CALIFORNIA - Pacificare Health Systems

the second PIE is effective on the date the
adoption becomes final. For enrollees who
complete a 90-day waiting period, coverage
is effective on the 91st consecutive calendar
day after the date the enrollment form is
received by the University of California
Customer Service Center. The Effective Date
of coverage for enrollment during an open
enrollment period is the date announced
by the University. In order to change from
individual to two-party coverage and from
two-party to family coverage, you will need to
obtain a change form from the University of
California Customer Service Center, complete
and return it.
PacifiCare will send you a letter that informs
you when your coverage begins. From your
Effective Date forward, you must receive all
routine Covered Services from Contracting
Medical Providers. Neither PacifiCare nor
Medicare will pay for services received from
Non-Contracting Medical Providers except for:
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Emergency Services anywhere in the
world;
Urgently Needed Services that were not
foreseeable when you left the Service Area;
Out-of-area renal dialysis services and
routine travel dialysis (must be received at
a Medicare Certified Dialysis Facility within
the United States);
Referrals that have received Prior
Authorization.
If you receive any medical services not
covered by Medicare before your Secure
Horizons Medicare Advantage Plan coverage
takes effect, you are financially responsible for
those services.
The Secure Horizons Group Retiree
Medicare Advantage Plan Discount Drug
Card*
The Medicare-approved drug discount
cards were offered as a transition step to
help people with Medicare save money on
prescription drug costs until Medicare Part D
Section 2 – Eligibility, Enrollment
Periods and Effective Date
became available. The Secure Horizons Group
Retiree Medicare Advantage Plan Discount
Drug Card* program is discontinued as of
December 31, 2005.
*Your Secure Horizons membership card
served as your Discount Drug Card.
Liability of PacifiCare Upon Initial
Enrollment
PacifiCare is responsible for the full scope
of Part B services as required by Medicare
beginning on your effective date. However,
if your Effective Date occurs during an
inpatient stay in a Hospital, PacifiCare is not
responsible for arranging or paying for any
of the inpatient Hospital services under the
Medicare Hospital Insurance Plan (Part A).
PacifiCare must assume responsibility for
arranging or paying for inpatient Hospital
services under the Medicare Hospital
Insurance Plan (Part A) on the day following
the day of discharge. PacifiCare is responsible
for the full scope of Part B services required
by Medicare beginning on your Effective Date.
About Your Medicare Supplement
(Medigap) Policy
You may consider canceling any Medicare
supplement (Medigap) policy you may
have after PacifiCare has sent you written
confirmation of your Effective Date. This is
because Health Plan Premiums, Copayments
or other amounts that MA Plans charge
for Medicare Covered Services will not be
reimbursed by Medigap policies. However,
if you Disenroll from the Secure Horizons
Medicare Advantage Plan, you may not be
able to have your Medigap policy reinstated.
Note: In certain cases you can be guaranteed
the issue (without medical underwriting
or pre-existing condition Exclusions)
of a Medicare supplemental (Medigap)
policy. Examples of these cases include the
following:
You Disenroll from Secure Horizons
Medicare Advantage Plan for a reason
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