CALIFORNIA - Pacificare Health Systems

PART B
Hospitalist
When you are admitted to a Hospital, a
Hospitalist may coordinate your inpatient
care. Hospitalists are Physicians who are
specially trained to care for patients who
are acutely ill in the Hospital, and are
responsible for coordinating all aspects
of your Hospital care. They remain in the
Hospital and are available to react should
your condition change. This allows your
Primary Care Physician to continue to see
other patients in his or her office while
you are hospitalized. Hospitalists collect
and manage all information related to your
condition and treatment, and communicate
with you, your family, and your Primary Care
Physician throughout your Hospital stay.
Hospitalists work together with your Primary
Care Physician during the course of your stay
and to transition your care upon discharge.
Upon discharge, your Primary Care Physician
will again assume coordination of your care.
Skilled Nursing Facility (SNF) Care
Secure Horizons Group Retiree Medicare
Advantage Plan covers Medically Necessary
inpatient Skilled Nursing Care and services in
a Medicare-certified Skilled Nursing Facility
under contract with PacifiCare. Skilled
Nursing Care is covered if the Member
requires Skilled Nursing Care services or
skilled rehabilitation services on a daily basis
and these skilled services can be provided
only on an inpatient basis in a Skilled Nursing
Facility. Inpatient stays solely to provide
Custodial Care are not covered. Members may
not self-refer to a Skilled Nursing Facility.
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Section 5 – Working With Your
Contracting Medical Providers
In certain circumstances, Members may be
able to receive Skilled Nursing Care from
a Skilled Nursing Facility that is not under
contract with PacifiCare. Generally, Members
must use Skilled Nursing Facilities contracted
with PacifiCare. PacifiCare may be able to
arrange for a Member to receive Skilled
Nursing Care from one of the following
facilities (“Home Skilled Nursing Facility”): A
nursing home or continuing care retirement
community where the Member was living
prior to the Hospital admission (as long as
the facility provides Skilled Nursing Care)
or in a Skilled Nursing Facility where the
Member’s spouse resides at the time of the
Member’s Hospital discharge.
In order to access these services, the Skilled
Nursing Facility that is not under contract
with PacifiCare must be willing to accept
PacifiCare’s rates for payment.
Organ Transplants
1. Organ Transplant Definitions
n Donor: A person who undergoes a
surgical procedure for the purpose of
donating either a body organ or body
tissue for transplant procedure.
n
n
n
Histocompatibility Testing: Testing
that involves matching or typing
of the human leukocyte antigen
in preparation for organ or tissue
transplant.
PacifiCare National Preferred
Transplant Network Facility: A
Network of transplant facilities that
are licensed in the state in which
they operate; certified by Medicare
as a transplant facility for a specific
organ transplant; and satisfies
PacifiCare’s quality of care standards
to be designated by PacifiCare as a
transplant facility for a specific organ
program. PacifiCare National Preferred
Transplant Network facilities may be
located outside the Service Area based
on a number of factors including
quality, cost and outcomes.
Regional Organ Procurement
Agency: An organization designated
by the federal government and
responsible for the procurement of
organs for transplantation and the
promotion of organ donation.
2. Transplant Services
Human organ and tissue transplants
are limited to non-experimental/noninvestigational
procedures that are
determined to be Medically Necessary.