CALIFORNIA - Pacificare Health Systems

The following definitions apply to this
Combined Evidence of Coverage and
Disclosure Information.
Acute Care
Treatment for an acute (immediate and
severe) episode of illness, for the subsequent
treatment of injuries related to an accident
or other trauma, or during recovery from
surgery. Acute Care is usually received
in a Hospital from specialized personnel
using complex and sophisticated technical
equipment and materials. This pattern of
care is often necessary for a short time,
unlike chronic care, where no significant
improvement can be expected.
Appeal
The type of complaint you make when
you want a reconsideration of a decision
(determination) that was made regarding
a service or what PacifiCare will pay for
a service. You can file an Appeal in the
following examples:
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If PacifiCare refuses to cover or pay for
services you think PacifiCare should cover.
If PacifiCare or one of the Contracting
Medical Providers refuses to give you a
service you think should be covered.
If PacifiCare or one of the Contracting
Medical Providers reduces or cuts back on
services you have been receiving.
If you think that PacifiCare is stopping
your coverage too soon.
Basic Benefits
All health care services that are covered under
the Medicare Part A and Part B programs,
(except Hospice services) which are covered
by the Secure Horizons Group Retiree
Medicare Advantage Plan, additional services
that PacifiCare uses Medicare funds to cover,
and other services for which you may be
required to pay a Health Plan Premium. All
Members of the Secure Horizons Group
Retiree Medicare Advantage Plan receive all
Basic Benefits.
Section 1 – Health Care Terms
Benefit Period
A Benefit Period is a way of measuring your
use of services under Medicare Part A. A
Benefit Period begins with the first day of
a Medicare-covered inpatient Hospital stay
and ends with the close of a period of sixty
(60) consecutive days during which you
were neither an inpatient of a Hospital nor
of a Skilled Nursing Facility (SNF). Inpatient
Hospital Care Copayments are charged on
a per admission basis. Original Medicare
Hospital Benefit Periods do not apply. For
Inpatient Hospital Care, you are covered
for an unlimited number of days as long
as the Hospital stay is Medically Necessary
and authorized by PacifiCare or Contracting
Medical Providers.
Calendar Year
A twelve (12)-month period that begins on
January 1 and ends twelve (12) consecutive
months later on December 31.
Centers for Medicare and Medicaid
Services (CMS)
The Federal agency responsible for
administering Medicare.
Coinsurance
The percentage of the cost of a Covered
Service a Member is required to pay.
Coinsurance is based on the amount that
Original Medicare would have covered. This
may not necessarily reflect the actual cost to
PacifiCare. If there is no set Medicare amount
for the service provided, the percentage
will be based on PacifiCare’s contractually
negotiated rate.
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.
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PART B