CALIFORNIA - Pacificare Health Systems

PART B
142
Welcome to the Secure Horizons Group
Retiree Medicare Advantage Plan
This document, your Retiree Benefits
Summary and Retiree Benefits Summary
Insert are an explanation of your rights,
benefits and responsibilities as a Member
of the Secure Horizons Group Retiree MA
Plan, offered by PacifiCare, a Medicare
Advantage Organization. These documents
also explain PacifiCare’s responsibilities to
you. Your Member contract for the Secure
Horizons Group Retiree Medicare Advantage
Plan consists of this Combined Evidence
of Coverage and Disclosure Information,
the Retiree Benefits Summary and Retiree
Benefits Summary Insert, your Election Form
and any current or future amendments.
This Combined Evidence of Coverage and
Disclosure Information, your Retiree Benefits
Summary and your Retiree Benefits Summary
Insert, contain important information. These
documents will be mailed to you annually and
will replace all prior Combined Evidence of
Coverage and Disclosure Documents, Retiree
Benefits Summaries and Retiree Benefits
Summary Inserts. Please read them carefully
and keep them in a safe place, available for
quick reference. If you have special needs,
this document may be available in other
formats.
Secure Horizons Group Retiree MA Plan is not
an insurance policy that merely pays Medicare
deductibles and Coinsurance charges
(commonly called a “Medigap” or “Medicare
supplement” policy). Instead, PacifiCare has
entered into a contract with the Centers for
Medicare and Medicaid Services (CMS), the
Federal government agency that administers
Medicare. PacifiCare is also regulated by the
Department of Managed Health Care. The
contract with CMS authorizes PacifiCare to
arrange for comprehensive health services
for individuals who are entitled to Medicare
benefits and who choose to enroll in the
Secure Horizons Group Retiree Medicare
Advantage Plan. When you join the Secure
Horizons Group Retiree Medicare Advantage
Plan, you usually do not pay Medicare
deductibles and Coinsurance charges,
but instead pay Health Plan Premiums,
Copayments and Coinsurance. The Secure
Horizons Group Retiree Medicare Advantage
Plan covers all services and supplies offered
by Original Medicare, plus additional services
and supplies not covered by Medicare.
PacifiCare has signed a contract with CMS
agreeing to cover you for one full year at a
time. Secure Horizons Group Retiree MA
Plan costs and benefits may change from
year to year, and PacifiCare will notify you
before any changes are made. (PacifiCare may
enhance the Secure Horizons Group Retiree
Medicare Advantage Plan’s benefits at any
time during the calendar year, with written
notice.) In addition, either CMS or PacifiCare
may choose not to renew all or a portion of
the contract. If the contract is not renewed,
your Medicare coverage will be switched to
Original Medicare unless you decide to switch
to another Medicare managed care plan. If
either CMS or PacifiCare decides not to renew
the contract at the end of the year, you will
receive a letter at least ninety (90) days before
the end of the contract. If CMS ends the
contract in the middle of the year, you will
receive a letter at least thirty (30) days before
the end of the contract. In either situation
the letter would explain your options for
health care coverage in your area and provide
you information about your right to obtain
Medicare supplemental insurance coverage.
By enrolling in Secure Horizons Group
Retiree MA Plan, you have agreed to receive
your health care services from Contracting
Medical Providers and facilities. You are
required to follow all plan rules, such as
obtaining Referrals and Prior Authorization,
when required.
If you need Emergency Services
(anywhere in the world) or Urgently
Needed Services (generally, outside the
area served under the Secure Horizons
Group Retiree Medicare Advantage
Plan), those services will be covered.
However, if you receive services from Non-
Contracting Medical Providers without
Prior Authorization, neither PacifiCare
nor Medicare will pay for those services,
except for: