CALIFORNIA - Pacificare Health Systems

Welcome to the Secure Horizons Group 142
Retiree Medicare Advantage Plan
Call Customer Service Whenever 143
You Need Information
Updating Your Membership Records 143
PacifiCare Is Interested in 143
Your Comments
How to Submit a Claim 143
Sponsorship and Administration 144
of the Plan
Section 1 – Health Care Terms 145
Section 2 – Eligibility, Enrollment 155
Periods and Effective Date
To Enroll in the Secure Horizons Group 155
Retiree Medicare Advantage (MA) Plan:
When You May Enroll in the Secure 155
Horizons Group Retiree Medicare
Advantage Plan
University of California Eligibility 157
Provisions
Enrollment Provisions 158
Your Enrollment Form 160
When Your Secure Horizons Group 160
Retiree Medicare Advantage (MA) Plan
Coverage Begins
Liability of PacifiCare Upon Initial 161
Enrollment
About Your Medicare Supplement 161
(Medigap) Policy
Section 3 – Secure Horizons Group 163
Retiree Medicare Advantage Plan
Member Rights and Responsibilities
Section 4 – How Your Secure Horizons 164
Group Retiree MA Plan Coverage
Works
How the Lock-In Feature Works for 164
You and PacifiCare
Table of Contents
Section 5 – Working With Your 165
Contracting Medical Providers
Your Primary Care Physician 165
You Can Change Primary Care
Physicians
165
Provider Terminations 166
How to Schedule an Appointment
With Your Primary Care Physician
167
How to Receive Care After-Hours 167
How to Receive Covered Services
From a Specialist
167
Standing Referrals to Specialists 167
Extended Referral for Coordination
of Care by a Specialist
168
Access to OB/GYN Physician Services
and Women’s Routine and Preventive
Health Care Services
168
Continuity of Care for Members With
Terminating Physicians
168
Access to Your Medical Records and
Files
169
Utilization Review 169
Second Medical Opinions 170
Prior Authorization 170
Hospitalization 171
Hospital Copayment and
Benefit Periods
171
Hospitalist 172
Skilled Nursing Facility (SNF) Care 172
Organ Transplants 172
Ambulance 176
Home Health Care Services 176
Hospice 177
Clinical Trials and Other Medicare 177
Benefits
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
139
PART B