CALIFORNIA - Pacificare Health Systems

PART A
40
Your Medical Benefits
n
n
n
n
to an initial neuropsychological testing by an
authorized Physician or licensed Provider and
the Medically Necessary treatment of functional
deficits as a result of traumatic brain injury or
cerebral vascular insult. This benefit is limited
to outpatient rehabilitation limitation, if any.
Exercise programs are only covered when they
require the direct supervision of a licensed
Physical Therapist and are part of an authorized
treatment plan.
Activities that are motivational in nature or that
are primarily recreational, social or for general
fitness are not covered.
Aquatic/pool therapy is not covered unless
conducted by a licensed Physical Therapist and
part of an authorized treatment plan.
Massage therapy is not covered.
The following Rehabilitation Services, special
evaluations and therapies are not covered;
n
n
n
n
n
n
Biofeedback (except for urinary incontinence,
fecal incontinence or constipation for Members
with organic neuromuscular impairment when
part of an authorized treatment plan.)
Cognitive Behavioral Therapy.
Developmental and Neuroeducational Testing
beyond initial diagnosis
Hypnotherapy
Psychological Testing
Vocational Rehabilitation
(Please refer to Section 11 for definitions of
capitalized terms.)
60. Respite Care – Respite care is not covered,
unless part of an authorized Hospice plan and
is necessary to relieve the primary caregiver in
a Member’s residence. Respite care is covered
only on an occasional basis, not to exceed five (5)
consecutive days at a time.
61. Routine Laboratory Testing Out-of-Area –
Routine laboratory tests are not a covered benefit
while the Member is outside of the geographic
area served by the Member’s Participating Medical
Group. Although it may be Medically Necessary,
out-of-area routine laboratory testing is not
considered an Urgently Needed Service because
it is not unforeseen and is not considered an
Emergency Service.
62. Services in the Home – Services in the home
provided by relatives or other household
members are not covered.
63. Services While Confined – Services required
for injuries or illnesses experienced while under
arrest, detained, imprisoned, incarcerated or
confined pursuant to federal, state or local
laws are not covered. However, PacifiCare will
reimburse Members their out-of-pocket expenses
for services received while confined in a city or
county jail or, if a juvenile, while detained in any
facility, if the services were provided or authorized
by your Primary Care Physician or Participating
Medical Group in accordance with the terms of
this Health Plan or were Emergency Services or
Urgently Needed Services. This exclusion does
not restrict PacifiCare’s liability with respect to
expenses for Covered Services solely because
the expenses were incurred in a state hospital;
however, PacifiCare’s liability with respect to
expenses for Covered Services provided in a state
Hospital is limited to the rate PacifiCare would
pay for those Covered Services if provided by a
Participating Hospital.
64. Skilled Nursing Facility Care/Subacute and
Transitional Care – Skilled Nursing Facility
room and board charges are excluded after 100
consecutive days per admission. Days spent out
of the Skilled Nursing Facility when transferred to
an acute Hospital setting are not counted toward
the 100 consecutive days when the Member is
transferred back to a Skilled Nursing Facility, but
the count resumes upon the Member’s return
to a Skilled Nursing Facility. Such days in an
acute Hospital setting also do not count toward
renewing the 100-consecutive-day benefit. In
order to renew the room and board coverage in
* 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.