CALIFORNIA - Pacificare Health Systems

PART B
Your Secure Horizons Group Retiree
MA Plan Membership Card
Your membership card provides you with
information to assist you in receiving all your
Secure Horizons Group Retiree Medicare
Advantage Plan Covered Services. In nearly
all instances, you will need to present your
membership card to your Contracting Medical
Provider to verify your coverage and/or obtain
Covered Services.
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Section 4 – How Your Secure Horizons
Group Retiree MA Plan Coverage Works
Carry your membership card with you at all
times.
Although you never need to discard your
Medicare card, you must now use your
membership card to receive Covered Services.
It is important for you to use only your
Secure Horizons Group Retiree MA Plan
Membership Card – NOT your Medicare
card – for these reasons:
1. To prevent you from receiving medical
services from Non-Contracting Medical
Providers in error.
2. In the case of a Medical Emergency, to
alert Hospital staff of the need to notify
our your Primary Care Physician or
PacifiCare as soon as possible so that
PacifiCare is involved in the management
of your care.
3. To prevent errors in billing. PacifiCare
pays the bills on behalf of Medicare.
Medicare will not pay the bills while you
are a Member of the Secure Horizons
Group Retiree Medicare Advantage Plan.
If you lose your membership card or move,
please contact Customer Service.
How the Lock-In Feature Works for You
and PacifiCare
As a Secure Horizons Group Retiree MA
Plan Member, all your medical benefits
(except for Emergency Services and Urgently
Needed Services and out-of-area renal
dialysis and routine travel dialysis) are
provided or arranged by your Primary Care
Physician, a personal Physician you choose
from PacifiCare’s list of Contracting Medical
Providers. The day you become a Member of
the Secure Horizons Group Retiree Medicare
Advantage Plan (your Effective Date), you are
“Locked-In” to your Primary Care Physician,
who will provide and coordinate all of your
routine health care services. Although the
Secure Horizons Medicare Advantage Plan
Provider Directory lists many Contracting
Providers, once you are “Locked-In”, you must
receive a Referral from your Primary Care
Physician/Contracting Medical Group/IPA to
receive services from other Secure Horizons
Medicare Advantage Plan Contracting Providers.
If you receive services from a Contracting
Medical Provider other than your Primary
Care Physician (except for Emergency Services
and Urgently Needed Services), without a
Referral from your Primary Care Physician or
Contracting Medical Group/IPA, the services
received may not be covered.
The “Lock-in” feature is an important part
of PacifiCare’s contract with CMS, the
government agency that oversees Medicare.
Using the Lock-in feature, PacifiCare is able
to offer Medicare beneficiaries the Secure
Horizons Group Retiree Medicare Advantage
Plan, with additional benefits that Original
Medicare does not offer. Under the CMS
contract, the federal government agrees
to pay PacifiCare a fixed monthly dollar
amount for each Member. PacifiCare uses the
monthly amount received from the federal
government to contract with Physicians,
Hospitals and other health care Providers to
arrange care for you. (Please refer to Section
12 for more information regarding Provider
compensation.)
If you receive services from Non-Contracting
Providers without Prior Authorization,
neither PacifiCare nor Medicare will pay
for those services except for:
n Emergency Services
n Urgently Needed Services
n Out-of-area renal dialysis and routine
travel dialysis