CALIFORNIA - Pacificare Health Systems

PART A
128
Custodial Care includes all homemaker services,
respite care, convalescent care or extended care not
requiring skilled nursing. Custodial Care does not
require the continuing attention of trained medical or
paramedical personnel.
Dependent – A Member of a Subscriber’s family who
is enrolled with PacifiCare after meeting all of the
eligibility requirements of the University of California
and PacifiCare and for whom applicable Health Plan
Premiums have been received by PacifiCare.
Developmental and Neurodevelopmental Testing
– Developmental and Neurodevelopmental Testing
is a battery of diagnostic tests for the purpose of
determining a child’s developmental status and need
for early intervention services. This may include,
but is not limited to, psychological and behavioral
developmental profiles.
Domestic Partner is a person who meets the eligibility
requirements, as defined by the Employer Group, and
the following:
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Is eighteen (18) years of age or older;
Is mentally competent to consent to contract;
Resides with the Subscriber and intends to do so
indefinitely;
Is jointly responsible with the Subscriber for their
common welfare and financial obligations;
Is unmarried or not a member of another domestic
partnership; and
Is not related by blood to the Subscriber to a
degree of closeness that would prohibit marriage in
the state of residence.
Emergency Medical Condition – A medical condition
manifesting itself by acute symptoms of sufficient
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:
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Definitions
placing the Member’s health in serious jeopardy;
serious impairment to bodily functions;
serious dysfunction of any bodily organ or part;
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 – Medical screening, examination
and evaluation by a Physician or other personnel
– to the extent provided by law – to determine if
an Emergency Medical Condition or psychiatric
Emergency Medical Condition exists. If this condition
exists, Emergency Services include the care, treatment
and/or surgery by a Physician necessary to relieve
or eliminate the Emergency Medical Condition or
psychiatric Emergency Medical Condition within the
capabilities of the facility. (For a detailed explanation of
Emergency Services, see Section 3. Emergency and
Urgently Needed Services.)
Employer Group – The University of California
through which you enrolled for coverage.
Experimental or Investigational – Defined in the
“Exclusions and Limitations of Benefits” section of this
Combined Evidence of Coverage and Disclosure Form.
Family Member – The Subscriber’s Spouse or
Domestic Partner and any person related to the
Subscriber, Spouse or Domestic Partner by blood,
marriage, adoption or guardianship. An enrolled Family
Member is a Family Member who is enrolled with
PacifiCare, meets all the eligibility requirements of the
University of California and PacifiCare, and for whom
Premiums have been received by PacifiCare. An eligible
Family Member is a Family Member who meets all the
eligibility requirements of University of California and
PacifiCare.
Grievance (Complaint) – A written or oral expression
of dissatisfaction regarding the plan and/or Provider,
including quality of care concerns, and shall include
a Complaint, dispute, request for reconsideration
or appeal made by a Member or the Member’s
representative.
Group Agreement – The Medical and Hospital Group
Subscriber Agreement entered into between PacifiCare
and the University of California through which you
enroll for coverage.
Health Plan – Your benefit plan as described in this
Combined Evidence of Coverage and Disclosure
Form, Schedule of Benefits and supplemental benefit
materials.
Health Plan Premiums (or Premiums) – Amounts
established by PacifiCare to be paid to PacifiCare
by Employer on behalf of Subscriber and his or her