CALIFORNIA - Pacificare Health Systems

PART B
Governing Law
This Combined Evidence of Coverage and
Disclosure Information is subject to the laws
of the State of California and the United States
of America, including, the Health Maintenance
Organization Act of 1973 and regulations
promulgated thereunder by the Department
of Health and Human Services of the United
States, and Title XVIII of the Social Security
Act and regulations promulgated thereunder
by CMS. Any provisions required to be in this
Evidence of Coverage by any of the above
acts and regulations shall bind PacifiCare and
you, whether or not expressly provided in this
document.
Your Financial Liability as a Secure
Horizons Group Retiree Medicare
Advantage Plan Member
As a Member of the Secure Horizons Group
Retiree Medicare Advantage Plan, you have the
following financial obligations:
Secure Horizons Group Retiree Medicare
Advantage Health Plan Premium
PacifiCare may Disenroll you for failure to
pay Health Plan Premiums. Your Health Plan
Premiums are paid for by the University of
California. However, prior to such action,
PacifiCare will:
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Section 12 – General Provisions
a. contact you within 20 days after the due
date of the delinquent charges.
b. provide an explanation of the
Disenrollment procedures.
c. advise you that failure to pay the Health
Plan Premiums within a thirty (30)day
grace period may result in your
Disenrollment.
d. give you a written notice of Disenrollment,
including an explanation of your right to a
hearing under Grievance procedures.
Increases in Health Plan Premiums and/or
decreases in your level of coverage are only
permitted at the beginning of each contract
year (which is usually the Calendar Year). You
will receive a written notice by the Fall of each
year of any changes that become effective the
following January. (Please note: Rate changes
and benefit changes for Secure Horizons
Group Retiree MA Plan Members enrolled
through the University of California are subject
to contractual arrangements between PacifiCare
and the University of California. The University
of California is responsible for notifying you of
any Secure Horizons Group Retiree Medicare
Advantage Plan Premium changes, contribution
changes, or University of California-sponsored
benefit changes 30 days before they become
effective.)
Copayments and Coinsurance
All Copayments and Coinsurance specified in
the Retiree Benefits Summary Insert must be
paid to the Contracting Medical Provider at the
time of service.
Member Non-Liability
In the event PacifiCare fails to reimburse a
Contracting Medical Provider’s charges for
Covered Services or in the event that PacifiCare
fails to pay a Non-Contracting Medical Provider
for Prior Authorized Services occurring when
you were actively enrolled in the Secure
Horizons Group Retiree Medicare Advantage
Plan, you will not be liable for any sums owed
by PacifiCare.
However, you will be liable if you receive
services from Non-Contracting Medical
Providers without Prior Authorization.
Neither PacifiCare nor Medicare will pay for
those services except for:
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Emergency Services
Urgently Needed Services
Out-of-area and routine travel renal dialysis
(must be received in a Medicare-certified
dialysis facility within the United States)
In addition, if you enter into a private
contract with a Non-Contracting Medical
Provider, neither PacifiCare nor Medicare
will pay for those services.
In the event a Contracting Medical Provider’s
contract with PacifiCare is terminated while
you are under Contracting Medical Provider’s