CALIFORNIA - Pacificare Health Systems

e voluntary or involuntary. (Please refer to
Section 8 for more information.)
Durable Medical Equipment (DME)
Equipment that can withstand repeated
use; is primarily and usually used to serve a
medical purpose; is generally not useful to
a person in the absence of illness or injury;
and is appropriate for use in the home. To
be covered, Durable Medical Equipment
must be Medically Necessary and prescribed
by a Contracting Medical Provider for use
in your home, such as oxygen equipment,
wheelchairs, Hospital beds and other items
that are determined Medically Necessary, in
accordance with Medicare law, regulations
and guidelines. Routine DME will not be
covered when the Member has exhausted
the one hundred (100) days Skilled
Nursing Facility benefits and remains
in an institution or distinct part of an
institution meeting the basic requirements
of a Hospital or Skilled Nursing Facility.
The decision to rent or purchase a DME
item is determined by your Contracting
Medical Group/IPA, Primary Care Physician or
PacifiCare.
Effective Date
The date your Secure Horizons Group Retiree
MA Plan coverage begins. You receive written
notification of your Effective Date from
PacifiCare.
Election Form
The enrollment form a Medicare beneficiary
or legal representative must complete
(with your signature and date) in order
to be enrolled as a Member of the Secure
Horizons Group Retiree MA Plan. This
form is submitted to CMS for approval.
Each Medicare beneficiary, or beneficiary
representative, must sign and date the
Election Form. The Election Form is part of
your agreement with Secure Horizons Group
Retiree Medicare Advantage Plan. (Please refer
to Section 2 for more information.)
Section 1 – Health Care Terms
Emergency Medical Condition
A medical condition manifesting itself
by acute symptoms of sufficient severity
(including severe pain) such that a prudent
layperson, with an average knowledge of
health and medicine, could reasonably expect
the absence of immediate medical attention
to result in: (1) placing the member’s health
in serious jeopardy; (2) serious impairment
to bodily functions; (3) serious dysfunction
of any bodily organ or part. In the case of
a pregnant woman, an Emergency Medical
Condition exists if the member is in Active
Labor, meaning labor at a time at which
either of the following would occur: (a) there
is inadequate time to effect safe transfer to
another hospital prior to delivery; or (b) a
transfer may pose a threat to the health and
safety of the member or the unborn child.
Emergency Services
Covered Services that are: (1) furnished by
a Provider qualified to furnish Emergency
Services; and (2) needed to evaluate or
stabilize a Medical Emergency. Please see
definition of Medical Emergency.
Evidence of Coverage and Disclosure
Information (EOC)
This document which explains Covered
Services and defines your rights and
responsibilities as a Member and those of
PacifiCare.
Exclusion or Excluded
Items or services that are not covered under
this Evidence of Coverage and Disclosure
Information, which includes the Retiree
Benefits Summary. Exclusions are disclosed
in the Retiree Benefits Summary. You are
responsible for paying for Excluded items or
services.
Experimental Procedures and Items
Items and procedures determined by
PacifiCare and Medicare not to be generally
accepted by the medical community. When
making a determination as to whether a
service or item is experimental, PacifiCare
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