.
No charge H. Skilled Nursing Care - Skilled Nursing Care is covered in a Skilled
Nursing Facility for up to thirty (30) days per benefit year when Medically
Necessary, as determined by the Contracting Medical Group's Medical Director or
Universal Care's Medical Director. Skilled Nursing Care includes, but is not lim-
ited to: room and board, general nursing care, pharmaceuticals, biologicals, sup-
plies and equipment ordinarily provided or arranged by a Skilled Nursing
Facility, when Medically Necessary, as determined by the Medical Director of the
Member's Contracting Medical Group or Universal Care's Medical Director.
PO_4LE PIOOMRX4
AS AN INPATIENT
COPAYMENTS
No charge
I. Hospice Care - Hospice services authorized by Member's Contracting
Medical Group are covered in a facility or on an outpatient basis when Member:
(i) has been determined to have six (6) months of life expectancy or less; and (ii)
no longer wishes to pursue aggressive medical treatment, but instead chooses
supportive nursing care and counseling during the terminal phase of an illness.
No charge
J. Alcohol, Drug and Other Substance Abuse - Treatment for detoxifica-
Inpatient services
tion (limited to 72 hours per occurrence and a maximum of eighteen (18) days
copayment is equal
per benefit year) is covered when authorized by Member's Contracting Medical
to the inpatient
Group. Rehabilitation for alcohol, drug or other substance abuse is not covered.
hospital benefit as
set forth under
"Benefits while
Hospitalized as
an Inpatient".
No charge
K. Mental Health Services - Inpatient Hospital Services when referred by a
Inpatient services
Contracting Physician for the diagnosis and Medically Necessary treatment of severe
copayment is equal
mental illness and/or serious emotional disturbances of a child. For a full descrip-
to the inpatient
tion of the benefit see Section II - "Benefits Available on an Outpatient Basis".
hospital benefit as
set forth under
"Benefits while
Hospitalized as
an Inpatient".
$50 copayment
L. Emergency Treatment - Emergency services for necessary medical ser-
vices are covered. (For additional information with regard to Emergency
Treatment, please see the sections of this document titled "Emergency Services
and Urgently Needed Services" and "Coverage of Emergency or Urgently Needed
Services").
27
P100MRX4 PO 4LE
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_ L'V
OR URGENTLY NEEDED SERVICES
IV. Coverage Of Emergency Or Urgently Needed Services
Emergency Services or Urgently Needed Services received in a Physician's office, hospital emergency
room or other facility providing Medical or Hospital Services.
An Emergency Service is a Medically Necessary Medical or Hospital Service required as a result of a
medical condition manifesting itself by acute symptoms of sufficient severity, which may include
severe pain, such that a reasonable person would expect the absence of immediate medical attention
to result in: (1) placing the health of the individual in serious jeopardy; (2) serious impairment to
bodily functions; or (3) serious dysfunction of any bodily part. An Emergency Service includes
Medically Necessary Medical or Hospital Services required as a result of active labor, which means a
labor at a time at which either (1) there is inadequate time to effect a safe transfer to another hospital
prior to delivery, or (2) a transfer may pose a threat to the health and safety of the Member or the
unborn child. Emergency Services includes ambulance and ambulance transport services provided
through the "911" emergency response system.
Urgently Needed Services are Medically Necessary services required outside of the Service Area to
prevent serious deterioration of the Member's health resulting from unforeseen illness or injury mani-
festing itself by acute symptoms of sufficient severity, which may include severe pain, such that treat-
ment cannot be delayed until the Member returns to the Service Area.
Examples of medical conditions requiring Emergency Services include chest pain, strokes, poisonings,
gunshot wounds, or the sudden inability to breathe. Urgent situations refer to less serious medical
conditions, such as broken bones, non -life -threatening cuts which nevertheless require immediate
suturing to ensure proper healing, and acute illnesses when the Member is outside the Universal Care
Service Area and the delay necessary to return to the Service Area or to contact the Member's
Contracting Medical Group would result in a serious deterioration in the Member's Health.
PO_4LE
P100MRX4
m
OR URGENTLY NEEDED SERVICES
Once the Member has received Emergency or Urgently Needed Services and has been stabilized, Prior
Authorization from the Member's Primary Care Physician or the Member's Contracting Medical Group is
required for the provision of Medically Necessary post -stabilization follow-up care. Universal Care or
the Contracting Medical Group will approve or disapprove a treating provider's request for authorization
to provide Medically Necessary post -stabilization medical care within one half-hour of the request.
Universal Care or the Contracting Medical Group may require the Member to receive follow-up care
from a Contracting Provider if the transfer or discharge of the Member does not have an adverse impact
upon the Member's care or medical condition. However, any Medically Necessary care required to
maintain the Member's stabilized condition up to the time that Universal Care effectuates the Member's
transfer will be covered.
Medical or Hospital Services which do not qualify as Emergency Services or Urgently Needed Services
are not covered unless Prior Authorization is received from Member's Primary Care Physician in
Member's Contracting Medical Group, except that a medical screening examination is covered in
cases in which the Member reasonably believed that he or she required Emergency Services or
Urgently Needed Services.
Medical or Hospital Services provided outside the Universal Care Service Area will not be covered if
the need for care is for a known or chronic condition that is not manifesting itself by acute symptoms
as set forth above. (For more information on Emergency Services and Urgently Needed
Services, please review the section of this EOC captioned "Emergency Services and
Urgently Needed Services").
PI00MRX4 P0_4LE
29
30
COPAYMENTS
•
Universal Care generally covers prescription drugs on a Formulary basis (includ-
ing FDA approved birth control pills and prescriptions for confirmed diagnoses
of severe mental illness and severe emotional disturbances of a child) prescribed
by a Universal Care physician only if they are dispensed at a Contracting phar-
macy. Universal Care may in certain specific instances cover prescription drugs
dispensed at Non -Contracting pharmacies. For more information regarding
these instances, please see the section titled "If a Universal Care Contracting
Pharmacy Is Not Available".
Universal Care shall not limit or exclude coverage for a drug if the drug was pre-
viously approved for coverage by Universal Care for a Member's medical condi-
tion and a Universal Care Contracting Physician continues to prescribe the drug
for the medical condition, provided that the drug is appropriately prescribed and
is considered safe and effective for treating the Member's medical condition.
Medications which are sold without a prescription and prescriptions from den-
tists (except Oral Surgeons) are not covered. Brand name medications are only
covered if a generic equivalent is unavailable or if the generic equivalent is med-
ically contraindicated.
$15 Copayment
Generic drugs on the Formulary or generic drugs not on the Formulary but Pre -
authorized by Universal Care;
$25 Copayment
Brand -name drugs on the Formulary when no generic is available; or brand name
drugs not on the Formulary, but Pre -authorized by Universal Care; or
$40 Copayment
Certain Medically Necessary brand name or generic drugs not on the Formulary
and not pre -authorized by Universal Care. Selected non -Formulary drugs will
have limitations consistent with guidelines developed by Universal Care Pharmacy
& Therapeutics Committee. Some non -Formulary drugs may also be excluded
from coverage, See Exclusions and Limitations Related to the Outpatient
Prescription Drug Benefit in this Evidence of Coverage (EOC). (This service is
not available for mail order drugs unless Pre -authorized by Universal Care).
PO_4LE
P100MRX4
e
COPAYMENTS
Mail Order Prescriptions
$22.50 Copayment
Three (3) month supply of generic maintenance drugs and medications.
$37.50 Copayment
Three (3) month supply of brand maintenance drugs and medications.
All copayments are per medication.
Treatment of PKU
Subject to Brand
Treatment will include those formulas and special food products that are part of a
Drug Copayment
diet prescribed by a Contracting Physician and managed by a health care profes-
after the treatment
sional in consultation with a Physician who specializes in the treatment of meta -
has been approved
bolic disease and who contracts with or is authorized by Universal Care, provid-
by Universal Care
ed that the diet is deemed Medically Necessary to avert the development of seri-
for a thirty (30)
ous physical or mental disabilities or to promote normal development or func-
day supply.
tion as a consequence of PKU.
Covered Prescription Drugs
The drug benefit will be provided for the following prescription drugs contained
on the Formulary, and for non -Formulary drugs and selected Formulary drugs
when pre -authorized under the procedure described below, when Medically
Necessary and ordered by a Universal Care Contracting Physician and filled at a
Contracting Pharmacy:
1. Federal Legend Drugs: Any medicinal substance which bears the legend:
"Caution: Federal law prohibits dispensing without a prescription".
2. State Restricted Drug: Any medicinal substance, which may be dispensed by
prescription only according to State law.
3. Compounded Medication: Any medicinal substance, which has at least one
ingredient that is Federal Legend or State Restricted in a therapeutic amount.
4. Generic Drugs: For brand -name drugs that have FDA -approved generic
equivalents, prescriptions will be filled with a generic drug unless a brand -
name drug is Medically Necessary and pre -authorized by Universal Care.
Notwithstanding the foregoing, Member may request that a prescription be
filled with a brand -name drug that has one or more FDA -approved generic
equivalents and is not included on the Formulary by paying the non -
Formulary copayment amount. Please refer to the schedule of Copayment
Requirements in the "Prescription Drug Benefit" section of this EOC for fur-
ther information on generic drug benefits.
P100MRX4
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31
iA
32
1[_..._._P _..RE_S__Q _R_..1_.P_s
Pre -Authorization for All Non -Formulary Drugs and Selected Formulary Drugs - All
non -Formulary drugs and selected Formulary drugs must be Pre -authorized as Medically Necessary
by Universal Care in order to be covered. Pre -authorization requests may be initiated by Member's
Universal Care Contracting Physician. Universal Care's pre -authorization review process for selected
Formulary drugs is to ensure that the drugs are Medically Necessary and being utilized according to
treatment guidelines consistent with good professional practice. Non -Formulary drugs which are not
benefit exclusion may be Pre -authorized in any of the following instances:
1. No Formulary alternative is appropriate and the drug is Medically Necessary for patient care, as
determined by Universal Care, consistent with professional practice.
2. The Formulary alternative has failed after a therapeutic trial. Member's Universal Care
Contracting Physician will be asked to provide a copy of the medical chart notes, pharmacy his-
tory, lab results, or other documentation specifically stating treatment failure with the
Formulary alternative.
3. The Formulary alternative is not medically appropriate as determined by a clinical review of
Physician chart notes or other requested information.
4. The Member has been under treatment of a Universal Care Plan and remains stable on a non -
Formulary prescription drug and conversion to a Formulary drug would be medically inappropri-
ate.
5. The Member experiences a typical allergic reaction or established adverse effects relating to the
pharmacological properties of the Formulary drug which are attributed to formulations or differ-
ences in absorption, distribution or elimination.
6. Medication for the diagnosis and treatment of infertility is covered.
Exclusions and Limitations Related to the Outpatient Prescription Drug Benefit -
Prescription drug benefits will not be covered for any prescription covering or prescribing the following:
1. Non -Formulary drugs and Formulary drugs that require Pre -Authorization and are not Pre -
Authorized by Universal Care.
2. Drugs or medicines purchased and received prior to the Member's effective date or subsequent
to the Members termination.
3. Therapeutic devices or appliances including hypodermic needles, syringes (except insulin
syringes), support garments and other non -medicinal substances (except as noted above).
4. Non -FDA approved contraceptive devices and supplies, however Universal Care Health Plan
covers a variety of FDA -approved prescription contraceptive methods as described under Family
Planning, above.
P0_4LE P100MRX4
Medications to be taken or administered to the eligible Member while he or she is receiving
Covered Services in a hospital, rest home, nursing home, Skilled Nursing Facility or other simi-
lar facility, since such medications are covered under the inpatient benefit.
Drugs or medicines delivered or administered to the Member by the Contracting Provider or the
Contracting Provider's staff.
Dietary supplements, including, but not limited to, vitamins (except prenatals) , fluoride supple-
ments, health or beauty aids, diet pills, formulas (except PKU) , liquid nutrition products, and
antioxidants.
8. Medications prescribed for experimental or investigational therapies, unless required by an inde-
pendent medical review organization pursuant to the section titled "Independent Review of
Denied Experimental or Investigational Treatment".
9. Non -FDA approved indications unless the drug is prescribed by a Contracting Physician for the
treatment of a life -threatening condition; or the drug is prescribed by a Contracting Physician
for the treatment of a chronic and seriously debilitating condition, the drug is Medically
Necessary to treat that condition, and the drug is on the Health Plan Formulary. If the drug is
not on the Health Plan Formulary, the drug shall be subject to pre -authorization by Universal
Care. All non -FDA approved indications must be recognized for treatment of the indicated con-
dition by one of the following: the American Medical Association Drug Evaluations; the
American Hospital Formulary Services edition of Drug Information; the United States
Pharmacopoeia Dispensing Information, Volume 1 "Drug Information for the Health Care
Professional"; two articles from major peer reviewed medical journals that present data support-
ing the proposed off -label use or uses as generally safe and effective unless there is clear and
convincing contradictory evidence presented in a major peer reviewed medical journal.
10. Medications available without a prescription (over the counter) or for which there is a non-pre-
scription equivalent available, even if ordered by a Contracting Physician.
11. Drugs or medicines prescribed for cosmetic purposes.
12. Medications prescribed by non -Contracting Physicians, except for prescriptions required as a
result of Emergency or Urgently Needed services.
13. Smoking cessation products including, but not limited to, nicotine gum and nicotine nasal spray.
14. Injectable drugs, except insulin.
15. Drugs purchased at a non -Contracting Pharmacy.
16. Anabolic steroids except when Medically Necessary.
17. Medication which may be properly received without charge under local, state or federal pro-
grams or which is reimbursable under other insurance programs including workers' compensation.
PIOOMRX4 PO 4LE
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34
Dispensing Quantity Limitations - The amount of drug that may be dispensed per prescription
or refill will be one Prescription Unit as consistent with good professional practice, not to exceed
more than thirty (30) days or as noted in the Universal Care Formulary. Maintenance medications as
noted in the Universal Care formulary may be dispensed up to a three (3) month supply and available
only from Universal Care's contracted mail order vendor.
If a Universal Care Contracting Pharmacy Is Not Available - The Outpatient Prescription
Drug Benefit is honored ONLY at Contracting Pharmacies. Members are eligible for direct reimburse-
ment only if a Contracting Pharmacy was not available or accessible. In this situation the Member
will be required to pay the price of the prescription and should file for reimbursement. For direct
reimbursement, the Member must send to Universal Care the following information:
1. Copies of the receipts, etc., showing the name of the drug, date filled, pharmacy name, name of
Member for whom the prescription was written, and proof of payment.
2. A statement describing why a Contracting pharmacy was not available to the Member.
3. The above information should be sent to the following address, Universal Care Claims
Department, ATTN: Pharmacy Claims, P.O. Box 16420, Signal Hill, CA 90806-3682.
If request for reimbursement is determined to be appropriate, payment will be forwarded to
the Member.
Universal Care's Formulary
Universal Care uses a comprehensive Formulary as a method of evaluating various drug products
available to treat illnesses. The Formulary is a list of covered and preferred medications that are:
• FDA approved for specified indications;
• Reviewed by Universal Care with participation by practicing Physicians;
• Safe and effective as well as Medically Necessary for the treatment or maintenance of a medical
condition; and
• Cost effective for the treatment of the medical condition.
Universal Care's Pharmacy and Therapeutics Committee, which is comprised of Physicians and phar-
macists, meets on a bi-monthly basis to review and update medications for inclusion or exclusion
from the Formulary. Results from these meetings are published and distributed to Contracting
Physicians via newsletters and updates.
PO_4LE
P100MRX4
r
The Formulary is available upon request. Simply contact your Member Services Representative at
1-800-673-4666. Please be advised that your Physician will determine when you require a particular
medication along with the correct dosage.
A Physician or pharmacist must request an exception process for those drugs not listed on the
Universal Care Formulary should he/she believe that a particular medication is required by an
enrollee. This provider must obtain Pre -authorization from Universal Care via a medical exception
review process. This means that he/she must complete a non -Formulary drug request form and sub-
mit it to Universal Care for review. Either a pharmacist or Physician will review the request within
two (2) days of receipt from the Health Plan Physician. Once the determination for the non -
Formulary request is complete, written notification will be forwarded to the Health Plan Physician.
Written notification will also be forwarded to the Member only for those requests that are modified or
denied.
V1. OUT-OF-POCKET MAXIMUM
To protect you from large expenses, a limit called the Out -of -Pocket Maximum is placed on the dollar
amount of certain Copayments you might have to pay during a benefit year. When the Copayments
you pay during any benefit year exceed the Out -of -Pocket Maximum, then no additional Copayments
will be required for services received during the remainder of the benefit year.
It is important to retain receipts of all Copayments paid in order to submit proof of reaching the
annual Out -of -Pocket Maximum.
Your Out -of -Pocket Maximum is $1,000 for each individual and $3,000 per family. After the Out -of -
Pocket Maximum has been paid, Universal Care will pay for 100% of Covered Services, except for
prescription drugs, non -mandated mental health benefits, infertility benefits, and durable medical
equipment.
35
P100MRX4 PO_4LE
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36
VI1. PRINCIPAL EXCLUSIONS AND LIMITATIONS OF BENEFITS
A. All services which are obtained without authorization from Member's Contracting Medical Group
or Universal Care's Medical Director (except for Emergency or Urgently Needed Services) and
except for obstetrical and gynecological physician services obtained directly from an OB/GYN or
Primary Care Physician affiliated with your Contracting Medical Group.
B. Any service obtained prior to Member's start date of coverage or subsequent to the date coverage
terminates, except as specified in the Evidence of Coverage and Disclosure Form with respect to
certain Members who have become totally disabled.
C. Services provided by non -Contracting Providers when the Member has refused treatment provid-
ed or authorized by Member's Contracting Medical Group.
D. Services which, in the judgment of Universal Care or Your Contracting Medical Group, are not
Medically Necessary.
E. Services which are part of a plan of treatment for a non -Covered Service and which are the sole,
direct and predictable consequence of such non -Covered Service; provided, however, that
Universal Care will not exclude coverage for Medically Necessary services required to treat an ill-
ness or injury that may be a consequence of non -Covered Services but are not predictable in
advance, such as unexpected complications of surgery.
Vill. OTHER EXCLUSIONS AND LIMITATIONS
A. Cosmetic or reconstructive surgery, used to alter or reshape normal structures of the body in
order to improve appearance, is not covered, except as provided under the reconstructive surgery
benefit above. When services are determined to be cosmetic, all services to be provided as part of
the cosmetic treatment plan are also excluded, including hospital, physician, medical supplies
and medications (injectable, intravenous or taken by mouth).
B. Inpatient mental health care services are not covered, other than the diagnosis and Medically
Necessary treatment of serious emotional disturbances of a child and the following severe mental
illnesses: schizophrenia, schizoaffective disorder, bipolar disorder -manic-depressive illness, major
depressive disorders, panic disorder, obsessive -compulsive disorder, pervasive developmental dis-
order or autism, anorexia nervosa; and bulimia nervosa.
C. Rehabilitative programs, including treatment for chronic alcoholism, drug addiction, or other
substance abuse are not covered.
P0_4LE P100MRX4
If
11
D. Services (including educational programs) that are primarily oriented towards treating a social,
developmental or learning problem rather than a medical problem, including dyslexia and behav-
ioral modification therapy are not covered.
E. Custodial or domiciliary care, extended care, homemaker services, respite care, convalescent care
or extended care not requiring skilled nursing care are not covered.
F. Experimental or investigational treatments are not covered unless required by an external, inde-
pendent review panel pursuant to California Health and Safety Code Section 1370.4. Please refer
to the section of this document titled, "Independent Review of Denied Experimental or
Investigational Treatment".
G. Personal or comfort items, including diapers, that are prescribed or recommended by a physician
are not covered unless Medically Necessary.
H. Private hospital rooms during inpatient hospitalization are not covered unless: (1) semi -private
room is not available; or (2) it is determined to be Medically Necessary.
I. Whole blood that has not been replaced, plasma and any specially processed derivative are not
covered. Only the administration of blood products is covered.
J. Blood bank fees are not covered.
K. Hearing aids and implantable hearing devices are not covered. Audiology services (other than
screening for acuity) are not covered. Hearing aid supplies are not covered. Implantable hearing
devices are not covered, except that cochlear devices for bilateral, profoundly hearing -impaired
individuals not benefited from conventional amplification (hearing aids) are covered.
L. Personal or home -based artificial kidney equipment is not covered.
M. Specialized footwear, including foot orthotics, custom made orthopedic shoes or customized
footwear, that is not permanently attached to an orthopedic brace is not covered.
N. House calls by a Physician are not covered, unless authorized by the Member's Contracting
Medical Group.
O. Routine foot care, including, but not limited to, removal and reduction of corns and calluses,
clipping of toenails, treatment for flat feet, fallen arches and chronic foot strain, is not covered,
except when determined to be Medically Necessary
37
P100MRX4 P0_4LE
If
38
U 1V_....le_M E_R_,S A I C—A R F __
P. Chiropractic and acupuncture services are not covered unless a supplemental benefit rider is pur-
chased.
Q. Procedures, services, medications and supplies related to sex transformations are not covered.
R. Eye examinations by an optometrist, as well as any eyeglass appliance, including, but not limited
to, corrective lenses and frames, contact lenses, contact lens fitting, and measurements, are not
covered. Keratotomy procedures and other refractive surgical procedures are not covered unless a
specialized vision supplemental benefit is purchased.
S. Dental care is not covered. Dental care includes all services required for prevention and treat-
ment of diseases and disorders of the teeth, gums, and jaws including but not limited to: x-rays,
topical fluoride treatment, prophylaxis, tooth decay, genetic malformations, periodontal disease,
tooth extraction, replacement of missing teeth, dental implants, dentures and other oral prosthet-
ic devices unless a specialized dental supplemental benefit is purchased.
T. Treatment for disabilities connected to military services for which the Member is legally entitled
to services through a federal government agency and to which the Member has reasonable acces-
sibility.
U. All forms of in -vitro fertilization (IVF) and zygote intrafallopian transfer (ZIFT) , as well as proce-
dures related to IVF or ZIFT; ovum transplants; ovum or ovum bank charges; and the Medical or
Hospital Services incurred by surrogate mothers who are not Universal Care Members are not
covered. Universal Care infertility benefit is limited to a lifetime maximum of $15,000 per mem-
ber. Male infertility treatment is not covered. Sperm, sperm bank and ovum bank charges are not
covered.
V. Marriage or family counseling is not covered, except for outpatient crisis intervention.
W. Family Planning Services:
• Norplant, Intra-uterine device (IUD), diaphragm, and cervical cap devices are not covered.
• Depo-Provera medication is not covered.
• Voluntary interruption of pregnancy when not Medically Necessary covered only through twenty
(20) weeks. Voluntary interruption of pregnancy after the twentieth (20th) week is covered only
when the mother's life is in jeopardy.
X. Reports, evaluations, examinations or hospitalizations required for employment, insurance exami-
nations, licensing, camp or school, including sports physicals, or other organizational activities,
are not covered.
PO_4LE
P100MRX4
3H
Y. Medical Services or Hospital Services for which a Contracting Provider or a Non -Contracting
Provider is paid under the Medicare program are not covered.
Z. Medical Services or Hospital Services for which a Contracting Provider or a Non -Contracting
Provider is paid under the Workers' Compensation payor (including, but not limited to, any
Workers' Compensation carrier, self -funded employer or employer association, or the State unin-
sured employers' fund) are not covered.
AA. Reversal of voluntary, surgically induced sterilization is not covered.
BB. Medical and Hospital Services of an organ donor or prospective organ donor are not covered
when the recipient of an organ transplant is not a Member.
CC. Organ transplants not Medically Necessary and organ transplants considered Experimental or
Investigational are not covered, unless required by an external, independent review panel pur-
suant to California Health and Safety Code Section 1370.4. Please refer to the section of this
document titled, "Independent Review of Denied Experimental or Investigational Treatment".
Organ transplants must be performed at a Universal Care designated transplant center.
DD. The following items of durable medical equipment are not covered: deluxe equipment, such as
motor driven wheelchairs and beds; items that are not primarily medical in nature or that are for
the Member's comfort and convenience, such as bedboards, bathtub lifts, overbed tables, adjust -
a -beds, ramps, telephone arm and air conditioners; replacement, repair or routine
periodic maintenance of durable medical appliances purchased or leased by the Health Plan;
physicians' equipment such as stethoscopes and blood pressure monitoring devices; exercise
and hygienic equipment, such as exercycles; Moore Wheels, bidet toilet seats and bathtub seats;
self-help devices that are not primarily medical in nature, such as humidifiers, sauna baths
and elevators; and items deemed, in the opinion of the Universal Care Medical Director, to be
experimental or research equipment. Corrective appliances, prosthetics and durable medical
equipment purchase or rental is limited to initial placement, repair or adjustment, and replace-
ment due to normal wear and tear or because of a significant change in the Member's physical
condition (as determined by Member's Contracting Medical Group).
EE. Acupressure, biofeedback, hypnotherapy, sleep therapy and behavioral training are not covered.
FE Bone -marrow transplants are not covered when they are Experimental or Investigational, unless
required by an external, independent review panel pursuant to California Health and Safety
Code Section 1370.4. Please refer to the section of this document titled, "Independent Review
of Denied Experimental or Investigational Treatment".
GG. Eating disorder programs (inpatient or outpatient) for dietary control and weight loss surgery or
other treatment of obesity, including but not limited to food and food supplements, laboratory
tests in association with weight reduction programs, or vitamins are not covered.
P100MRX4 PO 4LE
39
40
HH. Care for conditions for which state or local law requires treatment in a public facility are not
covered. Emergency or Urgently Needed Services required after participating in a criminal act
are covered only until the Member is stabilized and placed on a police hold. Notwithstanding
the foregoing, and in compliance with California Health & Safety Code Section 1374.12, this
provision shall not restrict Universal Care's liability for Covered Services solely because such
services were provided while the Member was in a state hospital.
II. Universal Care is not responsible for unusual circumstances, such as complete or partial destruc-
tion of facilities, war, riot, labor disputes, disability of a significant number of personnel, or similar
events which result in delay in providing services in or ability to provide services. The Health
Plan will make alternative arrangements as it is able and as necessary and appropriate.
JJ. Except for the diagnosis and Medically Necessary treatment of the following severe mental ill-
ness (including schizophrenia, schizoaffective disorder, bipolar disorder -manic-depressive ill-
ness, major depressive disorders, panic disorder, obsessive -compulsive disorder, pervasive devel-
opmental disorder or autism, anorexia nervosa, and bulimia nervosa) and/or serious emotional
disturbances of a child, mental health services are limited to outpatient short term or crisis
intervention services, up to a maximum of twenty (20) sessions per Benefit Year.
KK. Any travel immunization's not recommended and approved by the Center for Disease Control
are not covered.
LL. Circumcision without medical necessity is not a covered benefit.
MM. The number of visits of inpatient rehabilitation/subacute care is limited by a demonstration of
significant improvement within the total number of days allowed by your participating benefit
schedule.
NN. Physical therapy, speech therapy, occupational therapy and other outpatient rehabilitative
treatments are limited to thirty (30) sessions for any injury, illness or congenital abnormality.
An additional thirty (30) sessions, up to a maximum of sixty (60) sessions total, will be covered
if, in the opinion of the participating physician and Medical Director of Universal Care or
Contracting Medical Group, significant improvement will result from such treatment.
00. Skilled Nursing Care is limited to care received in a Skilled Nursing Facility for up to
thirty (30) days per benefit year when Medically Necessary.
PP. Vision care other than for the determination of the need for vision correction for members
through age eighteen (18).
QQ. Hearing examinations other than for the determination of the need for hearing correction for
members through age eighteen (18) .
RR. The annual copayment maximum excludes prescription drugs, DME, and maternity services.
SS. Upon referral to a clinical cancer trial by the member's treating physician, Universal Care will
cover the routine patient care costs for the member's participation in a cancer clinical trial,
subject to the specific requirements of Section 1370.6 of the California Health and Safety Code.
PO_4LE
P100MRX4
Universal Care®
Healthcare you can feel good about.
Section 3
• Confidentiality
• Eligibility
• Choice of Physicians and Providers —Accessing Care
Emergency Services and Urgently Needed Services
• Health Plan Premiums (Prepayment Fees)
• Changes in Coverage or Enrollment
• Reimbursement of Third Party Liability
• Coordination of Benefits
• Non -Duplication of Benefits with Champus
• Non -Duplication of Benefits with Workers' Compensation
• Non -Duplication of Benefits with Medicare
® How Universal Care Participating Providers are Compensated
Member Services
• 24 Hour Nurse AdviceLine
Grievance Process
• Public Policy Committee
s Your Rights & Responsibilities
• Important Information about Organ and Tissue Donation
P100MRX4 PO 4LE
42
CONFIDENTIALITY
Universal Care agrees to maintain and preserve the confidentiality of any and all
medical records of Member. However, Member authorizes the release of informa-
tion and access to any and all of Member's medical records for purposes of utiliza-
tion review, an Appeal review, processing of any claim, financial audit, coordination
of benefits, or for any other purpose reasonably related to the provision of benefits
under this Agreement to Universal Care, its agents and employees, Member's
Medical Group, and appropriate governmental agencies. Universal Care shall not
release any information to Subscriber Group, which would directly or indirectly
indicate to Subscriber Group that a Member is receiving or has received Covered
Services, unless authorized to do so by the Member. A STATEMENT DESCRIBING
UNIVERSAL CARE'S POLICIES AND PROCEDURES FOR PRESERVING THE CON-
FIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FUR-
NISHED TO YOU UPON REQUEST.
ELIGIBILITY, ENROLLMENT & BEGINNING DATE OF COVERAGE
You are eligible to enroll in Universal Care if you:
• Meet your Employer's and Universal Care's eligibility requirements;
• Permanently reside or work within the Universal Care Service Area, except that eligible children
do not need to reside within the Service Area to enroll; and
• Select a Contracting Medical Group/Primary Care Physician located within a 30-mile radius of
your Primary Residence or Primary Workplace.
Coverage for Dependents
If you as the Subscriber elect coverage, you may also enroll your eligible Dependents in the plan.
Eligible dependents include:
• Your Spouse.
• The unmarried dependent children of you or of your spouse (who rely on you or your spouse for
support and maintenance) from birth until the child's nineteenth (19th) birthday (or until the
child's twenty-fifth (25th) birthday if enrolled as a full-time student in an accredited school or
college). Children include: biological children; stepchildren; legally adopted children; children
placed with you for adoption; and children for whom you or your spouse are required to provide
health coverage pursuant to a qualified medical support order. Please note that the children of
your children or your spouse's children are not eligible for enrollment. To be and remain eligible,
the Subscriber and each Dependent must reside continuously within the Service Area, except that
PO_4LE P100MRX4
4-
_!_NL...l... V._E R._..E._.._
a Child who is outside the service area (for example attending school outside the Service Area)
may remain enrolled, if otherwise eligible. A Child outside the service area, like Members who
are temporarily outside the service area, will be covered for out -of -area Emergency Services and
Urgently Needed Services only. See "Emergency Services and Urgently Needed Services" below.
All other services must be obtained within the Service Area, and be provided or arranged or
authorized, except in an emergency, by your assigned or selected Contracting Medical Group.
• The children of you or your spouse who have reached nineteen (19) years of age or older and
who are both (1) incapable of self-sustaining employment by reason of mental retardation or
physical handicap and (2) chiefly dependent upon you for support and maintenance. You must
provide Universal Care proof of the child's disability within thirty-one (31) days after the child's
nineteenth (19th) birthday and once a year thereafter, if requested.
New Family Members
New additions to your family are invited to join Universal Care, as long as they meet your Employer's
and Universal Care's eligibility requirements. If you get married, have a baby, adopt a child or receive
a child in your home in anticipation of adoption, or are appointed the legal guardian of a child, please
submit legal documentation to your Employer for your new family member within thirty-one (31) days.
Coverage for newborn children begins at birth. In order for coverage for a newborn child to continue
for more than thirty-one (31) days after birth, an enrollment form for the newborn child must be sub-
mitted to your Employer prior to the expiration of the thirty-one (31) days.
Coverage for a new Spouse begins on the first (lst) day of the first (1st) calendar month beginning
after the date the completed request for coverage is received by Universal Care. Universal Care may
request certified documentation of proof of marriage.
Coverage for adopted children begins on the date of placement for adoption, which is the date you
assume and retain a legal obligation for full or partial support of the child in anticipation of the adop-
tion of the child. In order for coverage for a child for whom you or your spouse has adopted, placed
for adoption, or been appointed legal guardian to continue beyond thirty-one (31) days, an enroll-
ment form must be submitted by your Employer prior to the expiration of the thirty-one (31) days.
Universal Care may require you to present evidence that placement has been obtained, including
adoption agency documentation. Eligibility for an adopted child ends if the placement is interrupted
before legal adoption or the child is removed from your custody. Eligibility for a child for whom you
have been appointed legal guardian ends when the guardianship ends or the Child reaches the age of
nineteen (19). However, coverage shall continue if the child is both (1) incapable of self-sustaining
employment by reason of mental retardation or physical handicap and (2) chiefly dependent upon
you for support and maintenance. You must provide Universal Care proof of the child's disability
within thirty (30) days after the child's nineteenth (19th) birthday and once a year thereafter, if
requested.
P100MRX4 P0_4LE
43
i, y
44
Enrollment
If you are an eligible employee and you wish to enroll yourself and/or your eligible Dependents, you
must submit a completed enrollment form to your Employer during the Open Enrollment Period
In the event you, or your eligible Dependents, choose not to enroll in Universal Care during the ini-
tial Open Enrollment Period, enrollment in Universal Care may be delayed for up to twelve (12)
months from the date you, or your eligible Dependents, later decide to elect coverage. However, the
twelve (12) month waiting period will not be imposed if you, or your eligible Dependents, qualify for
Special Enrollment as discussed below or you, or your eligible Dependents, involuntarily lose cover-
age under another employer health benefit plan (or no -share -of -cost Medi-Cal coverage), and the cov-
erage under the other plan was the reason you initially declined coverage under the Universal Care
Health Plan. As part of your application for enrollment, your Employer will provide you with a
notice and certification of other coverage for your signature which will explain in detail the conse-
quences of declining enrollment during the initial Open Enrollment Period, the potential for imposi-
tion of a twelve (12) month waiting period should you or your eligible Dependents seek enrollment
after the initial Open Enrollment Period, and the conditions under which you and your eligible
Dependents may avoid the twelve (12) month waiting period.
Special Enrollment
An employee who previously declined to enroll in Universal Care may be eligible for special enroll-
ment (outside Open Enrollment) if another person becomes a dependent of the employee through
marriage, birth, adoption or placement for adoption. The employee and his or her newly acquired
dependents must request special enrollment within thirty (30) days of the marriage, birth, adoption
or placement for adoption. Note: For determination of eligibility to enroll outside the Open
Enrollment Period, Universal Care will follow the requirements imposed by the Employer and State
and Federal law
When Your Coverage Begins
The commencement date of coverage under the Health Plan for a Member shall be the first (1st) day
of the month following Universal Care's acceptance of the Member's enrollment application and verifi-
cation of the Member's eligibility in accordance with the terms and conditions of the Group
Subscriber Agreement. Universal Care's acceptance of Member's enrollment application is contingent
upon receipt of the applicable Health Plan Premium.
PO 4LE
P100MRX4
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Your Universal Care Member Identification Card
When you enroll in Universal Care, you receive a Universal Care Member Identification (I.D.) Card.
Your Universal Care I.D. Card lets people know you are a Universal Care Member. You should carry
your Universal Care I.D. Card with you at all times. You will need to show your Universal Care I.D.
Card whenever you have a doctor's appointment, pick up a prescription or receive medical care.
Never let another person use your Universal Care I.D. Card.
The telephone number of the Primary Care Physician you selected is printed on the front of your
Universal Care I.D. Card. Note: Possession of a Universal Care I.D. Card confers no right to the ser-
vices or benefits of Universal Care. To be entitled to Covered Services, the holder of the I.D. Card
must, in fact, be a Member on whose behalf the applicable Health Plan Premiums have actually been
paid to Universal Care. Therefore, any person receiving services or benefits for which he or she is not
then entitled pursuant to the Group Subscriber Agreement is personally responsible for the cost of all
services received.
45
PIOOMRX4 PO_4LE
46
CHOICE OF PHYSICIANS AND PROVIDERS ACCESSING CARE
Facilities - Provider Locations
Universal Care provides Covered Services through Universal Care Contracting Medical Groups and
Primary Care Physicians. The location and telephone number of the Contracting Medical Groups
and Primary Care Physicians are listed in the Universal Care Provider Directory accompanying this
Evidence of Coverage booklet. For more information, you may call the Universal Care Member
Services Department at 1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired, Monday
through Friday from 8:00 a.m. to 6:00 p.m. Emergency Services are available on a 24-hour basis,
seven (7) days a week by following the procedures set forth in this booklet under "Emergency and
Urgently Needed Services".
Relationship Between Universal Care and Providers
The relationship between Universal Care and the physicians, hospitals and other health care providers
who are its Contracting Physicians, Contracting Hospitals, and other Contracting Providers is that of
an independent contractor relationship. Contracting Providers are not agents or employees of
Universal Care, and Universal Care and its agents and employees are not agents or employees of those
Contracting Providers. Each Contracting Physician, Contracting Hospital, or other Contracting
Provider is to maintain a direct physician -patient, hospital -patient or other such relationship with
Universal Care Members to whom services are provided, and is solely responsible for its decisions as
to what health care diagnostic, treatment or other services are required. Notwithstanding the forego-
ing, a small number of Contracting Providers are the employees of Universal Care and provide ser-
vices at medical offices owned and operated by Universal Care.
Choosing a Primary Care Physician
You have the opportunity to choose a Primary Care Physician from among the Contracting Medical
Groups and Primary Care Physicians listed in the Universal Care Provider Directory. The Primary
Care Physician is responsible for providing or arranging all of your medical care.
If you have not chosen your Primary Care Physician, please choose from the Universal Care Provider
Directory a Primary Care Physician or Contracting Medical Group located within thirty (30) miles
from your Primary Residence or Primary Workplace. If you choose a Contracting Medical Group and
would like help selecting a Primary Care Physician within that group, you can call the group's Health
Plan Coordinator at the telephone number listed in the directory. Call Universal Care's Member
Services Department at 1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired, Monday
through Friday from 8:00 a.m. to 6:00 p.m. and let us know your choice.
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If you do not list a Primary Care Physician on the enrollment application or notify Universal Care of
your selection within thirty (30) days after the beginning date of your coverage in Universal Care,
Universal Care will assign a Primary Care Physician to you and notify you of the selection and the
opportunity to change the assigned Primary Care Physician. Universal Care will take into account
geographic accessibility and language capabilities of Primary Care Physicians in making such assign-
ments. If you later choose to change the Primary Care Physician, please follow the procedures
described in the section entitled "Changing Your Primary Care Physician".
Using the Primary Care Physician
Except for Emergency or Urgently Needed Services, you must obtain all Covered Services from your
Primary Care Physician unless you receive Prior Authorization from your Primary Care Physician to
receive services from another Contracting Provider or a Non -Contracting Provider. (Prior
Authorization is defined on page 10 of this booklet and explained in the sections that follow). You
may obtain Emergency or Urgently Needed Services without the Prior Authorization of your Primary
Care Physician as explained in the sections that follow. You may also obtain obstetrical and gyneco-
logical physician services directly from an OB/GYN or family practice physician affiliated with your
Contracting Medical Group without the Prior Authorization of your Primary Care Physician.
Scheduling Appointments
Whenever possible, you should call to schedule an appointment before a visit to your Primary Care
Physician. For routine office visits, please call your Primary Care Physician at least 48 hours in
advance to schedule an appointment. For health assessment appointments, such as your periodic
routine physical, please call at least two (2) or three (3) weeks in advance. If you need more immedi-
ate attention, call the Primary Care Physician right away and request the next available appointment.
IF YOU NEED TO CANCEL AN APPOINTMENT, CALL THE PRIMARY CARE
PHYSICIAN AS FAR IN ADVANCE AS POSSIBLE, PREFERABLY 24 HOURS BEFORE
THE SCHEDULED APPOINTMENT.
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Initial Health Assessment
Universal Care offers preventive health services to every Member, which includes a periodic health
assessment to help you maintain good health. It is important to schedule a visit to your Primary Care
Physician for an initial health assessment so that the Primary Care Physician can assess your health status
and health care needs. This is also an opportunity for you to get to know the Primary Care Physician.
For children, the initial health assessment will include a complete medical history, weight and height
data, blood pressure, those pediatric preventive health screens and tests recommended by the
American Academy of Pediatrics, a discussion of appropriate preventive measures, and arrangements
for follow-up appointments as indicated. The pediatric preventive screening services include, at a
minimum, immunizations and hearing, vision and dental exams by the Primary Care Physician.
Please call your Primary Care Physician or Contracting Medical Group's office to make an appoint-
ment for an initial health assessment as soon as possible, preferably within one hundred twenty (120)
days of your beginning date of coverage in Universal Care.
Referrals to Specialists
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 Contracting Medical Group. If you require services that are
not available within your Contracting Medical Group, the Primary Care Physician will arrange for a
referral to a specialist within Universal Care's extensive network of specialists.
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 Contracting Medical Group's Utilization
Review Committee. The Prior Authorization process is described below.
Prior Authorization — Approval, Modification,
or Denial of Health Care Services
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
Contracting Medical Group with which your Primary Care Physician is affiliated) to request that the
service be approved for coverage before the service is rendered.
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Universal Care and its Contracting Medical Groups use specific guidelines based on Medical
Necessity to review, approve, modify, or deny, requests by Primary Care Physicians for authorization
for the provision of health care services to Members, including authorization for subacute care, tran-
sitional inpatient care, and care provided in a skilled nursing facility. Universal Care provides these
guidelines to your Medical Group and will directly provide you with a copy of these guidelines upon
your request. In addition, Universal Care will automatically provide you with a copy of the guide-
lines it has used in when a decision has been made to modify, delay, or deny a specific service
requested by your Primary Care Physician.
Decisions to deny or modify requests for authorization of health care services for a Member, based on
medical necessity, are made only by licensed physicians or other appropriately licensed health care
professionals.
Universal Care and Contracting Medical Groups make these decisions within at least the following
time frames required by state law:
Decisions to approve, modify, or deny requests for authorization of health care services, based on
medical necessity, will be made in a timely fashion appropriate for the nature of the Member's condi-
tion, not to exceed five (5) business days from the receipt by Universal Care or the Contracting
Medical Group of the information reasonably necessary to make the decision.
• If the Member's condition poses an imminent and serious threat to the Member's health,
including potential loss of life, limb, or other major bodily function, or lack of timeliness would be
detrimental in regaining maximum function, a decision to approve, modify, or deny a request for
authorization of health care services shall be made in a timely fashion appropriate for the nature of
the Member's condition, not to exceed 72 hours after the receipt by Universal Care or the
Contracting Medical Group of the information reasonably necessary to make the decision.
• If the decision cannot be made within the time frames described above because additional
information is required, additional tests or examinations are required, or the consultation of an
expert is required, Universal Care or the Contracting Medical Group will notify the provider and the
Member, in writing, that a decision cannot be made within the expected time frames. The notifica-
tion will specify the information requested but not received, or the additional examinations or tests
required, or the name of the expert reviewer to be consulted, and the anticipated date on which a
decision may be rendered.
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Once a decision has been made to approve, modify, or deny a request for authorization of health
care services, it shall be communicated by telephone or facsimile to the Member's Primary Care
Physician within 24 hours. A decision to approve health care services shall specify the services that
are approved. A decision resulting in denial, delay, or modification of all or part of the requested
health care service shall be communicated both to the Member and to the Member's Primary Care
Physician in writing within two business days. Such written notifications shall include a clear and
concise explanation of the reasons for the decision, a description of the criteria or guidelines used to
make the decision, and a clinical reason for the decision that relates to Medical Necessity, and the
written notification to the Primary Care Physician shall include the name and direct dial extension
telephone number of the health care professional responsible for the denial, delay, or modification.
In addition, such written notifications shall include information about how to appeal the decision
with Universal Care pursuant to Universal Care's Grievance and Appeals Process as outlined in this
Combined Evidence of Coverage and Disclosure Form.
If you would like a description of the processes and guidelines utilized by Universal Care
for authorization, modification or denial of health care services, you may contact the
Universal Care Member Services Department at 1-800-635-6668 or TTY 1-866-321-5955
for the hearing unpaired, Monday through Friday from 8:00 a.m. to 6.00 p.m.
Standing Referrals to Specialists
You may receive a standing referral to a specialist if your Contracting Primary Care Physician deter-
mines, in consultation with the specialist and Universal Care's Medical Director or Contracted
Medical Group, that you need continuing care from a specialist. A standing referral means a referral
by your Contracting Primary Care Physician for more than one visit to a contracting specialist as
indicated in the treatment plan without the Contracting Primary Care Physician having to provide a
specific referral for each visit. The standing referral will be made according to a treatment plan
approved by your Contracting Medical Group or Universal Care, in consultation with your
Contracting Primary Care Physician, the specialist, and you, if you have a complex or serious medical
condition or a treatment plan is otherwise considered necessary. The treatment plan may limit the
number of visits to the specialist and may limit the period of time the visits are authorized. The spe-
cialist will provide your Contracting Primary Care Physician with regular reports on the health care
provided to you. You may request a standing referral by asking your Contracting Primary Care
Physician or specialist.
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Extended Referral for Coordination of Care by Specialist
If you have a life -threatening, degenerative, or disabling condition or disease, including, but not lim-
ited to HIV/AIDS, that requires specialized medical care over a prolonged period of time, you may
receive a referral to a contracting specialist or specialty care center that has expertise in treating the
condition or disease for the purpose of having the specialist coordinate your health care with your
Contracting Primary Care Physician. To receive an extended specialty referral your Contracting
Primary Care Physician must determine, in consultation with the specialist or specialty care center
and your Contracting Medical Group's Medical Director or a Universal Care Medical Director, that
this extended specialized medical care is Medically Necessary. The extended specialty referral will be
made according to a treatment plan approved by your Contracting Medical Group's Medical Director
or a Universal Care Medical Director, in consultation with your Contracting Primary Care Physician,
the specialist, and you. After the extended specialty referral is made, the specialist will serve as the
main coordinator of your care, subject to the approved treatment plan. You may request an extended
specialty referral by asking your Contracting Primary Care Physician or specialist. If you have a
chronic or life threatening illness that requires continuous specialty care and you would like to get
more information about specialists who have expertise in treating special conditions or diseases,
please contact your Contracted Medical Group or Universal Care's Member Services Department at
1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired.
Access to OB/GYN Physician Services and Women's Routine and
Preventive Health Care Services
You may obtain obstetrical and gynecological (OB/GYN) physician services directly from a
Contracting OB/GYN or Contracting Family Practice Physician affiliated with your Contracting
Medical Group. This means that no Prior Authorization or Referral from your Contracting Primary
Care Physician is required to obtain OB/GYN physician services from a Contracting OB/GYN or
Family Practice Physician affiliated with your Contracting Medical Group. However, if you directly
access an OB/GYN or Family Practice Physician not affiliated with your Contracting Medical Group,
you will be financially responsible for these services. Any OB/GYN inpatient or Hospital Services,
except Emergency or Urgently Needed Services, must be authorized in advance by your Contracting
Medical Group.
If you would like to obtain OB/GYN physician services directly from an OB/GYN or Family Practice
Physician affiliated with your Contracting Medical Group:
• Telephone your Contracting Medical Group (the telephone number is listed on your ID Card)
and request the names and telephone numbers of the OB/GYNs affiliated with your Contracting
Medical Group.
• Telephone and schedule an appointment with your selected Contracting OB/GYN or Family
Practice Physician.
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Your selected OB/GYN will communicate with your Contracting Primary Care Physician regarding
your condition, treatment and any need for follow-up care.
You also have direct access to women's routine and preventive health care services (as described in
the Benefit Schedule) by following the procedures outlined above.
Continuity of Care for New Members
Universal Care has a policy regarding continuity of care for new Members meeting a defined set of
criteria who are receiving medical services for acute conditions at the time of enrollment in Universal
Care and who are not subject to a Pre-existing Condition exclusion period. This policy applies to
those new Members who are currently undergoing treatment for an acute medical condition (a dis-
ease or injury which requires specific treatment for a specific period of time) whose treating physician
is not a Contracting Provider with Universal Care. Under this policy, an eligible Member currently
receiving specific treatment for an acute medical condition from a non -Contracting Provider at the
time of enrollment in Universal Care may be eligible to continue to receive medical care from the
Member's former, non -Contracting Provider until the Member's condition resolves or is stable.
To determine if you are eligible for a medical review under this policy, or to request a copy of this
policy, please call or write to Universal Care's Member Services Department. A Member Services
Representative is available to assist you with any questions regarding the review policy.
Terminated Providers - Continuity of Care for an Acute Condition,
Serious Chronic Condition, and Certain Pregnancies
In the event your Contracting Provider is terminated by Universal Care or your Contracting Medical
Group for reasons other than a medical disciplinary cause, fraud or other criminal activity, you may
be eligible to continue receiving care from your provider following the termination, provided that the
terminated provider agrees in writing to be subject to the same contractual terms and conditions that
were imposed upon the provider prior to termination and to payment rates offered by the Plan to
similarly situated providers. For purposes of this provision, "provider" means a licensed physician,
podiatrist, clinical psychologist, dentist or chiropractor. Continuity of care from terminated providers
is not available when the provider voluntarily leaves Universal Care or a Contracting Medical Group.
Medically Necessary continued care for an acute condition or a serious chronic condition may be pro-
vided by the terminated provider for up to nine (90) days or a longer period if necessary for a safe
transfer to another provider as determined by the plan in consultation with the terminated provider,
consistent with good professional practice. Medically Necessary continued care for a high -risk preg-
nancy, or for a pregnancy that has reached the second or third trimester may be provided by the ter-
minated provider until postpartum services related to the delivery are completed, or for a longer peri-
od if necessary for a safe transfer to another provider as determined by the plan in consultation with
52 1 the terminated provider, consistent with good professional practice.
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If you are receiving treatment for:
• an acute condition (such as open surgical wounds, or recent heart attack); or
• serious chronic condition (such as chemotherapy or radiation therapy) ; or
• a high risk pregnancy (such as multiple babies where there is a high likelihood of complications) ; or
• pregnancy in the second or third trimester;
and your provider is terminated; you may request permission to continue receiving treatment from the
terminated provider beyond the termination date by calling Universal Care. Your Contracting Medical
Group's Medical Director, in consultation with your terminated provider, will determine the best way
to manage your ongoing care. Prior Authorization must be obtained for all continued
care. If you have any questions, or would like a copy of Universal Care's Continuity
of Care Policy, or would like to appeal a denial of your request for continuation of
services from your terminated provider, you may call the Member Services
Department at 1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired,
Monday through Friday from 8:00 a.m. to 6:00 p.m. to obtain this information.
Second Medical Opinions
A Member, or his or her treating Contracting health professional, may submit a request for a second
medical opinion to the Contracting Medical Group (or in some cases Universal Care). The Member
should consult with his or her Primary Care Physician to assist the Member in this process. Second
medical opinions will be provided or authorized when medically appropriate including, but not limit-
ed to, the following: (i) the Member questions the reasonableness or necessity of recommended surgi-
cal procedures; (ii) the Member questions a diagnosis or plan for care for a condition that threatens
loss of life, loss of limb, loss of bodily functions, or substantial impairment, including but not limited
to a chronic condition; (iii) the clinical indications are not clear or are complex and confusing, a
diagnosis is in doubt due to conflicting test results, or the treating provider is unable to diagnose the
condition and the Member requests an additional diagnosis; (iv) the treatment plan in progress is not
improving the medical condition of the Member within an appropriate period of time given the diag-
nosis and plan of care, and the Member requests a second opinion regarding the diagnosis or continu-
ance of the treatment; or (v) the Member has attempted to follow the plan of care or consulted with
the initial provider concerning serious concerns about the diagnosis or plan of care.
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The request for a second medical opinion will be approved or denied by the Contracting Medical
Group (or a Universal Care Medical Director as applicable) in a timely fashion appropriate for the
nature of the Member's condition. When the Member's condition is such that the Member faces an
imminent and serious threat to his or her health, including, but not limited to, the potential loss of
life, limb, or other major bodily function, or lack of timeliness that would be detrimental to the
Member's ability to regain maximum function, the second opinion shall be authorized or denied in a
timely fashion appropriate for the nature of the Member's condition, not to exceed 72 hours after the
Contracting Medical Group's (or Universal Care's as applicable) receipt of the request, whenever pos-
sible. Second medical opinions will be rendered by an appropriately qualified health care profession-
al. An appropriately qualified health care professional is a primary care physician or a specialist who
is acting within his or her scope of practice and who possesses the clinical background related to the
illness or condition associated with the request for a second medical opinion.
If the Member is requesting a second medical opinion about care received from his or her Primary
Care Physician, the second medical opinion will be provided by an appropriately qualified health care
professional of the Member's choice within the same Contracting Medical Group. If the Member is
requesting a second medical opinion about care received from a specialist, the second medical opin-
ion will be provided by any provider of the Member's choice from any Contracting Medical Group
within the Universal Care Contracting provider network of the same or equivalent specialty. In the
rare event that an appropriately qualified health professional is not available within the Plan, the Plan
shall authorize a second medical opinion outside the Plan's provider network.
A second medical opinion is an examination by an appropriately qualified health professional docu-
mented by a consultation report. The consultation report will be made available to the Member and
his or her initial health professional and shall include any recommended procedures or tests that the
second opinion health professional believes are appropriate. If the Provider giving the second med-
ical opinion recommends a particular treatment, diagnostic test or service covered by Universal Care,
and is determined to be Medically Necessary by the Member's Contracting Medical Group or
Universal Care, the treatment, diagnostic test or service will be provided or arranged by the Member's
Contracting Medical Group. However, the fact that an appropriately qualified health care profession-
al, furnishing a second medical opinion, recommends a particular treatment, diagnostic test or service
does not necessarily mean that the treatment, diagnostic test or service is Medically Necessary or a
Covered Service under the Members Universal Care Health Plan. The Member shall be responsible
for paying an outpatient physician office Co -payment, as set forth in the Member's Universal Care
Health Plan, to the Universal Care Contracting Provider who renders the second medical opinion to
the Member.
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If a Member's request for a second medical opinion is denied, Universal Care will notify the Member
in writing of the reasons for the denial and shall inform the Member of his or her right to file a griev-
ance appeal with the Plan pursuant to the Grievance and Appeal procedures outlined below in this
Combined Evidence of Coverage and Disclosure Form. If the Member obtains a second medical
opinion without prior authorization from his or her Contracting Medical Group or Universal Care,
the Member will be financially responsible for the costs of such services.
If you would like further information on Universal Care's policies and procedures
on second opinions, including the timeline for authorizing second medical opin-
ions, you may contact the Universal Care Member Services Department at 1-800-
635-6668 or TTY 1-866-321-5955 for the hearing impaired, Monday through Friday
from 8:00 a.m. to 6:00 p.m., or write to the following address:
Universal Care
Member Services Department
1600 E. Hill Street
Signal Hill, CA 90806-3682
Cancer Clinical Trials
Upon referral to a clinical cancer trial by the member's treating physician, Universal Care will cover
the routine patient care costs for member's participation in a cancer clinical trial, subject to the specif-
ic requirements of Section 1370.6 of the California Health and Safety Code.
Changing Your Primary Care Physician
You can change your assigned Primary Care Physician or Contracting Medical Group by calling
Universal Care's Member Services Department at 1-800-635-6668 or TTY 1-866-321-5955 for the
hearing impaired, Monday through Friday from 8:00 a.m. to 6:00 p.m. A Member Services
Department representative will take your request and information over the telephone. You will
receive a new Universal Care I.D. card which will identify the name and telephone number of your
new Primary Care Physician or Contracting Medical Group. Remember to choose a Primary Care
Physician located within a 30 mile radius of your Primary Residence or Primary Workplace. All
changes are effective the first (1st) day of the second (2nd) full month following the request.
Universal Care has the right to change your selection of a Primary Care Physician, but only upon
notifying you and giving you the opportunity to choose a new Primary Care Physician. Universal
Care may need you to choose a new Primary Care Physician if there is a breakdown in the relation-
ship between you and the Primary Care Physician, or if for any reason your selected Primary Care
Physician is no longer available to provide your medical care. If so, you will need to choose a new
Primary Care Physician within thirty-one (31) days of receiving notice from Universal Care.
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Service Area
Except as otherwise indicated herein, you must reside or work within Universal Care's Service Area to
be eligible to enroll and remain enrolled in Universal Care. If you move out of Universal Care's
Service Area, you must inform Universal Care in writing thirty (30) days prior to the move and
request from your employer a transfer to another Contracting health plan that serves the new area in
which you will reside.
A zip code list of the Universal Care Service Area is located at the end of this Agreement.
EMERGENCY SERVICES AND URGENTLY NEEDED SERVICES
Emergency Services
Emergency Services are Medically Necessary ambulance, and ambulance transport services provided
through the "911 " emergency response system, and medical screening, examination and evaluation by
a physician, or other appropriate personnel under the supervision of a physician, to determine if an
Emergency Medical Condition, including a psychiatric emergency medical condition, exists, and if it
does, the care, treatment, and/or surgery by a physician necessary to relieve or eliminate the
Emergency Medical Condition, including psychiatric emergency medical condition, within the capa-
bilities of the facility.
An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of suf-
ficient severity (including severe pain) such that the absence of immediate medical attention could
reasonably be expected by the Member to result in any of the following:
• Placing the Member's health in serious jeopardy;
• Serious impairment to bodily functions;
• Serious dysfunction of any bodily organ or part; or
• Active labor, meaning labor at a time that either of the following would occur:
(1) There is inadequate time to effect safe transfer to another hospital prior to delivery; or
(2) A transfer poses a threat to the health and safety of the Member or unborn child.
WHAT TO DO WHEN YOU REQUIRE EMERGENCY SERVICES:
If you believe that you need Emergency Services you should Call "911" or
go directly to the nearest medical facility for treatment.
It is appropriate for you to use the "911" emergency response system, or alternative emergency sys-
tem in your area, for assistance in an emergency situation as described above when you reasonably
believe that your condition is immediate and serious and requires emergency ambulance transport
services to transport you to an appropriate facility.
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You must still notify your Universal Care Medical Group within 24 hours or as soon as reasonably
possible after the initial receipt of Emergency Services to inform them of the location, duration and
nature of the services provided.
Urgently Needed Services
An Urgently Needed Service is a Medically Necessary service required outside of the Service Area to
prevent a serious deterioration of your health resulting from unforeseen illness or injury manifesting
itself by acute symptoms of sufficient severity, which may include severe pain, such that treatment
cannot be delayed until your return to the Service Area.
What to do When You Require Urgently Needed Services:
If you are temporarily outside the Service Area and you believe that you require Urgently Needed
Services, you should:
• If possible, call, or have someone on your behalf call, your Universal Care Medical Group. The
telephone number for your Universal Care Medical Group is indicated on your Universal Care
Identification Card and in your Provider Directory. Assistance should be available 24 hours a day,
seven (7) days a week.
• Identify yourself as a Universal Care Member and ask to speak to a physician. If you are calling
during non -business hours and a physician is not immediately available, ask to have the physi-
cian -on -call paged. A physician should call you back shortly.
• Explain your situation and follow the instructions provided.
If you are unable to contact your Universal Care Medical Group, you should seek care for Urgently
Needed Services from a licensed medical professional where you are located. You must still notify
your Universal Care Medical Group within 24 hours or as soon as reasonably possible after the initial
receipt of Urgently Needed Services to inform them of the location, duration and nature of the ser-
vices provided.
It is very important that you follow the steps outlined under "What to do When you
Require Emergency Services" and "What to do When you Require Urgently Needed
Services". If you do not, you may be financially responsible for services received.
Post -Stabilization Care
Prior Authorization from your Primary Care Physician in your Contracting Medical Group is required
prior to the provision of Medically Necessary Covered Services following stabilization of an
Emergency Medical Condition. "Stabilization" means that, in the opinion of the treating provider,
your medical condition is such that, within reasonable medical probability, no material deterioration
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of your condition is likely to result from your transfer to another provider. Universal Care or your
Contracting Medical Group provides 24-hour access by telephone for you and providers to obtain
timely authorization for Medically Necessary Covered Services in situations where you have received
Emergency Services and your condition is stabilized, but the treating provider believes that you may
not be discharged safely.
Non -Qualifying Services
Medical Services or Hospital Services, which do not qualify as Emergency Services, or Urgently
Needed Services and which are received without Prior Authorization from your Primary Care
Physician are not covered by Universal Care. Thus, for example, medical care provided outside the
Universal Care Service Area will not be covered if the need for medical care is for a known or chronic
condition that is not showing acute symptoms as described in the "Emergency Services" or "Urgently
Needed Services" sections above.
Extraordinary Circumstances
In the unfortunate event of a major disaster, epidemic, war, riot, civil unrest or complete or partial
destruction of facilities, our Contracting Medical Groups and Contracting Hospitals will do their best
to provide the services you need.
Under these extreme conditions, go to the nearest Physician or hospital for Emergency Services or
Urgently Needed Services. Universal Care will reimburse you for Emergency Services or Urgently
Needed Services later. See procedure below for claiming reimbursement under the heading titled
"Claims Procedure (Reimbursement)."
HEALTH PLAN PREMIUMS (PREPAYMENT FEES)
Your employer is responsible for submitting all Health Plan Premiums for you to Universal Care.
However, your employer may require that you pay a portion of the Health Plan Premiums. Please
contact your health benefits officer at work for information on the method, amount and frequency of
your contribution, if any.
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COPAYMENTS
When you receive Covered Services, you are responsible for paying a minimal charge, called a
Copayment, at the time certain services are received. Those Covered Services for which Copayments
are due and the required Copayment amounts are listed in the Benefit Schedule accompanying this
Agreement.
Annual Copayment Maximum
To protect you from large medical expenses, a limit, called the annual Copayment maximum, has
been placed on the dollar amount of certain Copayments you might have to pay during a Benefit Year.
As set forth in the Benefit Schedule, Copayments for infertility studies and treatment and prescription
drug benefits do not apply toward the annual Copayment maximum. When the Copayments you
made during any Benefit Year reach the annual Copayment maximum, then no further Copayments
will be charged to you for Covered Services received during the remainder of the Benefit Year, except
for Copayments for infertility studies and treatment and prescription drug benefits. The amount of
the annual Copayment maximum is set forth in the Benefit Schedule.
It is important to keep receipts of all Copayments you paid for Covered Services received, including
Emergency or Urgently Needed Services, in order to submit documentation of reaching the annual
Copayment maximum. If the amount of Copayments paid reaches the annual Copayment maximum,
send the receipts along with a letter of explanation to Universal Care that you believe you have
reached the annual Copayment maximum to: Universal Care Member Services Department, 1600 East
Hill Street, Signal Hill, California 90806-3682. Any Copayments you pay beyond the annual
Copayment maximum will be reimbursed by Universal Care.
If you have any questions about Copayments or how to document that the annual Copayment maxi-
mum has been reached, please call the Universal Care Member Services Department at 1-800-635-
6668 or TTY 1-866-321-5955 for the hearing impaired, Monday through Friday from 8:00 a.m. to
6:00 p.m.
Your Protection and Liability
When Covered Services are received from or with the authorization of your Primary Care Physician
or Contracting Medical Group or when Emergency or Urgently Needed Services are received, you are
only responsible for any applicable Copayment. The Primary Care Physician or other Contracting
Provider cannot bill or charge you for any sums owed to the Primary Care Physician or other
Contracting Provider by Universal Care for Covered Services rendered.
If you choose to receive services that are not covered under this Health Plan, or ser-
vices not under the direction of your Contracting Medical Group or Primary Care
Physician (except OB/GYN physician services obtained from an OB/GYN or family
PIOOMRX4 PO 4LE
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. U__ALJ_ L E R S A I CAR F
practice physician affiliated with your Contracting Medical Group), or services
from a Non -Contracting Provider without a proper referral and authorization by
your Primary Care Physician or Contracting Medical Group, you may be responsi-
ble for payment of these services. (This does not apply for Emergency Services and
Urgently Needed Services).
CLAIMS PROCEDURE (REIMBURSEMENT)
If for some reason you are billed for Covered Services, submit the bill as soon as reasonably possible to:
Universal Care
Claims Department
P.O. Box 16420
Signal Hill, California 90806-3682
If the bill is for Covered Services, which have been authorized by your Primary Care Physician or
Contracting Medical Group, and you have not exceeded any benefit limits as specified in this
Evidence of Coverage booklet under "Health Benefits," the bill will be paid on your behalf. However,
if the bill is for non -Covered Services, or services which have not been prior authorized by your
Primary Care Physician, or you have exceeded any specified benefit limits, the bill will not be paid by
Universal Care and will remain your responsibility.
You should know that by law you have certain rights and responsibilities with regard to bills. If you
receive Covered Services from a Contracting Provider, you are not responsible for paying those bills
even in the unlikely event that Universal Care would be unable to pay them on your behalf.
However, if you receive authorized Covered Services from a Non -Contracting Provider, including
Emergency or Urgently Needed Services, you may be responsible for the amount of those bills in the
unlikely event that Universal Care would be unable to pay them on your behalf.
You must submit any bills, with proof of payment, to Universal Care when you request reimburse-
ment for the cost of Emergency or Urgently Needed Services rendered to you. Claims must be sub-
mitted to the Universal Care Claims Department within sixty (60) days or as soon as reasonably pos-
sible after the Emergency or Urgently Needed Services are rendered. Be prepared to give as much
information as possible, such as the date of the service, amount of the bill, and name and address of
the provider, and any copies of bills you received. You will be reimbursed for an approved
Emergency or Urgently Needed Services claim within forty-five (45) days of the date your claim was
received, unless additional information is needed. If your claim is denied, you will receive written
notice of the decision from Universal Care, including information about the reason for the denial of
the claim and your right to appeal the decision through Universal Care's grievance procedure.
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CHANGES IN COVERAGE OR ENROLLMENT
Notifying Us of Any Change in Your Status
It is very important that Universal Care know how to reach you. Please notify us of any change in
your name, address, telephone number, marital status or the status of any of your Dependents or any
of the other information you provided on the enrollment application within thirty (30) days of the
change. Call or write to Universal Care at:
Universal Care
Member Services Department
1600 E. Hill Street
Signal Hill, California 90806-3682
1-800-635-6668
TTY 1-866-321-5955 for the hearing impaired
Ending Coverage (Termination of Benefits)
Generally, your Universal Care membership ends when your Employer's Group Subscriber Agreement
ends. Your Employer may voluntarily terminate the Group Subscriber Agreement, in which case,
your membership in this Health Plan will terminate at the end of the month for which the last Health
Plan Premium has been received by Universal Care from your Employer on your behalf. In addition,
Universal Care may terminate your Employer's Group Subscriber Agreement for good cause, in which
case, termination shall become effective, except in the case of non-payment of Health Plan Premiums,
upon a thirty (30) day written notice to your Employer.
In cases in which your Employer fails to pay Health Plan Premiums by the due date, Universal Care
will send a written notice of termination to your Employer, to be effective on the last day of the
month for which full Health Plan Premiums were paid. If your Employer pays the delinquent
amount within fifteen (15) days of the date of the notice, your Universal Care membership will be
reinstated, and the termination notice will be considered canceled. If your Employer does not pay
the delinquent amount within fifteen (15) days of the date of the notice, the Health Plan may not
reinstate your Universal Care membership, or may require a new application and may place new con-
ditions upon the reinstatement of your Universal Care membership.
Good cause for termination of your Employer's Group Subscriber Agreement by Universal Care shall
include:
1. Failure of your Employer to pay Health Plan Premiums when due.
2. Failure of your Employer to maintain minimum Health Plan Premium contributions requirements
as set forth in the Application for the Group Subscriber Agreement.
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3. Knowing failure by your Employer to abide by and enforce the conditions of enrollment of
Subscribers as set forth in this Combined Evidence of Coverage and Disclosure Form and in the
application for the Group Subscriber Agreement,
4. Fraud or misrepresentation by your Employer's submission to Universal Care of materially incor-
rect or incomplete information which is reasonably relied upon by Universal Care in issuing or
renewing the Group Subscriber Agreement, and
5. A material change in the nature of your Employer's business.
If your Employer's Group Subscriber Agreement is terminated by either Universal Care or your
Employer, your Employer shall promptly mail or hand deliver to each covered Subscriber, a notice of
cancellation of the Group Subscriber Agreement. Your Employer shall, upon request by Universal
Care, provide Universal Care with a copy of the notification, a written statement that the notice of can-
cellation was mailed or hand delivered to each Subscriber, and the date of mailing or hand delivery.
Individual membership in the Health Plan may be revoked by Universal Care for any one of the fol-
lowing reasons:
1. Failure to pay required Health Plan Premiums, Copayments or fees for non -covered services. Any
Member being disenrolled from this Health Plan under this provision may be disenrolled by
Universal Care within fifteen (15) days after mailing written notice of termination via First Class
Mail for nonpayment to such Member. Such notice shall state that the receipt by Universal Care of
the applicable payment during the fifteen (15) days shall cause Universal Care to revoke the notice.
2. Fraud or deception in your enrollment application, or in your use of facilities or services. A
Member's membership in this Health Plan shall immediately terminate if such Member knowingly
provides Universal Care with fraudulent information upon which Universal care relies, which
materially affects a Member's eligibility for enrollment or benefits under this Health Plan. In such
instance, Universal Care shall send a written notice of termination to the Member.
3. Allowing unauthorized use of your Universal Care identification card. A Member's membership
in this Health Plan shall immediately terminate if such Member permits the use of his or her
Universal Care Identification Card by any other person. In such instance, Universal Care shall
mail a written notice of termination to the Member.
4. A Member may be disenrolled for cause if the Member's behavior is disruptive, threatening,
unruly, abusive, or uncooperative to the extent that his or her continuing membership in the
Health Plan seriously impairs Universal Care's ability to furnish or arrange services to the
Member or other Members. In addition, a Member may be disenrolled for continued refusal of
recommended medical treatment if the Contracting Medical Group determines that such refusal
to accept its recommendations is incompatible with the continuance of the physician -patient rela-
PO_4LE P100MRX4
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tionship and as obstructing the provision of proper medical care. A disenrollment for cause shall
be effective on the first (1st) day of the calendar month following the month in which notice of
disenrollment is given to the Member.
Relocation outside Universal Care's approved Service Area. Member's enrollment in this Health
Plan shall terminate immediately if Member changes his or her Primary Residence to a location
outside the Service Area, except with respect to certain dependent children. See "Coverage for
Dependents" above. In such instance, Universal Care shall mail a written notice of termination to
the Member at the Member's last known address.
6. In the event Member loses his or her eligibility for membership in this Health Plan, his or her
membership shall terminate on the last day of the month in which the Member's eligibility ceases.
In the event of a dissolution of a marriage, coverage for a subscriber's Spouse enrolled as a
Dependent shall terminate on the first (1st) day of the month following the month in which a
final judgment or decree of dissolution of marriage is entered. A Dependent child's membership
in this Health Plan shall continue notwithstanding dissolution of Subscriber's marriage as long as
the Dependent child remains eligible and Health Plan Premiums are received by Universal Care.
In the event the Subscriber dies, then coverage for individuals enrolled as Dependents shall ter-
minate on the first (1st) day of the month following the month in which the Subscriber died.
Notwithstanding the foregoing, a Member who loses eligibility shall be eligible for continuing
benefits as outlined in "Continuing Coverage" and "COBRA" sections.
In the event that a person has never been eligible for membership in this Health Plan, but has
received the benefits of membership in this Health Plan for reasons other than the fraud of decep-
tion of the person or another person through which the person is enrolled as a Dependent, such
person's benefits shall be terminated effective fifteen (15) days after mailing by Universal Care of
a written notice of termination.
8. Failure to cooperate with Universal Care's coordination of benefits and third -party liability rights.
Universal Care may terminate a Member if the Member fails to reasonably cooperate with
Universal Care in the enforcement of Universal Care's third party liability rights or in Universal
Care's efforts to coordinate benefits with other plans. Termination shall be effective the last day of
the month in which the Member receives notice of termination.
9. Voluntary termination in a manner determined by your Employer. A Member may voluntarily dis-
enroll by submitting a written request for disenrollment to his or her Employer in a manner to be
determined by the Employer. If the request complies with Employer requirements, Employer shall
forward all such requests to Universal Care for processing. Employer shall be responsible for pay-
ment of the Member's Health Plan Premium for the month in which the Member disenrolls.
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64
If your membership is terminated, you will be so notified in writing, and you will be informed of the
termination effective date.
Under no circumstances will your membership be terminated due to your health status or need for
health care services.
If you feel your membership has been unfairly revoked, you may request a review before the
California Department of Managed Health Care. For more information contact our Member Services
Department.
Notifying You of Changes in Your Plan
Amendments, modifications or termination by either your Employer or Universal Care do not require
the consent of the plan Members. Universal Care may amend or modify the Health Plan at any time
by providing a thirty (30) day written notice to your Employer prior to the effective date of such
amendment or modification. The Health Plan may only be terminated by Universal Care for good
cause. The Health Plan may be terminated by your Employer with a thirty (30) day prior written
notice to Universal Care. Either Universal Care or your Employer will promptly notify you of any
changes in your Universal Care Plan.
Renewal or Reinstatement
Unless terminated, your contract with Universal Care renews automatically, on a yearly basis, subject
to all terms and conditions of the Group Subscriber Agreement between Universal Care and your
Employer. If your Employer's Group Subscriber Agreement is terminated by Universal Care, rein-
statement with Universal Care is subject to all terms and conditions of the Group Subscriber
Agreement between Universal Care and your Employer.
If you have questions about your employer's conditions for renewal or reinstatement, please contact
your health benefits officer at your place of work.
Continuing Coverage
If you stop working full-time or lose your job for any reason, contact your employer to determine if
any arrangements can be made for continuing your coverage under your employer's group health
plan.
PO_4LE
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• If your Employer is subject to the federal Consolidated Omnibus Budget Reconciliation Act
(COBRA) of 1985, as amended, you and your covered dependents may be entitled to continua-
tion of coverage under your Employer's group health care plan. Generally, COBRA applies to
employers that offer their employees health coverage and that employed 20 or more employees
on 50% of the business days during the preceding calendar year. While both full-time and part-
time employees are considered in determining whether an employer had at least 20 employees, a
part-time employee will count as a fraction of a full-time employee, proportional to the amount of
time worked in comparison to a full-time employee. All Members may qualify for continuation
of coverage under COBRA if they lose coverage for one of the following reasons:
• The Subscriber's termination or separation from employment for reasons other than gross
misconduct.
• The Subscriber's reduction in hours of employment.
• With respect to a covered dependent only, the Subscriber's death.
• A spouse's loss of dependent status due to divorce or legal separation from a Subscriber.
• A child's loss of dependent status.
• With respect to a covered dependent only, the Subscriber's entitlement to Medicare.
Individual Conversion
You or your eligible Dependents may be able to convert to a Universal Care Individual Conversion
Plan once your Employer group benefits and continued benefits under COBRA end. There are some
enrollment guidelines for this coverage. Please consult the Group Subscriber Agreement between
Universal Care and your Employer for more details concerning individual conversion.
Please note: If the Group Subscriber Agreement between Universal Care and your Employer termi-
nates, neither continuation of benefits nor individual conversion provisions apply. Our Member
Services Department and your employer can provide you with more information.
Extension of Benefits for Totally Disabled Members Upon Termination of
Agreement Between Employer Group and Universal Care
If the Agreement between your Employer Group and Universal Care is terminated and you or any of
your Dependents are totally disabled at the time of termination, federal law may require your
Employer's succeeding carrier to provide coverage for treatment of the condition causing total disabil-
ity. However, in the event that your Employer does not contract with a succeeding carrier for health
coverage, or in the event that federal law would allow a succeeding carrier to exclude coverage of the
disability for a period of time, Universal Care will continue to provide benefits to you or any of your
P100MRX4 P0_4LE
65
66
Dependents for Covered Services directly relating to the condition causing total disability existing at
the time of termination for a period of up to twelve (12) months after the termination. The extension
of benefits may be terminated by Universal Care at such time as you or any of your Dependents is no
longer disabled, or at such time as a succeeding carrier is required by law to provide replacement cov-
erage to you or any of your Dependents without limitation as to the disabling condition.
For purposes of this provision "totally disabled" means:
(i) with respect to a Subscriber, one who, because of illness or injury, is prevented from engaging
in any occupation for wages or profit for which he is qualified based on education or training.
(ii) with respect to a Dependent, one who, because of illness or injury, is prevented from engag-
ing in substantially all of his or her normal activities.
REIMBURSEMENT OF THIRD PARTY LIABILITY
To the extent permitted under applicable federal and state law including California Civil Code Section
3040, and as provided for in this Agreement, in the case of injuries caused by any act or omission of a
third party, and any complications incident thereto, the benefits of this Agreement shall be furnished
by Universal Care to Member. Member agrees, however, to reimburse Universal Care, or its nominee,
for the cost of such services and benefits provided, to the extent described herein and/or the extent
allowed under state and/or federal law, immediately upon obtaining a monetary recovery, whether due
to judgment, arbitration award, or settlement agreement, on account of such injury. Member shall
hold any such sum in trust for Universal Care, but said sum shall not exceed the reasonable costs
actually paid by Universal Care or its nominee to perfect any lien, and, where services were not pro-
vided on a capitated basis, the amounts actually paid to treating providers. Where services were pro-
vided on a capitated basis, the sum reimbursable to Universal Care or its nominee shall not exceed an
amount equal to 80% of the usual and customary charges for the same services on a non-capitated
basis in the geographic region where the services were provided. Where the services were provided on
capitated and non-capitated bases, reimbursement to Universal Care or its nominee may not exceed
the sum of the reasonable costs to perfect a lien, the amount actually paid to treating providers in a
non-capitated situation, and an amount equal to 80% of the usual and customary charges for the
same non-capitated services in a capitated situation.
Where the Member has engaged an attorney to assist in obtaining recovery from a third party, any
lien by Universal Care or its nominee shall not exceed the lesser of the amounts set forth above,
whichever is applicable, and one third of the moneys due to the member pursuant to a final judg-
ment, arbitration award, or under a settlement agreement. Where the Member has not obtained the
services of an attorney to assist in recovery from a third party, any lien by Universal Care or its nomi-
nee may not exceed the lesser of the amounts set forth above, whichever is applicable, and one half of
the moneys due to the Member pursuant to a final judgment, arbitration award, or under a settlement
PO 4LE P100MRX4
agreement. The maximum amount of any lien asserted by Universal Care or its nominee may be fur-
ther reduced by any percentage of fault attributed to the Member by a judge, jury, or arbitrator so as to
reduce the amount of the Member's recovery. Universal Care or its nominee will bear a pro rata share
of the Member's reasonable attorney's fees and costs, in accordance with the common fund doctrine.
Member agrees that Universal Care's rights to reimbursement under this provision are the first priori-
ty claim against any third party. This means that Universal Care shall be reimbursed from any recov-
ery before payment of any other existing claims, including any claim by the Member for general dam-
ages. To the extent permitted by state and/or federal law, and as set forth in this provision, Universal
Care may collect from the proceeds of any settlement or judgment recovered by Member or his or her
legal representative regardless of whether the Member has been fully compensated.
Member agrees to cooperate in protecting the interest of Universal Care under this provision.
Member must execute and deliver to Universal Care or its nominee any and all liens, assignments or
other documents which may be necessary or proper to fully and completely effectuate and protect the
right of Universal Care, or its nominee, including, but not limited to, the granting of a lien right in
any claim or action made or filed on behalf of Member and the signing of documents evidencing
same. Member's failure to cooperate with Universal Care in a reasonable manner as provided in this
provision may result in such Member's termination from this Health Plan.
Member shall not settle any claim, or release any person from liability, without the written consent of
Universal Care, wherein such release or settlement will extinguish or act as a bar to Universal Care's
rights or reimbursement.
In the event Universal Care employs an attorney for the purpose of enforcing any part of this section
against a Member based on Member's failure to cooperate with Universal Care, the prevailing party in
any legal action or proceeding shall be entitled to reasonable attorney's fees.
In lieu of payment as indicated above, Universal Care, at its option, may choose to be subrogated to
the Member's rights to the extent of the benefits received under this Health Plan. Universal Care's
subrogation right shall include the right to bring suit in the Member's name. Member shall fully
cooperate with Universal Care when Universal Care exercises its right of subrogation and Member
shall not take any action or refuse to take any action which should prejudice the rights of Universal
Care under this provision.
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l!_ N_.1_V...- E_._8.._ S A.._ L CARE .
COORDINATION OF BENEFITS
If you or a family member are covered by Universal Care and another health plan (as defined by Title
28, California Code of Regulations, Section 1300.67.13), Universal Care will coordinate its benefits
with those of the other plan. Benefits will be coordinated with the following types of plans: Any
plan providing benefits or services for or by reason of medical or dental care or treatment, which ben-
efits or services are provided by (i) group, blanket or franchise insurance coverage, (ii) service plan
contracts, group practice, individual practice and other prepayment coverage, (iii) any coverage
under labor-management trustee plans, union welfare plans, employer organization plans, or employ-
ee benefit organization plans, and (iv) any coverage under governmental programs, and any coverage
required of provided by any statute.
The goal of this kind of coordination is to maximize coverage for your allowable expenses, minimize
your out-of-pocket costs and to prevent any payment duplication. Universal Care coordinates bene-
fits in accordance with the requirements of Title 28, California Code of Regulations, Section
1300.67.13 and with interpretive instructions promulgated by the California Department of Managed
Health Care. In order to ensure proper coordination, you must inform Universal Care of any other
health coverage for which you or your dependents may be eligible. If Universal Care pays more bene-
fits than appropriate, Universal Care may recover excess benefit payments from you, the plan with
primary responsibility, or any other person or entity that benefited from the overpayment.
For the purpose of determining the applicability of and implementing the terms of this provision, or
any similar provision in another health plan, Universal Care may release to or obtain from any insur-
ance company, health plan, or other organization or person any information, with respect to any per-
son, which Universal Care deems to be necessary for such purposes. Any person claiming benefits
under this Health Plan shall furnish such information as may be necessary to implement this provi-
sion. Your failure to cooperate with Universal Care in a reasonable manner in its efforts to secure
payment from another carrier may result in your termination form this Health Plan.
NON -DUPLICATION OF BENEFITS WITH CHAMPUS
The Member shall furnish information concerning any applicable benefits from the Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS) to which Member may be entitled to receive
upon request by Universal Care. Universal Care shall not furnish benefits under this Agreement on
behalf of Member, which duplicate the benefits to which Member is entitled under CHAMPUS.
If payment is made by Universal Care in duplication of the benefits available under CHAMPUS,
Universal Care may seek reimbursement up to the amount Universal Care has paid for benefits which
duplicate such coverage from CHAMPUS.
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NON -DUPLICATION OF BENEFITS WITH WORKERS' COMPENSATION
The Member shall notify Universal Care when Member or any other person or entity files a claim for
benefits under Workers Compensation laws, where such claim requests compensation for illness or
injuries for which Member has received Medical Services or Hospital Services pursuant to this
Agreement. Universal Care shall not pay any person or entity for Medical Services or Hospital
Services for which a Contracting Provider or a Non -Contracting Provider is paid under the Workers'
Compensation payor (including, but not limited to, any Workers' Compensation carrier, self -funded
employer or employer association, or the State uninsured employers' fund) .
If Universal Care makes any payments for Medical Services or Hospital Services provided to the
Member, which are reimbursed to Contracting Providers or Non -Contracting Providers by any
Workers' Compensation payor (including, but not limited to, any Workers' Compensation carrier,
self -funded employer or employer association, or the State uninsured employers' fund), Universal
Care may recover its payments from any person or entity (including the Member) which has received
or is in possession of Universal Care's payment, up to the amount that Universal Care paid for
Medical Services or Hospital Services that were reimbursed by such Workers' Compensation payor.
Should Universal Care assert any claim, including any lien, in any Workers Compensation case,
including, but not limited to a Workers' Compensation Appeals Board case, Member shall cooperate
with Universal Care by executing any documents and providing any records, testimony or materials
that Universal Care requests in supporting its claim.
NON -DUPLICATION OF BENEFITS WITH MEDICARE
The Member shall notify Universal Care when Member enrolls in Medicare (Part A and/or B).
Universal Care shall not pay any person or entity for Medical Services or Hospital Services for which
a Contracting Provider or a Non -Contracting Provider is paid under the Medicare program. However,
should the Member receive any Medical Services or Hospital Services for which the Member either is
not covered under the Medicare program, or where all or a portion of the Medical Services or
Hospital Services are not paid for under the Medicare program, and for which the Member has finan-
cial liability, then Universal Care will pay for all or a portion of such Medical Services or Hospital
Services pursuant to this Agreement.
If Universal Care makes any payments for Medical Services or Hospital Services provided to the
Member, which are reimbursed to Contracting Providers or Non -Contracting Providers by the
Medicare program, Universal Care may recover its payments from any person or entity (including the
Member) which has received or is in possession of Universal Care's payment, up to the amount that
Universal Care paid for Medical Services or Hospital Services that were reimbursed by Medicare.
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HOW UNIVERSAL CARE CONTRACTING PROVIDERS ARE COMPENSATED
Universal Care both owns and operates Contracting Medical Groups and contracts with independent
Contracting Medical Groups to provide Covered Services to you. The Contracting Medical Groups,
in turn, employ or contract with individual Physicians. Most of Universal Care's Contracting Medical
Groups receive an agreed upon monthly payment from Universal Care to provide Covered Services to
you. This monthly payment may be either a fixed dollar amount per Member or a percentage of the
monthly premium received by Universal Care. The monthly payment typically covers professional
services directly provided by the Contracting Medical Group, and may also cover certain referral ser-
vices. Some of Universal Care's Contracting Hospitals receive similar monthly payments in return for
providing Hospital Services to you. Other hospitals are paid a discounted fee -for -service amount or a
fixed charge per day of hospitalization.
At the beginning of each year, Universal Care and each Contracting Medical Group agree on a budget
for the cost of Hospital Services covered under the program, for all Universal Care Members treated
by the Contracting Medical Group. At the end of the year, the actual cost of Hospital Services for the
year is compared to the agreed upon budget. If the actual cost of services is less than the agreed
upon budget, the Contracting Medical Group shares in the savings.
Stop -loss insurance protects Contracting Medical Groups and Hospitals from large financial expenses.
If providers do not obtain stop -loss protection from Universal Care, they may obtain stop -loss insur-
ance from an insurance carrier acceptable to Universal Care.
If you choose or are assigned to one of the Contracting Medical Groups that is owned and operated
by Universal Care, the Primary Care Physician is an employee of Universal Care and is paid a salary
to provide Covered Services to you. If you are referred to a specialist provider, the specialist is paid
on a fee -for -service basis by Universal Care. Universal Care does not offer any bonuses or incentives
to Contracting Providers who are employees of Universal Care. You may request additional informa-
tion on Universal Care's compensation arrangements by contacting Universal Care.
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MEMBER SERVICES
Member Services Department & Multi -Lingual Services
Universal Care has a Member Services Department available to answer any questions you may have
regarding your benefits, where to obtain services, or to assist you with any problems you may have.
The address and telephone number for the Member Services Department is:
Universal Care
Member Services Department
1600 East Hill Street
Signal Hill, California 90806-3682
(562) 424-6200 or (800) 635-6668
TTY 1-866-321-5955 for the hearing impaired
The toll -free telephone number is available on regular business days from the hours of 8:00 a.m. to
6:00 p.m. Universal Care will provide staff bilingual in English and Spanish during all hours of tele-
phone service.
Universal Care provides 24 hour access to interpreter services for all non-English speaking Members
seeking health services within Universal Care's Service Area. When one of Universal Care's Member
Services staff or Health Services staff cannot directly speak with you in your own language, transla-
tion services will be quickly arranged. Universal Care has a current list of interpreters who are on 24
hour "on call" status to provide interpreter services if needed. You will not be required to utilize fam-
ily members or friends as interpreters.
Also, the Universal Care Provider Directory includes information about the linguistic capabilities of
Universal Care's Contracting Medical Groups and Primary Care Physicians.
24 Hour Nurse AdviceLine
If you have a health -related question, any time of the day or night, you can call the Universal Care
Nurse AdviceLine. The AdviceLine, available 24 hours a day, three hundred sixty-five (365) days a
year, is staffed by knowledgeable California Licensed Registered Nurses who can provide you with
information on a variety of topics, including first aid procedures and preventative health care. Nurse
AdviceLine staff can also help you decide whether a condition warrants further medical attention and
help you schedule an appointment for care at a Universal Care Medical Group location most conve-
nient for you. The AdviceLine can also issue a limited prior authorization for after hours requests for
non -formulary drugs.
For help in a specific situation, call Universal Care's Member Services Department
at 1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired.
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GRIEVANCE PROCESS
If you have a problem that you feel has not been resolved to your satisfaction through the Member
Services Department, you may submit a formal written complaint to Universal Care's Grievance and
Appeals Unit at:
Universal Care
Member Services Department
Grievance & Appeals Unit
Post Office Box 16048
Long Beach, CA 90806-6048
Forms for the submission of such complaints may be obtained from the Universal Care Member
Services Department by calling 1-800-635-6668 or TTY 1-866-321-5955 for the hearing impaired.
Universal Care will not discriminate against any member who files a grievance.
Quality of Care Complaints
All complaints that involve the quality of care rendered by a physician or other provider will be
referred to Universal Care's Quality Management Department for review. Complaints that affect a
Member's immediate condition will receive immediate review. Universal Care will investigate the
complaint, consulting with the Member's Contracting Medical Group and other Universal Care
departments and will review medical records as necessary. The Member may need to sign an autho-
rization to release his or her medical records.
Upon completion of the review, the Member will be notified of any changes in the Member's plan of
treatment. However, the actual findings, proceedings and records of the review are confidential and
immune from discovery by the Member under state law.
Note that while Universal Care has processes in place to continuously monitor the quality of care ren-
dered by its Contracted Providers, a Member's claims against an individual physician or against a hos-
pital or other provider based on the quality of care rendered by that provider are not governed by this
Agreement, and the Member may seek any appropriate legal action against such persons and entities
as the Member deems necessary.
If a Member has asserted a quality of care complaint that also includes a complaint relating to benefit
coverage, reimbursement for a service already received by the Member, or any other complaint, the
non -quality of care aspects of the complaint will be handled separately through the processes
described below.
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Benefit Coverage, Reimbursement and Other Complaints Not Involving
the Quality of Care Rendered by a Provider
Standard Review: Universal Care will review your complaint and provide you with a written
response containing a clear and concise explanation of Universal Care's conclusions within thirty (30)
days of receipt of your complaint. If the circumstances indicate that an expedited or independent
review of an Experimental Treatment is needed, the additional processes set forth below will be avail-
able to you. If your complaint involves the delay, denial, or modification of health care services,
Universal Care's written response will describe the criteria used and the clinical reasons for its decision,
including all criteria and clinical reasons related to Medical Necessity. For decisions delaying, denying,
or modifying health care services based on a finding that the proposed services are not a covered bene-
fit under the Member's Universal Care Health Plan contract, the written response will specify the provi-
sions in the plan contract that exclude that coverage. After completing or participating in the
Universal Care grievance process for thirty (30) days, you may submit your grievance directly to the
California Department of Managed Health Care for review by that agency as set forth below. If earlier
review is warranted, the Department will review your grievance without requiring your prior participa-
tion in the Plan's grievance process. Prior to exercising your right to submit a grievance to the
Department of Managed Health Care, you may request voluntary mediation with the Plan.
Voluntary Mediation: You, or an agent acting on your behalf, may also request voluntary media-
tion with Universal Care prior to exercising the right to submit a grievance to the Department of
Managed Health Care. The use of mediation services shall not preclude your right to submit a griev-
ance to the Department upon completion of mediation. In order to initiate mediation, you, or the
agent acting on your behalf, should submit a written request for voluntary mediation. If the parties
mutually agree to mediation, the mediation will be administered by the Judicial Arbitration and
Mediation Service (JAMS) in accordance with its Commercial Mediation Rules, unless otherwise
agreed to by the parties. Expenses for mediation shall be borne equally by both sides. The
Department shall have no administrative or enforcement responsibilities in connection with the vol-
untary mediation process.
Review by Director of Department of Managed Health Care: The California
Department of Managed Health Care is responsible for regulating health care service
plans. The Department has a toll free telephone number 1-888-HMO-2219 to
receive complaints regarding health plans. The hearing and speech impaired may
use the California Relay Service's toll -free telephone numbers 1-800-735-2929 TTY
or 1-888-877-5378 TTY to contact the Department. The Department's Internet web -
site (http://wwwhmohelp.ca.gov) has complaint forms and instructions online. If
you have a grievance against Universal Care, you should first telephone Universal
Care Member Services Department at 1-800-635-6668 or TTY 1-866-321-5955 for
P100MRX4 P0_4LE
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the hearing impaired and use Universal Care's grievance process before contacting
the Department. If you need help with a grievance involving an emergency, a griev-
ance that has not been satisfactorily resolved by Universal Care, or a grievance that
has remained unresolved for more than thirty (30) days, you may call the
Department's toll free telephone number for assistance. Universal Care's grievance
process and the Department's complaint review process are in addition to any other
dispute resolution procedures that may be available to you, and your failure to use
these processes does not preclude your use of any other remedy provided by law.
Expedited Review Process: Complaints involving an imminent and serious threat to the health
of the Member, including, but not limited to, severe pain, potential loss of life, limb, or major bodily
function, will be immediately referred to the Universal Care medical director for expedited review,
regardless of whether received orally or in writing, and Universal Care will immediately inform the
Member in writing of his or her right to notify the Department of Managed Health Care of the griev-
ance. Universal Care will provide the Member and the Department of Managed Health Care with a
written statement of the disposition or pending status of the expedited review no later than three (3)
days from receipt of the grievance.
Independent Medical Review of Grievances Involving
a Disputed Health Care Service
You may request an independent medical review ("IMR") of disputed health care services from the
Department of Managed Health Care ("DMHC") if you believe that health care services have been
improperly denied, modified, or delayed by the Plan or one of its Contracting Providers. A "disputed
health care service" is any health care service eligible for coverage and payment under your sub-
scriber contract that has been denied, modified, or delayed by the Plan or one of its Contracting
Providers, in whole or in part because the service is not medically necessary.
For more information regarding the IMR process, or to request and application form, please
call Universal Care's Member Services Department at 1-800-635-6668 or write to Universal
Care Attention: Member Grievance Unit at P.O. Box 16048, Signal Hill, CA 90806-3682.
The IMR process is in addition to any other procedures or remedies that may be available to you. You
pay no application or processing fees of any kind for IMR. You have the right to provide information
in support of the request for IMR. Universal Care must provide you with an IMR application form
with any grievance disposition letter that denies, modifies, or delays health care services. A decision
not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal
action against the plan regarding the disputed health care service.
Eligibility: Your application for IMR will be reviewed by the DMHC to confirm that:
PO_4LE
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(1) (A) Your provider has recommended a health care service as medically necessary, or (B) You have
received urgent care or emergency services that a provider determined was medically necessary, or
(C) You have been seen by an in -plan provider for the diagnosis or treatment of the medical con-
dition for which you seek independent review;
(2) The disputed healthcare service has been denied, modified, or delayed by the Plan or one of its
Contracting Providers, based in whole or in part on a decision that the healthcare service is not
medially necessary; and
(3) You have filed a grievance with the plan or its Contracting provider and the dispute decision is
upheld or the grievance remains unresolved after thirty (30) days. If your grievance requires
expedited review you may bring it immediately to the Department's attention. The DMHC may
waive the requirement that you follow the Plan's grievance process in extraordinary and com-
pelling cases.
If your case is eligible for IMR, the dispute will be submitted to a medical specialist who will make an
independent determination of whether or not the care is medically necessary. You will receive a copy
of the assessment made in your case. If the IMR determines the service is medically necessary, the
plan will provide the health care service.
For non -urgent cases, the IMR organization designated by the DMHC must provide its
determination with thirty (30) days of receipt of your application and supporting docu-
ments. For urgent cases involving imminent and serious threat to your health, includ-
ing, but not limited to, serious pain, the potential loss of life, limb, or major bodily
function, or the immediate and serious deterioration of your health, the IMR organiza-
tion must provide its determination within three (3) business days.
Independent Review of Denied Experimental
or Investigational Treatment
Eligibility Criteria
Universal Care provides the opportunity to seek an independent review under California's
Independent Medical Review System pursuant to Health & Safety Code Section 1370.4 of its coverage
decisions regarding experimental or investigational therapies for Universal Care Members who meet
all of the following criteria:
1. The Member has a life -threatening or seriously debilitating condition, defined as:
• "Life -threatening" means either or both of the following: (i) diseases or conditions where the
likelihood of death is high unless the course of the disease is interrupted; (ii) diseases or
conditions with potentially fatal outcomes, where the end point of clinical intervention is
survival.
• "Seriously debilitating" means diseases or conditions that cause major irreversible morbidity
75
and
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2. The Member's physician certifies that the Member has a life -threatening or seriously debilitating
condition, as defined above, for which standard therapies have not been effective in improving
the Member's condition, or for which standard therapies would not be medically appropriate for
the Member, or for which there is no more beneficial standard therapy covered by Universal Care
than the therapy proposed pursuant to paragraph (3); and
3. Either (a) the Member's Universal Care contracted physician has recommended a treatment, drug,
device, procedure or other therapy that he or she certifies in writing is likely to be more beneficial
to the Member than any available standard therapies, and he or she included a statement of the evi-
dence relied upon by the physician in certifying his or her recommendation; or (b) the Member, or
the Member's non -contracting physician who is a licensed, board -certified or board -eligible physi-
cian qualified to practice in the area of practice appropriate to treat the Member's condition, has
requested a therapy that, based on two documents from the medical and scientific evidence, as
defined in California Health and Safety Code Section 1370.4(d), is likely to be more beneficial for
you than any available standard therapy. The physician certification must include a statement of the
evidence relied upon by the physician in certifying his or her recommendation. Please note that
Universal Care is not responsible for the payment of services rendered by Non -Contracting
Providers that are not otherwise covered under the Member's Universal Care benefits; and
4. A Universal Care Medical Director has denied the Member's request for a treatment or therapy
recommended or requested pursuant to paragraph (3); and
5. The treatment or therapy recommended pursuant to paragraph (3) would be a covered service,
except for Universal Care's determination that the treatment, drug, device, procedure or other
therapy is experimental or investigational.
How to Request an Independent Review
Within five (5) business days of a decision to deny coverage for an experimental or investigational
therapy for a Member who has a life -threatening or seriously debilitating condition, Universal Care
will send the Member written notice of the denial and of the right to request an independent review if
the physician certification and evidence requirements listed in Items 2 & 3 above are met. The denial
notice from Universal Care will include an application form, along with a pre -addressed envelope, to
be used to request an independent review from the Department of Managed Health Care ("DMHC").
Universal Care also will include a physician certification form that must be completed by the
Member's physician for the Member to be eligible for an independent review.
A Member who has a life -threatening or seriously debilitating condition and receives written notice
from Universal Care of its denial of coverage for a requested experimental or investigational therapy
may request an independent review by completing the application form provided to the Member by
Universal Care and mailing the form to the DMHC in the pre -addressed envelope provided by
761 Universal Care.
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The Member's physician must provide the physician certification and evidence listed in Items 2 & 3
above. The Member may include the completed physician certification with the Member's application
mailed to the DMHC or the Member's physician may mail the physician certification and evidence
directly to the DMHC at the following address or fax number:
Department of Managed Health Care
California HMO Help Center
980 9th Street, Suite 500
Sacramento, CA 95814-2725
FAX (916) 229-0465
Upon receiving the Member's application for an independent review, the DMHC will review the
Member's request and notify the Member in writing as to whether the request has been approved.
The DMHC also will notify Universal Care and the physician providing the certification that the
Member's application has been approved.
Independent Review Procedures
If the Member requests an independent review, the review will be performed by an independent med-
ical review organization CIRO") that has a contract with the DMHC. The IRO will select an indepen-
dent panel of at least three physicians or other medical professionals who are experts in the treatment
of the Member's medical condition and knowledgeable about the recommended treatment. Neither
Universal Care nor the Member will choose or control the choice of physicians or other medical pro-
fessional experts. The costs of the independent review will be borne by Universal Care. The Member
pays no application or processing fees of any kind for an independent review.
If the Member requests an independent review, Universal Care will provide the following documents
to the IRO designated by the DMHC within three (3) business days of Universal Care's receipt of noti-
fication from the DMHC that a Member has applied for an independent review of Universal Care's
denial of experimental or investigational therapy: (a) the relevant medical records within Universal
Care's possession; (b) any other relevant documents or information used by Universal Care in deter-
mining whether the proposed therapy should be covered and any statement by Universal Care
explaining the reasons for its decision to deny coverage for the proposed therapy; and (c) all informa-
tion provided to the Member by Universal Care and any of its Contracting Providers concerning
Universal Care and provider decisions regarding the Member's condition and care (including a copy
of Universal Care's denial notice to the Member), and any materials that the Member or the Member's
physician submitted to Universal Care in support of the request for coverage of the experimental or
investigational therapy. If there is any information or evidence the Member or the Member's physi-
cian wish to submit to the DMHC in support of the independent review that has not previously been
77
P100MRX4 P0_4LE
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provided to Universal Care, the Member may include this information with the Member's application
to the DMHC for the independent review. Also, the Member's physician must provide to the DMHC
or the IRO, as required, copies of any relevant medical records and any newly developed or discov-
ered relevant medical records and respond to any requests for additional medical records or other rel-
evant information from the experts on the panel performing the independent review.
If there is an imminent and serious threat to the health of the Member, Universal Care will deliver all
necessary information and documents listed above to the IRO within 24 hours of approval of the
request for an independent review. After submitting all of the required material to the IRO, Universal
Care will promptly issue a notification to the Member that includes an annotated list of the docu-
ments submitted and offer the Member the opportunity to request copies of those documents from
Universal Care.
The independent review panel will render its analysis and recommendations in writing, in laypersons
terms to the maximum extent practicable, within thirty (30) days of receipt of the Member's request
for independent review and supporting information, or within less time as follows:
• If the Member's physician determines that the proposed course of treatment or therapy would be
significantly less effective if not promptly initiated, the analysis and recommendations will be ren-
dered within seven (7) days of the request for expedited review.
• If the proposed therapy has not been provided and the Member's provider or the DMHC certifies
in writing that an imminent and serious threat to the health of the Member may exist, including,
but not limited to, serious pain, the potential loss of life, limb or major bodily function, or the
immediate and serious deterioration of the health of the Member, the analyses and recommenda-
tions of the experts must be expedited and rendered within three (3) days of the receipt of the
Member's application and supporting information.
• If approved by the DMHC, the deadlines for the analyses and recommendations involving both
regular and expedited reviews may be extended by the DMHC for up to three days in extraordi-
nary circumstances or for good cause.
Each expert's analysis and recommendation will be written and state the reasons the requested experi-
mental or investigational therapy is or is not likely to be more beneficial for the Member than any
available standard therapy, and the reasons that the expert recommends that the therapy should or
should not be provided by Universal Care, citing the Member's specific medical condition, the rele-
vant documents provided to the IRO, and the relevant medical and scientific evidence, including but
not limited to, the Medical and Scientific Evidence defined in Health & Safety Code Section
1370.4(d), to support the expert's recommendation. The recommendation of the majority of the
experts on the panel will prevail. If the experts on the panel are evenly divided as to whether the
treatment should be provided, the panel's decision will be deemed to be in favor of coverage.
PO 4LE P100MRX4
a,
The IRO will provide the DMHC, Universal Care, the Member and the Member's physician with each
of the experts' analyses and recommendations, and a description of the qualifications of each expert.
The IRO will keep the names of the expert reviewers confidential, except in cases where the reviewer
is called to testify and in response to court orders.
Upon receipt of the decision from the IRO, the DMHC will immediately issue an order adopting the
decision of the IRO, and will promptly issue a written decision to the parties that will be binding on
Universal Care.
Upon receipt of the written decision adopted by the DMHC that proposed experimental or
investigational therapy should be provided to the Member, Universal Care will promptly implement
the decision.
• In the case of services not yet rendered to the Member, Universal Care will authorize the services
within five (5) working days of receipt of the written decision from the DMHC, or sooner if appro
priate for the nature of the Member's medical condition, and will inform the Member and provider
of the authorization in accordance with the requirements of California Health & Safety Code
Section 1367.01(h) (3).
• In the case of reimbursement for services already rendered, Universal Care will reimburse the
provider or Member, whichever applies, within five (5) working days.
• In any case where a Member secured urgent care or emergency services outside of Universal
Care's contracted provider network, which services are later found by the IRO to have been med-
ically necessary, the DMHC will require Universal Care to promptly reimburse the Member for
any reasonable costs associated with those services when the DMHC finds that the Member's
decision to secure the services outside of Universal Care's contracted provider network prior to
completing the Universal Care grievance process or seeking an independent medical review was
reasonable under the circumstances and the disputed health care services were a covered benefit
under the terms and conditions of the Universal Care subscriber contract.
Coverage for the proposed therapy or treatment will be provided subject to the terms and conditions
generally applicable to all other benefits under the Member's Universal Care Health Plan.
Members or Physicians who want additional information about California's independent review
process for denied experimental or investigational therapy for Members with life -threatening or seri-
ously debilitating conditions may request a copy of Universal Care's information packet by calling
Universal Care's Member Services Department.
P100MRX4 PO 4LE
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t,
so
Binding Arbitration
It is the intent of the parties to resolve any disputes they may have through the expeditious and rela-
tively inexpensive process of arbitration. Accordingly, any dispute or claim, of whatever nature, aris-
ing out of, or in connection with, or in relation to this Agreement, or breach thereof, or in relation to
care or delivery of care, including any claim based on contract, tort or statute, that is not resolved by
the dispute resolution or grievance processes described in this Agreement, must be resolved by arbi-
tration. The arbitration is begun by the Member making written demand on Universal Care for arbi-
tration of the dispute. All demands for arbitration should be sent to the address indicated on your
Universal Care ID Card. The arbitration shall be conducted by a single neutral arbitrator pursuant to
the JAMS Comprehensive Arbitration Rules and Procedures ("Rules") in effect at the time demand for
arbitration is made. The parties will endeavor to mutually agree to the appointment of the arbitrator,
but if such agreement cannot be reached within thirty (30) days following the date demand for arbi-
tration is made, the arbitrator appointment procedures in the Rules will be utilized. If the amount of
the claim is less than $200,000, then the arbitrator shall have no jurisdiction to award more than
$200,000. Arbitration hearings shall be held at the neutral administrator's offices in Los Angeles,
California, or at such other location as the parties may agree in writing. The arbitrator's award shall
be set forth in a writing that includes the legal and factual reasons for the arbitrator's decision. The
parties shall divide equally the fees and expenses of the arbitrator and the neutral administrator
except that, in cases of extreme hardship, Universal Care may assume all or part of a Member's share
of the fees and expenses of the arbitration provided the Member has submitted a hardship application
to JAMS or such other neutral administrator mutually agreed upon by Universal Care and Member.
The approval or denial of a hardship application shall be determined by such administrator or a neu-
tral arbitrator. The arbitrator's award shall be final and binding on the parties except that, in addition
to any statutory basis for vacating or correcting an award, an error of law made by the arbitrator in
his or her award may also be a basis to vacate or correct the award. The rights and duties of the par-
ties in any arbitration shall be governed or determined by the Federal Arbitration Act, 9 U.S.C. §§ 1-4
(the "FAA") as though the issue in question were being determined by a United States District Court,
except that the determination of whether arbitration is to be compelled shall not be decided by a jury.
However, to the extent it is not inconsistent with the provisions of the FAA, the rules of the
California Arbitration Act, C.C.P. § 1281 et seq., shall also apply to the arbitration. By way of exam-
ple only, the right to compel the arbitration of any dispute between the parties shall not be denied
based on the matters described in C.C.P. § 1281.2 (c); on the other hand, the right, if any, to discov-
ery in connection with the arbitration, shall be determined by the provisions of C.C.P. § 1283.1. In
addition, the provisions of the Knox -Keene Health Care Service Health Plan Act of 1975, as amended,
shall apply to the arbitration, including but not limited to, California Health & Safety Code Sections
1373.19.
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_U__N..._ _V E R S__A_L__..._C_...A. R_F _______
THE PARTIES HERETO EXPRESSLY AGREE TO WAIVE THEIR CONSTITUTIONAL
RIGHT TO HAVE DISPUTES BETWEEN THEM RESOLVED IN COURT BEFORE A
JURY AND ARE INSTEAD ACCEPTING THE USE OF ARBITRATION. THE PAR-
TIES FURTHER EXPRESSLY AGREE TO WAIVE ANY RIGHT THEY MIGHT OTH-
ERWISE HAVE TO RESOLVE THEIR DISPUTES IN A CLASS ACTION PROCEED-
ING OR A CLASS -WIDE ARBITRATION, THE PARTIES HAVING EXPRESSLY
AGREED INSTEAD TO HAVE THEIR DISPUTES DETERMINED THROUGH INDI-
VIDUAL ARBITRATION AS PROVIDED ABOVE
Exhaustion of Independent Review Rights Prior to Arbitration
You must avail yourself of and exhaust all Independent Review rights afforded to you in this Combined
Evidence of Coverage and Disclosure Form prior to initiating an arbitration proceeding against
Universal Care based on the denial, delay, or modification of health care services. However, you are
not required to complete the Independent Review process prior to initiating Arbitration if you have
been or will be substantially harmed before the completion of the applicable review. For purposes of
this provision, "substantial harm" means loss of life, loss or significant impairment of limb or bodily
function, significant disfigurement, severe and chronic physical pain, or significant financial loss.
PUBLIC POLICY COMMITTEE
Universal Care has established a Public Policy Committee consisting of representatives of Universal Care
Contracting Providers and Members to provide input to Universal Care regarding services and benefits
and to participate in policy making decisions. If you would like more information about the role of the
Committee and your opportunity to participate in it, please call the Member Services Department.
YOUR RIGHTS & RESPONSIBILITIES
Universal Care has a commitment to treating you in a manner that respects your rights as Universal
Care Members. You have the right:
• To be treated with respect and recognition of your dignity and need for privacy.
• To choose a Primary Care Physician who has primary responsibility for coordinating your
medical care.
• To be provided with information about managed care and your rights and responsibilities.
• To receive as much information about any proposed treatment or procedure, as you need in
order to give or withhold informed consent.
• To participate actively in decisions regarding your medical care.
• To full consideration of privacy concerning your medical care program. Case discussion,
consultation, examination and treatment are confidential and should be conducted discreetly.
81
P100MRX4 Po_4LE
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• To confidential treatment of all communications and records pertaining to your care. Your (or
your parent's, legal guardian's or authorized caretaker relative's) written authorization will be
obtained before medical records can be made available to anyone not directly concerned with
your medical care, except as required by law.
• To receive reasonable responses to any reasonable requests you may make for service.
• To reasonable continuity of care and to know in advance the time and location of an appoint -
meet as well as the Physician or other Contracting Provider providing the care.
• To be advised if a Physician proposes to engage in or perform human experimentation affect-
ing your care or treatment. You have the right to refuse to participate in such experimenta-
tion.
• To be informed of continuing health care requirements.
• To know the rules and policies that apply to obtaining benefits/Covered Services.
• To voice grievances about Universal Care or care provided by its Contracting Providers and to
a grievance procedure to ensure resolution of a complaint or grievance.
• To exercise the foregoing rights without regard to age, sex, marital status, sexual orientation,
race, color, religion, ancestry, national origin, disability, health status or the source of payment
or utilization of services.
Your Responsibilities
Universal Care also has expectations of your responsibilities as a Member of Universal Care. You are
responsible for:
• Knowing and understanding the terms, conditions and provisions of this agreement
and abiding by them.
• Informing the Member Services Department regarding any change in residence and any circum-
stance, which may affect your entitlement to coverage or eligibility.
• Learning about your medical condition and its significance to your overall well-being.
• Participating actively in decision -making regarding your medical care.
• Following preventive health guidelines, prescribed treatment plans and guidelines given by
those providing medical care.
• Scheduling or rescheduling appointments and informing the Contracting Medical Group or
Primary Care Physician when it is necessary to cancel an appointment.
• Providing, to the extent possible, information needed by Universal Care's professional staff and
Contracting Medical Groups and Primary Care Physicians to care for you.
• Being considerate and respectful to the medical staff and other Members.
• Expressing grievances through the Universal Care Grievance and Appeals Procedure regarding
Universal Care for care, which was provided.
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IMPORTANT INFORMATION ABOUT ORGAN AND TISSUE DONATION
Transplantation has helped thousands of people suffering from organ failure, or in need of corneas,
skin, bone or other tissue. The need for donated organs and tissues continues to outpace the supply.
At any given time, nearly 50,000 Americans may be waiting for organ transplants while hundreds of
thousands more need tissue transplants. Organ and tissue donations provides each of us with a spe-
cial opportunity to help others.
Almost everyone can be a donor. There is no age limit and the number of donor's age fifty (50) or
older has increased. If you have questions or concerns about organ donation, speak with your family,
doctor or clergy member. There are many resources that can provide the information you need to
make a responsible decision.
Be Sure to Share Your Decision. Sharing your decision to be an organ and tissue donor with your
family is as important as making the decision itself. Your organs and tissue will not be donated
unless a family member gives consent at the time of your death -even if you've signed your driver's
license or a donor card. A simple family conversation will prevent confusion or uncertainty about
your wishes.
It is also helpful to document your decision by completing a donor card in the presence of your fami-
ly and having them sign as witnesses. The donor card serves as a reminder to your family and med-
ical staff of your personal decision to be a donor. Carry it in your wallet or purse at all times.
How to Learn More
• To get your donor card and information on organ & tissue donation call 1-800-355-SHARE
or 1-800-633-6562
• Request Donor Information from your local Department of Motor Vehicles (DMV)
• On the Internet, contact:
— All About Transplantation and Donation (wwwtransweb.org)
— Dept. of Health & Human Services at (wwworgandonor.gov)
• Sign the donor card in your family's presence
• Have your family sign as witnesses and pledge to carry out your wishes
• Keep the card with you at all times where it can be easily found
• Keep in mind that even if you've signed a donor card, you must tell your family so they can act
on your wishes.
83
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Universal Care Service Area
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U N I V J R—S A L C A--8 , E.�___ _ -----_
Universal Care Service Area
For up to date confirmation of the covered Service Area and provider availability
please contact the Member Services Department at (800) 635-6668 or visit the
Universal Care website at wwwuniversalcare.com.
Los Angeles County
Agoura Hills
LA
91301
Los Angeles
LA
90070-101
Hawaiian Gardens
LA
90716
Cerritos
LA
90703
Alhambra
LA
91801-03
Lynwood
LA
90262
Hawthorne
LA
90250-51
Chatsworth
LA
91311-13
Alhambra
LA
91841
Malibu
LA
90263-65
Hermosa Beach
LA
90254
Compton
LA
90220-24
Alhambra
LA
91899
Manhattan Beach
LA
90266
Huntington Park
LA
90255
Covina
LA
91722-24
Altadena
LA
91001-03
Marina Del Rey
LA
90292
Inglewood
LA
90301-12
Culver City
LA
90230-33
Arcadia
LA
91066-77
Marina Del Rey
LA
90295
La Canada Flintridge
LA
91011-12
Diamond Bar
LA
91765
Arcadia
LA
91006-07
Maywood
LA
90270
La Habra
LA
90631-33
Downey
LA
90239-42
Artesia
LA
90702
Mira Loma
LA
91752
La Mirada
LA
90637-38
Duarte
LA
91009-10
Azusa
LA
91702
Monrovia
LA
91016-17
La Palma
LA
90623
El Monte
LA
91731-33
Baldwin Park
LA
91706
Montebello
LA
90640
La Puente
LA
91744-46
El Segundo
LA
90245
Bell
LA
90201
Monterey Park
LA
91754-55
La Puente
LA
91748
Encino
LA
91316
Bellflower
LA
90706-07
Montrose
LA
91020-21
La Verne
LA
91750
Encino
LA
91416
Beverly Hills
LA
90209-13
North Hollywood
LA
91605-08
Lakewood
LA
90711-15
Encino
LA
91426
Burbank
LA
91504-06
North Hollywood
LA
91601-02
Lancaster
LA
93534-36
Encino
LA
91436
Burbank
LA
91501-02
Northridge
LA
91324-30
Lancaster
LA
93539
Gardena
LA
90247-49
Calabasas
LA
91302
Norwalk
LA
90650-52
Lancaster
LA
93584
Glendale
LA
91201-10
Canoga Park
LA
91303-09
Pacific Palisades
LA
90272
Lancaster
LA
93586
Glendale
LA
91224-26
Canyon Country
LA
91351
Pacoima
LA
91331
Lawndale
LA
90260-61
Glendale
LA
91221-22
Carson
LA
90745-47
Palmdale
LA
93550-52
Lomita
LA
90717
Glendale
LA
91214
Carson
LA
90749
Palmdale
LA
93590-91
Long Beach
LA
90801- 53
Glendora
LA
91740-41
Castaic
LA
91384
Palos Verdes
LA
90274
Los Angeles
LA
90001-68
Harbor City
LA
90710
Cerritos
LA
90701
Palos Verdes Estates
LA
90274
PO_4LE
P100MRX4
Universal Care Service Area
For up to date confirmation of the covered Service Area and provider availability
please contact the Member Services Department at (800) 635-6668 or visit the
Universal Care website at www.universalcare.com.
Palos Verdes Peninsula LA
90274
Tarzana
LA
91356-57
West Covina
LA
91790-92
Temple City
LA
91780
Paramount
LA
90723
Topanga
LA
90290
West Hollywood
LA
90069
Torrance
LA
90501-10
Pasadena
LA
91101-09
Tujunga
LA
91042-43
Whittier
LA
90601-10
Valencia
LA
91354-55
Pasadena
LA
91114-18
Van Nuys
LA
91404-12
Wilmington
LA
90744
Van Nuys
LA
91401-02
Pico Rivera
LA
90660-62
Venice
LA
90291
Wilmington
LA
90748
Venice
LA
90294
Playa Del Rey
LA
90296
Walnut
LA
91789
Woodland Hills
LA
91364-65
Pomona
LA
91766-68
Orange County
Woodland Hills
LA
91367
Aliso Viejo
OC
92656
Rancho Palos Verdes
LA
90275
Anaheim
OC
92801-08
Redondo Beach
LA
90277-78
Anaheim
OC
92812-17
Reseda
LA
91335
Anaheim
OC
92812
Reseda
LA
91337
Anaheim
OC
92825
Rosemead
LA
91770
Atwood
OC
92811
San Dimas
LA
91773
Brea
OC
92821-23
San Fernando
LA
91340-46
Buena Park
OC
90620-22
San Gabriel
LA
91775-76
Buena Park
OC
90624
San Gabriel
LA
91778
Capistrano Beach
OC
92624
San Pedro
LA
90731-34
Corona Del Mar
OC
92625
Santa Clarita
LA
91321-22
Costa Mesa
OC
92626-28
Santa Clarita
LA
91350-51
Cypress
OC
90630
Santa Clarita
LA
91354-55
Dana Point
OC
92629
Santa Fe Springs
LA
90670
El Toro
OC
92630
Santa Monica
LA
90401-11
Foothill Ranch
OC
92610
Sherman Oaks
LA
91403
Fountain Valley
OC
92708
Sherman Oaks
LA
91413
Fountain Valley
OC
92728
Sherman Oaks
LA
91423
Fullerton
OC
92831-38
Sierra Madre
LA
91024-25
Garden Grove
OC
92840-46
South El Monte
LA
91733
Huntington Beach
OC
92646-49
South Gate
LA
90280
Huntington Beach
OC
92605
South Pasadena
LA
91030-31
Huntington Beach
OC
92615
Spring Valley
LA
91976-79
Irvine
OC
92616-20
Stanton
LA
90680
Irvine
OC
92603-04
Stevenson Ranch
LA
91381
Irvine
OC
92602
Studio City
LA
91604
Irvine
OC
92606
Sun Valley
LA
91352-53
Irvine
OC
92612
Sunland
LA
91040-41
Irvine
OC
92614
Sylmar
LA
91392
Irvine
OC
92623
P100MRX4
Po_4LE
87
88
Universal Care Service Area
For up to date confirmation of the covered Service Area and provider availability
please contact the Member Services Department at (800) 635-6668 or visit the
Universal Care website at www.universalcare.com.
Irvine
Irvine
Laguna Beach
Laguna Beach
Laguna Hills
Laguna Niguel
Los Alamitos
Midway City
Mission Viejo
Newport Beach
Orange
Orange
Orange
Orange
Orange
Placentia
Rancho Santa Margarit
San Clemente
San Juan Capistrano
San Juan Capistrano
San Juan Capistrano
Santa Ana
Santa Ana
Santa Ana
Santa Ana
Seal Beach
Silverado
South Laguna Beach
Sunset Beach
Surfside
Trabuco Canyon
Tustin
Westminster
Wildomar
Yorba Linda
a
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
OC
Riverside County
92650
92709-10
92652
92607
92653-54
92677
90720-21
92655
92690-92
92657-63
92863-66
92867-69
92856-57
92861-62
92859
92870-71
92688
92672-74
92675
92679
92693
92701-07
92711-12
92735
92799
90740
92676
92651
90742
90743
92678
92780-82
92683-84
92595
92885-87
Hemet
RV
92545
Holtville
RV
92250
Homeland
RV
92548
Idyllwild
RV
92549
PO_4LE
Indian Wells
Indio
Indo
Indo
La Quinta
Lake Ellsinore
Lake Ellsinore
Lake Ellsinore
March Air Force Base
Mecca
Menifee
Moreno Valley
Mountain Center
Murrieta
North Palm Springs
Nuevo
Ocotillo
Palm Desert
Palm Desert
Palm Desert
Palm Desert
Palm Springs
Palm Springs
Aguanga
Palm Springs
Anza
Palm Springs
Banning
Palo Verde
Bard
Parker Dam
Beaumont
Perris
Blythe
Rancho Mirage
Blythe
Riverside
Cabazon
Riverside
Calimesa
Riverside
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
RV
92210
92202
92201
92203
92253
92530
92531
92532
92518
92254
92584
92551-57
92561
92562-64
92258
92567
92259
92211
92255
92260
92261
92262
92263
92536
92264
92539
92292
92220
92266
92222
92267
92223
92570-72
92225
92270
92226
92501-09
92230
92513-17
92320
92519
P100MRX4
Universal Care Service Area
For up to date confirmation of the covered Service Area and provider availability
please contact the Member Services Department at (800) 635-6668 or visit the
Universal Care website at www.universalcare.com.
Cathedral City
RV
San Jacinto
RV
Cathedral City
RV
San Jacinto
RV
Coachella
RV
San Jacinto
RV
Corona
RIV
Seeley
RV
Desert Center
RV
Sun City
RV
Desert Hot Springs
RV
Sun City
RV
Desert Hot Springs
RV
Sun City
RV
Heber
RV
Temecula
RV
Hemet
RV
Thermal
RV
Hemet
RV
Thermal
RV
Thousand Palms
RV
Winchester
RV
San Bernardino County
Ludlow
Lytle Creek
Mentone
Acton
Montclair
Adelanto
Morongo Valley
Alta Loma
Mountain Pass
Alta Loma
Mt. Baldy
Alta Loma
Needles
Amboy
Newberry Springs
Angelus Oak
Nipton
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
92234
92581
92235
92582
92236
92583
91718-20
92273
92239
92585
92240
92586
92241
92587
92249
92589-93
92543
92274
92544
92275
92276
92596
92338
92358
92359
93510
91763
92301
92256
91701
92366
91737
91759
91737
92363
92304
92365
92305
92364
Apple Valley
Ontario
Baker
Ontario
Barstow
Oro Grande
Big Bear City
Patton
Big Bear Lake
Pearblossom
Bloomington
Phelan
Blue Jay
Phelan
Byrn Mawr
Pinon Hills
Cedar Glen
Pioneertown
Cedarpines Park
Rancho Cucamonga
Chino
Rancho Cucamonga
Chino
Redlands
Chino Hills
Rialto
Cima
Ridgecrest
Claremont
Rimforest
Colton
Running Springs
Crest Park
San Bernardino
Crestline
Skyforest
Daggett
Sugarloaf
Essex
Twentynine Palms
Fawnskin
Twentynine Palms
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
92307-08
91761-62
92309
91764
92311-12
92368
92314
92369
92315
93553
92316
92371
92317
92329
92318
92372
92321
92268
92322
91729-30
91708
91739
91710
92373-75
91709
92376-77
92323
93555-56
91711
92378
92324
92382
92326
92401-27
92325
92385
92327
92386
92332
92278
92333
92277
P100MRX4 PO 4LE
89
r
90
Universal Care Service Area
For up to date confirmation of the covered Service Area and provider availability
please contact the Member Services Department at (800) 635-6668 or visit the
Universal Care website at wwwuniversalcare.com.
Fontana
SB
Twin Peaks
SB
Forest Falls
SB
Upland
SB
Fort Irwin
SB
Victorville
SB
Grand Terrace
SB
Vidal
SB
Green Valley Lake
SB
Westmorland
SB
Guasti
SB
White Water
SB
Helendale
SB
Winterhaven
SB
Hesperia
SB
Wrightwood
SB
Highland
SB
Yermo
SB
Hinkley
SB
Yucaipa
SB
Joshua Tree
SB
Yucca Valley
SB
Lake Arrowhead
SB
Yucca Valley
SB
Landers
SB
Llano
SB
Loma Linda
SB
Lucerne Valley
SB
San Diego County
Alpine
Bonita
Bonsall
Borrego Springs
Tecate
Boulevard
Valley Center
Campo
Vista
Cardiff By The Sea
Warner Springs
PO 4LE
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
92335-37
92391
92339
91784-86
92310
92392-94
92313
92280
92341
92281
91743
92282
92342
92283
92345
92397
92346
92398
92347
92399
92252
92284
92352
92286
92285
93544
92354
92356
91901
91902
92003
92004
91980
91905
92082
91906
92083-85
92007
92086
Carlsbad
Chula Vista
Coronado
Coronado
Del Mar
Descanso
Dulzura
El Cajon
Encinitas
Escondido
Escondido
Fallbrook
Imperial Beach
Jacumba
Jamul
Julian
La Jolla
La Mesa
Lakeside
Lemon Grove
National City
Oceanside
Palomar Mountain
Pauma Valley
Pine Valley
Potrero
Poway
Ramona
Ranchita
Rancho Santa Fe
Rancho Santa Fe
San Diego
San Diego
San Diego
San Diego
San Luis Rey
San Marcos
San Ysidro
Santa Ysabel
Santee
Solana Beach
Spring Valley
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
92008-09
91909-15
92118
92178
92014
91916
91917
92019-21
92023-24
92029-33
92025-27
92028
91932-33
91934
91935
92036
92037-39
91941-44
92040
91945-46
91950-51
92049-58
92060
92061
91962
91963
92064
92065
92066
92067
92091
92145-72
92119-42
92182-98
92174-77
92068
92069
92173
92070
92071-72
92075
91976-79
P100MRX4
Universal Care Service Area
For up to date confirmation of the covered Service Area and provider availability
please contact the Member Services Department at (800) 635-6668 or visit the
Universal Care website at wwwuniversalcare.com.
Ventura County
Camarillo
VN
93010
Edwards
KN
93523
Camarillo
VN
93011-12
Fellows
KN
93224
Carpinteria
VN
93013-14
Frazier Park
KN
93225
Fillmore
VN
93015
Glennville
KN
93226
Fillmore
VN
93016
Inyokern
KN
93527
Moorpark
VN
93020-21
Johannesburg
KN
93528
Newbury Park
VN
91319
Keene
KN
93531
Newbury Park
VN
91320
Kernville
KN
93238
Oak View
VN
93022
Lake Isabella
KN
93240
Ojai
VN
93023-24
Lamont
KN
93241
Oxnard
VN
93030-35
Little Rock
KN
93543
Piru
VN
93040
Lost Hills
KN
93249
Port Hueneme
VN
93041-44
Maricopa
KN
93252
Santa Paula
VN
93060-61
Mc Farland
KN
93250
Simi Valley
VN
93062-63
McKittrick
KN
93251
Simi Valley
VN
93065
Mojave
KN
93501-02
Simi Valley
VN
93062-65
Onyx
KN
93255
Simi Valley
VN
93093
Randsburg
KN
93554
Somis
VN
93066
Rosamond
KN
93560
Thousand Oaks
VN
91358-60
Shafter
KN
93263
Thousand Oaks
VN
91362
Taft
KN
93268
Ventura
VN
93001
Tehachapi
KN
93561
Ventura
VN
93002
Tehachapi
KN
93581
Ventura
VN
93003
Tehachapi
KN
93582
Ventura
VN
93004
Tupman
KN
93276
Ventura
VN
93005
Wasco
KN
93280
Ventura
VN
93006
Weldon
KN
93283
Ventura
VN
93007
Wofford Heights
KN
93285
West Hills
VN
91307
Woody
KN
93287
Westlake Village
VN
91361
Visit Universal Care's web site at:
www.universalcare.com
Kern County
Arvin
KN
93203
Bakersfield
KN
93301-90
Bodfish
KN
93205
Boron
KN
93516
Buttonwillow
KN
93206
Caliente
KN
93518
California City
KN
93504-05
Cantil
KN
93519 '
Delano
KN
93215-16
P100MRX4 Po_4LE
91