CALIFORNIA - Pacificare Health Systems

PART A
20
Your Medical Benefits
responsible for payment of the difference
between the Non-Participating Provider’s
billed charges and the rate negotiated by
PacifiCare with Participating Providers,
in addition to any applicable Copayment,
coinsurance or deductibles.
Any additional expenses the Member may have to
pay beyond PacifiCare’s negotiated rate as a result
of using a Non-Participating Provider do not apply
to the Member’s annual Copayment maximum.
6. Hospice Services – Hospice services are covered
for Members with a terminal illness, defined as
a medical condition resulting in a prognosis of
life expectancy of one year or less, if the disease
follows its natural course. Hospice services are
provided as determined by the plan of care
developed by the Member’s interdisciplinary
team, which includes, but is not limited to, the
Member, the Member’s Primary Care Physician, a
registered nurse, a social worker and a spiritual
caregiver. Hospice services are provided in an
appropriately licensed Hospice facility when the
Member’s interdisciplinary team has determined
that the Member’s care cannot be managed at
home because of acute complications or the
temporary absence of a capable primary caregiver.
Hospice services include skilled nursing
services, certified home health aide services and
homemaker services under the supervision of a
qualified registered nurse; bereavement services;
social services/counseling services; medical
direction; volunteer services; pharmaceuticals,
medical equipment and supplies that are
reasonable and necessary for the palliation and
management of the terminal illness and related
conditions; and physical and occupational therapy
and speech language pathology services for
purposes of symptom control, or to enable the
Member to maintain activities of daily living and
basic functional skills. Inpatient Hospice services
are provided in an appropriately licensed Hospice
facility when the Member’s interdisciplinary team
has determined that the Member’s care cannot be
managed at home because of acute complications
or when it is necessary to relieve the Family
Members or other persons caring for the Member
(“respite care”). Respite care is limited to an
occasional basis and to no more than five (5)
consecutive days at a time.
7. Inpatient Hospital Benefits/Acute Care
– Medically Necessary inpatient Hospital Services
authorized by the Member’s Participating Medical
Group or PacifiCare are covered, including,
but not limited to: semi-private room; nursing
and other licensed health professionals;
intensive care; operating room; recovery room;
laboratory and professional charges by the
Hospital pathologist or radiologist; and other
miscellaneous Hospital charges for Medically
Necessary care and treatment.
8. Inpatient Physician and Specialist Care
– Services from Physicians, including specialists
and other licensed health professionals within,
or upon referral from, the Member’s Participating
Medical Group, are covered while the Member
is hospitalized as an inpatient. A specialist is a
licensed health care professional with advanced
training in an area of medicine or surgery.
9. Inpatient Rehabilitation Care – Rehabilitation
Services that must be provided in an inpatient
rehabilitation facility are covered. Inpatient
rehabilitation consists of the combined and
coordinated use of medical, social, educational
and vocational measures for training or retraining
individuals disabled by disease or injury. The goal
of these services is for the disabled Member to
obtain his or her highest level of functional ability.
Rehabilitation Services include, but are not limited
to, physical, occupational and speech therapy.
This benefit does not include drug, alcohol or
other substance abuse rehabilitation.
10. Inpatient Transgender Surgery – Inpatient
Transgender surgery requires prior authorization
from PacifiCare. Transgender surgery and services
related to the surgery that are authorized by
PacifiCare are subject to a combined Inpatient
and Outpatient lifetime benefit maximum of
$75,000 for each Member. PacifiCare covers
certain transgender surgery and services related
* The benefits described in Section Five will not be Covered Services unless they are determined to be Medically
Necessary by Member’s Participating Medical Group or PacifiCare and are provided by Member’s Primary Care
Physician or authorized by Member’s Participating Medical Group or PacifiCare.