CALIFORNIA - Pacificare Health Systems

PART A
132
Definitions
health care services described in this Combined Evidence
of Coverage and Disclosure Form and supplemental
benefit materials.
Prudent Layperson – A person without medical
training who reasonably draws on practical experience
when making a decision regarding whether Emergency
Services are needed.
Psychological Testing – Psychological Testing includes
the administration, interpretation, and scoring of tests
such as WAIS-R, Rorschach, MMPI and other medically
accepted tests for evaluation of intellectual strengths,
psychopathology, psychodynamics, mental health
risks, insight, motivation, and other factors influencing
treatment and prognosis.
Rehabilitation Services – The combined and
coordinated use of medical, social, educational and
vocational measures for training or retraining individuals
disabled by disease or injury.
Schedule of Benefits – An important part of your
Combined Evidence of Coverage and Disclosure Form
that provides benefit information specific to your Health
Plan, including Copayment information.
Serious Emotional Disturbances of a Child – A
Serious Emotional Disturbance (SED) of a Child is
defined as a child who:
1. Has one or more Mental Disorders as defined by
the Diagnostic and Statistical Manual IV (DSM-
IV), other than a primary substance use disorder
or developmental disorder, that results in behavior
inappropriate to the child’s age according to
expected developmental norms;
2. Is under the age of 18 years old; and
3. Meets one or more of the following criteria:
a. As a result of the Mental Disorder, the child
has substantial impairment in at least two
of the following areas: self-care, school
functioning; family relationships or ability to
function in the community; and either of the
following occur:
i. the child is at risk of removal from home or
has already been removed from the home;
ii. the Mental Disorder and impairments have
been present for more than six months or
are likely to continue for more than one
year without treatment; or
b. The child displays one of the following:
psychotic features, risk of suicide or risk or
violence due to a Mental Disorder; or
c. The child meets special education eligibility
requirement under Chapter 26.5 commencing
with Section 7570 of Division 7 of Title 1 of
the California Government Code.
Severe Mental Illness – Severe Mental Illness (SMI)
includes the diagnosis and Medically Necessary
treatment of the following conditions:
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Anorexia nervosa;
Bipolar disorder;
Bulimia nervosa;
Major depressive disorder;
Obsessive-compulsive disorder;
Panic disorder;
Pervasive developmental disorder or autism;
Schizoaffective disorder;
Schizophrenia.
Service Area – A geographic region in the state
of California where PacifiCare is authorized by the
California Department of Managed Health Care to
provide Covered Services to Members.
Skilled Nursing Care – The care provided directly
by or under the direct supervision of licensed nursing
personnel, including the supportive care of a home
health aide.
Skilled Nursing Facility – A comprehensive freestanding
rehabilitation facility or a specially designed
unit within a Hospital licensed by the state of California
to provide Skilled Nursing Care.
Skilled Rehabilitation Care – The care provided
directly by or under the direct supervision of licensed
nursing personnel or a licensed physical, occupational or
speech therapist.
Spouse – The Subscriber’s husband or wife who is
legally recognized as a husband or wife under the laws
of the state of California.
Subacute and Transitional Care – Subacute and
Transitional Care are levels of care needed by a Member
who does not require Hospital acute care but who
requires more intensive licensed Skill Nursing Care than