CALIFORNIA - Pacificare Health Systems

PART A
124
General Information
the agreed-upon budget. If the actual cost of services
is less than the agreed-upon budget, the Participating
Medical Group shares in the savings. The Participating
Hospital and Participating Medical Group typically
participate in programs for Hospital Services similar to
what is described above.
Stop-loss insurance protects Participating Medical
Groups and Participating Hospitals from large financial
expenses for health care services. PacifiCare provides
stop-loss protection to our Participating Medical
Groups and Participating Hospitals that receive the
monthly payments described above. If any Participating
Hospital or Participating Medical Group does not
obtain stop-loss protection from PacifiCare, it must
obtain stop-loss insurance acceptable to PacifiCare.
PacifiCare arranges with additional Providers or
their representatives for the provision of Covered
Services that cannot be performed by your assigned
Participating Medical Group or Participating Hospital.
Such services include authorized Covered Services
that require a specialist not available through your
Participating Medical Group or Participating Hospital or
Emergency and Urgently Needed Services. PacifiCare or
your Participating Medical Group pays these Providers
at the lesser of the Provider’s reasonable charges
or agreed-to rates. Your responsibility for Covered
Services received from these Providers is limited to
payment of applicable Copayments. (For more about
Copayments, see Section 7. Payment Responsibility.)
You may obtain additional information on PacifiCare’s
compensation arrangements by contacting PacifiCare
or your Participating Medical Group.
How do I become an organ and tissue donor?
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 donation
provides each of us with a special opportunity to help
others.
Almost anyone can be a donor. There is no age
limit, and the number of donors age 50 or older has
increased. If you have questions or concerns about
organ donation, speak with your family, doctor or
clergy.
There are many resources that can provide the
information you need to make a responsible decision.
If you do decide to become a donor, 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 family
and having them sign as witnesses. The donor card
serves as a reminder to your family and medical staff of
your personal decision to be a donor. Carry it in your
wallet or purse at all times.
How can I learn more about being an organ
and tissue donor?
To get your donor card and information on organ and
tissue donation call 1-800-355-SHARE or
1-800-633-6562. You can also request donor
information from your local Department of Motor
Vehicles (DMV).
On the Internet, contact:
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All About Transplantation and Donation
(www.transweb.org)
Department of Health and Human Services
(www.organdonor.gov)
Once you get a donor card, be sure to sign it in
your family’s presence. Have your family sign as
witnesses and pledge to carry out your wishes, then
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.
How can I participate in PacifiCare’s Public
Policy Participation?
PacifiCare gives its Members the opportunity to
participate in establishing the public policy of the
Health Plan. One-third of PacifiCare of California’s
Board of Directors is comprised of Health Plan
Members. If you are interested in participating in the