Application for Alternative Claim Adjudication Procedure

Transcription

1 No. D-1-GV /23/ :58:30 AM Velva L. Price District Clerk Travis County D-1-GV THE STATE OF TEXAS, v. Plaintiff, UNIVERSAL HMO OF TEXAS, Inc., IN THE DISTRICT COURT IN TRAVIS COUNTY, TEXAS 345TH JUDICIAL DISTRICT Defendant. Application for Alternative Claim Adjudication Procedure TO THE HONORABLE JUDGE OF SAID COURT: COMES NOW Jean Johnson, Special Deputy Receiver under contract to the Permanent Receiver of Universal HMO of Texas, Inc. ( Universal ), and files this Application for Alternative Claims Adjudication Procedure. In support of this Application the Special Deputy Receiver would respectfully show the Court the following: 1.0 Summary of Requested Relief 1.1 The Special Deputy Receiver requests authorization for an alternative claim adjudication procedure, due largely to Universal s inadequate prereceivership records (most particularly, the individual providers contracts) and the disproportionately high cost of adjudicating the claims without utilizing the proposed claims procedure designed to afford administrative convenience to all the parties involved. Application for Alternative Claim Adjudication Procedure State of Texas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

2 2.0 Background 2.1 On April 18, 2013, the Court entered its Agreed Order Appointing Rehabilitator and Permanent Injunction appointing the Texas Commissioner of Insurance as Rehabilitator of Universal. Effective that date, the Rehabilitator appointed Jean G. Johnson as Special Deputy Receiver. 2.2 On May 17, 2013, the Court entered its Order of Liquidation, placing Universal in liquidation and appointing the Commissioner as Liquidator. 2.3 On September 17, 2013, the Court entered its Order granting the SDR s Application to Approve Notice and Set Claims Filing Deadline. The claim filing deadline was June 30, The Special Deputy Receiver sent postcard notice of the receivership and of the claim filing deadline to 40,000 potential claimants. The Special Deputy Receiver also provided notice in certain publications authorized by the Court, and provided notice on the Internet at a web site maintained for the receivership. The notice advised recipients they could obtain a proof of claim by sending a written request to the Special Deputy Receiver or by downloading a claim form from her web site. The Special Deputy Receiver sent a proof of claim to all potential claimants requesting same. The proof of claim packet included a Notice to Claimants and Parties in Interest. This notice explains the process for being placed on the receivership certificate of service and that a copy of all pleadings, motions, notices and other documents filed in the receivership proceeding will be sent to the certificate of service list. 2.4 This Court has exclusive jurisdiction of the subject of this Application under Tex. Ins. Code Application for Alternative Claim Adjudication Procedure State of Texas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

3 2.0 Analysis and Recommendation 2.1 Universal was a health maintenance organization (HMO) providing Medicare Advantage products under contract to the Center for Medicare and Medicaid. Universal entered into provider contracts with hundreds of separate physicians, hospitals and other healthcare providers. Universal entered into numerous different agreements with different descriptions of service and coverage with a multitude of physicians and healthcare providers. Universal s recordkeeping as to its agreements proved less than ideal, as the records of its provider agreements located are not fully-documented. The SDR s inquiry of providers for copies of their executed agreements failed to net complete agreements. 2.2 These circumstances make it difficult and costly to adjudicate claims of members, physicians and healthcare providers according to the limited number of available agreements. It is difficult if not impossible to determine with certainty which agreement, if it can be found, applies to a particular claim. 2.3 Further, a portion of the claims are for services provided by out of network physicians and healthcare providers. The ordinary Medicare Advantage HMO maintains a strong provider network. Even so, the ordinary Medicare Advantage HMO is subject to payment of out-of-network claims for emergency care, urgent care, situations in which a referral must be given out of network, and situations in which the network lacks the resources in a given specialty. As to an ordinary HMO Medicare Advantage program with a strong provider network, the SDR would review out-of-network claims to ascertain if they fell within the required limited instances for payment. Unfortunately, Universal was not an ordinary Medicare Advantage HMO. Universal s provider network was inadequate to handle many of the health care specialties needed by its member base. Universal s internal records reflected that it often did not contest out-of-network referrals, because it lacked a strong provider network. Indeed, Universal lacked in some cases any network providers in some specialties for some locations. This creates a 3 Application for Alternative Claim Adjudication Procedure State of Texas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

4 tremendous administrative burden to try to ferret out those circumstances with a workable provider network option from those out-of-network situations in which the member had no ability to obtain health care services from a network provider. The Special Deputy Receiver represents that adjudicating these claims in such manner is not cost effective for the same reasons explained above. 2.4 To address these issues, the Special Deputy Receiver reviewed Universal agreements available to her in the company records and determined the guidelines to be applied: A. Provider Claims under Medicare Advantage plans will be handled as set forth in this motion. The allowable rate for Provider claims (whether in or out of network) shall be defined as one hundred percent of applicable Medicare rates for the applicable claim year, provided that the claim is otherwise covered. B. All claims will be subject to the terms and limitations of the Member agreement attached as Exhibit A-1, except as modified in this application; C. Both claims services provided by network provider and outside-of-network providers shall be treated as inside-network claims; provided, however, the Special Deputy Receiver shall have the right to reject an out-of-network claim if she finds that an evidentiary basis that the claim should be treated as outside the plan or outside the plan network; D. Only filed proofs of claims with proper documentation shall be considered for allowance, and nothing in this application and order shall relax the claims deadlines nor the requirements to document a covered claim. E. Claims of members and providers will still require compliance with the applicable member agreement and the Claims Processing Provider Agreement, and nothing in this motion shall make any person who was not a member or covered under a plan eligible for coverage by this HMO. Application for Alternative Claim Adjudication Procedure State of Texas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

5 2.5 The Special Deputy Receiver advises the Court that the proposed system of adjustment will be more cost-effective than other alternatives, in light of the documentation on hand. The Special Deputy Receiver will also: (1) eliminate all duplicate and previously paid claims; (2) determine eligibility; (3) verify charges were incurred while coverage was active; (4) apply applicable exclusions as set forth herein; and (5) apply, regarding all remaining claims, the payment percentage of 100% for claims. The Special Deputy Receiver submits her Affidavit as Exhibit A in support of her application. 3.0 Precedents 3.1 This Application follows previous Texas receivership court precedents; specifically, State of Texas v. Comprehensive Health Services of Texas, Inc., No , 353 rd Judicial District Court, Travis County, Texas; State of Texas v. American Benefit Plans, et al., No. GV , 53 rd Judicial District Court, Travis County, Texas; and State of Texas v. AmCare Health Plans of Texas, Inc. and AmCare Management, Inc., No. GV , 200 th Judicial District Court, Travis County, Texas. 4.0 Notice 4.1 The Special Deputy Receiver sent notice of the submission of this Application to all known parties of interest on the Certificate of Service. As state above, the Certificate of Service includes all persons who have requested to be placed on the Certificate of Service. The Special Deputy Receiver will also post this Application on the receivership web site which may be found at Application for Alternative Claim Adjudication Procedure State of Texas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

6 5.0 Relief Requested 5.1 Based on the foregoing, the Special Deputy Receiver requests that the Court enter an order authorizing her to institute and utilize an alternative, simplified claims adjudication procedure and approving notice as described herein. Respectfully submitted, y Roth, LLP Robert H. Nunnally, Jr. Bar No Cedar Sage Drive, Suite 240 Garland, Texas T: F: Attorneys for Jean Johnson, Special Deputy Receiver of Universal HMO oftexas, Inc. Application for Alternative Claim Adjudication Procedure State of Texas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

7 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing document has been served on the following interested parties in accordance with Tex. Ins. Code (d) and the Rehabilitation Order this the 23 rd day of January, Mr. Tom Collins, Receivership Master by serving his Docket Clerk Texas Department of Insurance 333 Guadalupe, Tower III, 5th Fl., MC-305-1D Austin, Texas specialmasterclerk@tdi.texas.gov Ms. Jemmie Russell, Rehabilitation & Liquidation Oversight Texas Department of Insurance 333 Guadalupe St., Tower III 5th Floor, MC-305-1C Austin, Texas Jemmie.Russell@tdi.texas.gov Universal Health Care Group, Inc. c/o Soneet Kapila, Chapter 11 Trustee 1000 South Federal Highway, Ste. 200 Fourt Lauderdale, Florida SKapila@kapilaco.com Soneet R. Kapila, Ch. 11 Trustee c/o Roberta A. Colton, Esq. Trenam Kemker P.O. Box 1102 Tampa, FL rcolton@trenam.com jfollman@trenam.com idawkins@trenam.com Patrick Cantilo SDR for Universal HMO of Nevada, Inc. Cantilo & Bennett LLP Centur Oaks Terrace, Ste. 300 Austin, Texas phcantilo@cb-firm.com Robert H. Nunnally, Jr. Wisener Nunnally Gold, LLP 245 Cedar Sage, Ste. 240 Garland, Texas robert@wnglaw.com Fifth Third Bank Attn: Muffin White, Assistant Vice President 201 East Kennedy Blvd, Ste MD T201KA Tampa, Florida Muffin.White@53.com Dr. A. K. Desai drakdesai86@gmail.com E. Stuart Phillips, Staff Attorney Texas Department of Insurance P.O. Box Austin, Texas stuart.phillips@tdi.texas.gov Universal Health Care Group, Inc. c/o Jeff Friedman, Esq. 575 Madison Avenue New York, New York jeff.friedman@kattenlaw.com BankUnited, N.A. c/o Frank Terzo, Esq Brickell Avenue, Ste Miami, Florida frank.terzo@gray-robinson.com Wells Fargo Bank, N.A. Attn: Tyree B. Bedell Senior Relationship Associate nd Avenue North, Ste. 300 St. Petersburg, Florida tyree.bedell@wellsfargo.com Sha Ron James, Division Director Division of Rehabilitation & Liquidation Florida Department of Financial Services 200 East Gaines Street Tallahassee, Florida Sha Ron.James@myfloridacfo.com Amy Jeanne Welton P.O. Box 1644 Dripping Springs, Texas ajwelton@ajweltonlaw.com Leah Stewart Beatty Bangle Strama P.C. 400 West 15th Suite 1450 Austin, Texas lstewart@bbsfirm.com

8 Leigh Vandiver Graves Fultz Maddox Hovious & Dickens 101 South Fifth Street, 27th Floor Louisville, KY Susanne Boston Wise County Medical & Surgical Association 1001 Eagle Drive Decatur, TX Tammi Scott Scott Medical 6236 N. Hwy 146, Suite 9 Baytown, TX tscott@scottmedical.net Traci L. Cotton Managing Attorney Claims & Financial Litigation The University of Texas System Office of Counsel 201 W. 7th Street Austin, TX tcotton@utsystem.edu Ms. Kathy Gartner, Receivership Analyst Rehabilitation & Liquidation Oversight Div. 333 Guadalupe St., Tower III, 5 th Floor Room 550-I, O/S, Mail Code 305-1D Austin, Texas kathy.gartner@tdi.texas.gov Cynthia A. Morales Attorney-in-Charge Financial Litigation, Tax, and Charitable Trusts Division Cynthia.morales@texasattorneygeneral.gov P.O. Box Austin, Texas /s/ Michael Roth Michael Roth

9 Exhibit A

10 attest: Affidavit of Jean Jolmson Came before me Jean Johnson, who, being duly sworn, did upon her oath 1. I am Jean Johnson. I am over the age of eighteen years. I am competent to be a witness. I have personal knowledge of the facts to which I attest. I acquired my personal knowledge in my role as Special Deputy Receiver of Universal HMO of Texas, Inc. I have over twenty years' experience in the handling of claims matters involving health maintenance organization, and have over ten years' experience with HMO receiverships. 2. I recommend to the Court the alternative claims procedure set forth in the foregoing Application. This procedure is reasonably designed to assist in the timely and efficient handling of this estate. For the reasons described in the application, the proposed alternative claims adjudication method provides a reasonable and fair way to value the proofs of claims of providers and members in this HMO receivership. 3. Attached as Exhibit "A-1" and incorporated herein by reference for all purposes is a true and correct copy of the Universal Healthcare member agreement. ~- Jean Johnson ore me on thisz3_day of January, RAEDON JONES Notary Public. State of Texas My Commission Expires March 21, 2018 Application for Alternative Claim Adjudication Procedure State oftexas v. UNIVERSAL HMO OF TEXAS, Inc., No. D-1-GV

11 Exhibit A-1

12 2013 Summary of Benefits January 1, December 31, 2013 SB_503 Universal Trust (HMO SNP) H6642_008 H6642_02834CY13 Accepted 10/03/ _HMO DSNP_SB 503

13 Section I: Introduction to the Summary of Benefits Thank you for your interest in Universal Trust (HMO SNP). Our plan is offered by Universal HMO of Texas, Inc., a Medicare Advantage Health Maintenance Organization (HMO) Special Needs Plan (SNP) that contracts with the federal government. This plan is designed for people who meet specific enrollment criteria. You may be eligible to join this plan if you receive assistance from the State and Medicare. All cost sharing in this summary of benefits is based on your level of Medicaid eligibility. Please call Universal Trust (HMO SNP) to find out if you are eligible to join. Our number is listed at the end of this introduction. This Summary of Benefits tells you some features of our plan. It doesn't list every service we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Universal Trust (HMO SNP) and ask for the "Evidence of Coverage." You Have Choices in Your Health Care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Universal Trust (HMO SNP). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. If you are eligible for both Medicare and Medicaid (dual eligible) you may join or leave a plan at any time. Please call Universal Trust (HMO SNP) at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. How Can I Compare My Options? You can compare Universal Trust (HMO SNP) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. 1

14 Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. Where Is Universal Trust (HMO SNP) Available? The service area for this plan includes: Bexar, Collin, Dallas, Denton, Galveston, Harris, Montgomery, Tarrant counties, TX. You must live in one of these areas to join the plan. Who Is Eligible to Join Universal Trust (HMO SNP)? You can join Universal Trust (HMO SNP) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in Universal Trust (HMO SNP) unless they are members of our organization and have been since their dialysis began. You must also receive assistance from the State to join this plan. Please call the plan to see if you are eligible to join. Can I Choose My Doctors? Universal Trust (HMO SNP) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory. For an updated list, visit us at Our customer service number is listed at the end of this introduction. What Happens If I Go to a Doctor Who's Not in Your Network? If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the Plan nor the Original Medicare Plan will pay for these services except in limited situations (for example, emergency care). Where Can I Get My Prescriptions If I Join this plan? Universal Trust (HMO SNP) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or visit us at Our customer service number is listed at the end of this introduction. 2

15 Does My Plan Cover Medicare Part B or Part D Drugs? Universal Trust (HMO SNP) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. What Is a Prescription Drug Formulary? Universal Trust (HMO SNP) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our website at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra Help With Other Medicare Costs? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: * MEDICARE ( ). TTY/TDD users should call , 24 hours a day/7 days a week and see 'Programs for People with Limited Income and Resources' in the publication Medicare & You. * The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call or * Your State Medicaid Office. What Are My Protections in this plan? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the Plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. 3

16 As a member of Universal Trust (HMO SNP), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your State. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of Universal Trust (HMO SNP), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your State. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What Is a Medication Therapy Management (MTM) Program? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Universal Trust (HMO SNP) for more details. What Types of Drugs May Be Covered Under Medicare Part B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Universal Trust (HMO SNP) for more details. 0 Some antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. 4

17 0 0 0 Osteoporosis drugs: Injectable osteoporosis drugs for some women. Erythropoietin (Epoetin Alfa or Epogen ): By injection if you have End-Stage Renal Disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia clotting factors: Self-administered clotting factors if you have hemophilia. Injectable drugs: Most injectable drugs administered incident to a physician's service. Immunosuppressive drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. Some oral cancer drugs: If the same drug is available in injectable form. Oral anti-nausea drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusion drugs administered through Durable Medical Equipment. Where Can I Find Information On Plan Ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select "Health and Drug Plans" then "Compare Drug and Health Plans" to compare the Plan Ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the Plan Ratings for this plan. Our customer service number is listed below. 5

18 Please call Universal for more information about Universal Trust (HMO SNP). Visit us at or, call us: Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8 a.m. to 11 p.m. Eastern Customer Service Hours for February 15 September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8 a.m. to 11 p.m. Eastern Current members should call toll-free for questions related to the Medicare Advantage Program. (TTY/TDD ) Prospective members should call toll-free for questions related to the Medicare Advantage Program. (TTY/TDD ) Current members should call locally for questions related to the Medicare Advantage Program. (TTY/TDD ) Prospective members should call locally for questions related to the Medicare Advantage Program. (TTY/TDD ) Current members should call toll-free for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) Prospective members should call toll-free for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD ) Current members should call locally for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) Prospective members should call locally for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD ) For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call customer service at the phone number listed above. Este documento puede estar disponible en otros formatos, como Braille, letra grande o otros formatos alternativos. Este documento puede estar disponible en otros idiomas además de inglés. Para obtener información adicional, llame a servicio al cliente al número de teléfono indicado anteriormente. 6

19 Section II: Summary of Benefits If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit Original Medicare IMPORTANT INFORMATION Universal Trust (HMO SNP) H6642_008 1 Premium and Other Important Information The Medicare cost sharing amount may vary based on your level of Medicaid eligibility. In 2012 the monthly Part B Premium was $0 or $99.90 and may change for 2013 and the annual Part B deductible amount was $0 or $140 and may change for 2013.* If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. * Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for original Medicare services $31.80 monthly plan premium in addition to your monthly Medicare Part B premium.* $3,400 out-of-pocket limit for Medicare-covered services.* See page 23 for information about Premium and Other Important Information. 2 Doctor and Hospital Choice (For more information, see Emergency Care - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. You must go to network doctors, specialists, and hospitals. Referral required for network specialists (for certain benefits). 3 Inpatient Hospital Care In 2012 the amounts for each benefit period were $0 or 0 Days 1-60: $1,156 deductible.* 0 Days 61-90: $289 per day.* INPATIENT CARE Plan covers 90 days each benefit period. $0 copay.

20 (includes Substance Abuse and Rehabilitation Services) 0 Days : $578 per lifetime reserve day.* These amounts may change for Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A "benefit period" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. See page 23 for information about Inpatient Hospital Care. 4 Inpatient Mental Health Care In 2012 the amounts for each benefit period were $0 or: 0 Days 1-60: $1,156 deductible.* You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 0 Days 61-90: $289 per day.* 190-day lifetime limitation only if certain conditions are met. This 0 Days : $578 per lifetime reserve day.* limitation does not apply to inpatient psychiatric services furnished in a general hospital. These amounts may change for $0 copay. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. See page 23 for information about Inpatient Mental Health Care. 5 Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay were: 0 Days 1-20: $0 per day.* 0 Days : $ per day.* These amounts may change for days for each benefit period. Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. $0 copay for SNF services. 8

21 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit Original Medicare Universal Trust (HMO SNP) H6642_008 A "benefit period" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. See page 23 for information about Skilled Nursing Facility (SNF). 6 Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay. Authorization rules may apply. $0 copay for Medicare-covered home health visits.* 7 Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. 8 Doctor Office Visits 0% or 20% coinsurance. OUTPATIENT CARE Authorization rules may apply.

22 8 Doctor Office Visits $0 copay for each Medicare-covered primary care doctor visit.* $0 copay for each Medicare-covered specialist visit.* 9 Chiropractic Services Supplemental routine care not covered. 0% or 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. $0 copay for Medicare-covered chiropractic visits.* Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor. 10 Podiatry Services Supplemental routine care not covered. 0% or 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. Authorization rules may apply. $0 copay for Medicare-covered podiatry visits.* Medicare-covered podiatry visits are for medically-necessary foot care. 11 Outpatient Mental Health Care 0% or 35% coinsurance for most outpatient mental health services. 0% or 35% coinsurance of the Medicare-approved amount for each service you get from a qualified professional as part of a partial hospitalization program. "Partial hospitalization program" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization. Authorization rules may apply. $0 copay for: 0 each Medicare-covered individual therapy visit* 0 each Medicare-covered group therapy visit* $0 copay for: 0 each Medicare-covered individual therapy visit with a psychiatrist* 0 each Medicare-covered group therapy visit with a psychiatrist* $0 copay for Medicare-covered partial hospitalization program services* 10

23 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit 12 Outpatient Substance Abuse Care Original Medicare 0% or 20% coinsurance. Universal Trust (HMO SNP) H6642_008 Authorization rules may apply. $0 copay for: 0 each Medicare-covered individual substance abuse outpatient treatment visit.* 0 each Medicare-covered group substance abuse outpatient treatment visit.* 13 Outpatient Services 0% or 20% coinsurance for the doctor's services. Specified copayment for outpatient hospital facility services. Copay cannot exceed the Part A inpatient hospital deductible. 0% or 20% coinsurance for ambulatory surgical center facility services. Authorization rules may apply. $0 copay for each Medicare-covered ambulatory surgical center visit.* $0 copay for each Medicare-covered outpatient hospital facility visit.* 14 Ambulance Services (medically necessary ambulance services) 0% or 20% coinsurance. Authorization rules may apply. $0 copay for Medicare-covered ambulance benefits.*

24 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 0% or 20% coinsurance for the doctor's services. Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. $0 copay for Medicare-covered emergency room visits.* Worldwide coverage. 16 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 0% or 20% coinsurance. NOT covered outside the U.S. except under limited circumstances. $0 copay for Medicare-covered urgently-needed-care visits.* 17 Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 0% or 20% coinsurance. Authorization rules may apply. There may be limits on physical therapy, occupational therapy, and speech and language pathology visits. If so, there may be exceptions to these limits. $0 copay for Medicare-covered occupational therapy visits.* $0 copay for Medicare-covered physical therapy and/or speech and language pathology visits.* OUTPATIENT MEDICAL SERVICES AND SUPPLIES 12

25 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit 18 Durable Medical Equipment (includes wheelchairs, oxygen, etc.) Original Medicare 0% or 20% coinsurance. Universal Trust (HMO SNP) H6642_008 Authorization rules may apply. $0 copay for Medicare-covered durable medical equipment.* 19 Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) 20% or 0% coinsurance. Authorization rules may apply. $0 copay for Medicare-covered prosthetic devices.* 20 Diabetes Programs and Supplies 0% or 20% coinsurance for diabetes self-management training. 0% or 20% coinsurance for diabetes supplies. 0% or 20% coinsurance for diabetic therapeutic shoes or inserts. $0 copay for Medicare-covered diabetes self-management training.* $0 copay for Medicare-covered: 0 Diabetes monitoring supplies.* 0 Therapeutic shoes or inserts.* 21 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 0% or 20% coinsurance for diagnostic tests and x-rays. $0 copay for Medicare-covered lab services. Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a Authorization rules may apply. $0 copay for Medicare-covered: 0 lab services.* 0 diagnostic procedures and tests.*

26 suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. 0 X-rays.* 0 diagnostic radiology services (not including X-rays).* 0 therapeutic radiology services.* 22 Cardiac and Pulmonary Rehabilitation Services 0% or 20% coinsurance for cardiac rehabilitation services. 0% or 20% coinsurance for pulmonary rehabilitation services. 0% or 20% coinsurance for intensive cardiac rehabilitation services. This applies to program services provided in a doctor's office. Specified cost sharing for program services provided by hospital outpatient departments. Authorization rules may apply. $0 copay for: 0 Medicare-covered cardiac rehabilitation services.* 0 Medicare-covered intensive cardiac rehabilitation services.* 0 Medicare-covered pulmonary rehabilitation services.* PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT PROGRAMS 23 Preventive Services, Wellness/Education and other Supplemental Benefit Programs No coinsurance, copayment or deductible for the following: 0 Abdominal aortic aneurysm screening. 0 Bone mass measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. 0 Cardiovascular screening. 0 Cervical and vaginal cancer screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. 0 Colorectal cancer screening. 0 Diabetes screening. 0 Influenza vaccine. 0 Hepatitis B vaccine for people with Medicare who are at risk. $0 copay for all preventive services covered under Original Medicare at zero cost-sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. The plan covers the following supplemental education/wellness programs: 0 Health education. 0 Nutritional education. 0 Additional smoking and tobacco use cessation visits. 0 Health club membership/fitness classes. 0 Nursing hotline. $0 copay for post discharge in-home medication reconciliation. 14

27 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit Original Medicare Universal Trust (HMO SNP) H6642_ Preventive Services, Wellness/Education and other Supplemental Benefit Programs 0 HIV screening. $0 co-pay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor's visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. 0 Breast cancer screening (mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages Medical nutrition therapy services nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. 0 Personalized prevention plan services (Annual Wellness Visits) 0 Pneumococcal vaccine. You may only need the pneumonia vaccine once in your lifetime. Call your doctor for more information. 0 Prostate cancer screening Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age Smoking and tobacco use cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Contact plan for details. $0 copay for in-home safety assessment. Contact plan for details. Plan covers a physical exam annually. See page 24 for information about Preventive Services, Wellness/ Education and other Supplemental Benefit Programs.

28 23 Preventive Services, Wellness/Education and other Supplemental Benefit Programs 0 Screening and behavioral counseling interventions in primary care to reduce alcohol misuse. 0 Screening for depression in adults. 0 Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs. 0 Intensive behavioral counseling for cardiovascular disease (bi-annual). 0 Intensive behavioral therapy for obesity. 0 Welcome to Medicare preventive visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a welcome to Medicare preventive visits or an annual wellness visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. 24 Kidney Disease and Conditions 0% or 20% coinsurance for renal dialysis. 0% or 20% coinsurance for kidney disease education services. Authorization rules may apply. $0 copay for Medicare-covered renal dialysis.* $0 copay for Medicare-covered kidney disease education services.* PRESCRIPTION DRUG BENEFITS 25 Outpatient Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs Covered Under Medicare Part B $0 copay for Medicare Part B drugs. $0 yearly deductible for Medicare Part B drugs.* $0 copay for Part B chemotherapy drugs and other Part-B drugs.* 16

29 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit 25 Outpatient Prescription Drugs Original Medicare Universal Trust (HMO SNP) H6642_008 Drugs Covered Under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at members/medicare-formulary.php on the web. Different out-of-pocket costs may apply for people who 0 have limited incomes, 0 live in long-term care facilities, or 0 have access to Indian/Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Universal Trust (HMO SNP) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website,

30 25 Outpatient Prescription Drugs formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. The plan charges a minimum cost-sharing amount for certain low-cost drugs. You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: 0 A $0 copay or 0 A $1.15 copay or 0 A $2.65 copay For all other drugs, either: 0 A $0 copay or 0 A $3.50 copay or 0 A $6.60 copay. Retail Pharmacy You can get drugs the following way(s): 0 one-month (31-day) supply. 0 three-month (90-day) supply. Long-Term Care Pharmacy You can get drugs the following way(s): 0 one-month (34-day) supply of drugs. 18

31 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit 25 Outpatient Prescription Drugs Original Medicare Universal Trust (HMO SNP) H6642_008 Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/ collection when less than a one-month supply is dispensed. Mail Order You can get drugs the following way(s): 0 one-month (31-day) supply. 0 two-month (60-day) supply. 0 three-month (90-day) supply. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay a $0 copay. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Universal Trust (HMO SNP). You can get out-of-network drugs the following way: 0 one-month (31-day) supply. Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by Universal Trust (HMO SNP) up to the plan's cost of the drug minus the following:

32 25 Outpatient Prescription Drugs For generic drugs purchased out-of-network (including brand drugs treated as generic), either: 0 A $0 copay or 0 A $1.15 copay or 0 A $2.65 copay. For all other drugs purchased out-of-network, either: 0 A $0 copay or 0 A $3.50 copay or 0 A $6.60 copay. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you will be reimbursed in full for drugs purchased out-of-network. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 26 Dental Services Preventive dental services (such as cleaning) not covered. $0 copay for Medicare-covered dental benefits.* $0 copay for the following preventive dental benefits: 0 up to 1 oral exam(s) every year. 0 up to 2 cleaning(s) every year. 0 up to 1 fluoride treatment(s) every year. 0 $0 to $75 copay for up to 1 dental X-ray(s) every year. Plan offers additional comprehensive dental benefits. $1,500 plan coverage limit for comprehensive dental benefits every year. See page 25 for information about Dental Services. 20

33 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. Benefit Original Medicare Universal Trust (HMO SNP) H6642_ Hearing Services Supplemental routine hearing exams and hearing aids not covered. 0% or 20% coinsurance for diagnostic hearing exams. $0 copay for Medicare-covered diagnostic hearing exams* $10 copay for up to 1 supplemental routine hearing exam(s) every year. $0 copay for up to 1 hearing aid(s) every year. $250 plan coverage limit for hearing aids every year. See page 26 for information about Hearing Services. 28 Vision Services 0% or 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Supplemental routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. 0 $0 or $10 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.* 0 $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.* 0 $0 copay for up to 1 supplemental routine eye exam(s) every year. 0 $10 copay for up to 1 pair(s) of glasses every year. 0 $10 copay for up to 1 pair(s) of contacts every year. $200 plan coverage limit for eye wear every year. Plan offers additional vision benefits. Contact plan for details. See page 25 for information about Vision Services. Over-the-Counter Items Not covered. Please visit our plan website to see our list of covered over-the-counter items.

34 OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. See page 26 for information about Over-the-Counter items. Transportation (Routine) Not covered. Authorization rules may apply. $0 copay for up to 20 round trip(s) to plan-approved location every year. See page 26 for information about Transportation (Routine). Acupuncture Not covered. This plan does not cover acupuncture. 22

35 Section III: Additional Information This section further explains some of the benefits of our plan. The availability of the benefits described below may vary depending on the plan you enroll in. To get a complete list of benefits, limitations, and exclusions call Universal and ask for the Evidence of Coverage. Premium and Other Important Information Maximum Out-of-Pocket (MOOP) The maximum out-of-pocket (MOOP) expenses paid annually apply to Medicare-covered in-network Part A and Part B services. While most expenses can be applied to the MOOP, the following DO NOT apply to the MOOP: Outpatient Part D prescription drugs. 0 Additional benefits and services not covered by Original Medicare (including but not limited to, routine dental, vision, and hearing services). Once you reach your maximum out-of-pocket limit, you will not have to pay for any in-network medical services covered by Part A and Part B. Inpatient Care Inpatient Hospital Care, Inpatient Mental Health Care, and Skilled Nursing Facility (SNF) You pay the amounts shown each time you're admitted to a hospital or skilled nursing facility, no matter how many days have passed since your last admission. Outpatient Care Outpatient services can occur at a variety of facilities. Including hospitals, mental health institutions, medical centers, and ambulatory surgical centers. The cost you pay may vary depending upon the facility you visit to obtain services. Also, if you obtain services at one of these facilities and are then sent to another facility for additional services, you may have to pay an additional copayment or coinsurance. 23

36 Health Wellness/Education Programs Preventive Services, Wellness/Education and other Supplemental Benefit Programs Health/Nutritional Education The plan provides health education programs to help members learn more about their specific conditions. The conditions covered by this program include Diabetes, Hypertension, COPD, CHF, Asthma, HIV/AIDS, and Cancer. Ongoing one on one interaction will be provided by a qualified health professional. The goal of the program is to help members remain independent in their own home. Additional Smoking and Tobacco Use Cessation Through our online smoking and tobacco cessation program QuitNet, you may be eligible to receive tips and advice online from our expert counselors, a personalized tobacco-cessation plan and quit guide, and access to a 24/7 online community with other members just like you. Nursing Hotline If you have a medical concern, day or night, you can call our 24/7 Nurse Hotline to get the professional advice you need from one of our registered nurses. They can guide you to a community resource for help, or put your mind at ease with the health information you need. In Home Safety Assessment After a stay in a hospital or skilled nursing facility (SNF), members may be eligible to participate in this program that is designed to help reduce their risk for falls and identifies how falls may be prevented in their home. A qualified provider will come to their home and assess any home and safety issues. In Home Medication Reconciliation After a stay in a hospital or skilled nursing facility (SNF), we will work with you and your doctor to review the medications you were taking before your stay and make sure that any new medication that has been prescribed does not cause any side effects or interaction that could result in further illness or injury. Meal Delivery Program After a stay in the hospital or nursing facility, members may be eligible to receive nutritious, precooked meals delivered to their home. Eligible members may receive up to 4 weeks of meals each year. The number of meals and duration of benefit will be determined by the plan's care management department. 24

37 Additional Benefits Dental Services: You must use the plan's network of providers to obtain covered services. To find a network provider near you please call Benefit Oral Exams Routine Cleanings Fluoride Treatments Dental X-rays Universal Trust (HMO SNP) H6642_008 $0 copay for routine oral exams. Limited to 1 per year. $0 copay for routine cleanings. Limited to 2 per year. $0 copay for fluoride treatments. Limited to 1 per year. $0 to $75 copay for dental x-rays. Limited to 1 per year. Vision Services: You must use the plan's network of providers to obtain covered services. To find a network provider near you please call Benefit Vision - Routine Eye Exams Vision - Eyewear (Glasses, Lenses, Frames, Contacts) Universal Trust (HMO SNP) H6642_008 $0 copay for routine eye exams. Limited to 1 per year. $10 copay for additional eyewear. $200 credit toward eyewear each year. 25

38 Additional Benefits Cont. Hearing Services: You must use the plan's network of providers to obtain covered services. To find a network provider near you please call Benefit Routine Hearing Exams Hearing Aids Universal Trust (HMO SNP) H6642_008 $10 copay for routine hearing exams. Limited to 1 per year. $0 copay for up to 1 hearing aid. $250 per year credit towards the purchase of 1 hearing aid. Over-the-Counter Items Members are eligible to receive a $50 monthly credit to be used toward the purchase of over-the-counter (OTC) health and wellness products available through the plan's mail order service. Unused amounts do not carry over to the next month. Transportation Services Members are eligible to receive 20 round trips per year to and from routine medical appointments. To schedule an appointment call Monday - Friday from 8AM to 5PM. Please call at least three business days in advance of your medical appointment. 26

39 Section IV: Medicaid Summary of Benefits for H6642_008 If you have any questions about this plan's benefits or costs, please contact Universal HMO of Texas, Inc. for details. People who qualify for Medicare and Medicaid are called dual eligible. People who are dual eligible are entitled to certain Medicaid benefits, but those benefits vary based on the level of Medicaid for which they qualify: Full Benefit Dual Eligible (FBDE) qualifies for payment of Medicare Part A and Part B premium and full Medicaid benefits. Specified Low Income Medicare Beneficiary Plus (SLMB Plus) qualifies for payment of Medicare Part B premium and full Medicaid benefits. Qualified Low Income Medicare Beneficiary Plus (QMB-Plus) qualifies for payment of Medicare Part A and Part B premiums and full Medicaid benefits, including coverage of Medicare deductibles, co-payments, and co-insurance (excluding Part D co-payments). SLMB qualifies for payment of Medicare Part B premium. QMB qualifies for coverage of Medicare Part A and Part B premium, deductibles, co-payments, and co-insurance (excluding Part D co-payments). Qualifying Individual (QI) qualifies for payment of Medicare Part B premium. *Medicaid benefits and premium payment may vary based on your level of Medicaid eligibility.

40 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. IMPORTANT INFORMATION 1 Premium and Other Important Information 2 Doctor and Hospital Choice (For more information, see Emergency Care -#15 and Urgently Needed Care #16.) *Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility. Inpatient hospital stays are a covered benefit for those who meet QMB requirements. Medicaid pays co-insurance, co-payments, and deductibles for Medicare-covered services. Members should follow Medicare guidelines related to hospital and doctor choice. $0 copay for Medicaid-covered services. *Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for Original Medicare services. $31.80 monthly plan premium in addition to your monthly Medicare Part B premium.* $3,400 out-of-pocket limit for Medicare-covered services.* You must go to network doctors, specialists, and hospitals. Referral required for network specialists (for certain benefits). 28

41 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. INPATIENT CARE 3 Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) 4 Inpatient Mental Health Care 5 Skilled Nursing Facility (SNF) (In a Medicare-certified skilled nursing facility) For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Prior authorization is required for inpatient substance abuse treatment. $0 copay for Medicaid-covered services. Note: Age restrictions are 13 years of age and above. Admissions for the single diagnosis of chemical dependency or abuse without an accompaning medical complication are not a benefit of Texas Medicaid. Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Inpatient psychiatric treatment is subject to applicable requirements. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Plan covers 90 days each benefit period. $0 copay. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. $0 copay. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Authorization rules may apply. Plan covers up to 100 days each benefit period.

42 6 Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) 7 Hospice Home health skilled nursing (SN) and home health aid (HHA) visits are a benefit of Texas Medicaid Title XIX Home Health Services. Private Duty Nursing services are a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for Medicaid clients 20 years of age or younger. Personal Care Services (PCS) is a benefit of the Texas Health Steps-Comprehenesive Care Program (THSteps-CCP) for Texas Medicaid clients birth through 20 years of age, who are not an inpatient or a resident of a hospital, in a nursing facility or ICF/MR, or in an institution for mental disease. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 co-pay for Medicaid-covered services. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: When clients elect hospice services, they waive their rights to all other Medicaid services related to their terminal illness. They do not waive their rights to Medicaid services unrelated to their terminal illness. Medicare and Medicaid clients must elect both the Medicare and Medicaid Hospice programs. No prior hospital stay is required. $0 copay for SNF services. Authorization rules may apply. $0 copay for Medicare-covered home health visit.* You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. OUTPATIENT CARE 8 Doctor Office Visits Texas Medicaid reimburses physician evaluation and management office visits. Group visits are limited to a maximum of 4 per year. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Authorization rules may apply. $0 copay for each Medicare-covered primary care doctor visit.* 30

43 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. 8 Doctor Office Visits 9 Chiropractic Services 10 Podiatry Services 11 Outpatient Mental Health Care Chiropractic manipulative treatment (CMT) performed by a chiropractor licensed by the Texas State Board of Chiropractic Examiners is a benefit of Texas Medicaid. CMT is reimbursed only for a diagnosis of subluxation of the spine. Diagnostic, therapeutic services, or adjunctive therapies furnished by a chiropractor or by others under his or her orders or direction are not a benefit of Texas Medicaid. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Podiatry and related services are a benefit of Texas Medicaid. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 co-pay for Medicaid-covered services. Note: Prior authorization requirements applied to services provided by physicians (MD or DO) also apply to services provided by a podiatrist. Outpatient mental health care is a benefit of Texas Medicaid. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Age limit of 13 years of age and older. $0 copay for each Medicare-covered specialist doctor visit.* $0 copay for Medicare-covered chiropractic visits.* Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor. Authorization rules may apply. $0 copay for Medicare-covered podiatry benefits.* Medicare-covered podiatry benefits are for medically-necessary foot care. Authorization rules may apply.

44 11 Outpatient Mental Health Care Prior authorization is optional; however, outpatient behavioral health services without prior authorization are limited to 30 encounters/ visits per client for each calendar year. $0 copay for: 0 each Medicare-covered individual therapy visit.* 0 each Medicare-covered group therapy visit.* $0 copay for: 0 each Medicare-covered individual therapy visit with a psychiatrist.* 0 each Medicare-covered group therapy visit with a psychiatrist.* $0 copay for Medicare-covered partial hospitalization program services.* 12 Outpatient Substance Abuse Care For dual-eligible Members, Medicaid managed care pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 co-pay for Medicaid-covered services. Authorization rules may apply. $0 copay for: 0 each Medicare-covered individual substance abuse outpatient treatment visit.* 0 each Medicare-covered group substance abuse outpatient treatment visit.* 13 Outpatient Services For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Authorization rules may apply. $0 copay for each Medicare-covered ambulatory surgical center visit.* $0 copay for each Medicare-covered outpatient hospital facility visit.* 32

45 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. 14 Ambulance Services (medically necessary ambulance services). 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) Emergency and non-emergency ambulance transport services are a benefit of Texas Medicaid. Emergency transports (including emergency interfacility ambulance transports) do not require prior authorization. Prior authorization is required for all non-emergency ambulance transports. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Authorization rules may apply. $0 copay for Medicare-covered ambulance benefits.* $0 copay for Medicare-covered emergency room visits.* Worldwide coverage. 16 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. $0 copay for Medicare-covered urgently needed care visits.*

46 17 Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy.) For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Tobacco, caffeine, and occupational therapy as part of a detoxification or treatment program are not covered. Therapy hour limitations do apply. Authorization rules may apply. There may be limits on physical therapy, occupational therapy, and speech and language pathology services. If so, there may be exceptions to these limits. $0 copay for Medicare-covered occupational therapy visits.* $0 copay for Medicare-covered physical and/or speech and language pathology visits.* OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 Durable Medical Equipment (includes wheelchairs, oxygen, etc.) 19 Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. For dual-eligible Members under age 21 (CCP), Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Prior authorization required. For all dual-eligible members, Medicaid pays for breast prostheses if not covered by Medicare or when the Medicare benefit is exhausted. Quantity limitations apply and vary with each device. Authorization rules may apply. $0 copay for Medicare-covered durable medical equipment.* Authorization rules may apply. $0 copay for Medicare-covered prosthetic devices.* 34

47 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. Prior authorization will NOT be required within limitations, except for miscellaneous codes. $0 copay for Medicaid-covered services. 20 Diabetes Programs and Supplies For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. $0 copay for Medicare-covered diabetes self-management training.* $0 copay for Medicare-covered: 0 Diabetes monitoring supplies.* 0 Therapeutic shoes or inserts.* 21 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Medically necessary diagnostic tests, lab, and radiological services are a benefit. CT/MRI requires prior authorization. Each procedure is subject to limitations. Authorization rules may apply. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicare-covered: $0 copay for Medicaid-covered services. 0 Lab services.* 0 Diagnostic procedures and tests.* 0 X-rays.* 0 Diagnostic radiology services (not including X-rays).* 0 Therapeutic radiology services.* 22 Cardiac and Pulmonary Rehabilitation Services Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions. Authorization rules may apply. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for: $0 copay for Medicaid-covered services. 0 Medicare-covered cardiac rehabilitation services.*

48 0 Medicare-covered intensive cardiac rehabilitation services.* 0 Medicare-covered pulmonary rehabilitation services.* PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT PROGRAMS 23 Preventive Services, Wellness/ Education and other Supplemental Benefit Programs 24 Kidney Disease and Conditions For dual-eligible Members, Medicaid pays for these services if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. The plan covers the following supplemental education/wellness programs: 0 Health education. 0 Nutritional education. 0 Additional smoking and tobacco use cessation visits. 0 Health club membership/fitness classes. 0 Nursing hotline. $0 copay for post discharge in-home medication reconciliation. Contact plan for details. $0 copay for in-home safety assessments. Contact plan for details. Plan covers a physical exam annually. Authorization rules may apply. $0 copay for Medicare-covered renal dialysis.* $0 copay for Medicare-covered kidney disease education services.* 36

49 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. PRESCRIPTION DRUG BENEFITS 25 Outpatient Prescription Drugs Outpatient prescribed medications are a benefit to eligible clients when obtained through a pharmacy contracted with the Medicaid vendor. Note: Drug Program or dual-eligible Members, Medicaid will not cover any Medicare Part D drug. $0 co-payment for Medicaid covered prescription drugs not covered by Medicare Part D. Drugs Covered Under Medicare Part B $0 copay for Medicare Part B drugs. $0 yearly deductible for Medicare Part B drugs.* $0 copay for Part B chemotherapy drugs and other Part-B drugs.* Drugs Covered Under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at members/medicare-formulary.php on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long-term care facilities, or have access to Indian/ Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Universal Trust (HMO SNP) for certain drugs.

50 25 Outpatient Prescription Drugs You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. The plan charges a minimum cost-sharing amount for certain low-cost drugs. You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: 0 A $0 copay or 0 A $1.15 copay or 0 A $2.65 copay For all other drugs, either: 0 A $0 copay or 0 A $3.50 copay or 0 A $6.60 copay. Retail Pharmacy You can get drugs the following way(s): 0 one-month (31-day) supply. 0 three-month (90-day) supply. Long-Term Care Pharmacy You can get drugs the following way(s): 0 one-month (34-day) supply of drugs. 38

51 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. 25 Outpatient Prescription Drugs Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/ collection when less than a one-month supply is dispensed. Mail Order You can get drugs the following way(s): 0 one-month (31-day) supply. 0 two-month (60-day) supply. 0 three-month (90-day) supply. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay a $0 copay. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Universal Trust (HMO SNP). You can get out-of-network drugs the following way: 0 one-month (31-day) supply. Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by Universal Trust (HMO SNP) up to the plan's cost of the drug minus the following: 0 For generic drugs purchased out-of-network (including brand drugs treated as generic), either:

52 25 Outpatient Prescription Drugs 0 A $0 copay or 0 A $1.15 copay or 0 A $2.65 copay. For all other drugs purchased out-of-network, either: 0 A $0 copay or 0 A $3.50 copay or 0 A $6.60 copay. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you will be reimbursed in full for drugs purchased out-of-network. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 26 Dental Services 27 Hearing Services Dental services are benefits of Texas Medicaid for Medicaid-eligible clients who are 20 years of age or younger through the THSteps program, and for clients who are 21 years of age or older in an ICF-MR. For dual-eligible Members who meet the above criteria, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Hearing screening and both monaural and binaural hearing aids are a benefit. Hearing aids do not require prior authorization for the initial hearing aid(s), except beyond stated limitations. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicare-covered dental benefits.* $0 copay for the following preventive dental benefits: 0 up to 1 oral exam(s) every year. 0 up to 2 cleaning(s) every year. 0 up to 1 fluoride treatment(s) every year. $0 to $75 co-pay for up to 1 dental X-ray(s) every year. Plan offers additional comprehensive dental benefits. $1,500 plan coverage limit for comprehensive dental benefits every year. $0 copay for Medicare-covered diagnostic hearing exams.* $10 copay for up to 1 supplemental routine hearing exam(s) every year. 40

53 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. 27 Hearing Services 28 Vision Services Over-the-Counter Items Transportation (Routine) $0 copay for Medicaid-covered services. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Services by an optician are limited to fitting and dispensing of medically necessary eyeglasses and contact lenses. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. For dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. $0 copay for up to 1 hearing aid(s) every year. $250 plan coverage limit for hearing aids every year. $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.* $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.* $0 copay for up to 1 supplemental routine eye exam(s) every year. $10 copay for up to 1 pair(s) of glasses every year. $10 copay for up to 1 pair(s) of contacts every year. $200 plan coverage limit for eyewear every year. Plan offers additional vision benefits. Contact plan for details. Please visit our plan website to see our list of covered over-the-counter items. OTC items may be purchased only for the enrollee. Please contact the plan for instructions for using this benefit. Authorization rules may apply.

54 Transportation (Routine) Acupuncture Not covered. $0 copay for up to 20 round trips to plan-approved location every year. This plan does not cover acupuncture. TEXAS HOME AND COMMUNITY BASED WAIVER SERVICES Those who meet QMB requirements, and also meet the financial criteria for full Medicaid coverage, may be eligible to receive all Medicaid Services not covered by Medicare, including Waiver services. Waiver services are limited to individuals who meet additional waiver eligibility criteria. Community Based Alternatives (CBA) Waiver Community Living Assistance and Support Services (CLASS) Waiver Consolidated Waiver Program (CWP) - Bexar County/San Antonio Only Deaf Blind with Multiple Disabilities Waiver (DB-MD) For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). 42

55 BENEFIT MEDICAID Universal Trust (HMO SNP) Note: The table below reflects Medicaid services available on a fee-for-service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits and the Universal Trust (HMO SNP) benefits. Home and Community Services (HCS) Waiver For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). Medically Dependent Children Program (MDCP) For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). STAR+PLUS Waiver For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). Texas Home Living Waiver (TxHmL) For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS).

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57 (TTY ) 8 AM 11 PM Eastern: 7 days a week, October 1 February 14; 5 days a week, February 15 September 30 Universal is a health plan with a Medicare contract and a contract with the Texas Medicaid program.