CALIFORNIA - Pacificare Health Systems

Dependents in consideration of the benefits provided
under this Health Plan.
Home Health Aide – A person who has completed
Home Health Aide training as required by the state in
which the individual is working. Home Health Aides
must work under a plan of care ordered by a physician
and under the supervision of a licensed nurse or
licensed therapist.
Home Health Aide Services – Medically Necessary
personal care such as bathing, exercise assistance and
light meal preparation, provided by trained individuals
and ordered along with skilled nursing and/or therapy
visits.
Home Health Care Visit – Defined as up to two
(2) hours of skilled services by a registered nurse or
licensed vocational nurse or licensed therapist or up to
four (4) hours of Home Health Aide Services.
Hospice – Specialized form of interdisciplinary health
care for a Member with a life expectancy of a year
or less due to a terminal illness. Hospice programs
or services are designed to provide palliative care;
alleviate the physical, emotional, social and spiritual
discomforts of a Member who is experiencing the last
phase of life due to the existence of a terminal disease;
and provide supportive care to the primary caregiver
and family of the Member receiving Hospice Services.
Hospital Services – Services and supplies performed
or supplied by a licensed Hospital on an inpatient or
outpatient basis.
Hospitalist – A Physician whose sole practice is the
management of acutely and/or chronically ill patients’
health services in a hospital setting.
Hypnotherapy – Medical Hypnotherapy is treatment
by hypnotism or inducing sleep.
Infertility – Either: (1) the inability to conceive a
pregnancy or to carry a pregnancy to a live birth after
a year or more of regular sexual relations without
contraception; or (2) the presence of a demonstrated
condition recognized by a licensed Physician who is a
Participating Provider as a cause of Infertility.
Intramuscular – Injection into the muscle.
Intravenous – Injection into the vein.
Late Enrollee – An employee who declined
enrollment in the PacifiCare Health Plan when offered
Definitions
and who subsequently requests enrollment outside the
designated Open Enrollment Period.
Learning Disability – A Learning Disability is a
condition which manifests as a significant discrepancy
between estimated cognitive potential and actual
level of educational performance and which is not a
result of generalized mental retardation, educational
or psychosocial deprivation, psychiatric disorder, or
sensory loss.
Limiting Age – The age established by the University
of California when a Dependent is no longer eligible to
be an enrolled Family Member under the Subscriber’s
coverage.
Medically Necessary (or Medical Necessity) refers
to an intervention, if, as recommended by the treating
Physician and determined by the Medical Director of
PacifiCare or the Participating Medical Group, it is all of
the following:
a. A health intervention for the purpose of treating a
medical condition;
b. The most appropriate supply or level of service,
considering potential benefits and harms to the
Member;
c. Known to be effective in improving health
outcomes. For existing interventions, effectiveness
is determined first by scientific evidence, then by
professional standards, then by expert opinion.
For new interventions, effectiveness is determined
by scientific evidence; and
d. If more than one health intervention meets the
requirements of (a) through (c) above, furnished
in the most cost-effective manner that may be
provided safely and effectively to the Member.
“Cost-effective” does not necessarily mean lowest
price.
A service or item will be covered under the PacifiCare
Health Plan if it is an intervention that is an otherwise
covered category of service or item, not specifically
excluded, and Medically Necessary.
An intervention may be medically indicated yet not
be a covered benefit or meet the definition of Medical
Necessity.
In applying the above definition of Medical Necessity,
the following terms shall have the following meanings:
Questions? Call the Customer Service Department at 1-800-624-8822. 129
PART A