Secure Horizons P.O. Box 489 Cypress, CA 90630

Transcription

1 Secure Horizons P.O. Box 489 Cypress, CA Customer Service TDHI :00 a.m. to 9:00 p.m. M o n d ay through Fri d ay Sales Inform a t i o n or TDHI Visit our Web site at w w w. s e c u re h o ri z o n s. c o m Secure Horizons Group Retiree Medicare+Choice Plans are offered by PacfiCare, that contracts with the federal government. Limitations, copayments and coinsurance will apply. Group Retiree prospects must meet the eligibility requirements to enroll for group coverage. Health plan premiums and benefits may vary by employer group. RTEOCCA04 SH SHEOC-PHS 2/04

2 Evɪdeɴce of Coveʀaɢe & Dɪscʟosuʀe Iɴfoʀmatɪoɴ Secure Horizons Medicare+Choice Plan Details of How the Plan Works Health Care Terms Your Rights and Responsibilities Effective January 1, 2004 Through December 31, 2004

3 April 1, 2004 Addendum to the 2004 Secure Horizons Medicare+Choice Plan Evidence of Coverage and Disclosure Information This is an Addendum to the Secure Horizons Medicare+Choice (M+C) Plan Evidence of Coverage and Disclosure Information. (For spouses, dependents and early retirees who are not entitled to Medicare and who are enrolled in the PacifiCare Commercial Plan through your employer group s selection of PacifiCare, please refer to the PacifiCare Evidence of Coverage.) The combined Evidence of Coverage and Disclosure Information contains important information. This book, combined with your Retiree Benefits Summary Brochure and Retiree Benefits Summary Insert, which is mailed to you on your annual renewal date, constitutes your official contract with PacifiCare. Together, these documents explain the details of your health care coverage. Please read them carefully. The fo l l owing section titled ERISA Require m e n t s is applicable to all Group Retiree Plan members : I. ERISA Requirements If your fo rmer employer is gove rned under the Employee Retirement Income Security A c t ( E R I S A ), the Summary Plan Description for this Plan is your fo rmer employe r s booklet for their e l i gi ble population from which you re t i re d. The Summary Plan Description also includes your Prov i d e r D i re c t o ry and the 2004 Secure Horizons M+C Plan Evidence of Cove rage and Discl o s u re Info rm a t i o n. For detailed information concerning ERISA special disclosures, which includes Retiree and dependent eligibility, enrollment, contributions, coverage terminations and other general plan information, please refer to your former employer s Summary Plan Description or contact your former employer who is the plan administrator for assistance. If your former employer is not governed by ERISA, generally, if you retired from a religious organization or a governmental plan, ERISA may not apply to you, although your former employer may be subject to some of the requirements below that look like ERISA but are under the Public Health Service Act. Please feel free to contact your former employer for more information. Qualified Medical Child Support Order You may be able to enroll a child on your former employer s group health plan benefits upon presentation of a request by a District Attorney, State Department of Health Services or a court order to provide medical support for such a dependent child without regard to any enrollment period restrictions. A p e rson having legal custody of a child or a custodial parent who is not a Secure Horizons Gro u p R e t i ree M+C Plan Member may ask about obtaining dependent cove rage as re q u i red by a court or a d m i n i s t ra t i ve ord e r, i n cluding a Qualified Medical Child Support Ord e r. Customer Service, Monday through Friday, 7:00 a.m. to 9:00 p.m., at , or for the hearing impaired,tdhi I

4 Your Provider Directory Choice of Physicians and Hospital (Facilities) Along with listing the Contracting Providers, your Provider Directory has detailed information about Contracting Medical Groups, and IPAs. This includes a Quality Index for helping you become familiar with the Contracting Medical Groups. You can also find an online version of the Directory at for Secure Horizons Group Retiree M+C Plan Members and at for spouses and dependents. Notifying You of Changes in Your Secure Horizons Group Retiree Medica re + C h o i ce Plan Amendments, modifications or termination of the employer group agreement by either your former employer group or PacifiCare do not require the consent of a Member. PacifiCare may amend or modify the group health plan, including the applicable Health Plan Premiums, at any time after sending written notice to your former employer, up to 60 days prior to the effective date of any amendment or modification. Your former employer may also change your health plan benefits during the contract year. Your former employer is obligated to notify Retirees who are Secure Horizons Group Retiree M+C Plan Members of any such amendment or modification. Federal COBRA Continuation Coverage If your former employer group is subject to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended ( COBRA ), you may be entitled to temporarily extend your Retiree coverage under the health plan at Retiree group rates, plus an administration fee, in certain instances where your coverage under the health plan would otherwise end. This disclosure is intended to inform you, in a summary fashion, of your rights and obligation under COBRA. However, your former employer group is legally responsible for informing you of your specific rights under COBRA. Therefore, please consult with your former employer group regarding the availability and duration of COBRA continuation coverage. If you are a spouse of a Retiree covered by this health plan, you have the right to choose COBRA continuation coverage for yourself if you lose your Retiree group health coverage under this health plan for any of the following reasons: 1. The death of the Retiree; 2. Divorce or legal separation from your spouse. In the case of a Dependent child of a Retiree eligible in a group health plan as a result of the Retiree s coverage, he or she has the right to continuation coverage if group health coverage is lost for any of the following reasons: 1. The death of the Retiree; 2. The Retiree s divorce or legal separation; 3. The dependent child ceases to be a Dependent eligi ble for cove rage under the fo rm e r e m p l oye r s commercial group health plan, s u ch as re a ching the limiting age or marry i n g. Under COBRA, the Retiree or enrolled family member has the responsibility to inform the former employer group (or if applicable, its COBRA administrator,) of the Retiree s death, divorce, legal separation or a child losing dependent status under the health plan within 60 days of the date Customer Service, Monday through Friday, 7:00 a.m. to 9:00 p.m., at , or for the hearing impaired,tdhi I I

5 of the event. Similar rights may apply to certain Retirees, spouses and dependent children if your former employer commences a bankruptcy proceeding and these individuals lose coverage. When the COBRA administrator is notified that one of these events has happened, the COBRA a d m i n i s t rator will in turn notify you that you have the right to choose continuation cove rage. U n d e r the law,you have at least 60 days from the date you would lose cove rage because of one of the eve n t s d e s c ribed ab ove to info rm the COBRA administrator that you want continuation cove rage. If you do not choose continuation coverage on a timely basis, your group health insurance coverage under this Health Plan will end and you will be financially responsible for all health care services you may receive after the terminating date. If you choose continuation coverage, your former employer is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or family members. COBRA permits you to maintain continuation coverage for up to 36 months, unless you lost group health coverage because of a termination of employment or reduction in hours. In that case, required continuation coverage is 18 months. The initial 18-month period may be extended for affected individuals up to 36 months from termination of employment if other events (such as a death, divorce, legal separation or Medicare entitlement) occur during that initial 18-month period. In addition, the initial 18-month period may be extended up to 29 months if you are determined by the Social Security Administration to be disabled at any time during the first 60 days of COBRA continuation coverage. Please contact your former employer group or its COBRA administrator for more information regarding the applicable length of COBRA continuation coverage available. A child who is born to or placed for adoption with the Retiree during a period of COBRA c o n t i nuation cove rage will be eligi ble to enroll as a COBRA qualified benefi c i a ry to other commerc i a l group health plan cove rage your fo rmer employer may have ava i l abl e. These COBRA qualifi e d b e n e fi c i a ries can be added to COBRA continuation cove rage upon proper notification to the fo rm e r e m p l oyer group or COBRA administrator of the birth or adoption. However, under COBRA, the continuation coverage may be cut short for any of the following five reasons: 1. Your former employer no longer provides group health coverage to any of its employees; 2. The premium for continuation coverage is not paid by you on time; 3. The qualified beneficiary becomes covered after the date he or she elects COBRA continuation coverage under another group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition he or she may have; 4. The qualified beneficiary becomes entitled to Medicare after the date he or she elects COBRA continuation coverage; or 5. The qualified beneficiary extends coverage for up to 29 months due to disability and there has been a final determination that the individual is no longer disabled. Customer Service, Monday through Friday, 7:00 a.m. to 9:00 p.m., at , or for the hearing impaired,tdhi I I I

6 Under the law, you may have to pay the entire premium for your continuation coverage. Premiums for COBRA continuation coverage are generally 102% of the applicable health plan premium. However, if you are on a disability extension, your cost will be 150% of the applicable premium. You are responsible for the timely submission of the COBRA premium to the former employer group or COBRA administrator. Your former employer group or COBRA administrator is responsible for the timely submission of the premium to PacifiCare or the other group health plan. At the end of the 18-month, 29-month or 36-month continuation coverage period, qualified beneficiaries may be allowed to enroll in a conversion product through the other group health plan or if you have Medicare, the individual Secure Horizons Medicare+Choice Plan. If you have questions about COBRA, please contact your former employer group. Newborn s And Mother s Rights Act Prenatal and maternity care services are covered, including labor, delivery and recovery room charges, delivery by cesarean section, treatment of miscarriage and complications of pregnancy or childbirth. A minimum 48-hour inpatient stay for normal vaginal delivery and a minimum 96-hour inpatient stay following delivery by cesarean section are covered. Coverage for inpatient hospital care may be for a time period less than the minimum hours if the treating Physician, in consultation with the Member, makes the decision for an earlier discharge of the mother and newborn. In addition, if the mother and newborn are discharged prior to the 48- or 96-hour minimum time periods, a post-discharge follow-up visit for the mother and newborn will be provided within 48 h o u rs of disch a rge, when pre s c ribed by the treating Phy s i c i a n. Under the Secure Horizons Gro u p Retiree M+C Plan coverage, newborns are not eligible dependents. Newborn care will be the financial responsibility of the Retire e. Please contact your fo rmer employer to arra n ge health plan benefits for your newborn dependent. Women s Health And Cancer Rights Act Medically Necessary mastectomy and lymph node dissection are covered, including prosthetic devices and or reconstructive surgery to restore and achieve symmetry for the Member incident to the mastectomy. The attending Physician and surgeon in consultation with the Member, consistent with sound clinical principles and processes, determine the length of a hospital stay. Coverage includes any initial and subsequent reconstructive surgeries or prosthetic devices for the diseased b reast on which the mastectomy was perfo rm e d. C ove rage is provided for surge ry and re c o n s t ru c t i o n of the other breast if, in the opinion of the attending surgeon, this surgery is necessary to achieve symmetrical appearance. Medical treatment for any complications from a mastectomy, including lymphedema, is covered. II. As a Secure Horizons Group Retiree M+C Plan Member, the following components of the enclosed Evidence of Coverage may not pertain to you: Welcome to Secure Horizons Medicare+Choice Plan Section If You Move From One Service Area To Another Service Area Within The Same State This section refers to a Benefit Plan Transfer Application. The Benefit Plan Transfer Application process does not apply to Group Retiree Plan Members. If you move, please contact Customer Service for assistance. Customer Service, Monday through Friday, 7:00 a.m. to 9:00 p.m., at , or for the hearing impaired,tdhi I V

7 Section 1 Health Care Terms The definition for Election Form refers to a Benefit Plan Transfer Application. The Benefit Plan Tra n s fer Application process does not apply to Group Retiree Plan Members. The definition for Select and Standard Hospitals does not apply to Group Retiree Plan Members. Group Retiree Plan Members have access to the entire provider network. Section 2 Eligibility, Enrollment Periods and Effective Date The language in this section pertaining to enrollment eligibility and effective date of enrollment may not apply to Group Retiree Plan Members who enroll in an employer group plan when that plan is open for enrollment. For more information regarding your effective date, please contact your former employer or trust administrator. Section 5 Working With Your Contracting Medical Providers The section titled Provider-Specific Benefit Plans does not apply to Group Retiree Plan Members. Group Retiree Plan Members are not enrolled in Provider-Specific Benefit plans. These plans pertain to members enrolled in the individual Secure Horizons M+C Plan. The language under Choosing a New Primary Care Physician or Contracting Medical Group/IPA Who Is With A Different Benefit Plan refers to Provider-Specific Benefit Plans and these do not apply to Group Retiree Plan Members. If you want to choose a new Primary Care Physician, please contact Customer Service for assistance. Under Hospitalization, the language pertaining to Select and Standard Hospitals does not apply to Group Retiree Plan Members. Section 7 Premiums and Payments In most cases, your fo rmer employer or trust administrator is re s p o n s i ble for making payment of a ny applicable Health Plan Premium dire c t ly to Pa c i fi C a re on behalf of its enrolled Group Retiree Plan M e m b e rs and their eligi ble dependent(s). Your fo rmer employer or trust administrator determines any re t i ree subscriber contribution towa rd Health Plan Pre m i u m s. The discussion regarding the Centers for Medicare & Medicaid Services (CMS) approval of Health Plan Premium changes applies to individuals with Secure Horizons M+C Plan and Group Retiree Plan Members who may be making payment of an applicable Health Plan Premium directly to PacifiCare. For all other Group Retiree Plan Members, your employer group or trust administrator is responsible for promptly notifying you of any premium changes or contribution changes before they become effective. Changes in the level of health care coverage may occur at the beginning of each Calendar Year and/or your retiree group contract year. You will receive a written notice at least 30 days prior to the date when such change shall become effective. If you do not pay a plan premium dire c t ly to Pa c i fi C a re / S e c u re Horizons M+C Plan, d i s e n ro l l m e n t due to your failure to pay plan premiums discussed in this section does not apply to you. However, if your former employer or trust administrator does not pay the plan premium, then you will be transferred to the individual Secure Horizons M+C Plan. Monthly Health Plan Premiums and Customer Service, Monday through Friday, 7:00 a.m. to 9:00 p.m., at , or for the hearing impaired,tdhi V

8 benefits for the individual Secure Horizons M+C Plan vary by the Member s county of residence. If you are responsible to pay a plan premium directly to PacifiCare/Secure Horizons M+C Plan, then disenrollment due to your failure to pay plan premiums discussed in this section does apply to you. Section 8 Optional Supplemental Benefits Since your fo rmer employer or trust administrator may offer you additional supplemental or b u y - u p b e n e fi t s, this section is not applicable to yo u. For info rmation re g a rding your supplemental b e n e fi t s, if applicabl e, please re fer to the Retiree Benefits Summary Insert which was prev i o u s ly mailed to you during open enrollment or on your employer s/trust administrator s annual renewal date. Section 10 Disenrollment From Secure Horizons Medicare+Choice Plan In the event you choose to cancel your membership under the Group Retiree Plan, re-enrollment may not be permitted until your next Open Enrollment Period. You should consult with your benefits administrator re g a rding the ava i l ability of other cove rage befo re canceling yo u r Group Retiree Plan membership outside of your former employer s or trust administrator s Open Enrollment Period. Please note that if you cancel your Group Retiree Plan, you may be eligible to e n roll in the individual Secure Horizons M+C Plan. Please re fer to Section 2 of the Secure Hori z o n s M+C Plan Evidence of Coverage and Disclosure Information for further information regarding e n ro l l m e n t. As an individual member of the Secure Horizons M+C Plan, you will re c e i ve the benefi t p a ck age approved by CMS for your county of re s i d e n c e. The individual Secure Horizons M+C Plan b e n e fits will be diffe rent than the benefit pack age ava i l able through your fo rmer employer or tru s t a d m i n i s t ra t o r, and a Health Plan Premium may apply. Please contact your benefits administrator regarding their disenrollment and move notification policies and the possible impact to your retiree health care coverage options and other retirement benefits. Additionally, please contact your former employer, trust administrator or PacifiCare for more information regarding your disenrollment effective date. Section 13 General Provisions The section titled Plan Premiums for Optional Supplemental Benefits does not apply for Group Retiree Plan Members. If you have any questions regarding this addendum or the Secure Horizons M+C Plan Evidence of Coverage and Disclosure Information, please contact Customer Service at the number below. Secure Horizons Group Retiree Medicare+Choice Plans are offered by PacifiCare, that contracts with the federal government. Limitations, copayments and coinsurance will apply. Group Retiree prospects must meet the eligibility requirements to enroll for group coverage. Health plan premiums and benefits may vary by employer group. Customer Service, Monday through Friday, 7:00 a.m. to 9:00 p.m., at , or for the hearing impaired,tdhi RUF040226A-PHS 2/04 V I CALIFORNIA SH

9 R e fe re n ce Pa g e Please fill this out for your reference: Your Secure Horizons Medicare+Choice Plan membership number (located on your membership card) PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. This document will be mailed to you annually. This document is effective January 1, 2004 through December 31, Your Effective Date of enrollment Questions? Problems? Need help? Call Customer Service at (TDHI ), 7:00 a.m. to 9:00 p.m., Monday through Friday, or Write: Customer Service P.O. Box 489 Cypress, CA Federal law mandates that PacifiCare comply with Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, and other laws applicable to recipients of federal funds, and all other applicable laws and rules. Specifically, PacifiCare does not discriminate both in the employment of staff and in the provision of health care services on the basis of race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin. Visit the web site at This Evidence of Coverage and Disclosure Information contains the terms and conditions of coverage, a Schedule of Benefits and rights you have with Secure Horizons Medicare+Choice Plan, offered by PacifiCare. All applicants have a right to view this document prior to enrollment. This information should be read completely and carefully. Individuals with special needs should carefully read those sections that apply to them. 1

10 Ta b le of Conte n t s Welcome to Secure Horizons Medicare+Choice Plan Call Customer Service Whenever You Need Information Updating your Membership Records Moves From One Service Area to Another Service Area PacifiCare is Interested in Your Comments How to Submit a Claim SECTION 1 Health Care Terms SECTION 2 Eligibility, Enrollment Periods and Effective Date Enrollment in Secure Horizons Medicare+Choice Plan Your Enrollment Form When Your Secure Horizons Medicare+Choice Plan Coverage Begins Liability of Secure Horizons Medicare+Choice Plan Upon Initial Enrollment About Your Medicare Supplement (Medigap) Policy SECTION 3 Member Rights and Responsibilities Timely, Quality Care Treatment with Dignity and Respect Your Responsibilities SECTION 4 How Your Secure Horizons Medicare+Choice Plan Coverage Works Your Secure Horizons Medicare+Choice Plan Membership Card How the Lock-In Feature Works for You and PacifiCare SECTION 5 Working With Your Contracting Medical Providers Your Primary Care Physician Provider-Specific Benefit Plans Changing Your Primary Care Physician Choosing a New Primary Care Physician with a Different Benefit Plan How to Schedule an Appointment with Your Primary Care Physician How to Receive Care After Hours How to Receive Covered Services From a Specialist Standing Referrals to Specialists Extended Referral for Coordination of Care By a Specialist Access to Women s Health Care Services Continuity of Care Access to Your Medical Records and Files Utilization Review Second Medical Opinions Prior Authorizations Hospitalization

11 Hospital Copayments and Benefit Periods Hospitalists Skilled Nursing Facility (SNF) Care Ambulance Home Health Care Services Hospice Clinical Trials Religious Non-Medical Health Care Institutions (RNHCIs) Care Organ Transplants Behavioral Health Services SECTION 6 Emergency and Urgently Needed Services What to Do in an Emergency Post-Stabilization Care Urgently Needed Services When You Need Urgent Care and You Are in Your Service Area Reimbursement for Services Paid by Member Right to Appeal SECTION 7 Premiums and Payments What Happens If You Do Not Pay Your Health Plan Premiums? Your Premium Payment Options Changes in Health Plan Premiums SECTION 8 Optional Supplemental Benefits SECTION 9 Organization Determination, Appeals and Grievance Procedures Organization Determinations Expedited/72-Hour Organization Determination Procedures How Your Expedited/72-Hour Review Request will be Processed General Information on the Medicare Appeals Process Who May File an Appeal Support for Your Appeal Assistance with Appeals Standard Appeal Procedures Expedited/72-Hour Appeal Procedures How to Request an Expedited Reconsideration How Your Expedited/72-Hour Reconsideration Request will be Processed Information You Should Receive During Your Hospital Stay Quality Improvement Review Getting a QIO Review of Your Hospital Discharge What if You Do Not Ask the QIO for a Review by the Deadline Another Option:Asking for an Expedited/72-Hour Review of Your Discharge Termination of Services in Certain Provider Settings (SNF, HHA or CORF) Review of Termination of SNF, HHA or CORF Services by the QIO

12 Asking for an Expedited/72-Hour Review of Your Termination of Services Grievance Procedures Informal Complaints Formal Complaints Complaints that Do Not Relate to Quality of Medical Care Issues Complaints Involving Quality of Medical Care Issues QIO Quality of Care Complaint Process Binding Arbitration SECTION 10 Disenrollment Voluntary Disenrollment The Effective Date of Your Disenrollment Moves or Extended Absence Involuntary Disenrollment Review of Termination and Reinstatement SECTION 11 Coordinating Other Benefits You May Have Who Pays First? SECTION 12 Advance Directives SECTION 13 General Provisions Governing Law Your Financial Liability as a Secure Horizons Medicare+Choice Plan Member Member Non-Liability Third Party Liability Acts Beyond the Control of PacifiCare Contracting Medical Providers are Independent Contractors PacifiCare s Contracting Arrangements How PacifiCare s Contracting Providers are Compensated Physician-Patient Relationship Facility Locations Practitioners and Utilization Review Notices Public Policy Participation Organ Donation SECTION 14 Secure Horizons Medicare+Choice Plan Service Area

13 We lcome To Secure Horizons Medica re + C h o i ce Plan This document and the Schedule of Benefits are an explanation of your ri g h t s, b e n e fits and responsibilities as a Member of the Secure Hori z o n s M e d i c a re+choice Plan,o ffe red by Pa c i fi C a re, a M e d i c a re+choice Org a n i z a t i o n. These documents also explain Pa c i fi C a re s responsibilities to yo u. Your Member contract for Secure Hori z o n s M e d i c a re+choice Plan consists of this Evidence of C ove rage and Discl o s u re Info rm a t i o n, the Sch e d u l e of Benefi t s, your Election Fo rm and any current or f u t u re amendments. This Evidence of Cove rage and Discl o s u re I n fo rmation and the Schedule of Benefits contain i m p o rtant info rm a t i o n. These documents will be mailed to you annu a l ly and will replace all pri o r Evidence of Cove rage and Discl o s u re Documents and Schedule of Benefi t s. Please read them c a re f u l ly and keep them in a safe place,ava i l able fo r q u i ck re fe re n c e. S e c u re Horizons Medicare+Choice Plan is not an i n s u rance policy which mere ly pays Medicare d e d u c t i bles and Coinsurance ch a rges (commonly called a M e d i g a p or M e d i c a re supplement p o l i c y ). I n s t e a d, Pa c i fi C a re has entered into a c o n t ract with the Centers for Medicare & Medicaid S e rvices (CMS), the fe d e ral gove rnmental age n c y that administers Medicare. Pa c i fi C a re is also regulated by the Department of Managed Health C a re. The contract with CMS authorizes Pa c i fi C a re to arra n ge for compre h e n s i ve health services fo r individuals who are entitled to Medicare benefi t s and who choose to enroll in Secure Hori z o n s M e d i c a re+choice Plan. When you join Secure H o rizons Medicare+Choice Plan,you usually do not p ay Medicare deductibles and Coinsurance ch a rge s, but instead pay Health Plan Pre m i u m s, C o p ay m e n t s and Coinsura n c e. S e c u re Hori z o n s M e d i c a re+choice Plan cove rs all services and supplies offe red by Medicare, plus additional s e rvices and supplies not cove red by Medicare. Pa c i fi C a re has signed a contract with CMS agre e i n g to cover you for one full year at a time. S e c u re H o rizons Medicare+Choice Plan costs and benefi t s m ay ch a n ge from year to year and Pa c i fi C a re will notify you befo re any ch a n ges are made. I n a d d i t i o n, either CMS or Pa c i fi C a re may choose not to re n ew all or a portion of the contra c t. If the c o n t ract is not re n ewe d, your Medicare cove rage will be sw i t ched to Ori ginal Medicare unless yo u decide to sw i t ch to another Medicare managed care p l a n. If either CMS or Pa c i fi C a re decides not to re n ew the contract at the end of the ye a r, you will re c e i ve a letter at least ninety (90) days befo re the end of the contra c t. If CMS ends the contract in the middle of the ye a r,you will re c e i ve a letter at least t h i rty (30) days befo re the end of the contra c t. I n either situation the letter would explain yo u r options for health care cove rage in your area and p rovide info rmation about your right to obtain M e d i c a re supplemental insurance cove rage By enrolling in Secure Horizons Medicare + C h o i c e P l a n, you have agreed to re c e i ve your health care s e rvices from Contracting Medical Prov i d e rs and fa c i l i t i e s. You are re q u i red to fo l l ow all plan ru l e s, s u ch as obtaining Refe rrals and Prior Au t h o ri z a t i o n when re q u i re d. If you need Emergency Services (any w h e re in the wo r l d ), or Urge n t ly Needed Services (ge n e ra l ly, outside the area served under the Secure Hori z o n s M e d i c a re+choice Plan),those services will be c ove re d. H oweve r, if you re c e i ve services fro m N o n - C o n t racting Medical Prov i d e rs without Pri o r Au t h o ri z a t i o n, ( except for Emergency Serv i c e s, U rge n t ly Needed Services or out-of-area re n a l d i a lysis services and routine travel dialy s i s, o r s e rvices for which Pa c i fi C a re allows you to self-re fe r to Contracting Prov i d e rs ), neither Pa c i fi C a re nor M e d i c a re will pay for those serv i c e s. Call Customer Service Whenever You Need Information In addition to arra n ging health care serv i c e s, Pa c i fi C a re stri ves to provide the info rmation yo u need about your Secure Horizons Medicare + C h o i c e Plan when you need it. 5

14 Pa c i fi C a re has specially trained Customer Serv i c e R e p re s e n t a t i ves who can answer your questions ab o u t : C ove red Serv i c e s Making address or telephone number ch a n ge s P ri m a ry Care Physician selection and ch a n ge s E n rollment or Disenro l l m e n t Appeal and Gri evance complaint ri g h t s Medical care when you are trave l i n g The quality of care you are re c e i v i n g I n fo rmation concerning your phy s i c i a n A ny other questions or concerns re g a rding yo u r S e c u re Horizons Medicare+Choice Plan. Updating Your Membership Records Your Secure Horizons Medicare+Choice Plan m e m b e rship re c o rd contains info rmation from yo u r Election Fo rm including your address and telephone nu m b e r, as well as your specific benefit plan c ove rage, P ri m a ry Care Physician and the C o n t racting Medical Gro u p / I PA you selected upon e n ro l l m e n t. These re c o rds are ve ry import a n t because they identify you as an eligi ble Secure H o rizons Medicare+Choice Plan Member and d e t e rmine where and if you are eligi ble to re c e i ve C ove red Serv i c e s. Please re p o rt any ch a n ges in name, a d d ress or phone number to Customer Service immediately. You should also re p o rt any ch a n ges in health i n s u rance cove rage you have from your employer or your spouse s employe r. A d d i t i o n a l ly, you should re p o rt any liability claims (such as claims ag a i n s t another dri ver in an auto accident), e l i gibility under Wo rke rs Compensation and Medi-Cal or Medicaid. If You Move From One Service Area to Another Service Area Within the Same State If you are moving from one Service A rea to another S e rvice A rea within the same State,you can still remain a Member of Secure Hori z o n s M e d i c a re+choice Plan. ( To locate the curre n t S e rvice A reas for the Secure Hori z o n s 6 M e d i c a re+choice Plan,please see Section 14.) After you move, call Customer Service and request a Benefit Plan Tra n s fer Ap p l i c a t i o n. Yo u must complete and re t u rn the fo rm within thirt y (30) days to tra n s fer from your existing benefit plan to the benefit plan ava i l able in your new Serv i c e A re a. G e n e ra l ly, completed Benefit Plan Tra n s fe r Applications re c e i ved by the end of the month will be effe c t i ve the 1st day of the fo l l owing month. Fo r ex a m p l e, if your Benefit Plan Tra n s fer Application is re c e i ved Ju ly 20th, your Effe c t i ve Date of your new b e n e fit plan will be August 1st. Please note that if you request a Benefit Plan Tra n s fer Application and then do not move, you must call Customer Serv i c e and notify them of your ch a n ge of plans. You will be Disenrolled from the Secure Horizons M e d i c a re+choice Plan if you request a Benefit Plan Transfer Application and you do not re t u rn the form within thirty (30) days of your re q u e s t. Until your Effe c t i ve Date, you will remain with yo u r p rev i o u s ly selected benefit plan and Pri m a ry Care P hy s i c i a n. You will continue to re c e i ve the benefi t s that are a part of that benefit plan and re c e i ve care f rom Contracting Prov i d e rs in that Service A re a ( except for Emergency Serv i c e s, U rge n t ly Needed S e rvices or out-of-area renal dialysis serv i c e s ), a s long as you have made any applicable Health Plan P remium pay m e n t s. B e n e fit plans in diffe re n t S e rvice A reas may offer diffe rent benefi t s, H e a l t h Plan Pre m i u m s, C o p ayment and Coinsura n c e a m o u n t s. Call Customer Service and ask for the S u m m a ry of Benefits for the Service A rea that yo u a re moving to so that you may rev i ew and u n d e rstand any diffe re n c e s. PacifiCare Is Interested in Your Comments Pa c i fi C a re s goal is to arra n ge the Cove red Serv i c e s you need to stay as healthy and active as you can. Pa c i fi C a re is interested in your comments. Fro m time to time, Pa c i fi C a re will be asking for yo u r thoughts on the Secure Horizons Medicare + C h o i c e Plan through vo l u n t a ry Member satisfa c t i o n s u rvey s. These surveys help Pa c i fi C a re measure both the perfo rmance of Secure Hori z o n s M e d i c a re+choice Plan Contracting Medical

15 P rov i d e rs, as well as Pa c i fi C a re s ability to assist yo u with your health care cove rage concern s. How to Submit a Claim All Cove red Services pre s c ribed by Pa c i fi C a re will be billed to either your Contracting Medical G ro u p / I PA or dire c t ly to the plan. H oweve r, if yo u re c e i ve a bill for a Cove red Service or Emerge n c y S e rvice delive red by a Non-Contracting Medical P rov i d e r, please send the claim to: Pa c i fi C a re of Califo rn i a. Claims Depart m e n t P. O. B ox 489 C y p re s s, CA If your plan includes Copay m e n t s, you are re s p o n s i ble for paying these dire c t ly to the P rov i d e r. If you have any questions about any cl a i m s, please call Customer Serv i c e. Section 1 Health Care Te r m s The following definitions apply to this Evidence of Coverage and Disclosure Information. Acute Care A pattern of health care in which a Member is treated for an acute (immediate and s eve re) episode of illness, for the subsequent t reatment of injuries related to an accident or other t ra u m a, or during re c ove ry from surge ry. A c u t e C a re is usually re c e i ved in a Hospital fro m specialized personnel using complex and sophisticated technical equipment and materi a l s. This pattern of care is often necessary for a short t i m e, u n l i ke ch ronic care, w h e re no signifi c a n t i m p rovement can be ex p e c t e d. A p p e a l The type of complaint you make when you want a re c o n s i d e ration of a decision ( d e t e rmination) that was made re g a rding a serv i c e or what Pa c i fi C a re will pay for a serv i c e. You can file an Appeal in the fo l l owing ex a m p l e s : If Pa c i fi C a re refuses to cover or pay for serv i c e s you think Pa c i fi C a re should cove r If Pa c i fi C a re or one of the Contracting Medical P rov i d e rs refuses to gi ve you a service you think should be cove re d If Pa c i fi C a re or one of the Contracting Medical P rov i d e rs reduces or cuts back on services yo u h ave been re c e i v i n g If you think that Pa c i fi C a re is stopping yo u r c ove rage too soon Basic Benefits All health care services that are c ove red under the Medicare Pa rt A and Pa rt B p ro grams (except Hospice services) which are c ove red by Secure Horizons Medicare+Choice Plan, additional services that Pa c i fi C a re uses Medicare funds to cove r, and other services for which yo u m ay be re q u i red to pay a Health Plan Pre m i u m. A l l M e m b e rs of Secure Horizons Medicare+Choice Plan re c e i ve all Basic Benefi t s. Benefit Period A Benefit Pe riod is a way of m e a s u ring your use of services under Medicare Pa rt A. A Medicare Benefit Pe riod begins with the fi rst day of a Medicare - c ove red inpatient Hospital S t ay and ends with the close of a period of sixty (60) consecutive days during which you we re not an inpatient of a Hospital or of a Skilled Nurs i n g Fa c i l i t y. For Secure Horizons Medicare+Choice Plan M e m b e rs, Inpatient Hospital Care Copayments are ch a rged on either a per admission basis or on a d a i ly basis for a limited number of day s. O ri gi n a l M e d i c a re Hospital Benefit Pe riods do not apply. Fo r Inpatient Hospital Care, you are cove red for an unlimited number of days as long as the Hospital S t ay is Medically Necessary and authorized by Pa c i fi C a re or Contracting Medical Prov i d e rs. Calendar Ye a r A twe l ve (12) month period that b e gins on Ja nu a ry 1 and ends twe l ve (12) c o n s e c u t i ve months later on December 31. Center for Health Dispute Resolution (CHDR) An independent rev i ew entity under contract with CMS that rev i ews Appeals by members of Medicare m a n aged care plans,i n cluding Secure Hori z o n s M e d i c a re+choice Plan. 7

16 Centers for Medicare & Medicaid Services ( C M S ) Fe d e ral A gency re s p o n s i ble fo r a d m i n i s t e ring Medicare (fo rm e r ly known as the Health Care Financing A d m i n i s t ration (HCFA ). C o i n s u r a n c e The perc e n t age of the cost of a C ove red Service a Member is re q u i red to pay. C o i n s u rance is based on the amount Medicare would have cove re d. This may not necessari ly re flect the actual cost to Pa c i fi C a re. If there is no set Medicare amount for the service prov i d e d, t h e p e rc e n t age will be based on Pa c i fi C a re s c o n t ra c t u a l ly negotiated ra t e s. Contracting Hospital A Hospital that has a c o n t ract with Pa c i fi C a re to provide services and/or supplies to Secure Horizons Medicare+Choice Plan M e m b e rs. Contracting Medical Gro u p / I n d e p e n d e n t Physicians Association (IPA ) C o n t r a c t i n g Medical Gro u p s a re physicians organized as a legal entity for the purpose of providing medical care. The Contracting Medical Group has an agre e m e n t with Pa c i fi C a re to provide medical services to M e m b e rs. Independent Physicians Associations ( I PA s ) a re organizations or affiliated groups of p hysicians that deliver or arra n ge for the delive ry of health services and function as Contracting Medical G roups with physicians practicing out of their ow n independent medical offi c e s. Contracting Medical Pro v i d e r A health p ro fe s s i o n a l, a supplier of health items, or a health c a re facility having an agreement with Pa c i fi C a re or a Contracting Medical Gro u p / I PA to provide or coordinate medical services to Members. C o n t racting Medical Prov i d e rs are independent c o n t ra c t o rs and are not the employees or age n t s of Pa c i fi C a re. C o p a y m e n t The fee you pay at the time of medical services in accordance with your Secure H o rizons Medicare+Choice Plan. C o v e red Services Those benefi t s, s e rvices and supplies listed in the Schedule of Benefits which are : S e rvices provided or furnished by Contra c t i n g Medical Prov i d e rs or authorized by Pa c i fi C a re or C o n t racting Medical Prov i d e rs 8 E m e rgency Services and Urge n t ly Needed S e rv i c e s, for which you do not need Pri o r Au t h o rization and which may be provided by N o n - C o n t racting Prov i d e rs (Please re fer to Section 6 for more info rmation about Emerge n c y S e rvices and Urge n t ly Needed Serv i c e s. ) Po s t - S t abilization services furnished by Non- C o n t racting Prov i d e rs or facilities that are Pri o r Au t h o rized by Pa c i fi C a re or we re not Pri o r Au t h o rized because Pa c i fi C a re did not re s p o n d to a request for Prior Au t h o rization for such s e rvices within one (1) hour of the request or because Pa c i fi C a re could not be contacted fo r P rior Au t h o rization Renal Dialysis services provided while you are t e m p o ra ri ly outside of the Service A re a A ny services for which Pa c i fi C a re provides Pri o r Au t h o ri z a t i o n. Custodial Care Not a cove red serv i c e. C u s t o d i a l C a re includes services that assist an individual in the activities of daily living. Examples incl u d e : assistance in wa l k i n g, getting in or out of bed, b a t h i n g, d re s s i n g, feeding and using the toilet, p re p a ration of special diets, and supervision of the a d m i n i s t ration of medication that usually can be s e l f - a d m i n i s t e re d. Custodial Care includes all h o m e m a ker serv i c e s, respite care, c o nvalescent care or extended care not re q u i ring skilled nu rs i n g. Custodial Care does not re q u i re the continu i n g attention of trained medical or para m e d i c a l p e rs o n n e l. Customer Service A department dedicated to a n swe ring your questions concerning (but not limited to) your members h i p, C ove red Serv i c e s, G ri evances and Ap p e a l s. D i s e n roll or Disenro l l m e n t The process of ending your membership in Secure Hori z o n s M e d i c a re+choice Plan. D i s e n rollment can be vo l u n t a ry or invo l u n t a ry. Durable Medical Equipment (DME) Equipment that can withstand repeated use; i s p ri m a ri ly and usually used to serve a medical p u r p o s e ; is ge n e ra l ly not useful to a person in the

17 absence of illness or injury ; and is appro p riate fo r use in the home. To be cove re d, D u rable Medical Equipment must be Medically Necessary and p re s c ribed by a Contracting Medical Provider fo r use in your home,s u ch as ox y gen equipment, w h e e l ch a i rs, hospital beds and other items that are d e t e rmined Medically Necessary, in accord a n c e with Medicare law, regulations and guidelines. Routine DME will not be cove red when the Member has exhausted the one hundred (100) day s Skilled Nursing Facility benefits and remains in an institution or distinct part of an institution meeting the basic re q u i rements of a Hospital or Skilled N u rsing Fa c i l i t y. E ffective Date The date your Secure Hori z o n s M e d i c a re+choice Plan cove rage begi n s. Yo u re c e i ve written notification of your Effe c t i ve Date f rom Pa c i fi C a re. Election Form The enrollment fo rm a Medicare b e n e fi c i a ry or legal re p re s e n t a t i ve must complete (with your signature and date) in order to be e n rolled as a Member of Secure Hori z o n s M e d i c a re+choice Plan. This fo rm is submitted to CMS for approva l. A Benefit Plan Tr a n s f e r A p p l i c a t i o n (also known as an A bb rev i a t e d Election Fo rm or short enrollment fo rm) is used by M e m b e rs or benefi c i a ry re p re s e n t a t i ves to elect a d i ffe rent benefit plan offe red by Pa c i fi C a re or to m ove from one Service A rea to another Serv i c e A re a. E m e rgency Services Cove red Services that are 1) furnished by a Provider qualified to furn i s h E m e rgency Serv i c e s, and 2) needed to evaluate or s t abilize a Medical Emerge n c y. Please see defi n i t i o n of Medical Emerge n c y. Evidence of Coverage and Disclosure I n f o rm a t i o n This document explains Cove re d S e rvices and defines your rights and re s p o n s i b i l i t i e s as a Member and those of Pa c i fi C a re. Exclusion or Excluded Items or services which a re not cove red under this Evidence of Cove rage and Discl o s u re Info rm a t i o n, w h i ch includes the S chedule of Benefi t s. E x clusions are disclosed in the Schedule of Benefi t s. ( E x clusions applicable to the Secure Horizons Group Retiree Medicare + C h o i c e Plan Members may be found in the Retiree Benefi t S u m m a ry rather than the Schedule of Benefi t s. ) You are re s p o n s i ble for paying for ex cluded items or serv i c e s. Experimental Pro c e d u res and Items Items and pro c e d u res determined by Pa c i fi C a re and M e d i c a re not to be ge n e ra l ly accepted by the medical commu n i t y. When making a determ i n a t i o n as to whether a service or item is ex p e ri m e n t a l, Pa c i fi C a re will fo l l ow CMS guidance (via the M e d i c a re Carri e rs Manual and Cove rage Issues M a nual) if applicabl e, or re ly upon determ i n a t i o n s a l re a dy made by Medicare. E x p e ri m e n t a l P ro c e d u res and Items are not cove red under this Evidence of Cove rage. Fee-for-Service Medicare A payment system by w h i ch doctors, Hospitals and other Prov i d e rs are paid for each service perfo rmed (also known as t raditional and/or Ori ginal Medicare ). G r i e v a n c e The type of complaint you make if you have a complaint or pro blem that does not i nvo l ve payment or services by Pa c i fi C a re or a C o n t racting Medical Prov i d e r. For ex a m p l e, yo u would file a Gri evance if you have a pro blem with things such as: the quality of your care, ge n e ra l d i s s a t i s faction with the way the Secure Hori z o n s M e d i c a re+choice Plan benefits are designed, waiting times for appointments or in the wa i t i n g ro o m, the way your doctors or others behave, b e i n g able to re a ch someone by phone or obtain the i n fo rmation you need,or the cleanliness or condition of the doctor s offi c e. G roup Retiree Members (Secure Horizons G roup Retiree Medicare+Choice Plan M e m b e r s ) Medicare - e l i gi ble re t i red employe e s and their Medicare - e l i gi ble dependents who meet the eligibility re q u i rements of their fo rm e r e m p l oye r,or trust administrator for enrollment in the employe r - s p o n s o red group re t i ree health plan ava i l able through Pa c i fi C a re. Health Plan Pre m i u m The monthly payment to Pa c i fi C a re, if applicabl e, along with the Medicare Pa rt B Premiums and Medicare Pa rt A Pre m i u m s, 9

18 paid to Medicare if applicabl e, that entitle you to the Cove red Services outlined in this Evidence of C ove rage. Home Health Agency A Medicare - c e rt i fi e d agency which provides intermittent Skilled Nurs i n g C a re and other Medically Necessary thera p e u t i c s e rvices in your home when you are confined to your home and when authorized by your Pri m a ry C a re Phy s i c i a n. H o s p i c e An organization or agency cert i fied by M e d i c a re that is pri m a ri ly engaged in prov i d i n g pain re l i e f,symptom management and support i ve s e rvices to term i n a l ly ill people and their fa m i l i e s. H o s p i t a l A Medicare - c e rt i fied institution licensed by the State, w h i ch provides inpatient, o u t p a t i e n t, e m e rge n c y, d i agnostic and therapeutic serv i c e s. T h e t e rm H o s p i t a l does not include a conva l e s c e n t nu rsing home, rest fa c i l i t y, or facility for the age d w h i ch furnishes pri m a ri ly Custodial Care, i n cl u d i n g t raining in routines of daily living. Hospital Stay A Hospital Stay commences on the fi rst day of Cove red Services in an Acute Care H o s p i t a l. A Hospital Stay ends when the Member is either disch a rged from the Hospital or tra n s fe rre d to another level of care, e. g. home health care or Skilled Nursing Fa c i l i t y. If a Member subsequently t ra n s fe rs fro m : an Acute Care Hospital to a Skilled N u rsing Fa c i l i t y ; a Skilled Nursing Facility to an Acute Care Hospital, or Home Health A gency to an acute or Skilled Nursing Fa c i l i t y, another applicabl e C o p ayment will be applied. H o s p i t a l i s t When you are admitted for a M e d i c a l ly Necessary pro c e d u re or treatment at a C o n t racting Hospital,your health care may be c o o rdinated by a physician who specializes in t reating inpatients (patients in a Hospital). T h i s a l l ows your Pri m a ry Care Physician to continue to see other patients in his or her office while you are h o s p i t a l i z e d. Lock-In Feature An arra n gement under which all C ove red Serv i c e s, with the exception of Emerge n c y S e rv i c e s, U rge n t ly Needed Services and out-of-are a and routine travel renal dialysis serv i c e s, must be p rovided or authorized by your Contracting Medical P rovider or your Pri m a ry Care Phy s i c i a n. If yo u re c e i ve services from a Non-Contracting Medical P rov i d e r, Fa c i l i t y, or a Contracting Medical Prov i d e r s u ch as a Specialist without Prior Au t h o ri z a t i o n f rom Pa c i fi C a re or your Contracting Medical G ro u p / I PA, neither Pa c i fi C a re nor Medicare will pay for that care. T h e re are ve ry limited exceptions to this ru l e. See the Schedule of Benefits for specifi c limitations that apply. Medi-Cal or Medicaid A joint fe d e ra l / S t a t e medical assistance pro gram established by Title XIX of the Social Security A c t. Some Medicare b e n e fi c i a ries are also eligi ble for Medi-Cal. M e d i - C a l, u n l i ke Medicare, can cover long-term care, s u ch as Custodial Care. Medi-Cal can cover all or part of your Medicare premiums and/or deductibles and C o i n s u ra n c e, if your income and re s o u rces are low e n o u g h. You may inquire about Medi-Cal and other related pro gra m s : Q u a l i fied Medicare Benefi c i a ry, Special Low Income Medicare Benefi c i a ry, Q u a l i fi e d D i s abled Wo rking Individual, Q u a l i fied Individual; a t your local Department of Social Serv i c e s. Pa c i fi C a re has contracted with Premium Assist to help Secure H o rizons Medicare+Choice Plan Members with the application process to these pro grams at no cost to yo u. If you have any questions you can contact P remium Assist at ,TTY , M o n d ay through Fri d ay from 8:00 a.m. to 5:00 p.m. and speak to a re p re s e n t a t i ve who will determine if you may be eligi ble for one of these pro gra m s. I f you are eligi bl e, t h ey will walk you through the e n t i re pro c e s s. Medical Dire c t o r A licensed physician who is an e m p l oyee of Pa c i fi C a re and is re s p o n s i ble fo r m o n i t o ring and ove rseeing the quality of care to the Members. Medical Emerg e n c y A medical condition m a n i festing itself by acute symptoms of suffi c i e n t s eve rity (including seve re pain) such that a pru d e n t l ay p e rs o n, with an ave rage know l e d ge of health and m e d i c i n e, could re a s o n ably expect the absence of immediate medical attention to result in: 1) seri o u s j e o p a rdy to the health of the individual or,in the case of a pregnant wo m a n, the health of the wo m a n 10

19 or her unborn ch i l d ; 2) serious impairment to b o d i ly functions; or 3) serious dysfunction of any b o d i ly organ or part. Medically Necessary or Medical Necessity A n i n t e rvention will be cove red under the Pa c i fi C a re Health Plan if it is an otherwise cove red catego ry of s e rv i c e, not specifi c a l ly ex cl u d e d, and Medically Necessary. An intervention may be medically indicated yet not be a cove red benefit or meet the d e finition of Medical Necessity. An intervention is Medically Necessary i f,as recommended by the t reating physician and determined by the medical d i rector of Pa c i fi C a re, it is (all of the fo l l ow i n g ) : ( a ) A health intervention for the purpose of t reating a medical condition; ( b ) The most appro p riate supply or level of s e rv i c e, c o n s i d e ring potential benefits and h a rms to the Member; ( c ) K n own to be effe c t i ve in treating the medical c o n d i t i o n. For existing interve n t i o n s, e ffe c t i veness is determined fi rst by scientifi c ev i d e n c e, then by pro fessional standard s, t h e n by ex p e rt opinion. For new interve n t i o n s, e ffe c t i veness is determined by scientifi c ev i d e n c e ; a n d ( d ) If more than one health intervention meets the re q u i rements of (a) through (c) ab ove, f u rnished in the most cost-effe c t i ve manner w h i ch may be provided safe ly and effe c t i ve ly to the Member. In applying the ab ove definition of Medical N e c e s s i t y, the fo l l owing terms shall have the fo l l owing meanings: ( i ) A health intervention is an item or serv i c e d e l i ve red or undert a ken pri m a ri ly to t re a t (that is, p reve n t, d i ag n o s e, d e t e c t, t re a t, o r palliate) a medical condition or to maintain or re s t o re functional ab i l i t y. A medical condition is a disease, i l l n e s s, i n j u ry, genetic or conge n i t a l d e fe c t, p re g n a n c y, or a biological condition that lies outside the ra n ge of norm a l, age - a p p ro p riate human va ri a t i o n. A health i n t e rvention is defined by the interve n t i o n i t s e l f,the medical condition and the patient indications for which it is being applied. ( i i ) E ff e c t i v e means that the intervention can re a s o n ably be expected to produce the intended results and to have expected benefi t s that outweigh potential harmful effe c t s. ( i i i ) Scientific evidence consists pri m a ri ly of c o n t rolled clinical trials that either dire c t ly or i n d i re c t ly demonstrate the effect of the i n t e rvention on health outcomes. If contro l l e d clinical trials are not ava i l abl e, o b s e rva t i o n a l studies that suggest a causal re l a t i o n s h i p b e t ween the intervention and health outcomes can be used. S u ch studies do not by t h e m s e l ves demonstrate a causal re l a t i o n s h i p unless the magnitude of the effect observe d exceeds anything that could be ex p l a i n e d either by the natural history of the medical condition or potential ex p e rimental biases. For existing interve n t i o n s, the scientifi c evidence should be considered fi rs t, and to the greatest extent possibl e, should be the basis fo r d e t e rminations of Medical Necessity. If no s c i e n t i fic evidence is ava i l abl e, p ro fe s s i o n a l s t a n d a rds of care should be considere d. I f p ro fessional standards of care do not ex i s t, o r a re outdated or contra d i c t o ry, decisions ab o u t existing interventions should be based on ex p e rt opinion. Giving pri o rity to scientifi c evidence does not mean that cove rage of existing interventions should be denied in the absence of concl u s i ve scientific ev i d e n c e. Existing interventions can meet the defi n i t i o n of Medical Necessity in the absence of s c i e n t i fic evidence if there is a stro n g c o nviction of effe c t i veness and benefi t ex p ressed through up-to-date and consistent p ro fessional standards of care, or in the absence of such standard s, c o nvincing ex p e rt o p i n i o n. ( i v ) A new intervention is one which is not yet in w i d e s p read use for the medical condition and patient indications being considere d. N ew i n t e rventions for which clinical trials have not been conducted because of epidemiologi c a l 11

20 reasons (i.e., ra re or new diseases or orphan populations) shall be evaluated on the basis of p ro fessional standards of care. If pro fe s s i o n a l s t a n d a rds of care do not ex i s t, or are outdated or contra d i c t o ry, decisions about such new i n t e rventions should be based on conv i n c i n g ex p e rt opinion. ( v ) An intervention is considered cost eff e c t i v e if the benefits and harms re l a t i ve to costs re p resent an economically efficient use of re s o u rces for patients with this condition B-PHS 12/00 M e d i c a re( O ri ginal Medicare) The fe d e ra l gove rnment health insurance pro gram establ i s h e d by Title XVIII of the Social Security Act for people 65 ye a rs of age or older, c e rtain yo u n ger people with disabilities and people with end-stage re n a l disease (ESRD). M e d i c a re Part A Hospital insurance benefi t s i n cluding inpatient Hospital care, Skilled Nurs i n g Facility care, Home Health A gency care and Hospice care offe red through Medicare. M e d i c a re Part A Pre m i u m Pa rt A is fi n a n c e d by part of the Social Security pay roll withholding tax paid by wo rke rs and their employe rs and by p a rt of the Self-Employment Tax paid by selfe m p l oyed pers o n s. G e n e ra l ly,people age 65 and older can obtain pre m i u m - f ree Medicare Pa rt A b e n e fits based on their own or their spouse's e m p l oy m e n t. If you are under 65,you can obtain p re m i u m - f ree Medicare Pa rt A benefits if you have been a disabled benefi c i a ry under Social Securi t y or the Railroad Retirement Board for more than 24 months. If you do not qualify for pre m i u m - f re e Pa rt A benefi t s, you may buy the cove rage if yo u a re at least 65 ye a rs old and meet cert a i n re q u i re m e n t s. A l s o, you may be able to buy M e d i c a re Pa rt A if you are disabled and lost yo u r p re m i u m - f ree Pa rt A because you are wo rk i n g. M e d i c a re Part B Supplementary medical i n s u rance that is optional and re q u i res a monthly p re m i u m. Pa rt B cove rs physician services (in both Hospital and non-hospital settings) and serv i c e s f u rnished by certain non-physician pra c t i t i o n e rs. Other Pa rt B services include lab testing, D u rabl e Medical Equipment,d i agnostic tests,a m b u l a n c e s e rv i c e s, p re s c ription drugs that cannot be selfa d m i n i s t e re d, c e rtain self-administered anti-cancer d ru g s, some other thera py serv i c e s, c e rtain other health serv i c e s, and blood not cove red under Pa rt A. M e d i c a re Part B Pre m i u m A monthly pre m i u m paid to Medicare (usually deducted from yo u r Social Security ch e ck) to cover Pa rt B serv i c e s. Yo u must continue to pay this premium to Medicare to re c e i ve Cove red Services whether a M e d i c a re+choice Plan or Medicare cove rs yo u. M e d i c a re+choice (M+C) Coordinated Care P l a n s These are Medicare+Choice Plans that use a netwo rk of Prov i d e rs that are under contract or a rra n gement with a Medicare+Choice Org a n i z a t i o n or its Contracting Medical Gro u p s / I PAs to prov i d e c ove red benefi t s. S e c u re Hori z o n s M e d i c a re + C h o i c e Plan is a Coordinated Care Plan. M e d i c a re+choice Organization (M+CO) A p u blic or pri vate entity organized and licensed by the State as a ri s k - b e a ring entity that is cert i fied by CMS as meeting Medicare+Choice re q u i re m e n t s. M+COs can offer one or more Medicare + C h o i c e P l a n s. Pa c i fi C a re is a M+CO. M e d i c a re+choice (M+C) Plan A policy or b e n e fit pack age offe red by a Medicare + C h o i c e O rganization under which a specific set of health b e n e fits are offe red at a unifo rm premium and u n i fo rm level of cost-sharing to all Medicare b e n e fi c i a ries residing in the Service A rea cove red by the Medicare+Choice Plan. A M+CO may offe r m o re than one Medicare+Choice Plan in the same S e rvice A re a. S e c u re Horizons Medicare + C h o i c e Plan is a M+C Plan. M e m b e r Yo u, the Medicare benefi c i a ry entitled to re c e i ve Cove red Serv i c e s, who has vo l u n t a ri ly elected to enroll in Secure Hori z o n s M e d i c a re+choice Plan and whose enrollment has been confi rmed by CMS. N e t w o r k Prov i d e rs, facilities and Hospitals c o n t racted by Pa c i fi C a re to deliver the Cove re d S e rvices provided for in this Evidence of Cove rage 12

21 and Discl o s u re Info rmation and the Schedule of B e n e fi t s. Non-Contracting Medical Provider or Facility A ny pro fessional pers o n, o rg a n i z a t i o n, health fa c i l i t y, H o s p i t a l, or other person or institution licensed and/or cert i fied by the State or Medicare to delive r or furnish health care serv i c e s ; and who is neither e m p l oye d, ow n e d, o p e rated by, nor under contra c t with Pa c i fi C a re to deliver Cove red Services to yo u. O ffice Vi s i t A visit for Cove red Services to yo u r P ri m a ry Care Phy s i c i a n, S p e c i a l i s t, other Contra c t i n g Medical Provider or Non-Contracting Medical P rovider upon Refe rra l. Optional Supplemental Benefits Non-Medicare c ove red benefits that can be purchased beyond the b e n e fits included in the basic Secure Hori z o n s M e d i c a re+choice Plan which may be elected at a M e m b e r s option. T h e re is a Plan Pre m i u m associated with Optional Supplemental Benefi t s. M e m b e rs of Secure Horizons Medicare+Choice Plan must vo l u n t a ri ly elect Optional Supplemental B e n e fits in order to re c e i ve them. ( O p t i o n a l Supplemental Benefits may not be ava i l able to G roup Retiree Members. ) Outpatient Services A m b u l a t o ry medical serv i c e s re c e i ved by a Member when the Member is not admitted to a Hospital or Skilled Nursing Fa c i l i t y. P a c i f i C a re A State corporation that is org a n i z e d and licensed by the State as a ri s k - b e a ring entity and is cert i fied by CMS as meeting Medicare + C h o i c e re q u i re m e n t s. Pa c i fi C a re is a Medicare + C h o i c e O rganization that offe rs Secure Hori z o n s M e d i c a re+choice Plans. P rescription Unit The maximum amount (quantity) of medication that may be dispensed per p re s c ription for a single Copay m e n t. For most o ral medications, the Pre s c ription Unit re p resents a thirty (30) day supply of medication. T h e P re s c ription Unit for other medications will re p resent a single container, inhaler unit, p a ck age, o r c o u rse of thera py. For drugs that could be hab i t - fo rm i n g, the Pre s c ription Unit is set at a smaller quantity for your protection and safe t y. Primary Care Physician The Contra c t i n g Medical Provider you choose who is re s p o n s i ble fo r p roviding or authorizing Cove red Services while you are a Member of Secure Hori z o n s M e d i c a re+choice Plan. P ri m a ry Care Physicians are ge n e ra l ly physicians specializing in Intern a l M e d i c i n e, Fa m i ly Practice or General Pra c t i c e. H oweve r, t h ey may also be other Provider types, based on your pre fe rence and health care needs. Prior Authorization A system where by a P rovider must re c e i ve approval from Pa c i fi C a re or your Contracting Medical Gro u p / I PA befo re yo u, the Member, re c e i ve certain Cove red Serv i c e s. All services re n d e red by Non-Contracting Medical P rov i d e rs must have Prior Au t h o rization unless p rovided during an Emergency or while you are t e m p o ra ri ly out of the Service A rea and need U rgent Care. P ro v i d e r A ny pro fessional pers o n, o rg a n i z a t i o n, health fa c i l i t y, H o s p i t a l, or other person or institution licensed and/or cert i fied by the State or M e d i c a re to deliver or furnish health care serv i c e s. Quality Improvement Organization (QIO) ( Fo rm e r ly known as Peer Rev i ew Org a n i z a t i o n ( P RO) - An independent contractor paid by CMS to rev i ew Medical Necessity,a p p ro p riateness and quality of medical care and services provided to M e d i c a re benefi c i a ri e s. The QIO must rev i ew complaints about the quality of care gi ven by p hysicians in inpatient Hospitals, o u t p a t i e n t Hospital fa c i l i t i e s, Hospital emergency ro o m s, Skilled Nursing Fa c i l i t i e s, Home Health A ge n c i e s, a m b u l a t o ry surgical centers and Pri vate Fe e - fo r - S e rvice plans. R e f e r r a l A fo rmal recommendation by yo u r P ri m a ry Care Physician for you to re c e i ve care fro m a Specialist,C o n t racting Medical Provider or Non- C o n t racting Medical Prov i d e r. Schedule of Benefits The document which p rovides the details of your particular benefit plan, i n cluding any Copayments and Coinsurance that you should pay when receiving a Cove red Serv i c e. To gether with this Evidence of Cove rage and 13

22 D i s cl o s u re Info rmation document, the Schedule of B e n e fits explains your health care cove rage. ( G roup Retiree Members re c e i ve the Retire e S u m m a ry of Benefi t s. ) S e c u re Horizons Medicare+Choice Plan A M e d i c a re+choice Plan offe red by Pa c i fi C a re, a M e d i c a re+choice Org a n i z a t i o n. Select and Standard Hospitals Select H o s p i t a l s a re facilities that, within a specifi c ge o graphic Service A re a, p rovide services with favo rable financial terms to Pa c i fi C a re and the M e m b e rs. When Members re c e i ve Hospital care at a Select Hospital,t h ey share in the savings the Select Hospital prov i d e s. S t a n d a rd Hospitals a re all Netwo rk Hospitals within in a specific Serv i c e A rea that are not designated as Select Hospitals. A l l S e c u re Horizons Medicare+Choice Plan Netwo rk Hospitals have met Pa c i fi C a re s cre d e n t i a l i n g s t a n d a rd s. The contracting rates betwe e n Pa c i fi C a re and Hospitals depend on nu m e ro u s fa c t o rs. Select status does not re fl e c t, e i t h e r p o s i t i ve ly or negative ly,the quality of the Hospital s s e rv i c e. Please see the Schedule of Benefits fo r m o re info rm a t i o n. Service Area A ge o graphic area approved by CMS within which a Medicare+Choice e l i gi ble individual may enroll in a part i c u l a r M e d i c a re+choice Plan offe red by Pa c i fi C a re. S e rvice A reas may contain diffe rent benefit plans that offer diffe rent benefi t s, Health Plan P re m i u m s, C o p ayment and Coinsurance amounts. Skilled Nursing Care Medically Necessary s e rvices that can only be perfo rmed by, or under the supervision of, licensed nu rsing pers o n n e l. Skilled Nursing Facility A facility which p rovides inpatient Skilled Nursing Care, re h abilitation services or other related health s e rvices and is State licensed and/or cert i fied by M e d i c a re. The term Skilled Nursing Fa c i l i t y d o e s not include a convalescent nu rsing home,re s t facility or facility for the aged which furn i s h e s p ri m a ri ly Custodial Care, i n cluding training in routines of daily living. S p e c i a l i s t A ny duly licensed phy s i c i a n, o s t e o p a t h, p s y ch o l o gist or other practitioner (as d e fined by Medicare) who provides health care s e rvices for a specific disease,condition or body p a rt and that your Pri m a ry Care Physician or C o n t racting Medical Provider may re fer you to. Also any duly licensed emergency room phy s i c i a n who provides Emergency Services to yo u. S t a t e The State of Califo rn i a, re s p o n s i ble fo r licensing and regulating Pa c i fi C a re. Technology Assessment Pa c i fi C a re re g u l a r ly rev i ews new pro c e d u re s, d evices and drugs to d e t e rmine whether or not they are safe and e fficacious for our Members. N ew pro c e d u res and t e ch n o l o gy that are safe and efficacious are eligi bl e to become Cove red Serv i c e s. If the tech n o l o gy becomes a cove red service it will be subject to all other terms and conditions of the plan,i n cl u d i n g Medical Necessity and any applicable Member C o p ay m e n t s, d e d u c t i bles or other pay m e n t c o n t ri b u t i o n s. In determining whether to cover a serv i c e, Pa c i fi C a re uses pro p ri e t a ry tech n o l o gy guidelines to rev i ew new dev i c e s, p ro c e d u res and dru g s, i n cluding those related to behav i o ral health. W h e n clinical necessity re q u i res a rapid determination of the safety and efficacy of a new tech n o l o gy or new application of an existing tech n o l o gy for an individual Member, a Pa c i fi C a re Medical Dire c t o r m a kes a Medical Necessity determination based on individual Member medical documentation; rev i ew of published scientific evidence and when a p p ro p riate seeks re l evant specialty or pro fe s s i o n a l opinion from an individual who has ex p e rtise in the tech n o l o gy. Ti m e - S e n s i t i v e A situation in which waiting fo r a standard decision on an authori z a t i o n, request fo r s e rvices or an Appeal could seri o u s ly jeopard i z e your life, h e a l t h, or your ability to re c over from an i l l n e s s, i n j u ry or condition. U rgently Needed Services Cove red Serv i c e s p rovided when you are tempora ri ly absent fro m the Secure Horizons Medicare+Choice Plan Serv i c e A rea (or, under unusual and ex t ra o rd i n a ry 14

23 c i rc u m s t a n c e s, p rovided when you are in the S e rvice A rea but your Pri m a ry Care Physician is t e m p o ra ri ly unava i l able or inaccessible) when such s e rvices are Medically Necessary and immediately re q u i re d : 1) as a result of an unfo reseen illness, i n j u ry, or condition; and 2) it is not re a s o n abl e gi ven the circumstances to obtain the serv i c e s t h rough your Pri m a ry Care Phy s i c i a n. Utilization Review A compre h e n s i ve, i n t e gra t e d p rocess in which a team of health care p ro fessionals evaluates your treatment in an effo rt to promote the efficient use of re s o u rces and the quality of health care. Duties of the Utilization R ev i ew staff include Prior Au t h o ri z a t i o n, c o n c u rrent and re t ro s p e c t i ve rev i ew of medical s e rv i c e s. P rior Au t h o rization is the process of obtaining prior approval as to the cove rage and a p p ro p riateness of serv i c e, as defined in Section 1 (Health Care Te rms) and described in Section 4 ( H ow Your Secure Horizons Medicare+Choice Plan C ove rage Wo rk s ). C o n c u rrent and re t ro s p e c t i ve rev i ew is an assessment which determines Medical Necessity or appro p riateness of services as they a re being or have alre a dy been re n d e re d, a s a p p l i c abl e. Section 2 Eligibility, Enrollment Periods and Effe c t i ve Date To enroll in Secure Horizons Medicare+Choice Plan you: 1. Must be entitled to Medicare Pa rt A and e n rolled in Medicare Pa rt B. 2. Must not curre n t ly have end-stage renal disease or re c e i ve routine kidney dialy s i s. H oweve r, i f either of these conditions should apply to yo u, in some instances you may still enroll if you are a current Member of Pa c i fi C a re, either thro u g h an employer group sponsored health plan or as an individual. If you develop end-stage re n a l disease while a Member of Secure Hori z o n s M e d i c a re+choice Plan,you can continue yo u r m e m b e rs h i p : If you have re c e i ved a transplant that has re s t o red your kidney function and you no l o n ger re q u i re a regular course of dialy s i s, yo u a re not c o n s i d e red to have ESRD and yo u a re e l i gi ble to enroll in the Secure Hori z o n s M e d i c a re+choice Plan. Individuals with ESRD who are affected by the non-re n ewal of another Medicare + C h o i c e O rganization may make one election to enro l l in another Medicare+Choice Org a n i z a t i o n. 3. Must perm a n e n t ly reside in the Service A rea as d e fined in Section Must complete and sign an Election Fo rm. I f another person assists you in completing the Election Fo rm, that person must also sign the fo rm and state his or her relationship to yo u. 5. Must agree to abide by Secure Hori z o n s M e d i c a re+choice Plan ru l e s. If you meet the above eligibility re q u i rements, you cannot be denied membership in Secure Horizons M e d i c a re+choice Plan on the basis of your health status, excluding end-stage re n a l disease as described above. Enrollment E l i gi ble individuals can enroll in Secure Hori z o n s M e d i c a re+choice Plan at the fo l l owing times: C o n t i nuous Open Enrollment - Secure Hori z o n s M e d i c a re+choice Plans may have continu o u s open enro l l m e n t. If you are eligi bl e, you may submit a completed Election Fo rm at any time. N o t e : With a thirty (30) day advance publ i c n o t i c e, e n rollment in Secure Hori z o n s M e d i c a re+choice Plans may be closed to new e n rollees (except for benefi c i a ries cove red by an ICEP, AEP or SEP). Initial Cove rage Election Pe riod (ICEP) - Yo u m ay elect to enroll in a Medicare + C h o i c e (M+C) Plan when you fi rst become entitled to both Pa rt A and Pa rt B of Medicare. The Initial Election Cove red Pe riod begins on the fi rst day of the third month befo re the date on which 15

24 you are entitled to both Pa rt A and Pa rt B and ends on the last day of the month befo re the date on which you become eligi ble for both Pa rts of Medicare. For ex a m p l e : If you are e l i gi ble for both Pa rt A and Pa rt B on September 1, you may enroll in Secure Hori z o n M e d i c a re+choice Plan as early as June 1 but not later than August 31, for a September 1 Effe c t i ve D a t e. A n nual Election Pe riod (AEP) - The AEP occurs f rom November 15 through December 31 of eve ry ye a r. D u ring this time, a l l M e d i c a re + C h o i c e Plans are re q u i red to accept e n ro l l m e n t s - e l e c t i o n s, e ffe c t i ve the fo l l ow i n g Ja nu a ry 1. T h u s, at this time, you can ch a n ge your enrollment from Secure Hori z o n s M e d i c a re+choice Plan to Medicare or to a d i ffe rent Medicare+Choice Plan. B e n e fi c i a ri e s e n rolled in Medicare or another M e d i c a re+choice Plan may also ch a n ge e n rollment to any other Medicare+Choice Plan, or enroll in Secure Horizons Medicare + C h o i c e P l a n. You may not be enrolled in more than one (1) Medicare+Choice Plan at any gi ven time. I f you are alre a dy a Member of a Medicare + C h o i c e Plan when you enroll with a diffe re n t M e d i c a re+choice Plan,m e m b e rship in that plan will automatically be terminated on the Effe c t i ve Date of your enrollment in the new M e d i c a re+choice Plan. Special Election Pe riod (SEP) - Special peri o d s of time in which an enrollee can discontinu e e n rollment in a Medicare+Choice Plan and ch a n ge his or her enrollment to another M e d i c a re+choice Plan or re t u rn to Medicare. In the event of the fo l l owing circ u m s t a n c e s, a Special Election Pe riod is wa rra n t e d : t h e M e d i c a re+choice Plan in which the enrollee is e n rolled is discontinued in the Service A rea in w h i ch the enrollee live s ; the enrollee move s out of the Service A rea of the Medicare + C h o i c e P l a n ; the Medicare+Choice Org a n i z a t i o n o ffe ring the plan violated a material prov i s i o n of its contract with the enro l l e e ; or the enro l l e e meets such other material conditions as CMS m ay prov i d e. fi n a n c i a l ly re s p o n s i ble for those serv i c e s. 16 Your Enrollment Form The Secure Horizons Medicare+Choice Plan e n rollment fo rm is also re fe rred to as an Election Fo rm. Once you complete and sign an Election Fo rm, it is submitted to CMS for ve ri fication of e l i gibility in Secure Horizons Medicare + C h o i c e P l a n. If for any reason an Election Fo rm is re j e c t e d by CMS,Pa c i fi C a re will contact you for additional i n fo rmation or provide instructions to fo l l ow re g a rding resubmission of the Election Fo rm. When Your Secure Horizons Medicare+Choice Plan Coverage Begins The Effe c t i ve Date of enrollment in Secure Hori z o n s M e d i c a re+choice Plan will depend on when Pa c i fi C a re re c e i ves your signed and completed Election Fo rm. Pa c i fi C a re will send you a letter that i n fo rms you when your cove rage begi n s. G e n e ra l ly, completed Election Fo rms re c e i ved by the end of the month will be effe c t i ve the 1st day of the fo l l owing month. For ex a m p l e, if Pa c i fi C a re re c e i ve s your Election Fo rm on the 31st of Ju ly, yo u r E ffe c t i ve Date is August 1. If Pa c i fi C a re re c e i ve s your Election Fo rm on the 31st of Au g u s t, yo u r E ffe c t i ve Date is September 1. From your Effe c t i ve Date fo r wa rd, you must re c e i ve all routine Cove red Services from Contra c t i n g Medical Prov i d e rs. Neither Pa c i fi C a re nor Medicare will pay for services re c e i ved from Non-Contra c t i n g Medical Prov i d e rs except fo r : E m e rgency Services any w h e re in the wo r l d U rge n t ly Needed Services that we re not fo re s e e able when you left the Service A rea O u t - o f - a rea renal dialysis services and ro u t i n e t ravel dialysis Those services for which Secure Hori z o n s M e d i c a re+choice Plan allows you to self-re fer to C o n t racting Medical Prov i d e rs R e fe rrals that have re c e i ved Prior Au t h o ri z a t i o n If you re c e i ve any medical services not cove red by Medicare befo re your Secure Hori z o n s M e d i c a re+choice Plan cove rage takes effe c t, you are

25 Liability of PacifiCare Upon Initial Enrollment Pa c i fi C a re is re s p o n s i ble for the full scope of Pa rt B s e rvices as re q u i red by Medicare, b e ginning on your Effe c t i ve Date. H oweve r, if your Effe c t i ve Date o c c u rs during an inpatient stay in a Hospital, Pa c i fi C a re is not re s p o n s i ble for arra n ging or pay i n g for any of the inpatient Hospital services under the M e d i c a re Hospital Insurance Plan (Pa rt A ). Pa c i fi C a re must assume responsibility for arra n gi n g or paying for inpatient Hospital services under the M e d i c a re Hospital Insurance Plan (Pa rt A) on the d ay fo l l owing the day of disch a rge. Pa c i fi C a re is re s p o n s i ble for the full scope of Pa rt B serv i c e s re q u i red by Medicare beginning on your Effe c t i ve D a t e. About Your Medicare Supplement (Medigap) Policy You may consider canceling any Medicare supplement (Medigap) policy you may have after Pa c i fi C a re has sent you written confi rmation of your Effe c t i ve Date. This is because Health Plan P re m i u m s, C o p ay m e n t s, or other amounts that M+C Plans ch a rge for Medicare - c ove red serv i c e s will not be re i m b u rsed by Medigap policies. H oweve r, if you Disenroll from Secure Hori z o n s M e d i c a re+choice Plan,you may not be able to h ave your Medigap policy re i n s t a t e d. N o t e : In certain cases you can be guaranteed the issue (without medical underwriting or pre - ex i s t i n g condition ex clusions) of a Medicare supplemental (Medigap) policy. Examples of these cases incl u d e the fo l l ow i n g : You Disenroll from Secure Hori z o n s M e d i c a re+choice Plan for a reason that does not invo l ve any fault on your part (e.g.,yo u m ove out of the Secure Hori z o n s M e d i c a re+choice Plan Service A rea or Pa c i fi C a re s contract with CMS terminates or the S e rvice A rea in which you reside is d i s c o n t i nu e d ) You enrolled in Secure Hori z o n s M e d i c a re+choice Plan upon fi rst re a ch i n g M e d i c a re eligibility at age 65,but Disenroll fro m S e c u re Horizons Medicare+Choice Plan within t we l ve (12) months of your Effe c t i ve Date Your supplemental cove rage under an e m p l oyee we l fa re benefit plan term i n a t e s Your enrollment in a Medigap policy ceases because of the bankruptcy or insolvency of the i n s u rer issuing the policy, or because of other i nvo l u n t a ry termination of cove rage for which t h e re is no State law provision relating to c o n t i nuation of cove rage You we re prev i o u s ly enrolled under a Medigap policy and terminated your enrollment to p a rt i c i p a t e, for the fi rst time, in Secure Hori z o n s M e d i c a re+choice Plan and you Disenroll duri n g the fi rst twe l ve (12) months. You will be entitled to purchase the same Medigap policy you had befo re, if it is still ava i l able from the same insure r. If it is not ava i l abl e, you will be entitled to purchase any Medigap Plan A, B, C, or F sold in your State. You must apply for a Medigap policy within s i x t y - t h ree (63) days after your Secure Hori z o n s M e d i c a re+choice Plan cove rage terminates and submit evidence of the date of your loss of c ove rage. For additional info rmation re g a rd i n g g u a ranteed Medicare supplemental policies, p l e a s e call MEDICARE. Should you choose to keep your Medicare supplement (Medigap) policy,you may not be re i m b u rsed for services you re c e i ve from N o n - C o n t racting Medical Prov i d e rs. M o s t supplemental (Medigap) policies will not pay for any portion of such services because: Supplemental insure rs (Medigap insure rs ) p rocess their claims based on proof of an O ri ginal Medicare pay m e n t, u s u a l ly in the fo rm of an explanation of Medicare benefits (EOMB). H oweve r, as long as you are a Member of S e c u re Horizons Medicare+Choice Plan, O ri ginal Medicare will not process any cl a i m s for medical services that you re c e i ve. 17

26 Pa c i fi C a re has the financial responsibility for all M e d i c a re - c ove red health services you need as long as you fo l l ow Secure Hori z o n s M e d i c a re+choice Plan pro c e d u res on how to re c e i ve medical serv i c e s. A d d i t i o n a l ly, if Pa c i fi C a re / S e c u re Hori z o n s M e d i c a re+choice Plan reduces your benefi t s, i n c reases your Copay m e n t s, C o i n s u ra n c e, or Health Plan Pre m i u m, or terminates the contract with your Pri m a ry Care Phy s i c i a n, S p e c i a l i s t, o r C o n t racting Medical Gro u p / I PA, you may be e l i gi ble for enrollment in a Secure Hori z o n s M e d i c a re Supplement policy on a guaranteed issue b a s i s. For more info rmation or to enro l l, p l e a s e contact Pa c i fi C a re at or (TDHI) , 7:00 a.m. to 7:00 p.m., M o n d ay t h rough Fri d ay. Section 3 S e c u re Horizons Medica re + C h o i ce Plan Member Rights and Responsibilities As a Member/Enrollee you have the right to re c e i ve i n fo rmation ab o u t, and make re c o m m e n d a t i o n s re g a rd i n g, your rights and re s p o n s i b i l i t i e s. You Have the Right To: Timely, Quality Care Discuss and active ly participate in decisionmaking with your Contracting Prov i d e r re g a rding the full ra n ge of appro p riate or M e d i c a l ly Necessary treatment options for yo u r c o n d i t i o n, re g a rdless of cost or benefit cove rage. Refuse any treatment or leave a medical fa c i l i t y, even against the advice of a Contra c t i n g P rov i d e r. Your refusal in no way limits or otherwise pre cludes you from receiving other M e d i c a l ly Necessary Cove red Services for which you consent. Without discri m i n a t i o n, submit complaints re g a rding Pa c i fi C a re or Contracting Prov i d e rs or request Appeals for services denied by Pa c i fi C a re or by Contracting Prov i d e rs. Treatment with Dignity and Respect Be treated with dignity and respect and have your right to pri vacy recognized in accord a n c e with State and fe d e ral law s. E xe rcise these rights re g a rdless of your ra c e, p hysical or mental disab i l i t y, e t h n i c i t y, ge n d e r, s exual ori e n t a t i o n, c re e d, age, re l i gi o n, n a t i o n a l o ri gi n, c u l t u ral or educational back gro u n d, economic or health status, English pro fi c i e n c y, reading skills, or source of payment for yo u r health care. Complete an A d vance Dire c t i ve, living will or other dire c t i ve and provide it to yo u r C o n t racting Provider to include in your medical re c o rd. Treatment decisions are not based on whether or not an individual has executed an a d vance dire c t i ve. Your Responsibilities Are To : R ev i ew info rmation re g a rding your benefi t s, C ove red Serv i c e s, a ny Excl u s i o n s, l i m i t a t i o n s, d e d u c t i bles or Copay m e n t s, and the rules yo u need to fo l l ow as stated in your Evidence of C ove rage / C e rt i fi c a t e. P rovide Pa c i fi C a re and Contracting Prov i d e rs, t o the degree possibl e, the info rmation needed to p rovide care to yo u. Follow treatment plans and care instructions as agreed upon with your Contracting Provider. Actively participate, to the degree possible, in understanding and improving your own medical and behavioral health condition and in developing mutually agreed upon treatment goals. Accept your financial responsibility for Health Plan Pre m i u m s, a ny other ch a rges owe d, and any C o p ayment or Coinsurance associated with s e rvices re c e i ved while under the care of a C o n t racting Provider or while a patient in a fa c i l i t y. 18

27 If you have questions or concerns about your ri g h t s, please call Customer Service at the phone nu m b e r listed on the back of your membership card. Yo u can also get free help and info rmation from yo u r State Health Insurance Assistance Pro gram or SHIP at In addition, the Medicare p ro gram has written a booklet called Your Medicare Rights and Pro t e c t i o n. To get a free copy call MEDICARE ( ) or TTY ). Or you can access the Medicare web site at www. M e d i c a re. gov to order this booklet or print it dire c t ly from your computer A - P H S / P P O If you think you have been treated unfa i r ly due to your ra c e, c o l o r, national ori gi n, d i s ab i l i t y, age, o r re l i gi o n, please call Customer Serv i c e. You may also call the Office for Civil Rights at (TDHI ). Section 4 H ow Your Secure Horizons M e d i ca re + C h o i ce Plan C ove rage Wo r k s Your Secure Horizons Medicare+Choice Plan Membership Card Your membership card provides you with i n fo rmation to assist you in receiving all your S e c u re Horizons Medicare+Choice Plan Cove re d S e rv i c e s. In nearly all instances, you will need to p resent your membership card to your Contra c t i n g Medical Provider to ve rify your cove rage and/or obtain Cove red Serv i c e s. C a rry your membership card and your Medicare c a rd with you at all times. Although you never need to discard your Medicare c a rd, you must now use your membership card to receive Covered Services. It is important for you to use only your Secure H o rizons Medicare+Choice Plan membership card N O T your Medicare card for these re a s o n s : 1. To prevent you from receiving medical serv i c e s f rom Non-Contracting Medical Prov i d e rs in erro r 2. In the case of a Medical Emerge n c y, to alert Hospital staff of the need to notify your Pri m a ry C a re Physician or Pa c i fi C a re as soon as possibl e so that Pa c i fi C a re is invo l ved in the manage m e n t of your care 3. To prevent erro rs in billing. Pa c i fi C a re pays the bills on behalf of Medicare. M e d i c a re will not p ay the bills while you are a Member of Secure H o rizons Medicare+Choice Plan. If you lose your membership card or move, p l e a s e contact Customer Serv i c e. How the Lock-In Feature Works for You and PacifiCare As a Secure Horizons Medicare+Choice Plan M e m b e r, all your medical benefits (except fo r E m e rgency Services and Urge n t ly Needed Serv i c e s ) a re provided or arra n ged by your Pri m a ry Care P hy s i c i a n, a personal physician you choose fro m Pa c i fi C a re s list of Contracting Medical Prov i d e rs. You are L o cke d - I n to this Provider who will prov i d e and coordinate all your routine health care serv i c e s. The L o ck - I n fe a t u re enables Pa c i fi C a re to offer yo u S e c u re Horizons Medicare+Choice Plan because of Pa c i fi C a re s contract with CMS, the gove rn m e n t a l agency that ove rsees Medicare. Under this contra c t, the fe d e ral gove rnment agrees to pay Pa c i fi C a re a fi xed monthly dollar amount for each Member. Pa c i fi C a re uses the monthly amount re c e i ved fro m the fe d e ral gove rnment to contract with phy s i c i a n s, Hospitals and other health care Prov i d e rs to arra n ge c a re for yo u. If you receive services without Prior Authorization from Non-Contracting P roviders, except for Emergency Services, U rgently Needed Services, out-of-area re n a l dialysis and routine travel dialysis, or services for which PacifiCare allows you to self-refer to Contracting Providers, neither PacifiCare nor M e d i c a re will pay for those services. 19

28 Section 5 Working With Your Contra c t i n g M e d i cal Prov i d e rs Your Primary Care Physician Your relationship with your Pri m a ry Care Physician is an important one. Pa c i fi C a re stro n g ly re c o m m e n d s that you choose a Pri m a ry Care Physician close to your home. H aving your Pri m a ry Care Phy s i c i a n n e a r by makes receiving medical care and deve l o p i n g a trusting and open relationship easier. If you need assistance in choosing your Pri m a ry C a re Phy s i c i a n, please re fer to the Prov i d e r D i re c t o ry for a listing of Pri m a ry Care Phy s i c i a n s. For a copy of the most recent Provider Dire c t o ry, o r to seek additional assistance,please call Customer S e rv i c e, or you may consult the online Prov i d e r d i re c t o ry at: w w w. s e c u re h o ri z o n s. c o m To help promote a smooth transition of your health c a re when you fi rst join Secure Hori z o n s M e d i c a re+choice Plan,please info rm Pa c i fi C a re if you are curre n t ly seeing a Specialist, re c e i v i n g Home Health A gency services or using Durabl e Medical Equipment. Please call Customer Service so that Pa c i fi C a re can assist you with the tra n s fer of c a re or equipment. Once you have chosen your Pri m a ry Care Phy s i c i a n, Pa c i fi C a re recommends that you have all yo u r medical re c o rds tra n s fe rred to his or her offi c e. T h i s will provide your Pri m a ry Care Physician access to your medical history,and make him or her awa re of a ny existing health conditions you may have. A lways ask to see your Pri m a ry Care Phy s i c i a n when you make an appointment. Your Pri m a ry C a re Physician is now re s p o n s i ble for all yo u r routine health care serv i c e s, so he or she should be the fi rst one you call with any health concern s. When you select a Primary Care Physician it is important to remember this limits you to the panel of Specialists who are aff i l i a t e d with the Contracting Medical Gro u p / I PA you have selected. Provider-Specific Benefit Plans P rov i d e r - S p e c i fic Benefit Plans are curre n t ly ava i l able for Members in A l a m e d a, C o n t ra Costa, L o s A n ge l e s, San Diego and Ora n ge Counties. A P rov i d e r - S p e c i fic Benefit Plan means that Pri o r Au t h o rized services are cove red through cert a i n C o n t racting Medical Gro u p s / I PAs in the county that is specifi c a l ly assigned to a benefit plan. Ty p i c a l ly along with a diffe rent Health Plan Pre m i u m, t h e p ri m a ry diffe rence between a standard benefit plan and a Prov i d e r - S p e c i fic Benefit Plan is the ava i l ability of Contracting Medical Gro u p s / I PAs and H o s p i t a l s. For more info rmation re g a rding Prov i d e r - S p e c i fic Benefit Plans, please see the Summary of B e n e fits and the Schedule of Benefi t s. L i ke standard benefit plans,you must use C o n t racting Medical Gro u p s / I PAs and Pri m a ry Care P hysicians for the coordination of all your medical c a re. Your access to Specialists care is linked to the C o n t racting Medical Gro u p / I PA with which yo u r P ri m a ry Care Physician is affi l i a t e d. Please re fer to the Summary of Benefits for specific info rmation on the benefit plans offe red within your Service A re a. S o m e t i m e s, your Pri m a ry Care Physician may be ava i l able through va rious Contracting Medical G ro u p s / I PAs as part of a standard benefit plan or a P rov i d e r - S p e c i fic Benefit Plan. For more i n fo rmation you may consult the Secure Hori z o n s M e d i c a re+choice Plan online Provider dire c t o ry a t : w w w. s e c u re h o ri z o n s. c o m, ask your Pri m a ry C a re Physician or call Customer Serv i c e. W h e n you select a Pri m a ry Care Physician it is import a n t to remember this limits you to the netwo rk of Specialists who are affiliated with your Pri m a ry C a re Phy s i c i a n s Contracting Medical Gro u p / I PA. M e m b e rs enrolled in the Value Plan or Standard Plan I in Los A n geles County, S t a n d a rd Plan I in A l a m e d a C o u n t y, C o n t ra Costa County or Ora n ge County or M e m b e rs enrolled in Standard Plan I or Standard Plan III in San Diego County, a re cove red o n l y t h rough Contracting Medical Gro u p s / I PAs that are with the benefit plan selected by the Member. T h e o n ly exceptions are Emergency Serv i c e s, U rge n t ly Needed Serv i c e s, or out-of-area and routine trave l 20

29 d i a lysis in the United States at a Medicare - c e rt i fi e d facility or when authorized by the Medical Dire c t o r of the Contracting Medical Gro u p / I PA or Pa c i fi C a re. Please see the Schedule of Benefits for more i n fo rm a t i o n. Changing Primary Care Physicians Within Your Contracting Medical Group/IPA If you wish, you may request to ch a n ge Pri m a ry C a re Physicians within your Contracting Medical G ro u p / I PA at any time. If the Pri m a ry Care P hysician is accepting additional Secure Hori z o n s M e d i c a re+choice Plan Members, the ch a n ge will become effe c t i ve the fi rst day of the month fo l l owing your re q u e s t. You will re c e i ve a new m e m b e rship card that shows this ch a n ge. C a l l Customer Service for assistance. Choosing a New Primary Care Physician Who Is With a Different Contracting Medical Group/IPA If you want to ch a n ge to a Pri m a ry Care Phy s i c i a n who is affiliated with a diffe rent Medical Gro u p / I PA, you must contact Customer Serv i c e. If the Pri m a ry C a re Physician is accepting additional Secure H o rizons Medicare+Choice Plan Members and yo u r request is re c e i ved on or befo re the 15th of the m o n t h, the tra n s fer will become effe c t i ve on the fi rst day of the fo l l owing month. If your request is re c e i ved after the 15th of the month, the tra n s fe r will become effe c t i ve the fi rst day of the month fo l l owing the month of your re q u e s t. For ex a m p l e, i f Pa c i fi C a re re c e i ves your ch a n ge request on the 15th of Ju ly,your ch a n ge is effe c t i ve on August 1. If Pa c i fi C a re re c e i ves your ch a n ge request on the 16th of Ju ly, your ch a n ge is effe c t i ve on September 1. You will re c e i ve a new membership card that show s this ch a n ge. Although Pa c i fi C a re wo n t deny your re q u e s t, fo r c o n t i nuity of care reasons it is recommended that you postpone a request to ch a n ge your Pri m a ry C a re Physician or Contracting Medical Gro u p / I PA if you are an inpatient in a Hospital,a Skilled Nurs i n g Fa c i l i t y, or other medical institution at the time of your re q u e s t. If you ch a n ge your Pri m a ry Care Physician to one who is in a diffe rent Contracting Medical G ro u p / I PA, a ny Refe rrals to Specialists or Refe rra l s for Cove red Services that you prev i o u s ly re c e i ve d m ay no longer be va l i d. In this situation, you will need to ask your new Pri m a ry Care Physician for a n ew Refe rra l, w h i ch may re q u i re further eva l u a t i o n. In some cases, the request for a new Refe rral will need to have Prior Au t h o rization from yo u r C o n t racting Medical Gro u p / I PA or Pa c i fi C a re. Since your Pri m a ry Care Physician is re s p o n s i ble fo r the coordination of all of your health care needs, i t is important that you notify him or her if you wish to continue to re c e i ve services or Specialist care f rom a Provider who was affiliated with yo u r p revious Pri m a ry Care Physician or Contra c t i n g Medical Gro u p / I PA. If you think that you need to continue to re c e i ve o n going services or Specialist care from the pri o r C o n t racting Medical Gro u p / I PA, then for continu i t y of care reasons you should discuss this with yo u r P ri m a ry Care Physician prior to the determ i n a t i o n to tra n s fer to a diffe rent Pri m a ry Care Physician or C o n t racting Medical Gro u p / I PA. If you continue to re c e i ve services or Specialist care without a new Refe rral from your new Pri m a ry Care P hy s i c i a n, you may be fi n a n c i a l ly re s p o n s i ble for the cost of those serv i c e s. In certain circ u m s t a n c e s, Pa c i fi C a re may authorize continued care. Continuity of Care When You Change Your Contracting Medical Group/IPA To help promote a smooth transition of your health c a re when you ch a n ge your Contracting Medical G ro u p / I PA, please let Pa c i fi C a re know if you are c u rre n t ly seeing a Specialist,receiving Home Health A gency serv i c e s, or using Durable Medical E q u i p m e n t. It is important that you contact Customer Service who will assist you in tra n s fe rri n g your care and/or equipment. 21

30 If Your Primary Care Physician Changes to a Different Contracting Medical Group/IPA Sometimes a Pri m a ry Care Physician will ch a n ge to a diffe rent Contracting Medical Gro u p / I PA. If yo u choose to continue care with the Pri m a ry Care P hysician and ch a n ge your Contracting Medical G ro u p / I PA, you may need to ask him or her fo r n ew Refe rrals to Specialists or for Cove re d S e rv i c e s, w h i ch may re q u i re further eva l u a t i o n. In some cases, this request for a new Refe rral will need to have Prior Au t h o rization from yo u r C o n t racting Medical Gro u p / I PA or Pa c i fi C a re. Because your Pri m a ry Care Physician is affi l i a t e d with a diffe rent group of Specialists,if you think that you need to continue to re c e i ve ongoing services or Specialist care from the prior Contracting Medical G ro u p / I PA, then for continuity of care reasons yo u should discuss this with your Pri m a ry Care P hy s i c i a n. A new authorization may be needed fo r c o n t i nued care from the prior Specialist. If you continue to re c e i ve services or Specialist c a re without a new Refe rral from your new P ri m a ry Care Phy s i c i a n, you may be fi n a n c i a l ly re s p o n s i ble for the cost of those serv i c e s. I n c e rtain circ u m s t a n c e s, Pa c i fi C a re may authori z e c o n t i nued care. It is important to remember that your Pri m a ry Care P hysician selection determines the netwo rk of Specialists who are affiliated with your Pri m a ry C a re Phy s i c i a n s Contracting Medical Gro u p / I PA. Provider Terminations It is Pa c i fi C a re s policy that each affected Member re c e i ves timely and consistent notice when his or her Pri m a ry Care Physician or Specialist no longe r c o n t racts with a Pa c i fi C a re Contracting Medical G ro u p / I PA. It is Pa c i fi C a re s goal to make a go o d faith effo rt to notify you within thirty (30) days of the termination of your Pri m a ry Care Phy s i c i a n. Your Contracting Medical Gro u p / I PA will notify you when a Specialist is terminated and you will be impacted. Pa c i fi C a re will assist you in selecting a new Pri m a ry Care Physician or arra n ging access to all Cove red Serv i c e s. Choosing a New Primary Care Physician or Contracting Medical Group/IPA Who Is With a Different Benefit Plan A Prov i d e r - S p e c i fic Benefit Plan is curre n t ly ava i l able for Members in A l a m e d a, C o n t ra Costa, Los A n ge l e s, San Diego and Ora n ge Counties. If the P ri m a ry Care Physician you would like to choose is in a diffe rent benefit plan, you will need to complete and re t u rn a Benefit Plan Tra n s fe r Application to tra n s fer to that benefit plan and e n roll with that Pri m a ry Care Phy s i c i a n. G e n e ra l ly, completed Benefit Plan Tra n s fer Ap p l i c a t i o n s re c e i ved by the end of the month will be effe c t i ve the 1st day of the fo l l owing month. For ex a m p l e, i f your Benefit Plan Tra n s fer Application is re c e i ve d Ju ly 20th,your Effe c t i ve Date of your new benefi t plan will be August 1. Until your Effe c t i ve Date, you will remain with your prev i o u s ly selected b e n e fit plan and Pri m a ry Care Physician and re c e i ve the benefits that are a part of that benefi t p l a n, as long as you have made any applicabl e Health Plan Premium pay m e n t s. B e n e fit plans within a Service A rea may offer diffe rent benefi t s, Health Plan Pre m i u m s, C o p ayment and C o i n s u rance amounts. Please call Customer S e rvice for the Summary of Benefits for yo u r S e rvice A rea so that you may rev i ew and u n d e rstand any diffe re n c e s. If the Pri m a ry Care Physician you would like to choose is in a diffe rent Contracting Medical G ro u p / I PA, a ny Refe rrals to a Specialist or Refe rra l s for Cove red Services that you prev i o u s ly re c e i ve d m ay no longer be va l i d. In this situation, you will need to ask your new Pri m a ry Care Physician fo r n ew Refe rra l s, w h i ch may re q u i re furt h e r eva l u a t i o n. In some cases, the request for a new R e fe rral will need to have Prior Au t h o rization fro m Pa c i fi C a re or your Contracting Medical Gro u p / I PA. Since your Pri m a ry Care Physician is re s p o n s i bl e for the coordination of all of your health care n e e d s, it is important that you notify him or her if you wish to continue to re c e i ve services or Specialist care from a Provider who was affi l i a t e d with your previous Contracting Medical G ro u p / I PA. 22

31 If you think that you need to continue to re c e i ve o n going services or Specialist care from the pri o r C o n t racting Medical Gro u p / I PA, then you should discuss this with your Pri m a ry Care Physician pri o r to the determination to tra n s fe r. If you continue to re c e i ve services or Specialist care without a new Refe rral from your new Pri m a ry Care P hy s i c i a n, you may be fi n a n c i a l ly re s p o n s i ble for the cost of those serv i c e s. In certain circ u m s t a n c e s, Pa c i fi C a re may authorize continued care. S o m e t i m e s, your Pri m a ry Care Physician may be ava i l able through va rious Contracting Medical G ro u p s / I PAs as part of a standard benefit plan or a P rov i d e r - S p e c i fic Benefit Plan. For this info rm a t i o n, you can consult the online Provider dire c t o ry at: w w w. s e c u re h o ri z o n s. c o m, your Pri m a ry Care P hysician or call Customer Serv i c e. When yo u select a Pri m a ry Care Physician it is important to remember this limits you to the netwo rk of Specialists who are affiliated with your Pri m a ry C a re Phy s i c i a n s Contracting Medical Gro u p / I PA. How to Schedule an Appointment With Your Primary Care Physician To schedule an appointment, call your Pri m a ry Care P hy s i c i a n s offi c e. T h e re are no special rules to fo l l ow. Appointments are scheduled according to the type of medical care you are re q u e s t i n g. M e d i c a l conditions re q u i ring more immediate attention are s cheduled sooner. If you have difficulty obtaining an appointment with your Pri m a ry Care Phy s i c i a n, please call Customer Serv i c e. The telephone number for your Pri m a ry Care P hysician and/or Contracting Medical Gro u p / I PA is listed on your membership card. If at all possibl e, please call your Pri m a ry Care P hysician twe n t y - four (24) hours in advance if yo u a re unable to keep a scheduled appointment. How to Receive Care After Hours If you need to talk to or see your Pri m a ry Care P hysician after the office has closed for the day,c a l l your Pri m a ry Care Phy s i c i a n s offi c e. When the p hysician on call re t u rns your call, he or she will advise you on how to pro c e e d. See Section 6 E m e rgency and Urge n t ly Needed Services for what to do in cases of an emerge n c y. How to Receive Covered Services From a Specialist E ven though your Pri m a ry Care Physician is tra i n e d to handle the majority of common health care n e e d s, t h e re may be a time when he or she fe e l s you need more specialized tre a t m e n t. In that case, you may re c e i ve a Refe rral to an appro p ri a t e S p e c i a l i s t. In some cases, the request for a Refe rra l will need to have Prior Au t h o rization fro m Pa c i fi C a re or your Contracting Medical Gro u p / I PA. When you select a Pri m a ry Care Physician it is i m p o rtant to remember this limits you to the n e t wo rk of Specialists who are affiliated with yo u r P ri m a ry Care Phy s i c i a n s Contracting Medical G ro u p / I PA. Neither PacifiCare nor Medicare will pay for your care if you receive services from a Specialist without a Referral or Prior Authorization from your Primary Care P h y s i c i a n, Contracting Medical Gro u p / I PA, or PacifiCare, except for Emergency or U rgently Needed services. O c c a s i o n a l ly,specialists contracting with Pa c i fi C a re a re invo l u n t a ri ly term i n a t e d. Pa c i fi C a re or yo u r C o n t racting Medical Gro u p / I PA will make a go o d faith effo rt to info rm you of your right to maintain your treatment with the Specialist through other ave nues which may include joining a diffe re n t M e d i c a re+choice Coordinated Care Plan or re t u rning to Medicare. Please re fer to the Provider Dire c t o ry for a listing of Secure Horizons Medicare+Choice Plan Specialists ava i l able through your Netwo rk. For a c o py of the most recent Provider Dire c t o ry, or to seek additional assistance,please call Customer S e rvice or you may consult the online Prov i d e r d i re c t o ry at: w w w. s e c u re h o ri z o n s. c o m 23

32 Standing Referrals to Specialists You may re c e i ve a standing Refe rral to a Specialist, if your Pri m a ry Care Physician determ i n e s, i n consultation with the Specialist and yo u r C o n t racting Medical Gro u p s / I PA s Medical Dire c t o r or a Pa c i fi C a re Medical Dire c t o r,that you need c o n t i nuing care from a Specialist. A s t a n d i n g R e fe rra l means a Refe rral by your Pri m a ry Care P hysician for more than one visit to a Specialist as indicated in the treatment plan without the Pri m a ry C a re Physician having to provide a specific Refe rra l for each visit. The standing Refe rral will be made a c c o rding to a treatment plan approved by yo u r C o n t racting Medical Gro u p / I PA or a Pa c i fi C a re Medical Dire c t o r,in consultation with your Pri m a ry C a re Phy s i c i a n, the Specialist, and yo u, if you have a c o m p l ex or serious medical condition or a t reatment plan is otherwise considered necessary. The treatment plan may limit the number of visits to the Specialist or may limit the period of time the visits are authori z e d. The Specialist will prov i d e your Pri m a ry Care Physician with regular re p o rt s on the health care provided to yo u. You may request a standing Refe rral from your Pri m a ry Care P hysician or Specialist. Extended Referral for Coordination of Care by a Specialist If you have a life - t h re a t e n i n g, d e ge n e ra t i ve, o r d i s abling condition or disease that re q u i re s specialized medical care over a pro l o n ged peri o d of time, you may re c e i ve a Refe rral to a Specialist or specialty care center that has ex p e rtise in t reating the condition or disease,for the purpose of h aving the Specialist coordinate your health care with your Pri m a ry Care Phy s i c i a n. To re c e i ve an extended specialty Refe rra l, your Pri m a ry Care P hysician must determ i n e, in consultation with the Specialist or specialty care center and yo u r C o n t racting Medical Gro u p s / I PA s Medical Dire c t o r or a Pa c i fi C a re Medical Dire c t o r, that this ex t e n d e d specialized medical care is Medically Necessary. The extended specialty Refe rral will be made a c c o rding to a treatment plan approved by yo u r C o n t racting Medical Gro u p s / I PA s Medical Dire c t o r or a Pa c i fi C a re Medical Dire c t o r, in consultation with your Pri m a ry Care Phy s i c i a n, the Specialist, and yo u. After the extended specialty Refe rral is made,the Specialist will serve as the main c o o rdinator of your care, subject to the approve d t reatment plan. You may request an ex t e n d e d specialty Refe rral by asking your Pri m a ry Care P hysician or Specialist. Access to OB/GYN Physician Services and Women s Routine and Preventive Health Care Services You may self-re fer to an obstetrical and gy n e c o l o gical (OB/GYN) Specialist within yo u r C o n t racting Medical Gro u p / I PA, for an annu a l routine Pap smear, pelvic exam and breast ex a m. You may re c e i ve these Cove red Services without P rior Au t h o rization or a Refe rral from your Pri m a ry C a re Phy s i c i a n. In all cases, h oweve r, you mu s t re c e i ve Cove red Services from an obstetrical and gy n e c o l o gical (OB/GYN) Specialist within yo u r C o n t racting Medical Gro u p / I PA. If you visit an OB/GYN or fa m i ly practice Specialist not affiliated with your Contracting Medical G ro u p / I PA Netwo rk or without Prior Au t h o ri z a t i o n or a Refe rra l, you will be fi n a n c i a l ly re s p o n s i ble fo r these serv i c e s. A ny OB/GYN inpatient or Hospital s e rv i c e s, except Emergency or Urge n t ly Needed S e rv i c e s, must be Prior Au t h o rized by yo u r C o n t racting Medical Gro u p / I PA or Pa c i fi C a re. To re c e i ve OB/GYN Specialist serv i c e s : Select an OB/GYN Specialist within yo u r C o n t racting Medical Gro u p / I PA. You may select an OB/GYN Specialist from the Prov i d e r D i re c t o ry, v i s i t : w w w. s e c u re h o rizons.com fo r an on-line dire c t o ry,or call Customer Serv i c e for assistance in selecting an OB/GYN within your Contracting Medical Gro u p / I PA. You may also obtain OB/GYN Cove red Services fro m your Pri m a ry Care Phy s i c i a n. Telephone and schedule an appointment with your selected OB/GYN, or Pri m a ry Care P hysician if applicabl e. 24

33 Continuity of Care for Members With Terminating Physicians In the event your Contracting Medical Provider is t e rminated by Pa c i fi C a re or your Contra c t i n g Medical Gro u p / I PA for reasons other than a medical d i s c i p l i n a ry cause, f raud or other criminal activity, you may be eligi ble to continue receiving care fro m your physician fo l l owing the term i n a t i o n, p rov i d i n g the terminated physician agrees to the terms and conditions of the contra c t. C o n t i nued care from the t e rminated physician may be provided for up to ninety (90) day s, or a longer period if Medically N e c e s s a ry, for ch ronic serious or acute conditions or through the post-partum period for pre g n a n c y related conditions or until your care can safe ly be t ra n s fe rred to another phy s i c i a n. This does not a p p ly to physicians who have vo l u n t a ri ly t e rminated their contract with Pa c i fi C a re or a C o n t racting Medical Gro u p / I PA. If you are receiving treatment fo r : an acute condition (such as open surgi c a l wo u n d s, or recent heart attack ) s e rious ch ronic condition (such as ch e m o t h e ra py or radiation thera py ) a high-risk pregnancy (such as multiple bab i e s w h e re there is a high likelihood of c o m p l i c a t i o n s ) p regnancy in the second or third tri m e s t e r and your physician is term i n a t e d, you may request to c o n t i nue receiving treatment from the term i n a t e d p hysician beyond the termination date by calling Customer Serv i c e. Your Contracting Medical G ro u p s / I PA s Medical Director in consultation with your terminated physician will determine the best way to manage your ongoing care. Pa c i fi C a re mu s t p rovide Prior Au t h o rization of services for continu e d c a re. If you have any questions,or would like a copy of Pa c i fi C a re s Continuity of Care Po l i c y, or wo u l d l i ke to appeal a denial of your request fo r c o n t i nuation of services from your term i n a t e d p hy s i c i a n, call Customer Serv i c e. If Pa c i fi C a re terminates the contract with yo u r P ri m a ry Care Phy s i c i a n, S p e c i a l i s t, or Contra c t i n g Medical Gro u p / I PA, you may be eligi ble fo r e n rollment in a Secure Horizons Medicare Supplemental policy on a guaranteed issue basis. For more info rmation or to enro l l, please call Pa c i fi C a re at or (TDHI) , 7:00 a.m. to 7:00 p.m., M o n d ay t h rough Fri d ay. Access to Your Medical Records and Files You have the right to access your medical re c o rd s and fi l e s. Pa c i fi C a re must provide timely access to your re c o rds and any info rmation that pertains to t h e m. Please contact your Contracting Medical P rovider dire c t ly for a copy of your medical re c o rd s. Except as authorized by fe d e ral and State law s, Pa c i fi C a re must obtain written permission from yo u or your authorized re p re s e n t a t i ve befo re medical re c o rds can be made ava i l able to any person not d i re c t ly concerned with your care or re s p o n s i bl e for making payments for the cost of such care. Utilization Review Pa c i fi C a re and its Contracting Medical Gro u p s / I PA s use(s) processes to rev i ew, a p p rove, m o d i f y,d e l ay, or deny, based on Medical Necessity,requests by P rov i d e rs for authorization of the provision of health care services to Members. This process of Utilization Rev i ew (or medical management) is a way to make sure that Members re c e i ve the ri g h t c a re, at the right place, by the right Prov i d e r. Pa c i fi C a re and its Contracting Medical Gro u p s / I PA s m ay also use Utilization Rev i ew cri t e ria or guidelines to determine whether to approve, m o d i f y, d e l ay, or deny,based on Medical Necessity, requests by Prov i d e rs of health care services fo r M e m b e rs. The cri t e ria used as the basis of a decision to modify, d e l ay, or deny requested health c a re services in a specific case under rev i ew, will be d i s closed to the Provider and the Member in that s p e c i fic case. The cri t e ria or guidelines used to d e t e rmine whether to authori z e, m o d i f y,d e l ay, o r d e ny health care services are ava i l able to the publ i c 25

34 upon re q u e s t, limited to the cri t e ria or guidelines for the specific pro c e d u re or condition re q u e s t e d. Decisions to modify,d e l ay, or deny requests fo r a u t h o rization of health care services for a Member, based on Medical Necessity, a re made only by licensed phy s i c i a n s. Pa c i fi C a re and its Contracting Medical Gro u p s / I PA s m a ke these decisions within at least the timefra m e s re q u i red by fe d e ral law or re g u l a t i o n. Please see Section 9 of this Evidence of Cove rage and D i s cl o s u re Info rmation for specific info rm a t i o n re g a rding the timeframes by which Pa c i fi C a re mu s t m a ke a determination (decision) on your re q u e s t for payment or the provision of health care serv i c e s. If you have questions re g a rding Utilization Rev i ew and/or would like a copy of Pa c i fi C a re s policies and pro c e d u res (a description of the pro c e s s e s utilized for authori z a t i o n, m o d i fi c a t i o n, d e l ay, o r denial of health care serv i c e s ), or Pa c i fi C a re cri t e ri a or guidelines, please call Customer Serv i c e. Second Medical Opinions You may request an authorization for a Second Medical Opinion re g a rding the advisability of a p a rticular surge ry, major nonsurgical pro c e d u re or t h e rapeutic pro c e d u re from your Pri m a ry Care P hy s i c i a n. The request will be evaluated by the C o n t racting Medical Gro u p / I PA, (or a Pa c i fi C a re Medical Director as applicable) based on Medical N e c e s s i t y. In some instances, s u ch as when yo u re c e i ve conflicting Fi rst and Second Medical O p i n i o n s, you may request an authorization for a T h i rd Medical Opinion from your Pri m a ry Care P hy s i c i a n. All decisions re g a rding Second Medical Opinions will be re n d e red within the fo l l ow i n g time limits:e m e rgency pro c e d u res within t we n t y - four (24) hours ; u rgent pro c e d u res within seve n t y - t wo (72) hours ; and elective p ro c e d u res within fo u rteen (14) calendar day s. Second Medical Opinions can only be re n d e red by a p hysician qualified to rev i ew and treat the medical condition in question. R e fe rrals to Non-Contra c t i n g Medical Prov i d e rs or Facilities will be approved only when the services requested are not ava i l abl e within the Contracting Medical Prov i d e r s (or Pa c i fi C a re s as appro p riate) netwo rk of Contra c t i n g Medical Prov i d e rs. If the Provider giving the Second Medical Opinion recommends a part i c u l a r t re a t m e n t, d i agnostic test or service cove red by S e c u re Horizons Medicare+Choice Plan and it is M e d i c a l ly Necessary, the tre a t m e n t, d i agnostic test or service will be provided or arra n ged by the M e m b e r s Contracting Medical Gro u p / I PA. If yo u a re denied a Second Medical Opinion,you may appeal the denial by fo l l owing the pro c e d u re s outlined in Section 9, the Appeals Pro c e s s. Pa c i fi C a re has approved pro c e d u res to identify, a s s e s s, and establish treatment plans (including dire c t access visits to Specialists) for Members with c o m p l ex or serious medical conditions. In addition, Pa c i fi C a re will maintain pro c e d u res to make sure that M e m b e rs are info rmed of health care needs which re q u i re fo l l ow-up and re c e i ve training in self-care and other measures to promote their own health. Prior Authorization For a number of elective tre a t m e n t s, s u rge ri e s, a n d d rug thera p i e s, P rior Au t h o rization is re q u i re d. T h e P rior Au t h o rization process is employed to make s u re the requested pro c e d u re is a Cove red Serv i c e and is necessary and appro p riate for the individual M e m b e r s medical situation. The Member s C o n t racting Medical Gro u p / I PA or Pa c i fi C a re medical personnel ch e ck to make sure the Member meets specific pre d e t e rmined medical cri t e ri a, a n d either approve or deny the requested tre a t m e n t based upon the assessment. While Pa c i fi C a re or the Member s Contracting Medical Gro u p / I PA, m ay d e t e rmine the specific requested treatment is not n e c e s s a ry and a more appro p riate thera py is ava i l abl e, nothing pre cludes the Member fro m seeking out and pri va t e ly paying for the re q u e s t e d t re a t m e n t. As a Member you have the right to fi l e an Expedited Appeal or a Standard Appeal when a P rovider denies a requested tre a t m e n t. For furt h e r i n fo rmation on how to file an Ap p e a l, please re fer to Section 9,O rganization Determ i n a t i o n, Appeal and G ri evance Pro c e d u re s. Decisions to deny cove rage because a treatment is not Medically Necessary are made only by licensed phy s i c i a n s. 26

35 Neither PacifiCare nor Medicare will pay for services, pro c e d u res, treatments, surg e r i e s, and/or drug therapies for which Prior Authorization is re q u i red but was not obtained from your Primary Care Physician, Specialist or Contracting Medical Gro u p / I PA, or PacifiCare except for Emergency or U rgently Needed services. Hospitalization If your Pri m a ry Care Physician or Specialist d e t e rmines you re q u i re hospitalization, O u t p a t i e n t S e rv i c e s, Home Health Care or Skilled Nurs i n g C a re, he or she will arra n ge these Cove red Serv i c e s for yo u. C ove rage for Acute Care (re fe rred to in the Member m a t e rials as inpatient Hospital benefits ) consists of M e d i c a l ly Necessary inpatient Hospital serv i c e s a u t h o rized by your Contracting Medical Prov i d e r, i n cluding Hospital ro o m, i n t e n s i ve care, d e fi n i t i ve o b s e rva t i o n,i s o l a t i o n, o p e rating ro o m, re c ove ry ro o m,l abor and delive ry ro o m,l ab o ra t o ry, d i ag n o s t i c and therapeutic ra d i o l o gy,nu clear medicine, p h a rm a c y,inhalation thera py, d i a ly s i s, E K G, E E G, E M G,blood and blood plasma, anesthesia supplies, s u rgi c a l ly implanted devices and implanted bre a s t p rosthesis post mastectomy, nu rsing serv i c e s,a n d p ro fessional ch a rges by the Hospital pathologist or ra d i o l o gi s t, c o o rdinated disch a rge planning and other miscellaneous Hospital ch a rges for Medically N e c e s s a ry care and tre a t m e n t. C ove rage for Acute Care and subacute care incl u d e s M e d i c a l ly Necessary inpatient services authori z e d by your Contracting Medical Provider provided in an Acute Care Hospital, a compre h e n s i ve, f re e - standing acute re h abilitation fa c i l i t y,or a specially designed unit within a Skilled Nursing Fa c i l i t y. With the exception of Emergency or Urge n t ly Needed Serv i c e s, you will only be admitted to those Hospitals; Acute Care, subacute care, t ransitional inpatient care and Skilled Nurs i n g Facilities that are Prior Au t h o rized by yo u r C o n t racting Medical Gro u p / I PA and under c o n t ract with Pa c i fi C a re. You may call Customer Service to request a copy of Pa c i fi C a re s Utilization Rev i ew and Pri o r Au t h o rization processes that apply to care p rovided in subacute care, t ransitional inpatient c a re and Skilled Nursing Fa c i l i t i e s. Pa c i fi C a re s Medical Director or designee d e t e rmines the Hospital or Outpatient Serv i c e s facility designated by Pa c i fi C a re for elective s e rv i c e s. Pa c i fi C a re re s e rves the right to tra n s fe r patients who are stable for tra n s fer to other facilities based upon fa c t o rs which may incl u d e C o n t racting Medical Provider Hospital pri v i l e ge s, c a p abilities of the Hospital, and outcomes. Please note: Pa c i fi C a re will not pay fe d e ra l H o s p i t a l s, s u ch as Ve t e ra n s A d m i n i s t ration (VA ) H o s p i t a l, for Emergency and non-emergency items and services furnished to ve t e ra n s, re t i red military p e rsonnel or eligi ble dependents. H oweve r, Pa c i fi C a re will re i m b u rse Members who are ve t e ra n s, re t i red military personnel or eligi bl e dependents for any Copayments or Coinsura n c e paid to the VA Hospitals for Emergency Serv i c e s, u p to the amount of the Secure Hori z o n s M e d i c a re+choice Plan Emergency Serv i c e s C o p ay m e n t. For Members who are not eligi ble fo r VA benefi t s, Pa c i fi C a re will cover emerge n c y,u rge n t and post-stabilization care provided by a VA fa c i l i t y ; these services are considered out-of-netwo rk. Please re fer to the Schedule of Benefits for furt h e r d e t a i l s. ( B e n e fits and Exclusions applicable to G roup Retiree Members may be found in the R e t i ree Benefit Summary rather than the Sch e d u l e of Benefi t s. ) ( For Members in Santa Clara, San Mateo, S t a n i s l a u s, A l a m e d a, C o n t ra Costa, Fresno and Madera Counties who are enrolled in Standard Plan I and M e m b e rs enrolled in the Value Plan in Los A n ge l e s C o u n t y, a u t h o rized Inpatient Hospital Services are ava i l able at Select and Standard Hospitals. S e l e c t Hospitals are listed in the Schedule of Benefits and in the Summary of Benefi t s. Please call Customer S e rvice if you have questions re g a rding Select and S t a n d a rd Hospitals. 27

36 If you are admitted to your Select Netwo rk H o s p i t a l, a Copayment will be due to the fa c i l i t y. I f you are admitted to a Standard Netwo rk Hospital,a higher Copayment will be due to the fa c i l i t y. If yo u a re admitted to a non-netwo rk Hospital on an e m e rgency or authorized basis,a higher Copay m e n t (the same as the Standard Netwo rk Hospital C o p ayment) will be due to the fa c i l i t y. Please see the Schedule of Benefits for info rmation re g a rd i n g t ra n s fe rs between Select and Standard Hospitals. Select Hospitals are facilities that, within a specifi c ge o graphic Service A re a, p rovide services with favo rable financial terms to Pa c i fi C a re and the M e m b e rs. When Members re c e i ve Hospital care at a Select Hospital,t h ey share in savings that the Select Hospital prov i d e s. S t a n d a rd Hospitals are all N e t wo rk Hospitals within a specific Service A re a that are not designated as Select Hospitals. All Secure Horizons Medicare+Choice Plan N e t wo rk Hospitals have met Pa c i fi C a re s c redentialing standard s. A Hospital s Select or S t a n d a rd designation depends on nu m e ro u s fa c t o rs. Select status does not re fl e c t, e i t h e r p o s i t i ve ly or negative ly,the quality of the Hospital s s e rv i c e. Please see the Schedule of Benefits fo r m o re info rm a t i o n. ) Hospital Copayments and Benefit Periods Inpatient Hospital care Copayments are ch a rge d for each Hospital Stay. Once you are disch a rge d f rom a Hospital,a ny subsequent Hospital a d m i s s i o n s, even for the same medical condition at the same Hospital, will re q u i re a Hospital C o p ay m e n t. In certain circ u m s t a n c e s, you may be d i s ch a rged from a Hospital and tra n s fe rred to a Skilled Nursing Care unit or transitional care unit within the same Hospital. If you are later re - admitted to the Hospital from the Skilled Nurs i n g C a re unit or transitional care unit,you will pay the Hospital Copay m e n t. O ri ginal Medicare Hospital B e n e fit Pe riods do not apply. For inpatient Hospital c a re, you are cove red for an unlimited number of d ays as long as the Hospital Stay is medically n e c e s s a ry and authorized by Pa c i fi C a re or c o n t racting Prov i d e rs. Hospitalist When you are admitted to a Hospital,a Hospitalist m ay coordinate your inpatient care. H o s p i t a l i s t s a re physicians who are specially trained to care fo r patients who are acutely ill in the Hospital,and are re s p o n s i ble for coordinating all aspects of yo u r Hospital care. T h ey remain in the Hospital and are ava i l able to react should your condition ch a n ge. This allows your Pri m a ry Care Physician to c o n t i nue to see other patients in his or her offi c e while you are Hospitalized. Hospitalists collect and manage all info rmation related to yo u r condition and tre a t m e n t, and communicate with yo u, your fa m i ly,and your Pri m a ry Care Phy s i c i a n t h roughout your Hospital Stay. Hospitalists wo rk t o gether with your Pri m a ry Care Physician duri n g the course of your stay and to transition your care upon disch a rge. Upon disch a rge, your Pri m a ry C a re Physician will again assume coordination of your care. Skilled Nursing Facility (SNF) Care S e c u re Horizons Medicare+Choice Plan cove rs M e d i c a l ly Necessary inpatient Skilled Nursing Care and services in a Medicare - c e rt i fied Skilled Nurs i n g Facility under contract with Pa c i fi C a re. For a list of Skilled Nursing Facility serv i c e s, please see the S chedule of Benefi t s. Skilled Nursing Care is c ove red if the Member re q u i res Skilled Nurs i n g C a re services or skilled re h abilitation services on a d a i ly basis and these skilled services can be p rovided only on an inpatient basis in a Skilled N u rsing Fa c i l i t y. Inpatient stays solely to prov i d e Custodial Care are not cove re d. M e m b e rs may be able to re c e i ve Skilled Nurs i n g C a re from a Skilled Nursing Facility that is not under contract with Pa c i fi C a re. Pa c i fi C a re may be able to arra n ge for a Member to re c e i ve Skilled N u rsing Care from one of the fo l l owing fa c i l i t i e s ( Home Skilled Nursing Fa c i l i t y ) : A nu rsing home or continuing care re t i rement community where the Member was living prior to the Hospital admission (as long as the facility provides Skilled N u rsing Care) or in a Skilled Nursing Fa c i l i t y w h e re the Member s spouse resides at the time of 28

37 the Member s Hospital disch a rge. In order to access these serv i c e s, the Skilled Nursing Fa c i l i t y that is not under contract with Pa c i fi C a re must be willing to accept Pa c i fi C a re s rates for pay m e n t. Ambulance S e c u re Horizons Medicare+Choice Plan cove rs M e d i c a l ly Necessary ambulance services fo r E m e rgency or Urge n t ly Needed Services or when a u t h o rized by Pa c i fi C a re or its designee, a c c o rd i n g to Medicare guidelines. S e c u re Hori z o n s M e d i c a re+choice Plan will not cover a m b u l a n c e s e rvices that are : 1. Member initiated for social or conve n i e n c e reasons not pri m a ri ly medical in nature, i n cl u d i n g, but not limited to, ch a n ging to a d i ffe rent Contracting Medical Gro u p / I PA, m oving to be closer to fa m i ly, and tra n s fe rri n g f rom one nu rsing facility to another, while an inpatient in an acute, p s y ch i a t ric or nu rs i n g fa c i l i t y. 2. From a contracting facility to another c o n t racting fa c i l i t y, unless the tra n s fer is n e c e s s a ry to deliver medical services not ava i l able at the fi rst facility or authorized by Pa c i fi C a re. Home Health Care Services If your Pri m a ry Care Physician or Specialist d e t e rmines that you re q u i re Home Health Care, h e or she will arra n ge these Cove red Services for yo u. In order to qualify for home health benefi t s, a n individual must be confined to his or her home, b e under a plan of treatment rev i ewed and approve d by a phy s i c i a n, and re q u i re a Medically Necessary qualifying skilled serv i c e. C ove red Home Health Services for those who q u a l i f y m ay incl u d e : p a rt-time or interm i t t e n t skilled nu rsing and home health aide serv i c e s, p hysical and occupational thera py and speech p a t h o l o gy serv i c e s, medical social serv i c e s, m e d i c a l s u p p l i e s, and Durable Medical Equipment (such as w h e e l ch a i rs, hospital beds, ox y ge n, wa l ke rs ). When you qualify for cove rage of Home Health S e rv i c e s, S e c u re Horizons Medicare+Choice Plan c ove rs either part-time or intermittent skilled nu rsing and home health aide services in a c c o rdance with Medicare guidelines. Pa rt-time or i n t e rmittent means any number of days per we e k up to twenty-eight (28) hours per week of skilled nu rsing and home health aide services combined for less than eight (8) hours per day,based upon the re a s o n able need for such care. S e c u re Hori z o n s M e d i c a re+choice Plan may cove r,subject to rev i ew on a case-by-case basis depending on the need fo r s u ch care, t h i rt y - fi ve (35) or fewer hours per we e k of skilled nu rsing and home health aide serv i c e s combined for less than eight (8) hours per day. A homebound Member has re s t ricted ab i l i t y,due to an illness or injury, to leave home without assistance of another person or aid of a support i ve d evice (such as cru t ch e s, a cane, a wheelchair or a wa l ke r ), or if leaving the home is contra i n d i c a t e d. You do not have to be bedridden in order to be c o n s i d e red confined to the home. H oweve r,yo u r condition should be such that there exists a norm a l i n ability to leave the home, and consequently, l e aving the home would re q u i re a considerable and taxing effo rt. If you leave the home,you may be c o n s i d e red homebound if the absences from the home are infrequent or for periods of re l a t i ve ly s h o rt dura t i o n, or to re c e i ve medical tre a t m e n t, i n cluding regular absences for the purpose of p a rticipating in thera p e u t i c, p s y chosocial or medical treatment in an adult day - c a re pro gra m that is licensed or cert i fied by the State, or to attend re l i gious serv i c e s. Home health services do not include the costs of houseke e p e rs, food serv i c e a rra n ge m e n t s, or full-time nu rsing care at home. Hospice Hospice provides palliative serv i c e. It is based on the philosophy that eve ryone has the right to spend his or her remaining days in peace and with d i g n i t y. Hospice focuses on comfo rt, dignity and pain contro l, responding to the symptoms, n e e d s and goals of patients and fa m i l i e s. Hospice is dedicated to helping the term i n a l ly ill live each day 29

38 to the fullest throughout the dying pro c e s s, a n d s u p p o rting them to be with their fa m i ly and f riends in a home setting if they wish. In order to access Hospice care, M e m b e rs mu s t elect Hospice care under Medicare. Upon making this election,all care related to the terminal illness will be provided by the Medicare - c e rt i fied Hospice, w h i ch is billed dire c t ly to Medicare. You may remain enrolled in Secure Hori z o n s M e d i c a re+choice Plan even if you elect Medicare - c e rt i fied Hospice cove rage for your term i n a l c o n d i t i o n. Pa c i fi C a re will continue to arra n ge c ove rage of non-medicare related benefits which a re not related to your Medicare Hospice benefi t s. As a Secure Horizons Medicare+Choice Plan M e m b e r, you have the right to obtain info rm a t i o n about all ava i l able Medicare - c e rt i fied Hospice P rov i d e rs. For more info rmation re g a rding electing Hospice care, i n cluding those Hospice facilities that h ave an agreement with your Contracting Medical G ro u p / I PA, please call Customer Serv i c e. Clinical Trials and Other Medicare Benefits If you participate as a patient in a clinical trial that meets Medicare re q u i re m e n t s, M e d i c a re cove rs routine costs of qualifying clinical tri a l s. C l i n i c a l t rials are not a Secure Horizons Medicare + C h o i c e Plan Cove red Serv i c e. If you join a clinical tri a l, yo u will be re s p o n s i ble for any Coinsurance under M e d i c a re. When you enroll in a clinical tri a l, the Prov i d e rs are paid dire c t ly by Medicare for all the Cove re d S e rvices you re c e i ve. The clinical trial Prov i d e rs do not have to be Contracting Medical Prov i d e rs. This means you do not need to obtain a Refe rral to join a clinical tri a l. H oweve r, you should info rm Pa c i fi C a re befo re you begin a clinical tri a l. T h i s a l l ows Pa c i fi C a re to continue to keep tra ck of yo u r health care serv i c e s. You may remain enrolled in S e c u re Horizons Medicare+Choice Plan even if yo u elect to participate in a clinical tri a l. Your care u n related to the clinical trial must continue to be a rra n ged by Pa c i fi C a re. The Medicare pro gram has w ritten a booklet about M e d i c a re and Clinical Tri a l s. To get a free copy, call MEDICARE ( ) or visit www. M e d i c a re. gov on the we b. E ffe c t i ve Ja nu a ry 1, , M e d i c a re now cove rs lung volume reduction surge ry (LV R S ). LVRS is not a Secure Horizons Medicare+Choice Plan Cove re d S e rv i c e. If you have LV R S, you will be re s p o n s i bl e for any Coinsurance under Medicare. To re c e i ve i n fo rmation on LVRS centers for Medicare, c o n t a c t M e d i c a re at MEDICARE ( ) or visit www. M e d i c a re. gov. A d d i t i o n a l ly, e ffe c t i ve October 1, , M e d i c a re cove rs ve n t ricular assist d evices (VA D s ). VADs are not a Secure Hori z o n s M e d i c a re+choice Plan Cove red Serv i c e, but yo u r c a re must be coordinated by your Pri m a ry Care P hy s i c i a n. If you get a VA D, you will be re s p o n s i bl e for any Coinsurance under Medicare. Religious Non-medical Health Care Institutions (RNHCIs) Care Care in a Medicare-certified Religious Nonmedical Health Care Institution (RNHCI) is covered by PacifiCare under certain conditions. Covered Services in a RNHCI are limited to nonreligious aspects of care. To be eligible for Covered Services in a RNHCI, you must have a medical condition that would allow you to receive inpatient Hospital care or extended care services, or care in a Home Health agency. You may get services when furnished in the home, but only items and services ordinarily furnished by Home Health agencies that are not RNHCIs. In addition, you must sign a legal document that says you are conscientiously opposed to the acceptance of non-excepted medical treatment. ( Excepted medical treatment is medical care or treatment that you receive involuntarily or that is required under federal, State or local law. Non-excepted medical treatment is any other medical care or treatment.) You must also get authorization (approval) in advance from PacifiCare, or your stay in the RNHCI may not be covered. 30

39 Organ Transplants 1. O rgan Transplant Definitions D o n o r : A person who undergoes a surgi c a l p ro c e d u re for the purpose of donating either a b o dy organ or body tissue for tra n s p l a n t p ro c e d u re s. Histocompatibility Te s t i n g : Testing that i nvo l ves matching or typing of the human l e u kocyte antigen in pre p a ration for organ or tissue tra n s p l a n t. P a c i f i C a re National Pre f e r red Tr a n s p l a n t Network facility: A netwo rk of tra n s p l a n t facilities that are licensed in the State in which t h ey opera t e, c e rt i fied by Medicare as a t ransplant facility for a specific org a n t ra n s p l a n t, and satisfy Pa c i fi C a re s quality of c a re standard s, to be designated by Pa c i fi C a re as a transplant facility for a specific org a n p ro gra m. Pa c i fi C a re National Pre fe rre d Transplant Netwo rk Facilities may be located outside the Service A rea based on a number of fa c t o rs including quality, c o s t, and outcomes. Regional Organ Pro c u rement Agency: An organization designated by the fe d e ra l gove rnment and re s p o n s i ble for the p ro c u rement of organs for transplantation and the promotion of organ donation. 2. Transplant Services Human organ and tissue transplants are limited to n o n - ex p e ri m e n t a l / n o n - i nvestigational pro c e d u re s that are determined to be Medically Necessary. C ove rage is provided for the medical, s u rgical and Hospital services re q u i red for pre - t ra n s p l a n t, t ransplant and post-tra n s p l a n t. All tra n s p l a n t p ro c e d u res must be perfo rmed by approve d Pa c i fi C a re National Pre fe rred Transplant Netwo rk Fa c i l i t i e s. Examples of cove red tra n s p l a n t s e rvices incl u d e : H e a rt tra n s p l a n t s Lung tra n s p l a n t s H e a rt/lung tra n s p l a n t s L i ve r K i d n ey tra n s p l a n t s S i multaneous pancre a s / k i d n ey transplants Pa n c reas transplant after kidney tra n s p l a n t Intestinal and mu l t i v i s c e ral tra n s p l a n t s C o rnea transplants (not part of Pre fe rre d Transplant Pro gra m ) A l l o geneic bone marrow or stem cell tra n s p l a n t Au t o l o gous bone marrow or stem cell t ra n s p l a n t Pa c i fi C a re shall interm i t t e n t ly rev i ew new d evelopments in medical tech n o l o gy based on s c i e n t i fic evidence to determine if the list of c ove red transplants should be rev i s e d. Bone Marrow and Stem Cell Tra n s p l a n t s : T h e testing of immediate blood re l a t i ves to determ i n e compatibility of bone marrow and stem cells is limited to sisters, b ro t h e rs, p a rents and natura l ch i l d re n. The testing for compatible unre l a t e d d o n o rs and costs for computerized national and i n t e rnational searches for unrelated alloge n e i c bone marrow or stem cell donors conducted t h rough a re gi s t ry are cove red when the Member is the intended re c i p i e n t. An approved Pa c i fi C a re National Pre fe rred Transplant Netwo rk facility mu s t conduct the computerized search e s. T h e re is no dollar limitation for Medically Necessary donor related clinical transplant services once a donor is identifi e d. 3. O rgan Pro c u rement, Transplant and Transplant Services C ove rage of services shall incl u d e : P re - t ransplant testing and eva l u a t i o n, i n cl u d i n g histocompatibility testing of tra n s p l a n t recipient and non-related or related donor O rgan pro c u rement from cadaver or live donor and organ tra n s p o rt a t i o n. C ove red Services fo r living donor are limited to Medically Necessary s e rvices once a donor is identifi e d 31

40 O ral or dental examination perfo rmed on an inpatient basis as part of compre h e n s i ve evaluation wo rk-up prior to tra n s p l a n t p ro c e d u re When the transplant recipient is a Secure H o rizons Medicare+Choice Plan Member, re a s o n able and necessary Hospital services of the donor solely for the transplant pro c e d u re a re cove red (the donor does not need to be a S e c u re Horizons Medicare+Choice Plan M e m b e r ) S e rvices and/or ch a rges related to a national donor search O u t p a t i e n t, p o s t - t ra n s p l a n t, i m mu n o s u p p re s s i ve d rug thera py (Please see your Schedule of B e n e fi t s. ) R e a s o n able tra n s p o rtation and lodging fo r t ransplant recipient and one person escort d e t e rmined by transplant facility and/or Pa c i fi C a re. Tra n s p o rtation and non-cl i n i c a l expenses of the living donor are ex cluded and a re the responsibility of the Member,who is the recipient of the tra n s p l a n t 4. Prior Authorization C ove rage for transplant services must be a u t h o rized by Pa c i fi C a re prior to tra n s p l a n t evaluation and prior to listing and must be p e r fo rmed at a Pa c i fi C a re National Pre fe rre d Transplant Netwo rk fa c i l i t y, w h i ch may be located outside the Service A rea based on a number of fa c t o rs including quality, cost and outcomes. N ew M e m b e rs, a l re a dy listed at a non-pa c i fi C a re National P re fe rred Transplant Netwo rk fa c i l i t y, will be evaluated for continuity of care. Pa c i fi C a re re q u i re s t h i rty (30) days to obtain and rev i ew re l eva n t clinical info rm a t i o n. Transplant benefits are ava i l able only where a facility designated by Pa c i fi C a re is utilized and the Member is a re c i p i e n t of the tra n s p l a n t. The Pa c i fi C a re National Pre fe rred Tra n s p l a n t facilities that may be ava i l able to Secure Hori z o n s M e d i c a re+choice Plan Members are the fo l l ow i n g : Northern California B M T Heart Kidney Kidney/ Pa n c re a s, Liver Heart/ L u n g, L u n g Southern California All t ra n s p l a n t s except Heart/ Lung Heart/ Lung San Diego All t ra n s p l a n t s except Heart/ Lung Heart/ Lung S t a n fo rd Unive rsity Medical Center, Alta Bates Medical Center S t a n fo rd Unive rsity Medical Center, Sutter Memorial Hospital Sacramento S t a n fo rd Unive rsity Medical Center, Sutter Memorial Hospital Sacramento, California Pacific Medical Center S t a n fo rd Unive rs i t y Medical Center, California Pacific Medical Center S t a n fo rd Unive rs i t y Medical Center St Vincent Medical Center, USC Medical Center, UCLA Medical Center, Loma Linda University Medical Center Stanford University Medical Center UCSD Medical Center Stanford University Medical Center Please note: Pa c i fi C a re evaluates each tra n s p l a n t case to determine the appro p riate tra n s p l a n t facility for each Member. Pa c i fi C a re will select a t ransplant facility within the ab ove National P re fe rred Transplant Netwo rk based on the medical needs of the Member in consultation with the 32

41 M e m b e r s treating physician and Pa c i fi C a re s Transplant Medical Dire c t o r. Notwithstanding the fo re go i n g, Pa c i fi C a re re s e rves the right to utilize a l t e rn a t i ve transplant facilities as authorized by Pa c i fi C a re. 5. Continuity and Coordination of Care Pa c i fi C a re s Centralized Transplant Unit (CTU) will c o n t i nu a l ly wo rk cl o s e ly with the Member, t h e Member's fa m i ly, the Member s treating phy s i c i a n s and facilities to monitor the continuity and c o o rdination of services during the pre - t ra n s p l a n t eva l u a t i o n, t ransplant hospitalization, and postt ransplant fo l l ow-up care. This incl u d e s, but is not limited to, rev i ewing requests from Pri m a ry Care P hy s i c i a n s / t reating physician for tra n s p l a n t s e rv i c e s, facilitating placement on National P re fe rred Transplant Netwo rk (NPTN) Fa c i l i t y waiting lists, and coordinating post-tra n s p l a n t s e rv i c e s. Fo l l owing a determination by Pa c i fi C a re s CTU and the NPTN facility that a Member is a candidate for a tra n s p l a n t, the Member will be placed on the t ransplant waiting list of the NPTN fa c i l i t y. Fo r M e m b e rs who re c e i ve transplant services from a NPTN facility outside of the Service A re a, Pa c i fi C a re will wo rk cl o s e ly with the Member,the NPTN fa c i l i t y,and the Member s Pri m a ry Care P hy s i c i a n / t reating physician to coordinate travel to the NPTN fa c i l i t y, as appro p riate and at no ex p e n s e to the Member. Fo l l owing transplant and the stabilization of the M e m b e r, Pa c i fi C a re s CTU will coordinate postt ransplant services between the NPTN Facility and the Member's Pri m a ry Care Phy s i c i a n / t re a t i n g p hy s i c i a n. Depending on the NPTN fa c i l i t y, t h e Member may re c e i ve post-transplant serv i c e s l o c a l ly or the Member may be re q u i red to trave l outside of the Service A re a. If the Member is re q u i red to travel outside the Service A re a, Pa c i fi C a re will coordinate travel as appro p riate at no expense to the Member. 6. Continuity of Care Listing of the Member at a second Pa c i fi C a re National Pre fe rred Transplant Netwo rk facility is ex cl u d e d, unless the Regional Organ Pro c u re m e n t A gencies are diffe rent for the two facilities and the Member is accepted for listing by both fa c i l i t i e s, when associated with continuity of care. If the Member is dual listed, his or her cove rage is limited to the actual transplant fa c i l i t y. Pa c i fi C a re will c o l l ab o rate with the Member to determine what t ransplant facility he or she should be re fe rred to. Duplicated diagnostic costs at a second Pa c i fi C a re National Pre fe rred Transplant Netwo rk fa c i l i t y when the Member has alre a dy been evaluated at a Pa c i fi C a re National Pre fe rred Transplant Netwo rk fa c i l i t y, will be determined on a case-by-case basis when associated with continuity of care, h a rd s h i p or Medically Necessary as defined by Pa c i fi C a re t ransplant policy. 7. Case Management and Medical Management Pa c i fi C a re shall establish and maintain rev i ew p ro c e d u res and screening cri t e ria based on s c i e n t i fic ev i d e n c e. Pa c i fi C a re s Case Manage m e n t p ro gram will serve the needs of all Members in t e rms of: C o o rdination of care Patient advo c a c y Liaison for accurate claims pay m e n t Payment of all services will be contingent upon Pa c i fi C a re s Case Management rev i ew and Pri o r Au t h o rization pro c e s s. 8. Exclusions and Limitations Equipment and medication that is ex p e ri m e n t a l / i nvestigational and/or not M e d i c a l ly Necessary unless re q u i red by an ex t e rnal Independent Rev i ew Panel (CHDR). U n a u t h o rized or not Prior Au t h o rized org a n p ro c u rement and transplant related services are not cove re d. 33

42 Transplants perfo rmed in a non-pa c i fi C a re National Pre fe rred Transplant Netwo rk fa c i l i t y a re not cove re d. Transplant serv i c e s, i n cluding donor costs, when the transplant recipient is not a Member a re not cove re d. A rt i ficial or non-human organs are not cove re d. Tra n s p o rtation services for any day a Member is not receiving Medically Necessary tra n s p l a n t s e rv i c e s. Tra n s p o rtation of any potential donor fo r typing and matching are not cove re d. Tra n s p o rtation provided for the Member and one person escort to a Pa c i fi C a re National P re fe rred Transplant fa c i l i t y, if the facility is greater than 60 (sixty) miles from the M e m b e r s pri m a ry re s i d e n c e, or out-of-state, re g a rdless of mileage, as Prior Au t h o ri z e d. Food and housing will be provided for the Member and one escort and is limited to $125 per day (ex cludes liquor and tobacco). Food and housing for any day a Member is not receiving Medically Necessary tra n s p l a n t s e rv i c e s. S t o rage costs for any organ or bone marrow are not cove red unless authorized by the Pa c i fi C a re Transplant Medical Dire c t o r. S e rvices for which gove rnment funding or other i n s u rance cove rage is ava i l able are not cove re d. Behavioral Health Services If you would like to re c e i ve a Refe rral fo r b e h av i o ral health serv i c e s, please contact yo u r P ri m a ry Care Physician or Contracting Medical G ro u p / I PA. Au t h o rized behav i o ral health serv i c e s will be provided for a specific number of visits fo r a specific period of time. If you ch a n ge your Pri m a ry Care Physician to one who is in a diffe rent Contracting Medical G ro u p / I PA, a ny Refe rrals for behav i o ral health s e rvices that you prev i o u s ly re c e i ved may no l o n ger be va l i d. In this situation, you will need to ask your new Pri m a ry Care Physician for a new R e fe rra l, w h i ch may re q u i re further eva l u a t i o n. I n some cases, the request for a new Refe rral will need to have Prior Au t h o rization from yo u r C o n t racting Medical Gro u p / I PA or Pa c i fi C a re. Since your Pri m a ry Care Physician is re s p o n s i bl e for the coordination of all of your health care n e e d s, it is important that you notify him or her if you wish to continue to re c e i ve behav i o ral health s e rvices from a Provider who was affiliated with your previous Pri m a ry Care Physician or C o n t racting Medical Gro u p / I PA. If you continue to re c e i ve behav i o ral health s e rvices without a new Refe rral from your new P ri m a ry Care Phy s i c i a n, you may be fi n a n c i a l ly re s p o n s i ble for the cost of those serv i c e s. In cert a i n c i rc u m s t a n c e s, Pa c i fi C a re may authorize continu e d c a re. In the event of a behav i o ral health emerge n c y, go to the closest emergency room or call 911. Pa c i fi C a re will cover Emergency Services whether you are in or out of the Service A re a. A m b u l a n c e S e rvices dispatched through 911 are only cove re d if tra n s p o rtation in any other ve h i cle could e n d a n ger your life. E m e rgency Services are c ove red whether or not a Contracting Medical P rovider provides them. It is important to notify your Pri m a ry Care Physician or Pa c i fi C a re within fo rty-eight (48) hours or as soon as is re a s o n ably p o s s i ble of a Behav i o ral Health Medical Emerge n c y, so that your Pri m a ry Care Physician or Pa c i fi C a re can be invo l ved in the management of your health c a re. (Please see Section 6 for more info rm a t i o n re g a rding Emergency and Urge n t ly Needed S e rvices.) 34

43 Section 6 E m e rgency and Urg e n t ly Needed Service s Emergency Services - Prior Authorization for treatment of Medical Emergencies is not required. What To Do in an Emergency In the event of a Medical Emerge n c y,go to the closest emergency room or call 911 for assistance. Pa c i fi C a re will cover Emergency Services whether you are in or out of the Service A re a. A m b u l a n c e s e rvices dispatched through 911 are only cove red if tra n s p o rtation in any other ve h i cle could e n d a n ger your life. You need to have someone telephone your Pri m a ry Care Physician or Pa c i fi C a re at the number listed on your Secure H o rizons Medicare+Choice Plan membership card as soon as re a s o n ably possibl e. S e c u re Hori z o n s M e d i c a re + C h o i c e Plan offe rs wo r l dw i d e e m e rgency cove rage. Emergency Services are covered inpatient or outpatient services that are: 1. furnished by a Provider qualified to furnish Emergency Services, and 2. needed to evaluate or stabilize a Medical Emergency. A Medical Emergency is a medical condition m a n i festing itself by acute symptoms of suffi c i e n t s eve rity (including seve re pain) such that a p rudent lay p e rs o n, with an ave rage know l e d ge of health and medicine, could re a s o n ably ex p e c t the absence of immediate medical attention to result in: 1. s e rious jeopardy to the health of the individual o r, in the case of a pregnant wo m a n, the health of the woman or her unborn ch i l d 2. s e rious impairment to bodily functions,or 3. s e rious dysfunction of any bodily organ or part. E m e rgency Services are cove red whether or not a C o n t racting Medical Provider provides them. It is i m p o rtant to notify your Pri m a ry Care Physician or Pa c i fi C a re of a Medical Emergency so your Pri m a ry C a re Physician or Pa c i fi C a re can be invo l ved in the m a n agement of your health care. If the Medical E m e rgency re q u i res that you be admitted to an inpatient Hospital, it is important that you notify your Pri m a ry Care Physician or Pa c i fi C a re so that a t ra n s fer can be arra n ged when your medical condition is stable (as determined by your tre a t i n g p hy s i c i a n ). Please contact your Pri m a ry Care P hysician or Pa c i fi C a re at the number located on your membership card within fo rty-eight (48) h o u rs or as soon as re a s o n ably possibl e. If you have a Medical Emergency while out of the S e rvice A re a, Pa c i fi C a re pre fe rs that you re t u rn to the Service A rea to re c e i ve fo l l ow-up care thro u g h your Pri m a ry Care Phy s i c i a n. H oweve r, after yo u h ave been treated for your condition,fo l l ow - u p c a re will be cove red out of the Service A rea as long as the care re q u i red continues to meet the d e finition for either Emergency Services or U rge n t ly Needed Serv i c e s. If you have a Medical Emergency within the S e rvice A re a, you should contact your Pri m a ry Care P hysician or Contracting Medical Gro u p / I PA or Pa c i fi C a re within fo rty-eight (48) hours or as soon as re a s o n ably possible after the emerge n c y, so he or she can arra n ge for your fo l l ow-up care. Post-Stabilization Care M e d i c a l ly Necessary, n o n - e m e rgency serv i c e s fo l l owing receipt of emergency care to enable yo u to remain stabilized are cove re d : when Pa c i fi C a re or its Contracting Medical Prov i d e rs provide Pri o r Au t h o rization for such serv i c e s ; when Pa c i fi C a re or its Contracting Medical Prov i d e rs do not re s p o n d within one (1) hour to a request for a Pri o r Au t h o rization from a Non-Contracting Provider or Fa c i l i t y ; or when Pa c i fi C a re or its Contra c t i n g Medical Prov i d e rs could not be contacted for Pri o r Au t h o ri z a t i o n. 35

44 C ove rage for post-stabilization care provided by a N o n - C o n t racting Provider continues to be effe c t i ve until one of the fo l l ow i n g : You are disch a rge d A Contracting Medical Provider arri ves and assumes responsibility for your care The Non-Contracting Provider and Pa c i fi C a re agree to other arra n ge m e n t s A Contracting Medical Provider assumes responsibility for your care through the tra n s fe r to a contracting fa c i l i t y Urgently Needed Services S e c u re Horizons Medicare+Choice Plan also cove rs U rge n t ly Needed Serv i c e s. U rgently Needed Services are Covered Services provided when you are temporarily* absent from the are a served by your Primary Care Physician or Contracting Medical Gro u p / I PA (or, under unusual and extraordinary circumstances, you a re in the Service Area but your Contracting Medical Gro u p / I PA is temporarily unavailable or inaccessible), when such services are Medically Necessary and immediately re q u i re d : as a result of an unforeseen illness, injury, or condition, and it is not reasonable, given the c i rcumstances, to obtain the services t h rough your Primary Care Physician. *A tempora ry absence is an absence from the S e rvice A rea lasting not more than six (6) months and it is not a permanent move. If such a medical need ari s e s, Pa c i fi C a re re q u e s t s that if possibl e, you fi rst contact your Pri m a ry Care P hysician or Pa c i fi C a re, then seek care from a local d o c t o r. If this is not possibl e, you may seek care f rom a Hospital emergency room or other medical fa c i l i t y. If you must visit a Provider or a Hospital emerge n c y room for Urge n t ly Needed Services when outside the Service A re a, you should contact your Pri m a ry C a re Physician or Contracting Medical Gro u p / I PA or Pa c i fi C a re within fo rty-eight (48) hours or as soon as re a s o n ably possibl e, so that Pa c i fi C a re can be i nvo l ved in the management of your care. W h i l e Pa c i fi C a re pre fe rs you re t u rn to the Service A rea and re c e i ve fo l l ow-up care through your Pri m a ry Care P hy s i c i a n, fo l l ow-up care will be cove red out of the S e rvice A rea when the care re q u i red continues to meet the ab ove definition of Urge n t ly Needed S e rv i c e s. If you receive services without Prior Authorization, except for Emergency Services, U rgently Needed Services, out-of-area and routine travel renal dialysis, or services for which PacifiCare allows you to self-refer to Contracting Providers, neither PacifiCare nor M e d i c a re will pay for those services. When You Need Urgent Care and You Are in Your Service Area M a ny Contracting Medical Prov i d e rs have on-site u rgent care centers. M a ny of these centers have extended hours and do not re q u i re appointments. Pa c i fi C a re encourages you to take adva n t age of this c o nvenience in an urgent medical situation. If you need urgent medical care within your Serv i c e A re a : 1. Call your Contracting Medical Gro u p / I PA or P ri m a ry Care Phy s i c i a n s office at the nu m b e r listed on your membership card. 2. Identify yo u rself as a Secure Hori z o n s M e d i c a re+choice Plan Member and let them k n ow you feel you need immediate medical a t t e n t i o n. 3. Fo l l ow any fi rst aid instructions provided (yo u m ay be advised to go to your Provider or to a n e a r by Hospital). All Contracting Medical Gro u p s / I PAs have a 24-hour emergency nu m b e r. I f,for any re a s o n, you are unable to re a ch your Contracting Medical P rov i d e r,fo l l ow the steps for out-of-area Urge n t ly 36

45 Needed Services as prev i o u s ly descri b e d. Fo l l ow - u p medical care must be re c e i ved or authorized by your Pri m a ry Care Physician or Contracting Medical G ro u p / I PA. Reimbursement for Services Paid by Member P rov i d e rs should submit bills to Pa c i fi C a re fo r p ay m e n t. H oweve r, if you paid for any Emerge n c y S e rvices or Urge n t ly Needed Services or e m e rgency out-of-area and routine travel dialy s i s obtained from Non-Contracting Medical Prov i d e rs, you should submit your bills to Pa c i fi C a re for a p ayment determ i n a t i o n. Bills should be submitted to the fo l l owing addre s s : Pa c i fi C a re Claims Depart m e n t P. O. B ox 489 C y p re s s, CA If you have questions about any bills, c o n t a c t Customer Serv i c e. Right to Appeal Pa c i fi C a re provides you with a written notice if a s e rvice or payment is denied. If Pa c i fi C a re has denied payment for services you think should have been cove re d, or if Pa c i fi C a re refused to arra n ge fo r s e rvices that you believe are cove red by Medicare, you have the right to appeal. If you think wa i t i n g for a decision about authorization for a serv i c e could seri o u s ly harm your health, you may re q u e s t an Expedited Appeal (Please see Section 9). Section 7 P remiums and Pa y m e n t s As a Member of Secure Horizons Medicare + C h o i c e P l a n, you will be fi n a n c i a l ly re s p o n s i ble for the Health Plan Pre m i u m s, C o p ayments and C o i n s u ra n c e amounts that are listed in the S chedule of Benefi t s. S e c u re Horizons Medicare+Choice Health Plan Premium - Your monthly Health Plan P remium is listed in the Schedule of Benefi t s and is due on the fi rst of each month. M e d i c a re Part A Premium - Most Medicare b e n e fi c i a ries are automatically entitled to M e d i c a re Hospital Insurance (Pa rt A ). If you are not entitled to Medicare Pa rt A, and you have p u rchased Pa rt A through Social Securi t y,yo u must continue to pay your Medicare Pa rt A P re m i u m. If you would like to purchase Pa rt A f rom Social Securi t y, please call your local Social S e c u rity Office or call toll fre e. For the hearing impaired the toll-free number to re a ch Social Security is M e d i c a re Part B Premium - A monthly p remium paid to Medicare to cove r Supplemental Medical Insurance (Pa rt B). As a Secure Horizons Medicare+Choice Plan M e m b e r, you must continue to pay yo u r M e d i c a re Pa rt B Pre m i u m. If you re c e i ve a Social Security annuity ch e ck, this premium is u s u a l ly automatically deducted from yo u r ch e ck. Otherwise your Premium is paid d i re c t ly to Medicare by you or someone on your behalf such as Medicaid or Medi-Cal. S e c u re Horizons Medicare+Choice Plan Part A Equivalent Benefit Health Plan P remium - If you have purchased a Pa rt A b e n e fit from Pa c i fi C a re in the past, you mu s t c o n t i nue to pay this amount to continue your cove rage with Secure Hori z o n s M e d i c a re+choice Plan, p rovided yo u r m e m b e rship with Pa c i fi C a re started prior to Ja nu a ry 1, N o t e : If you are enrolled in Pa rt B only and not entitled to Pa rt A and you Disenroll fro m S e c u re Horizons Medicare+Choice Plan,you will not be eligi ble to re - e n roll in Secure Hori z o n s M e d i c a re+choice Plan or any other M e d i c a re+choice Plan until you are eligi ble fo r Pa rt A cove rage and meet other eligibility cri t e ri a. 37

46 What Happens If You Don t Pay Your Health Plan Premiums? Pa c i fi C a re has the right to Disenroll you fro m S e c u re Horizons Medicare+Choice Plan for fa i l u re to pay Health Plan Premiums (except for plan p remiums which cover Optional Supplemental B e n e fi t s, see Section 8). H oweve r, p rior to such a c t i o n, Pa c i fi C a re will: ( a ) contact you within twenty (20) days after the date of the delinquent ch a rges are due, ( b ) advise you that fa i l u re to pay Health Plan P remiums within a ninety (90) day grace peri o d will result in your Disenro l l m e n t, a n d ( c ) i n clude an explanation of your rights under the G ri evance pro c e d u re s. Should you decide later to re - e n roll in Secure H o rizons Medicare+Choice Plan or to enroll in another plan offe red by Pa c i fi C a re, you may be re q u i red to pay any outstanding Health Plan P remiums due from your previous enrollment in Secure Horizons Medicare+Choice Plan. If you have chosen to add ex t ra benefits (Optional Supplemental Benefits) to your basic cove rage and you do not pay your past due plan premiums within a ninety (90) day grace peri o d, you will be re t u rn e d to the Basic Benefit plan without any optional b e n e fi t s. Until you are notified of your Disenro l l m e n t, you will continue to be a Secure Horizons M e d i c a re+choice Plan Member and must continue to use Contracting Medical Pro v i d e r s. For details on Disenrollment for non-payment of Health Plan Pre m i u m s, see Section 10. Your Premium Payment Options As a Secure Horizons Medicare+Choice Plan M e m b e r,you have two (2) options for paying yo u r m o n t h ly Health Plan Premium or any other p remiums that may be associated with Optional Supplemental Benefi t s. Your options are the EasyPay method and the Monthly Payment Booklet method. With the convenient EasyPay method,you can have your plan premium(s) automatically deducted m o n t h ly from your personal ch e cking account and e l e c t ro n i c a l ly transmitted for pay m e n t. You will h ave no more ch e cks to wri t e, and can enjoy peace of mind knowing that your plan premium pay m e n t s a re taken care of, even if you are trave l i n g. If you do not elect the EasyPay method of pay m e n t, you will be automatically enrolled in the Monthly Pay m e n t Booklet method. Using the Monthly Payment Booklet method is s i m p l e. As plan premiums become due, re m ove the a p p ro p riate payment slip from your pay m e n t b o o k l e t, complete a ch e ck or money order for the amount shown on the payment slip, and mail them in the envelope provided to the address indicated on the payment slip. If you have any questions re g a rding your plan p remium payment ch o i c e s, please call Customer S e rv i c e. Changes in Health Plan Premiums I n c reases in Health Plan Premiums and/or decre a s e s in your level of cove rage are only allowed at the b e ginning of each contract year (which is based on the Calendar Ye a r ). These ch a n ges must be a p p roved by CMS. T h e re will be no benefit ch a n ge s d u ring the contract year unless they are to yo u r a d va n t age. You will re c e i ve a written notice in the Fall of any ch a n ges for the new contract ye a r. If Secure Horizons Medicare+Choice Plan re d u c e s your benefi t s, i n c reases your Copay m e n t s, C o i n s u ra n c e, or Health Plan Pre m i u m, you may be eligi ble for enrollment in a Secure Hori z o n s M e d i c a re Supplement policy on a guaranteed issue b a s i s. For more info rmation or to enro l l, p l e a s e contact Pa c i fi C a re at or (TDHI ), 7:00 a.m. to 7:00 p.m., M o n d ay t h rough Fri d ay. (Please note: Rate ch a n ges and employe r - s p o n s o re d b e n e fit ch a n ges for Group Retiree Members e n rolled through an employer group or tru s t a d m i n i s t rator are subject to contra c t u a l a rra n gements between Pa c i fi C a re and your fo rm e r 38

47 e m p l oyer or trust administra t o r. Your fo rm e r e m p l oyer or trust administrator is re s p o n s i ble fo r notifying you of any Secure Hori z o n s M e d i c a re+choice Plan premium ch a n ge s, c o n t ribution ch a n ge s, or employe r - s p o n s o re d b e n e fit ch a n ges thirty (30) days befo re they become e ffe c t i ve. ) Section 8 If you elect the Optional Plus Plan, you may tra n s fe r to the Standard Plan without additional Optional Plus Plan benefits only once d u ring the Calendar Ye a r. If you choose the High Option Dental Plan, you may tra n s fer to the Optional Dental Plan o n l y o n c e d u ring the Open Enrollment Pe ri o d. If yo u h ave elected the Optional Dental Plan or the High Option Dental Plan, you may tra n s fer to the S t a n d a rd Plan without optional dental benefits o n l y o n c e d u ring the Calendar Ye a r. Optional Supple m e n tal Benefits Adding Optional Supplemental Benefits to Your Secure Horizons Medicare+Choice Plan Based on where you live, S e c u re Hori z o n s M e d i c a re+choice Plans may offer an Optional Supplemental Benefit Plan (the Optional Plus Plan, High Option Dental Plan and/or Optional Dental Plan) which provides supplemental benefits for an additional monthly plan pre m i u m. For more i n fo rmation re g a rding Optional Supplemental B e n e fit Plans, and their ava i l ability in your Serv i c e A re a, please re fer to your Member materials or contact Customer Serv i c e. Electing an Optional Supplemental Benefit Plan You may enroll in an Optional Supplemental B e n e fit Plan by completing an Optional Plan Application ava i l able through Customer Serv i c e. If you are an existing Member, you may enroll in an Optional Supplemental Benefit Plan o n l y o n c e d u ring the Open Enrollment Pe ri o d, N ovember 15, 2003 through June 30, If yo u a re a new Member, you may enroll in an Optional Supplemental Benefit Plan at the time of e n ro l l m e n t, within the thirty (30) days of yo u r E ffe c t i ve Date or until June 30, In ge n e ra l, completed Optional Plan Ap p l i c a t i o n s re c e i ved by the last day of the month will be e ffe c t i ve the fi rst day of the fo l l owing month. Fo r ex a m p l e, if Pa c i fi C a re re c e i ves your completed Optional Plan Application on December 31,yo u r Optional Supplemental Benefit Plan benefits wo u l d b e gin on Ja nu a ry Disenrolling From an Optional Supplemental Benefit Plan If you wish to Disenroll from the Optional Plus Plan, High Option Dental Plan and/or Optional Dental P l a n, you must notify Pa c i fi C a re in wri t i n g. You may either send Pa c i fi C a re an Optional Plan Ap p l i c a t i o n, a letter or a fa x. To obtain an Optional Plan Ap p l i c a t i o n, please call Customer Serv i c e. P l e a s e mail your request to P. O. B ox 489, C y p re s s, CA Optional Supplemental Benefit Plan(s) D i s e n rollment requests re c e i ved by the last day of the month will be effe c t i ve the fi rst day of the fo l l owing month. M e m b e rs will be re s p o n s i ble fo r their Optional Supplemental Benefit Plan pre m i u m p ayment if the Disenrollment request is re c e i ve d after the last day of the month. D i s e n rollment fro m Optional Supplemental Benefit Plan(s) will not result in Disenrollment from your Secure Hori z o n s M e d i c a re+choice Plan. N o n - p ayment of plan premiums for Optional Supplemental Benefit Plan(s) will not result in D i s e n rollment from your Secure Hori z o n s M e d i c a re+choice Plan,o n ly the loss of the Optional Supplemental Benefits Plan(s). Refund of Premium M e m b e rs enrolled in an Optional Supplemental B e n e fit Plan(s) have a monthly plan premium and a re entitled to a refund for any ove r p ayments of plan premiums made during the course of the ye a r or at the time of Disenro l l m e n t. O ve r p ayments of Optional Supplemental Benefit Plan premiums will be refunded upon request or Disenro l l m e n t. Pa c i fi C a re will refund any ove r p ayments within

48 t h i rty (30) business days of notifi c a t i o n. Pa c i fi C a re m ay apply your ove r p ayment of Optional Supplemental Benefit Plan premiums to your Health Plan Premiums for the standard plan. (Please note: This section is not applicable to G roup Retiree Members. E m p l oyer groups and t rust administra t o rs may offer Group Retire e M e m b e rs additional supplemental or buy-up b e n e fi t s. For info rmation re g a rding Group Retire e supplemental benefi t s, if applicabl e, please re fer to the Retiree Benefits Summary document.) Section 9 O rganization Dete r m i n a t i o n, Appeal and Grieva n ce Pro ce d u re s As a Secure Horizons Medicare+Choice Plan Member you are encouraged to let Pa c i fi C a re k n ow if you have concerns or ex p e rience any p ro blems with Pa c i fi C a re or Secure Hori z o n s M e d i c a re+choice Plan. Pa c i fi C a re has re p re s e n t a t i ves ava i l able to help you with yo u r questions and concern s. The pro c e d u res described in this section may be used if you have an Appeal or Gri evance you wa n t Pa c i fi C a re to rev i ew. Appeals are defined as the type of complaint yo u m a ke when you want a re c o n s i d e ration of a decision (determination) that was made re g a rding a s e rvice or the amount of payment Pa c i fi C a re pay s or will pay for a serv i c e. You may file an Appeal fo r the fo l l owing re a s o n s : Pa c i fi C a re refuses to cover or pay for serv i c e s you think Pa c i fi C a re should cove r. Pa c i fi C a re or one of the Contracting Medical P rov i d e rs refuses to gi ve you a service you think should be cove re d. Pa c i fi C a re or one of the Contracting Medical P rov i d e rs reduces or cuts back on services yo u h ave been re c e i v i n g. If you think that Pa c i fi C a re is stopping yo u r c ove rage too soon. G ri evances are defined as the type of complaint yo u m a ke if you have any other type of pro blem (other than an Appeal) with Pa c i fi C a re or a Contra c t i n g Medical Prov i d e r. You would file a Gri evance if yo u h ave a pro blem with things such as: the quality of your care ge n e ral dissatisfaction with the way the S e c u re Horizons Medicare+Choice Plan benefi t s a re designed waiting times for appointments or in the wa i t i n g room the way your doctors or others behave being able to re a ch someone by phone or obtain the info rmation you need the cleanliness or condition of the doctor s o ffi c e. If either your Appeal or Gri evance invo l ves a cl i n i c a l i s s u e, a medical rev i ewer who has the education, t raining and re l evant ex p e rtise that is pertinent to evaluate the specific clinical issues that serve as the basis of your complaint, will rev i ew it. Organization Determinations Pa c i fi C a re must make a determination (decision) on your request for the provision of services or p ayment of claims within the fo l l owing timefra m e s : Request for Services or Referrals. If yo u request services or re q u i re Prior Au t h o rization of a R e fe rra l, Pa c i fi C a re must make a decision as ex p e d i t i o u s ly as your health care re q u i re s, but no later than fo u rteen (14) calendar days after receiving your request for serv i c e. An ex t e n s i o n up to fo u rteen (14) calendar days is perm i t t e d, i f you request the extension or if Pa c i fi C a re fi n d s that additional info rmation is needed that will b e n e fit you (for ex a m p l e, if Pa c i fi C a re needs additional medical re c o rds from Non-Contra c t i n g Medical Prov i d e rs that could ch a n ge a denial d e c i s i o n ). When Pa c i fi C a re takes an ex t e n s i o n, yo u will be notified of the extension in wri t i n g. 40

49 Requests for Payment. If you request pay m e n t for services you have alre a dy re c e i ve d, Pa c i fi C a re must make a decision on whether or not to pay the claim no later than sixty (60) calendar day s f rom receiving your re q u e s t. Pa c i fi C a re must notify you in writing of any o rganization determination denial decision, ( p a rt i a l or complete) within the timeframes listed ab ove. The notice must state the reasons for the denial, i n fo rm you of your right to a standard and expedited re c o n s i d e ration (Appeal) process and the right to appoint a re p re s e n t a t i ve to file an Appeal on your behalf. You also have the right to submit additional info rmation re g a rding the re q u e s t e d s e rvice in writing or in pers o n. If you have not re c e i ved such a notice within fo u rteen (14) calendar days of your request for serv i c e s, or within sixty (60) calendar days of a request for pay m e n t, you may assume the decision is a denial, and yo u m ay file an Ap p e a l. Expedited/72-Hour Organization Determination Procedures You have the right to request and re c e i ve ex p e d i t e d decisions affecting your medical treatment in Ti m e - S e n s i t i ve s i t u a t i o n s. A Ti m e - S e n s i t i ve situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seri o u s ly jeopard i z e your life or health,or your ability to re g a i n m a x i mum function. If Pa c i fi C a re, your Pri m a ry Care P hy s i c i a n, or Contracting Medical Gro u p / I PA d e c i d e s, based on medical cri t e ri a, that yo u r situation is Ti m e - S e n s i t i ve or if any physician calls or w rites in support of your request for an ex p e d i t e d rev i ew, Pa c i fi C a re, your Pri m a ry Care Physician or C o n t racting Medical Gro u p / I PA will issue a decision as ex p e d i t i o u s ly as possibl e, but no later than s eve n t y - t wo (72) hours after receiving the re q u e s t. Pa c i fi C a re, your Pri m a ry Care Physician or C o n t racting Medical Gro u p / I PA may extend this t i m e f rame by up to fo u rteen (14) calendar days if you request the extension or if Pa c i fi C a re, yo u r P ri m a ry Care Phy s i c i a n, or Contracting Medical G ro u p / I PA needs additional info rm a t i o n, and the extension of time benefits you (for ex a m p l e, i f Pa c i fi C a re, your Pri m a ry Care Physician or C o n t racting Medical Gro u p / I PA needs additional medical re c o rds from Non-Contracted Medical P rov i d e rs that could ch a n ge a denial decision). I f the timeframe is ex t e n d e d, you will be notified of the reasons for the delay and info rmed of your right to file a Gri evance should you disagre e with an ex t e n s i o n. You will be notified pro m p t ly of the organization determ i n a t i o n, but no later than upon ex p i ration of the ex t e n s i o n. If you believe you need a service and you believe it is a Ti m e - S e n s i t i ve situation, you or any phy s i c i a n, i n cluding a physician with no connection to Pa c i fi C a re, m ay request that the decision be ex p e d i t e d. If Pa c i fi C a re, your Pri m a ry Care P hy s i c i a n, or Contracting Medical Gro u p / I PA decides that it is a Ti m e - S e n s i t i ve situation, or if any p hysician indicates that applying the standard t i m e f rame for making a determination could s e ri o u s ly jeopardize your life or health or yo u r ability to regain maximum function, Pa c i fi C a re, yo u r P ri m a ry Care Phy s i c i a n, or Contracting Medical G ro u p / I PA will make a decision on your request for a service on an expedited/72-hour basis (subject to extension as discussed below ). To request an expedited seve n t y - t wo (72) hour O rganization Determination call Pa c i fi C a re, yo u r P ri m a ry Care Phy s i c i a n, or Contracting Medical G ro u p / I PA at the phone number on yo u r m e m b e rship card. Be sure to ask for an expedited seventy-two (72) hour review when you make your re q u e s t. How Your Expedited/72-Hour Review Request Will Be Processed 1. Upon receiving your re q u e s t, Pa c i fi C a re, yo u r P ri m a ry Care Phy s i c i a n, or Contracting Medical G ro u p / I PA will determine if your request meets the definition of Time Sensitive. If your request does not meet the defi n i t i o n, i t will be handled within the standard rev i ew t i m e f ra m e : ( fo u rteen (14) calendar days fo r o rganization determ i n a t i o n s ). You will be i n fo rmed by telephone that your request fo r the expedited seve n t y - t wo (72) hour rev i ew 41

50 has been denied and you will also re c e i ve a w ritten confi rmation that the request will be p rocessed within the standard rev i ew t i m e f ra m e ; within three (3) calendar days of the telephone call. If you disagree with Pa c i fi C a re, your Pri m a ry Care Phy s i c i a n s, or Contra c t i n g Medical Gro u p s / I PA s decision to process yo u r request within the standard timefra m e, yo u m ay file a Gri evance with Pa c i fi C a re. T h e w ritten confi rmation letter will incl u d e i n s t ructions on how to file a Gri eva n c e. I f your request is Ti m e - S e n s i t i ve, you will be n o t i fied of Pa c i fi C a re s, your Pri m a ry Care P hy s i c i a n s, or Contracting Medical G ro u p s / I PA s decision within seve n t y - t wo (72) hours. You will also re c e i ve a fo l l ow - u p letter within three (3) calendar days of the phone call. 2. Your request must be processed within s eve n t y - t wo (72) hours if any physician calls or w rites in support of your request for an expedited seve n t y - t wo (72) hour rev i ew, a n d the physician indicates that applying the s t a n d a rd rev i ew timeframe could seri o u s ly j e o p a rdize your life or health, or your ability to regain maximum function. If a Non-Contracted Medical Provider support s your re q u e s t, Pa c i fi C a re, your Pri m a ry Care P hy s i c i a n, or Contracting Medical Gro u p / I PA will have seve n t y - t wo (72) hours from the time all the necessary medical info rmation is re c e i ved from that Provider to make a decision. 3. Pa c i fi C a re, your Pri m a ry Care Physician or C o n t racting Medical Gro u p / I PA will make a decision and notify you of it within seve n t y - t wo (72) hours of receipt of your re q u e s t. If Pa c i fi C a re, your Pri m a ry Care Phy s i c i a n, or Contracting Medical Gro u p / I PA do not a p p rove your re q u e s t, you can appeal to Pa c i fi C a re (see below ) : T h e re are four possible dispositions to a request fo r an expedited organization determ i n a t i o n : Your request to expedite an org a n i z a t i o n d e t e rmination decision is accepted; Pa c i fi C a re, your Pri m a ry Care Phy s i c i a n, or Contracting Medical Gro u p / I PA makes a decision in seve n t y - t wo (72) hours and notifies you that they will a rra n ge or continue the serv i c e. Your request to expedite an org a n i z a t i o n d e t e rmination decision is accepted; Pa c i fi C a re, your Pri m a ry Care Phy s i c i a n, or Contra c t i n g Medical Gro u p / I PA makes a decision in s eve n t y - t wo (72) hours and notifies you that t h ey will n o t a rra n ge or continue the serv i c e, and you can appeal to Pa c i fi C a re. Your request to expedite the org a n i z a t i o n d e t e rmination is n o t a c c e p t e d, and Pa c i fi C a re, your Pri m a ry Care Physician or Contra c t i n g Medical Gro u p / I PA info rms you that yo u r request will be handled under the standard o rganization determination pro c e s s. Your request to expedite an org a n i z a t i o n d e t e rmination cannot be made in seve n t y - t wo (72) hours, and Pa c i fi C a re, your Pri m a ry Care P hy s i c i a n, or Contracting Medical Gro u p / I PA i n fo rms you that they will need up to an additional fo u rteen (14) calendar days to p rocess your re q u e s t. If you have questions re g a rding these ri g h t s, p l e a s e call Customer Serv i c e. General Information on the Medicare Appeals Process As a Secure Horizons Medicare+Choice Plan M e m b e r, you have the right to appeal any o rganization determination about Pa c i fi C a re s p ayment fo r, or fa i l u re to arra n ge or continue to a rra n ge fo r, what you believe are Cove re d S e rvices (including Optional Supplemental B e n e fits) under your Medicare+Choice Plan. These include the fo l l ow i n g : Payment for out-of-area renal dialysis and routine travel dialysis serv i c e s, E m e rge n c y S e rv i c e s, Po s t - S t abilization Care, or Urge n t ly Needed Serv i c e s Payment for any other health services furn i s h e d by a Non-Contracted Medical Provider or Facility you believe are cove red under Ori gi n a l 42

51 M e d i c a re or should have been arra n ged fo r, o r re i m b u rsed by Pa c i fi C a re S e rvices you have not re c e i ve d, but you believe a re the responsibility of Pa c i fi C a re to pay for or a rra n ge D i s c o n t i nuation of services you believe are M e d i c a l ly Necessary Cove red Serv i c e s Fa i l u re of Pa c i fi C a re to approve, f u rn i s h, a rra n ge fo r, or provide payment fo r, health care serv i c e s in a timely manner or to provide you with a t i m e ly notice of an adve rse determ i n a t i o n, s u ch that a delay would adve rs e ly affect your health. Use the Appeal pro c e d u re when you want a re c o n s i d e ration of a decision (org a n i z a t i o n a l d e t e rmination) that was made re g a rding a serv i c e or the amount of payment Pa c i fi C a re paid for a s e rv i c e. Use the Gri evance pro c e d u re for any complaints or other disputes that are not denied claims or denied s e rvices subject to organization determinations as explained ab ove. If you have a question ab o u t w h i ch complaint process to use, please call Customer Serv i c e. Pa c i fi C a re is re q u i red to tra ck all Appeals and G ri evances in order to re p o rt cumu l a t i ve data to CMS and to Secure Horizons Medicare + C h o i c e Plan Members upon re q u e s t. Who May File an Appeal 1. You may file an Ap p e a l. 2. Someone else may file the Appeal for you on your behalf. You may appoint an individual to act as your re p re s e n t a t i ve to file the Appeal fo r you by fo l l owing the steps below : ( a ) P rovide Pa c i fi C a re with your name, yo u r M e d i c a re number and a statement,w h i ch appoints an individual as yo u r re p re s e n t a t i ve. ( N o t e : you may appoint a p hysician or a Prov i d e r.) For ex a m p l e : I [ your name] appoint [name of re p re s e n t a t i ve] to act as my re p re s e n t a t i ve in requesting an Appeal fro m Pa c i fi C a re and/or CMS re g a rding the denial or discontinuation of medical serv i c e s. ( b ) You must sign and date the statement. ( c ) Your re p re s e n t a t i ve must also sign and date this statement unless he or she is an a t t o rn ey. ( d ) You must include this signed statement with your Ap p e a l. 3. A Non-Contracted Medical Provider may file a s t a n d a rd Appeal of a denied claim if he or she completes a wa i ver of payment statement, w h i ch says he or she will not bill yo u re g a rdless of the outcome of the Ap p e a l. Support for Your Appeal You are not re q u i red to submit additional i n fo rmation to support your request fo r re c o n s i d e ration (Ap p e a l ). Pa c i fi C a re is re s p o n s i bl e for gathering all necessary medical info rm a t i o n. H oweve r, it may be helpful to include additional i n fo rmation to cl a rify or support your re q u e s t. Fo r ex a m p l e, you may want to include in your Ap p e a l re q u e s t, i n fo rmation such as medical re c o rds or p hysician opinions in support of your re q u e s t. To obtain medical re c o rd s, you may send a wri t t e n request to your Pri m a ry Care Phy s i c i a n. If yo u r medical re c o rds from a Specialist are not incl u d e d in your medical re c o rds from your Pri m a ry Care P hy s i c i a n, you may need to submit a separa t e request to the Specialist who provided medical s e rvices to yo u. Assistance With Appeals R e g a rdless whether you request a standard or expedited Ap p e a l,you can have a fri e n d, l aw yer or someone else help yo u. T h e re are law ye rs who do not ch a rge unless you win your Ap p e a l. G ro u p s s u ch as law yer Refe rral services can help you find a l aw ye r. T h e re are also gro u p s, s u ch as legal aid s e rv i c e s, who will provide free legal services if yo u q u a l i f y. 43

52 Standard Appeal Procedures If you decide to proceed with the Medicare S t a n d a rd Appeals Pro c e d u re, the fo l l owing steps will occur: 1. You must submit a written request for a re c o n s i d e ration to the Pa c i fi C a re Appeals and G ri evance Unit at 5757 Plaza Dri ve, C y p re s s, C A You may also request a re c o n s i d e ra t i o n t h rough the Social Security office (or, if you are a ra i l road re t i rement benefi c i a ry,t h rough a R a i l road Retirement Benefits Offi c e ). You mu s t submit your written request within sixty (60) calendar days of the date of the notice of the initial organization determ i n a t i o n. N o t e : The sixty (60) day limit may be extended fo r good cause. I n clude in your written request the reason why you could not file within the sixty (60) day timefra m e. 2. Pa c i fi C a re will conduct a re c o n s i d e ration and notify you in writing of the decision within t h i rty (30) day s, if the Appeal is for a request fo r a denied serv i c e. Note that Pa c i fi C a re mu s t notify you of the re c o n s i d e ration decision as ex p e d i t i o u s ly as possibl e, but no later than t h i rty (30) calendar days from receipt of yo u r re q u e s t. Pa c i fi C a re may extend this timefra m e by up to fo u rteen (14) calendar days if yo u request the extension or if Pa c i fi C a re finds that additional info rmation is needed and the extension of time benefits you (for ex a m p l e, i f Pa c i fi C a re needs additional medical re c o rd s f rom Non-Contracted Medical Prov i d e rs that could ch a n ge a denial decision). If the Appeal is for a denied cl a i m, Pa c i fi C a re must notify you of the re c o n s i d e ra t i o n d e t e rmination no later than sixty (60) days after receiving your request for a re c o n s i d e ra t i o n d e t e rm i n a t i o n. Pa c i fi C a re s re c o n s i d e ration decision will be made by a person(s) not invo l ved in the initial d e c i s i o n. A physician must make all re c o n s i d e rations of adve rse org a n i z a t i o n d e t e rminations based on Medical Necessity with ex p e rtise in the field of medicine that is 44 a p p ro p riate for the service at issue. H oweve r, that physician need not be of the same specialty or subspecialty as the tre a t i n g p hy s i c i a n. 3. If Pa c i fi C a re decides to reve rse the ori gi n a l a d ve rse decision, Pa c i fi C a re must authorize or a rra n ge your service as ex p e d i t i o u s ly as yo u r health re q u i re s, but no later than thirty (30) calendar days from the date Pa c i fi C a re re c e i ve d your request for an Ap p e a l ; or Pa c i fi C a re will p ay your claim within sixty (60) calendar day s of your request for an Ap p e a l. 4. If Pa c i fi C a re decides to uphold the ori gi n a l a d ve rse decision, either in whole or in part, o r if Pa c i fi C a re fails to provide you with a decision on your re c o n s i d e ration within the re l eva n t t i m e f ra m e, Pa c i fi C a re will automatically fo r wa rd the case to the Center for Health Dispute Resolution (CHDR) for a new and impart i a l rev i ew and you will be notifi e d. CHDR is C M S s independent contractor for appeal rev i ews involving Medicare+Choice manage d c a re plans, l i ke Secure Hori z o n s M e d i c a re+choice Plan. Pa c i fi C a re must send CHDR the file within thirty (30) days of a request for services and within sixty (60) day s of a request for pay m e n t. CHDR will either uphold Pa c i fi C a re s decision or issue a new d e c i s i o n. If Pa c i fi C a re fo r wa rds the case to C H D R, Pa c i fi C a re still must notify you of the decision within the re l evant timefra m e discussed ab ove. 5. For cases submitted to CHDR for rev i ew, C H D R will make a re c o n s i d e ration decision and notify you in writing of their decision and the re a s o n s for the decision. If CHDR decides in your favor and reverses PacifiCare s decision, the following must occur: Request for Service: If CHDR decides in yo u r favo r, Pa c i fi C a re must authorize the serv i c e under dispute within seve n t y - t wo (72) hours f rom the date of receipt of CHDR s notice reve rsing Pa c i fi C a re s decision,or provide the s e rvice under dispute as ex p e d i t i o u s ly as yo u r health condition re q u i re s, but no later than

53 fo u rteen (14) calendar days from date of receipt of CHDR s notice. Request for Payment: If CHDR decides in your favo r, Pa c i fi C a re must pay for the serv i c e no later than thirty (30) calendar days from the date of CHDR s notice. If CHDR maintains Pa c i fi C a re s decision, their notice will info rm you of your right to a hearing befo re an a d m i n i s t ra t i ve law judge of the Social Securi t y A d m i n i s t ra t i o n. 6. You may request a hearing befo re an a d m i n i s t ra t i ve law judge (ALJ) by submitting a w ritten request to Pa c i fi C a re, CMS or the Social S e c u rity A d m i n i s t ration within sixty (60) day s of the date of CHDR s notice that the re c o n s i d e ra t i o n decision was not in your favo r. This sixty (60) day notice may be extended fo r good cause. A hearing can be held only if the amount in controve rsy is one hundred dollars ($100) or more as determined by the a d m i n i s t ra t i ve law judge. All hearing re q u e s t s will be fo r wa rded to CHDR. CHDR will then fo r wa rd your request and your re c o n s i d e ra t i o n file to the hearing offi c e. Pa c i fi C a re will also be made a party to the Appeal at the ALJ leve l. 7. If the administra t i ve law judge s decision is a d ve rs e, either you or Pa c i fi C a re may request a rev i ew by the Departmental Appeals Board ( DAB) of the Social Security A d m i n i s t ra t i o n, w h i ch may either rev i ew the decision or d e cline rev i ew. If the administra t i ve law judge decides in your favo r,pa c i fi C a re must pay fo r, a u t h o ri z e, or provide the service you have a s ked for within 60 calendar days from the date Pa c i fi C a re re c e i ves notice of the decision. H oweve r, if Pa c i fi C a re appeals this decision by asking for a rev i ew by the DA B, Pa c i fi C a re may await the DA B s decision befo re comply i n g with the decision of the A L J. 8. If the amount invo l ved is one thousand dollars ($1,000) or more, either you or Pa c i fi C a re may request that a decision made by the DAB or the a d m i n i s t ra t i ve law judge, or if the DAB has d e clined rev i ew,be rev i ewed by a fe d e ra l d i s t rict court A ny initial or re c o n s i d e red decision made by Pa c i fi C a re, C H D R, the administra t i ve law judge or the DAB can be re o p e n e d : (a) within twe l ve (12) months; (b) within four (4) ye a rs for just c a u s e ; or (c) at any time for cl e rical corre c t i o n or in cases of fra u d CHDR Reopenings; A reopening is not an Appeal ri g h t. A ny of the parties to a re c o n s i d e ration determination may request a re o p e n i n g, h owever granting a reopening is s o l e ly at CHDR s discre t i o n. The part y requesting a reopening must cl e a r ly state in w riting the basis on which the request is made. All CHDR determinations advise the parties of the standards for reopening of the case by C H D R. A ny party to the determination may request a reopening if the party believes one of the fo l l owing grounds for reopening is a p p l i c abl e : E rror on the face of the evidence by CHDR in its rev i ew Fra u d N ew and additional info rmation that was not ava i l able at the time CHDR made its initial d e t e rmination in the case A Medicare+Choice Org a n i z a t i o n s request fo r a reopening does not re l i eve the M e d i c a re+choice Organization of the responsibility to comply with CHDR s decision within the re q u i red timefra m e s. H oweve r, i f C H D R s decision at the conclusion of the reopening rev i ew is unfavo rable to yo u, yo u will be liable for the cost of the care re n d e re d The re c o n s i d e red determination is final and binding upon Pa c i fi C a re. The binding arbitra t i o n clause in your Individual Election Fo rm does not a p p ly to disputes subject to CMS s appeals p ro c e s s. Expedited/72-Hour Appeal Procedures You have the right to request and re c e i ve an expedited seve n t y - t wo (72) hour re c o n s i d e ra t i o n ( Ap p e a l ), in situations where waiting for a

54 re c o n s i d e ration (Appeal) decision to be made within the standard timeframe could seri o u s ly j e o p a rdize your life or health, or your ability to regain maximum function. If Pa c i fi C a re decides, based on medical cri t e ri a, that your situation is Ti m e - S e n s i t i ve or if any physician calls or writes in s u p p o rt of your request for an ex p e d i t e d re c o n s i d e ration (Appeal) rev i ew, Pa c i fi C a re will issue a decision as ex p e d i t i o u s ly as possibl e, but no later than seve n t y - t wo (72) hours after re c e i v i n g the re q u e s t. Pa c i fi C a re may extend this timefra m e by up to fo u rteen (14) days if you request the extension or if Pa c i fi C a re needs additional i n fo rm a t i o n, and the extension of time benefits yo u ( for ex a m p l e, if Pa c i fi C a re needs additional medical re c o rds from Non-Contracted Medical Prov i d e rs that could ch a n ge a denial decision). If the re c o n s i d e ration (Appeal) timeframe is ex t e n d e d, you will be notified of the reasons for the delay and info rmed of your right to file a Gri eva n c e should you disagree with an ex t e n s i o n. You will be n o t i fied pro m p t ly of Pa c i fi C a re s determ i n a t i o n, b u t no later than upon ex p i ration of the ex t e n s i o n. If you wish to request a re c o n s i d e ration (Appeal) of a decision by Pa c i fi C a re to deny a service you requested or to discontinue a service you a re receiving that you believe is a Medically N e c e s s a ry Cove red Service and you believe it is a Ti m e - S e n s i t i ve situation, you or yo u r a u t h o rized re p re s e n t a t i ve may request that the re c o n s i d e ration (Appeal) be ex p e d i t e d. If a p hysician wishes to file an expedited Appeal fo r yo u, you must gi ve him or her authorization to act on your behalf. If Pa c i fi C a re or any phy s i c i a n decides that it is a Ti m e - S e n s i t i ve situation, Pa c i fi C a re will make a decision on your Appeal on an expedited seve n t y - t wo (72) hour basis. Examples of service decisions which you may appeal on an expedited basis, when you believe it is a Ti m e - S e n s i t i ve situation, i n clude the fo l l ow i n g : If you re c e i ved a denial of a service yo u re q u e s t e d If you think you are being disch a rged from any of the fo l l owing too soon and you have missed the deadline for a Quality Improvement Org a n i z a t i o n (QIO) rev i ew : Hospital Skilled Nursing Facility (SNF) Home Health A gency (HHA) C o m p re h e n s i ve Outpatient Rehab i l i t a t i o n Facility (CORF) The pro c e d u res for requesting and receiving an expedited Appeal are described in the fo l l ow i n g s e c t i o n s. How to Request an Expedited Reconsideration To request an expedited seve n t y - t wo (72) hour rev i ew,you or your authorized re p re s e n t a t i ve may c a l l, w ri t e, fax or visit Pa c i fi C a re. Be sure to ask for an expedited seventy-two (72) hour review when you make your re q u e s t. C a l l : Business Hours : 8:00 a.m. - 5:00 p.m. M o n d ay through Fri d ay, Pa c i fi C a re will document your request in wri t i n g. T D H I : Business Hours : 8:00 a.m. - 4:00 p.m. M o n d ay through Fri d ay, Pa c i fi C a re will document your request in wri t i n g. W ri t e : Pa c i fi C a re Appeals and Gri evance Unit 5757 Plaza Dri ve C y p re s s, CA Fa x : A t t e n t i o n : Appeals and Gri evance Unit Wa l k - i n : Pa c i fi C a re Customer Service Center 5701 Plaza Dri ve C y p re s s, CA Business Hours : 9:00 a.m. - 5:00 p.m. M o n d ay through Fri d ay How Your Expedited/72-Hour Review Request Will Be Processed 1. Upon receiving your re c o n s i d e ration re q u e s t, Pa c i fi C a re will determine if your request meets the definition of Ti m e - S e n s i t i ve. 46

55 If your request does not meet the defi n i t i o n, i t will be handled within the standard rev i ew p rocess (thirty (30) days for Ap p e a l s ). You will be info rmed by telephone that your re q u e s t for the expedited seve n t y - t wo (72) hour Appeal rev i ew has been denied and will also re c e i ve a written confi rmation that the request will be processed within the standard rev i ew timefra m e, within three (3) calendar d ays of the telephone call. If you disagre e with Pa c i fi C a re s decision to process yo u r request within the standard timefra m e, yo u m ay file a Gri evance with Pa c i fi C a re. T h e w ritten confi rmation letter will incl u d e i n s t ructions on how to file a Gri eva n c e. If your request is Ti m e - S e n s i t i ve, you will be n o t i fied of Pa c i fi C a re s Appeal decision within s eve n t y - t wo (72) hours. You will also re c e i ve a fo l l ow-up decision letter within three (3) calendar days of the telephone call. An extension up to fo u rteen (14) calendar d ays is permitted for a seve n t y - t wo (72) hour Appeal if the extension of time benefits yo u, for ex a m p l e, if you need time to prov i d e Pa c i fi C a re with additional info rmation or if Pa c i fi C a re needs to have additional diag n o s t i c testing completed. Pa c i fi C a re will make a decision as ex p e d i t i o u s ly as your health re q u i re s, but no later than the end of any extension peri o d. If the timeframe is ex t e n d e d, you will be notified of the re a s o n s for the delay and info rmed of your right to fi l e a Gri evance should you disagree with an ex t e n s i o n. 2. Your request must be processed within s eve n t y - t wo (72) hours if any physician calls or writes in support of your request for an expedited seve n t y - t wo (72) hour rev i ew, a n d the physician indicates that applying the s t a n d a rd rev i ew timeframe could seri o u s ly j e o p a rdize your life or health or your ability to regain maximum function. If a Non-Contracted Medical Provider support s your re q u e s t, Pa c i fi C a re may request a fo u rt e e n (14) day extension if obtaining necessary medical info rmation from the Provider will b e n e fit yo u. 3. Pa c i fi C a re will make a decision on the Ap p e a l and notify you of it within seve n t y - t wo (72) h o u rs of receipt of your re q u e s t. If Pa c i fi C a re decides to uphold the ori ginal adve rs e d e t e rm i n a t i o n, either in whole or in part, Pa c i fi C a re will fo r wa rd the entire file to CHDR for rev i ew no later than twe n t y - four (24) hours after Pa c i fi C a re s decision. CHDR will send yo u a letter with their decision within seve n t y - t wo (72) hours of receipt of your case fro m Pa c i fi C a re, or at the end of the fo u rteen (14) day ex t e n s i o n. T h e re are four possible dispositions to a request fo r expedited Ap p e a l s : Your request to expedite an Appeal decision is a c c e p t e d, Pa c i fi C a re makes a decision in s eve n t y - t wo (72) hours and notifies you that the care will be arra n ged or continu e d. Your request to expedite an Appeal decision is a c c e p t e d, Pa c i fi C a re makes a decision in s eve n t y - t wo (72) hours and notifies you that that the care will n o t be arra n ged or continu e d and the case will be sent to CHDR fo r d e t e rmination within twe n t y - four (24) hours. Your request to expedite an Appeal decision is n o t a c c e p t e d, and Pa c i fi C a re info rms you that your request will be handled under the s t a n d a rd Appeal pro c e s s. Your request to expedite an Appeal decision cannot be made in seve n t y - t wo (72) hours, a n d Pa c i fi C a re info rms you that Pa c i fi C a re will need up to an additional fo u rteen (14) calendar day s to process your re q u e s t. If you have questions re g a rding these ri g h t s, p l e a s e call Customer Serv i c e. Information You Should Receive During Your Hospital Stay When you are admitted to the Hospital, s o m e o n e at the Hospital should gi ve you a notice called the I m p o rtant Message from Medicare. This notice 47

56 explains your rights under the law. When a doctor decides that you are re a dy to leave the Hospital (to be disch a rge d ), and if you believe you should not be disch a rged ye t, you should be gi ven a copy of another notice that includes specific info rm a t i o n about your Hospital disch a rge. This other notice is called the Notice of Disch a rge and Medical Ap p e a l R i g h t s. It will tell yo u : W hy you are being disch a rge d. The date that we will stop cove ring your Hospital S t ay (stop paying our share of your Hospital costs). What you can do if you think you are being d i s ch a rged too soon. Who to contact for help. As a Member,you should re c e i ve this info rm a t i o n about your disch a rge b e f o re you leave the Hospital. You (or someone you authorize) may be asked to sign and date this document, to show that yo u re c e i ved the notice. Signing the notice does not mean that you agree that you are re a dy to leave the Hospital it only means that you re c e i ved the n o t i c e. If you do not re c e i ve the notice after yo u h ave told the Hospital that you think you are being d i s ch a rged too soon, ask for the Notice of Disch a rge and Medicare Appeal Rights immediately. Quality Improvement Review If you are in the Hospital and you think that you are being disch a rged too soon, you have the right by l aw to ask for a rev i ew of your disch a rge date. A s explained in the Notice of Disch a rge and Medicare Appeal Rights, if you act quick ly, you can ask an outside agency called the Quality Improve m e n t O rganization (QIO) to rev i ew whether yo u r d i s ch a rge is medically appro p ri a t e. The QIO is a group of doctors and other health care ex p e rts paid by the fe d e ral gove rnment to ch e ck on and help improve the care gi ven to Medicare p a t i e n t s. T h ey are not part of Pa c i fi C a re or yo u r H o s p i t a l. T h e re is one QIO in each State. Q I O s h ave diffe rent names, depending on which State t h ey are in. The phone number and address of the QIO for your area is: L u m e t ra CitiCorp Center One Sansome Stre e t, Suite 600 San Fra n c i s c o, CA The doctors and other health ex p e rts in the QIO rev i ew certain types of complaints made by M e d i c a re patients. These include complaints ab o u t quality of care and complaints from Medicare patients who think the cove rage for their Hospital S t ay is ending too soon. Getting a QIO Review of Your Hospital Discharge If you want to have your disch a rge rev i ewe d, yo u must act quick ly to contact the QIO. The Notice of D i s ch a rge and Medicare Appeal Rights gi ves the name and telephone number of your QIO and tells you what you must do. You must ask the QIO for an expedited seve n t y - t wo (72) hour rev i ew of whether you are re a dy to l e ave the Hospital. You must be sure that you have made your re q u e s t to the QIO no later than noon on the fi rst wo rk i n g d ay after you are gi ven written notice that you are being disch a rged from the Hospital. This deadline is ve ry import a n t. If you meet this deadline, you are a l l owed to stay in the Hospital past your disch a rge date without paying for it yo u rs e l f, while you wa i t to get the decision from the QIO (see below ). If the QIO rev i ews your disch a rge, it will fi rst look at your medical info rm a t i o n. Then it will gi ve an opinion about whether it is medically appro p ri a t e for you to be disch a rged on the date that has been set for yo u. The QIO will make this decision within one full wo rking day after it has re c e i ved yo u r request and all of the medical info rmation it needs to make a decision. If the QIO decides that your disch a rge date wa s m e d i c a l ly appro p ri a t e, you will not be re s p o n s i bl e for paying the Hospital ch a rges until noon of the calendar day after the QIO gi ves you its decision. 48

57 If the QIO agrees with yo u, then we will continu e to cover your Hospital Stay for as long as Medically N e c e s s a ry. What if You Do Not Ask the QIO for a Review by the Deadline? You may have to pay if you stay past your d i s ch a rge date. If you do not ask the QIO by noon of the nex t wo rking day after you are gi ven written notice that you are being disch a rged from the Hospital,and if you stay in the Hospital after this date, you run the risk of having to pay for the Hospital care yo u re c e i ve on and after this date. H oweve r,you can appeal any bills for Hospital care you re c e i ve as d e s c ribed ab ove. Another Option: Asking for an Expedited/72-Hour Review of Your Discharge If you do not ask the QIO to do an ex p e d i t e d s eve n t y - t wo (72) hour rev i ew of your disch a rge, yo u can ask us for an expedited seve n t y - t wo (72) hour rev i ew of your disch a rge. This is described ab ove. If you ask us for an expedited seve n t y - t wo (72) hour rev i ew of your disch a rge and you stay in the Hospital past your disch a rge date, you run the ri s k of having to pay for the Hospital care you re c e i ve past your disch a rge date. Whether you have to pay or not depends on the decision we make. If we decide, based on the expedited seve n t y - t wo (72) hour rev i ew, that you need to stay in the H o s p i t a l, we will continue to cover your Hospital c a re for as long as Medically Necessary. If we decide that you should not have stayed in the Hospital beyond your disch a rge date, then we will n o t c over any Hospital care you re c e i ved if you stayed in the Hospital after the disch a rge date. 49 Termination of Services in Certain Provider Settings (Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF)) When cove rage for a Prior Au t h o rized course of t reatment ends in a SNF, H H A, or CORF, you should re c e i ve advance written notification of the t e rmination of services that includes your Ap p e a l rights and the date on which cove rage of the s e rvice ends. This notice is called the Notice of D i s ch a rge and Medicare Appeal Rights. You mu s t re c e i ve the notice no later than two (2) days pri o r to the termination (or at the time of admission if your stay is expected to be less than two (2) day s ). You (or someone you authorize) will be asked to sign and date this document,to show that yo u re c e i ved the notice. Signing the notice does not mean that you agree that you are re a dy to leave the S N F,H H A, or CORF it only means that yo u re c e i ved the notice. If you do not re c e i ve the notice when you are being told about the t e rmination of serv i c e s, ask for it immediately. Review of Termination of SNF, HHA or CORF Services by the QIO If you think cove rage of your services in a SNF, H H A or CORF is being terminated too soon, you have the right by law to request a fa s t - t ra ck Appeal by contacting the QIO in writing or by telephone n o later than noon of the fi rst day after delive ry of the termination notice. The QIO will notify us that you are appealing the term i n a t i o n, and we will issue a Detailed Explanation of Non-Cove rage to both of you and the QIO. The QIO will rev i ew your medical info rm a t i o n, then gi ve an opinion about whether it is medically a p p ro p riate that your services are being t e rm i n a t e d. The QIO will make this decision within one full wo rking day after it has re c e i ve d your request and all of the medical info rmation it needs to make a decision. If the QIO decides that the termination of serv i c e s was medically appro p ri a t e, you may request a re c o n s i d e ration by the QIO, but you will be liabl e for any services re c e i ved fo l l owing the date on w h i ch you re c e i ve the QIO s initial decision.

58 If the QIO agrees with yo u, then we will continu e your services for as only long as is Medically N e c e s s a ry or based on Medicare cove rage l i m i t a t i o n s. Asking for an Expedited/72-Hour Review of Your Termination of Services If you miss the deadline for a fa s t - t ra ck Ap p e a l, yo u m ay appeal the termination of SNF, HHA or CORF s e rvices under the Expedited (72-Hour) Ap p e a l P rocess described earlier in this section. Grievance Procedures Informal Complaints Pa c i fi C a re will attempt to re s o l ve any complaint ( G ri evance) you might have. Pa c i fi C a re encourage s the info rmal resolution of complaints (i.e., over the telephone), e s p e c i a l ly if such complaints re s u l t f rom misinfo rm a t i o n, m i s u n d e rstanding or lack of i n fo rm a t i o n. If you have a complaint,please call Customer Serv i c e. A more fo rmal Member G ri evance pro c e d u re is ava i l abl e, if your complaint cannot be re s o l ved in this manner. Formal Complaints As a Secure Horizons Medicare+Choice Plan M e m b e r, you have the right to file a complaint, a l s o called a Gri eva n c e, about pro blems you observe or ex p e ri e n c e, i n cl u d i n g : Complaints about the quality of services that you re c e i ve or delays in providing care Complaints re g a rding such issues as offi c e waiting times,p hysician behav i o r, adequacy of fa c i l i t i e s, or other similar Member concern s G e n e ral complaints about increases in Member l i ability or benefit design and the Cove re d Medications List. I nvo l u n t a ry Disenrollment situations (see Section 10) If you disagree with Pa c i fi C a re s decision to extend the timeframe on a standard or expedited re q u e s t If you disagree with Pa c i fi C a re s decision to extend the timeframe on a standard or expedited Ap p e a l If you disagree with Pa c i fi C a re s decision to p rocess your Organization Determ i n a t i o n request for service under the standard fo u rt e e n (14) day timeframe rather than ex p e d i t e d s eve n t y - t wo (72) hour timefra m e If you disagree with Pa c i fi C a re s decision to p rocess your re c o n s i d e ration (Appeal) re q u e s t under the standard thirty (30) day timefra m e rather than the expedited seve n t y - t wo (72) hour t i m e f ra m e To use the fo rmal Gri evance pro c e d u re, s u b m i t your Gri evance in writing to Pa c i fi C a re Appeals and G ri evances Unit. H oweve r, complaints about a decision re g a rd i n g p ayment or provision of Cove red Services that yo u b e l i eve are cove red by Medicare and should be a rra n ged or paid for by Pa c i fi C a re, must be appealed t h rough the Secure Horizons Medicare+Choice Plan M e d i c a re Appeals pro c e d u re (see ab ove ). Complaints That Do Not Relate to Quality of Medical Care Issues Pa c i fi C a re rev i ews complaints that do not relate to quality of medical care issues in consultation with a p p ro p riate Pa c i fi C a re depart m e n t s. Pa c i fi C a re will w rite you to ack n ow l e d ge your complaint and let you know how Pa c i fi C a re has addressed yo u r c o n c e rn within thirty (30) days of receiving yo u r w ritten Gri eva n c e. In some instances, Pa c i fi C a re will need additional time to address your concern. If additional time is needed, Pa c i fi C a re will keep yo u i n fo rmed re g a rding the status of your Gri eva n c e. Complaints Involving Quality of Medical Care Issues All complaints that invo l ve quality of medical care issues are re fe rred to Pa c i fi C a re s Health Serv i c e s D e p a rtment for rev i ew. Complaints that affect a M e m b e r s immediate condition will re c e i ve immediate rev i ew. Pa c i fi C a re will investigate the c o m p l a i n t, consulting with your Contra c t i n g 50

59 Medical Group and appro p riate Pa c i fi C a re d e p a rt m e n t s, and rev i ewing medical re c o rds as n e c e s s a ry. You may need to sign an authorization to release your medical re c o rd s. Pa c i fi C a re will c o n fi rm receipt of your complaint within thirty (30) d ays of receiving your complaint,w h e n eve r p o s s i bl e. The results of the Quality Manage m e n t rev i ew are confi d e n t i a l. QIO Quality of Care Complaint Process If you are concerned about the quality of care yo u h ave re c e i ve d, you may also file a complaint with the QIO in your local are a. (The name, a d d ress and telephone number of your local QIO are re fe re n c e d in the Quality Improvement Rev i ew portion of Section 9.) Binding Arbitration A ny and all disputes of any kind whatsoeve r, i n cluding claims relating to the delive ry of serv i c e s under the plan and claims of medical malpra c t i c e (that is as to whether any medical services re n d e re d under the health plan we re unnecessary or u n a u t h o ri z e d, or we re impro p e r ly neglige n t, o r i n c o m p e t e n t ly re n d e re d ), except for claims subject to ERISA, b e t ween Member (including any heirs or assigns) and Pa c i fi C a re, or any of its pare n t s, s u b s i d i a ries or affiliates (collective ly, Pa c i fi C a re ), shall be submitted to binding arbitra t i o n. A ny such dispute will not be re s o l ved by a lawsuit or re s o rt to c o u rt pro c e s s, except as the Fe d e ral A r b i t ration A c t p rovides for judicial rev i ew of arbitra t i o n p ro c e e d i n g s. Member and Pa c i fi C a re are giving up their constitutional rights to have any such dispute decided in a court of law befo re a jury, and are instead accepting the use of binding arbitration by a single arbitrator in accordance with the C o m p re h e n s i ve Rules of JA M S, and administra t i o n of the arbitration shall be perfo rmed by JAMS or s u ch other arbitration service as the parties may agree in wri t i n g. The parties will endeavor to mu t u a l ly agree to the appointment of the arbitra t o r, but if such agreement cannot be re a ched within t h i rty (30) days fo l l owing the date demand fo r a r b i t ration is made, the arbitrator appointment p ro c e d u res in the Compre h e n s i ve Rules will be u t i l i z e d. A r b i t ration hearings shall be held in the county in w h i ch the Member lives or at such other location as the parties may agree in wri t i n g. Civil discove ry m ay be taken in such arbitra t i o n. The arbitra t o r selected shall have the power to control the timing, scope and manner of the taking of discove ry and shall further have the same powe rs to enfo rce the p a rt i e s re s p e c t i ve duties concerning discove ry as would a Superior Court of Califo rnia incl u d i n g, b u t not limited to, the imposition of sanctions. T h e a r b i t rator shall have the power to grant all re m e d i e s p rovided by fe d e ral and State law. The parties shall divide equally the expenses of JAMS and the a r b i t ra t o r. In cases of ex t reme hard s h i p, Pa c i fi C a re m ay assume all or part of the Member s share of the fees and expenses of JAMS and the arbitra t o r, p rovided the Member submits a hard s h i p application to JA M S. The approval or denial of the h a rdship application will be determined solely by JA M S. The arbitrator shall pre p a re in writing an awa rd that i n cludes the legal and factual reasons for the d e c i s i o n. The re q u i rement of binding arbitra t i o n shall not pre clude a party from seeking a tempora ry re s t raining order or pre l i m i n a ry injunction or other p rovisional remedies from a court with juri s d i c t i o n ; h oweve r, a ny and all other claims or causes of action incl u d i n g, but not limited to,those seeking d a m age s, shall be subject to binding arbitration as p rovided here i n. The Fe d e ral A r b i t ration A c t, 9 U. S. C. 1-16,shall also apply to the arbitra t i o n. BY ENROLLING IN PACIFICARE BOTH MEMBER (INCLUDING ANY HEIRS OR ASSIGNS) AND PACIFICARE AGREE TO WA I V E THE CONSTITUTIONAL RIGHT TO A JURY TRIAL AND INSTEAD VOLUNTA R I LY AGREE TO THE USE OF BINDING ARBITRATION AS DESCRIBED IN THIS EVIDENCE OF C O V E R A G E. A r b i t ration does not apply to claims and serv i c e disputes that are subject to the Medicare re c o n s i d e ration and Appeals pro c e s s. 51

60 Section 10 D i s e n rollment From Secure Horizons Medica re + C h o i ce Plan Voluntary Disenrollment You may choose to end your membership in Secure H o rizons Medicare+Choice Plan for any re a s o n. I f you wish to Disenro l l : You or your authorized re p resentative may request Disenrollment directly fro m P a c i f i C a re; you must send a written signed and dated letter to PacifiCare. If you have any questions about the letter please contact Customer Service. Call the national Medicare help line at MEDICARE ( ) TTY/TDD access line to D i s e n roll via the phone, or You can contact your nearest Social Security office or, if you have Railro a d R e t i rement benefits, you can contact the R a i l road Retirement Board off i c e. The Effective Date of Your Disenrollment In most cases,a written Disenrollment re q u e s t re c e i ved by Pa c i fi C a re by the end of the month will m a ke your Disenrollment effe c t i ve the 1st of the fo l l owing month. For ex a m p l e, if yo u r D i s e n rollment request is re c e i ved on March 31, your Disenrollment from Secure Hori z o n s M e d i c a re+choice Plan would be processed for an E ffe c t i ve Date of Ap ril 1. T h e re is an exception to this ge n e ral ru l e. The Disenrollment date fo r requests made in November can be effe c t i ve December 1, or Ja nu a ry 1. Until your membership ends, you will continue to be a Member of Secure Horizons Medicare + C h o i c e Plan and must continue to re c e i ve all ro u t i n e C ove red Services from Contracting Medical P rov i d e rs until the date your Disenrollment is e ffe c t i ve. Pa c i fi C a re will send you a letter that i n fo rms you when your Disenrollment is effe c t i ve. Once your Disenrollment is effe c t i ve, you can begi n using your re d, w h i t e, and blue Medicare card to obtain services under Medicare unless you have joined another Medicare+Choice Coordinated C a re Plan. ( N o t e : You can call Social Security at if you need a new Medicare card.) Moves or an Extended Absence From the Service Area If you are perm a n e n t ly moving out of the Serv i c e A rea or plan an extended absence of more than six (6) months, it is important to notify Pa c i fi C a re of the m ove or extended absence befo re you leave the S e rvice A re a. If you move perm a n e n t ly out of Pa c i fi C a re s Service A re a, or if you are away fro m Pa c i fi C a re s Service A rea for more than six c o n s e c u t i ve months, you will need to Disenro l l f rom Secure Horizons Medicare+Choice Plan. Fa i l u re to notify Pa c i fi C a re of a permanent move or an extended absence may result in your invo l u n t a ry D i s e n rollment from Secure Horizons Medicare + C h o i c e P l a n, since Pa c i fi C a re is re q u i red to Disenroll you if you have moved out of the Service A rea for more than six (6) months. If you remain enrolled after a m ove or extended absence (and have not been i nvo l u n t a ri ly Disenrolled as described ab ove ), yo u should be awa re that services will not be cove re d unless they are re c e i ved from Contracting Medical P rov i d e rs (except for Emergency Serv i c e s, U rge n t ly Needed Services and Prior Au t h o rized Refe rra l s ). S e c u re Horizons Medicare+Choice Plans are c u rre n t ly offe red in the fo l l owing States: A ri z o n a, C a l i fo rn i a, C o l o ra d o, N eva d a, O k l a h o m a, O re go n, Texas and Wa s h i n g t o n. If you are moving outside of your Service A re a, you may be eligi ble to enroll in a S e c u re Horizons Medicare+Choice Plan in your new l o c a t i o n. Health Plan Pre m i u m s, C o p ayments and C ove red Services will va ry from one area to a n o t h e r. Please contact Customer Service fo r i n fo rmation and assistance in completing any n e c e s s a ry paperwo rk. For info rmation on other plans ava i l able in yo u r a re a, you can call MEDICARE ( ) or the hearing impaired TTY/TDD access line , or visit the CMS web site at: w w w. M e d i c a re. gov 52

61 What Happens if Secure Horizons Medicare+Choice Plan Leaves the Medicare Program or Leaves the Service Area Where You Live? If Pa c i fi C a re leaves the Medicare pro gram or d i s c o n t i nues the Secure Horizons Medicare + C h o i c e Plan in your Service A re a, Pa c i fi C a re will notify yo u in wri t i n g. If either of these situations occur, you will be allowed to change the way you receive Medicare coverage. Your choices will a lways include Ori ginal Medicare, and they may also i n clude joining another Medicare managed care plan or a Pri vate Fe e - Fo r - S e rvice plan if such plans a re ava i l able in your area and are accepting new M e m b e rs. Pa c i fi C a re of Califo rnia has a contract with the CMS. This contract re n ews each ye a r. At the end of each ye a r,the contract is rev i ewe d, and either Pa c i fi C a re or CMS can decide to end it. It is also possible fo r Pa c i fi C a re s contract to end at some other time. I f the contract is going to end, Pa c i fi C a re will ge n e ra l ly notify you at least ninety (90) days in adva n c e. Yo u r a d vance notice may be as little as thirty (30) days or even fewer days if CMS ends Pa c i fi C a re s contract in the middle of the ye a r. Until Pa c i fi C a re notifies you in writing that yo u must leave the Secure Horizons Medicare + C h o i c e Plan and indicates the date when your members h i p e n d s, you will continue as a Member of Secure H o rizons Medicare+Choice Plan and you mu s t c o n t i nue to re c e i ve all Cove red Services fro m C o n t racting Medical Prov i d e rs until the date yo u r D i s e n rollment is effe c t i ve. All Cove red Services and rules described in this document will continue until your membership ends. Once Pa c i fi C a re has notified you in writing that Pa c i fi C a re is leaving the Medicare pro gram or the a rea where you live, you may sw i t ch to another way of getting your Medicare benefits at any t i m e. If yo u decide to sw i t ch from Secure Hori z o n s M e d i c a re+choice Plan to Ori ginal Medicare, yo u will have the right to buy a Medigap policy re g a rdless of your health. This is called g u a ra n t e e d issue ri g h t s. You may contact the Califo rnia Health I n s u rance Counseling and A d vocacy Pro gram at about how and when to buy a Medigap policy if you need one. Coverage That Ends During an Inpatient Hospital Stay If your cove rage under Secure Hori z o n s M e d i c a re+choice Plan ends while you are an inpatient in a Hospital (or Hospital unit), Pa c i fi C a re m ay be re s p o n s i ble for the inpatient services until the date of your disch a rge. Pa c i fi C a re s Customer S e rvice Repre s e n t a t i ves can advise you if Pa c i fi C a re is re s p o n s i ble for your inpatient serv i c e s. In this c a s e, Pa c i fi C a re is not re s p o n s i ble for serv i c e s, o t h e r than inpatient Hospital serv i c e s, f u rnished on or after the Effe c t i ve Date of your Disenro l l m e n t. Involuntary Disenrollment Pa c i fi C a re must Disenroll you from Secure Hori z o n s M e d i c a re+choice Plan under the conditions listed b e l ow. You will not be Disenrolled due to yo u r health status. If you move out of the Service A rea or live outside the Service A rea for more than six (6) months at a time and do not vo l u n t a ri ly Disenro l l. If you do n o t s t ay continu o u s ly enrolled in both M e d i c a re Pa rt A and Medicare Pa rt B. If you request a Benefit Plan Tra n s fer Ap p l i c a t i o n to move from one Service A rea to another Serv i c e A rea within the same State and you do not re t u rn the fo rm within thirty (30) days of your re q u e s t. You may be Disenrolled from Secure Hori z o n s M e d i c a re+choice Plan under the fo l l ow i n g c o n d i t i o n s : If you provide info rmation on your Election Fo rm that is false or delibera t e ly misleading, and it a ffects whether or not you can enroll in Secure H o rizons Medicare+Choice Plan. If you behave in a way that is unru ly, u n c o o p e ra t i ve, d i s ru p t i ve, or ab u s i ve, and this b e h avior seri o u s ly affects our ability to arra n ge C ove red Services for you or for others who are M e m b e rs of Secure Horizons Medicare + C h o i c e P l a n. B e fo re Pa c i fi C a re can Disenroll you for this 53

62 re a s o n, P a c i f i C a re must obtain perm i s s i o n f rom the Centers for Medicare & Medicaid S e rvices (CMS), the gove rnment agency that ru n s M e d i c a re. If you allow someone else to use your Secure H o rizons Medicare+Choice Plan membership card to obtain Cove red Serv i c e s. B e fo re Pa c i fi C a re will D i s e n roll you for this re a s o n, Pa c i fi C a re must re fe r your case to the Inspector Genera l, w h i ch may result in criminal pro s e c u t i o n. If you do not pay the Health Plan Pre m i u m s. Pa c i fi C a re will info rm you of a 90-day grace peri o d d u ring which you can pay the Health Plan P remiums befo re you are re q u i red to Disenro l l f rom Secure Horizons Medicare+Choice Plan. Should you decide later to re - e n roll in a Secure H o rizons Medicare+Choice Plan, you must pay any outstanding Health Plan Premiums due from yo u r p revious enro l l m e n t. You Have the Right to File a Complaint if PacifiCare Asks You to Leave If Pa c i fi C a re does ask you to leave Secure Hori z o n s M e d i c a re+choice Plan,Pa c i fi C a re will info rm you of the reasons in writing and explain how you can fi l e a Gri evance if you choose to. Until PacifiCare notifies you in writing that you have been Disenrolled, you will continue to be a Secure Horizons Medicare+Choice Plan Member and must continue to obtain ro u t i n e C o v e red Services from Contracting Medical P roviders. Neither PacifiCare nor Medicare will pay for services received from Non- Contracting Providers except for: Urg e n t l y Needed Services; Emergency Services a n y w h e re in the world; out-of-area re n a l dialysis services; services for which Secure Horizons Medicare+Choice Plan allows you to s e l f - refer to Contracting Medical Pro v i d e r s ; and Referrals that have received Prior A u t h o r i z a t i o n. 54 PacifiCare Cannot Ask You to Leave Due to Your Health You can only be asked to leave Secure Hori z o n s M e d i c a re+choice Plan under certain special conditions that are described ab ove. T h e s e conditions do not include asking you to leave due to your health. No Member of any Medicare health plan can be asked to leave the plan for any healthrelated re a s o n s. If you ever feel you are being encouraged or aske d to leave Secure Horizons Medicare+Choice Plan due to your health, you should call the national M e d i c a re help line at MEDICARE or , or TTY/TDD access line Review of Termination and Reinstatement No Member shall be Disenrolled due to the Member's health status or re q u i rements for health c a re services other than as stated within this S e c t i o n. A ny Member who believes he/she wa s D i s e n rolled by Secure Horizons Medicare + C h o i c e Plan due to the Member's health status or re q u i rements for health care serv i c e s, m ay request a rev i ew by the Califo rnia Director of Manage d Health Care pursuant to Califo rnia Health and Safe t y C o d e, Section 1365, or call the national Medicare help line at MEDICARE or , or TTY/TDD access line In the event the Dire c t o r d e t e rmines the Disenrollment was contra ry to Section 1365, the Member shall be re i n s t a t e d re t ro a c t i ve ly to the date of the Disenro l l m e n t. Section 11 C o o rdinating Other Benefits You May Have Who Pays First? As a Member,you are always entitled to re c e i ve C ove red Services through the Secure Hori z o n s M e d i c a re+choice Plan. M e d i c a re law, h oweve r, gi ves Pa c i fi C a re or its designee the right to re c ove r p ayments from certain t h i rd part y i n s u ra n c e

63 companies or from you if you we re paid by a t h i rd p a rt y. Because of this, Pa c i fi C a re may ask you fo r i n fo rmation about other insurance you may have. If you have other insura n c e, you can help Pa c i fi C a re obtain payment from the other insurer by pro m p t ly p roviding the requested info rm a t i o n. If any no-fault or any liability insurance is ava i l abl e to yo u, b e n e fits under that plan must be applied to the costs of health care cove red by that plan. W h e re Pa c i fi C a re has provided benefits and a judgment or settlement is made with a no-fault or l i ability insure r, you must re i m b u rse Pa c i fi C a re or its designee (entity or person selected for this purpose) to the extent of your medical ex p e n s e s. H oweve r, Pa c i fi C a re s re i m b u rsement may be reduced by a share of pro c u rement costs (e.g., a t t o rn ey fees and costs). Wo rke rs C o m p e n s a t i o n f rom treatment of a wo rk - related illness or injury should also be applied to cove red health care costs. If you do not have end-stage renal disease (ESRD), and have cove rage under an employer group plan of an employer of twenty (20) or more employe e s, either through your own current employment or the employment of a spouse,you must use the b e n e fits under that plan prior to using your Secure H o rizons Medicare+Choice Plan benefi t s. S i m i l a r ly, if you do not have end-stage renal disease (ESRD), but have Medicare based on disability and are c ove red under an employer group plan of an e m p l oyer of one hundred (100) or more employe e s (or a multiple employer plan that includes an e m p l oyer of one hundred or more employe e s ) t h rough a spouse s employer group cove rage, yo u must use the benefits under that plan prior to using your Secure Horizons Medicare+Choice Plan b e n e fi t s. In such cases you will only re c e i ve b e n e fits not cove red by your employer group plan t h rough Pa c i fi C a re s contract with Medicare (and Pa c i fi C a re will only be paid an amount by Medicare to cover such w rap aro u n d b e n e fi t s ). A special rule applies if you have or develop ESRD. If you have (or develop) ESRD and are cove re d under an employer group plan, you must use the b e n e fits of that plan for the fi rst thirty (30) months after becoming eligi ble for Medicare based on E S R D. M e d i c a re is the pri m a ry payer after this c o o rdination peri o d. H oweve r, if your employe r group plan cove rage was secondary to Medicare when you developed ESRD because it was not based on current employment as described ab ove, M e d i c a re continues to be the pri m a ry paye r. Section 12 A d va n ce Dire c t i ves: Making Yo u r Health Care Wishes Known Pa c i fi C a re is re q u i red by law to info rm you of yo u r right to make health care decisions and to exe c u t e an A d vance Dire c t i ve. An A d vance Dire c t i ve is a fo rmal document, w ritten by you in advance of an incapacitating illness or injury. As long as you can speak for yo u rs e l f, C o n t racting Medical Prov i d e rs will honor your wishes. If you become so sick that you cannot speak for yo u rs e l f, this dire c t i ve will guide your health care Prov i d e rs in treating yo u and will save your fa m i ly, f riends and phy s i c i a n s f rom having to guess what you would have wa n t e d. T h e re may be seve ral types of A d vance Dire c t i ve s you can choose fro m, depending on State law. Most States re c o g n i z e : 1. D PAHC (Durable Power of A t t o rn ey for Health C a re)/medical Durable Power of A t t o rn ey 2. Health Care Dire c t i ve 3. Living Wi l l s 4. N a t u ral Death Act Decl a ra t i o n s 5. C a rd i o p u l m o n a ry Resuscitation (CPR) Dire c t i ve 6. Do Not Resuscitate (DNR) Ord e rs You are not re q u i red to initiate an A d va n c e D i re c t i ve, and you will not be denied care if you do not have an A d vance Dire c t i ve. It is necessary for you to provide copies of yo u r completed dire c t i ve to all of the fo l l ow i n g : 1. your Pri m a ry Care Phy s i c i a n 2. your agent or re p re s e n t a t i ve (if you have one) 55

64 3. your fa m i ly If you decide that you want to have an A d va n c e D i re c t i ve, t h e re are seve ral ways to get this type of legal fo rm. You can get a fo rm from your law ye r, f rom a social wo rke r, and from some office supply s t o re s. Be sure to keep a copy with you and take a copy to the Hospital when you are Hospitalized for medical c a re. If you have questions re g a rding your health c a re ch o i c e s, please contact Califo rnia Health I n s u rance Counseling and A d vocacy Pro gram at Section 13 G e n e ral Provisions Governing Law This Evidence of Cove rage and Discl o s u re I n fo rmation is subject to the laws of the State of C a l i fo rnia and the United States of A m e ri c a, i n cl u d i n g : the Health Maintenance Organization A c t of 1973, and regulations pro mulgated thereunder by the Department of Health and Human Services of the United States, and Title XVIII of the Social S e c u rity Act and regulations pro mu l g a t e d t h e reunder by CMS. A ny provisions re q u i red to be in this Evidence of Cove rage and Discl o s u re I n fo rmation by any of the ab ove acts and regulations shall bind Pa c i fi C a re and yo u, w h e t h e r or not ex p re s s ly provided in this document. Your Financial Liability as a Secure Horizons Medicare+Choice Plan Member As a Member of Secure Horizons Medicare + C h o i c e P l a n, you have the fo l l owing financial obl i g a t i o n s : All Copayments and Coinsurance s p e c i fied in the Schedule of Benefits must be paid to the C o n t racting Medical Provider at the time of s e rv i c e. Plan Premiums for Optional Supplemental B e n e f i t s the Optional Plus Plan,High Option Dental Plan and/or Optional Dental Plan. 56 N o n - p ayment of the Optional Plus Plan,High Option Dental Plan and/or Optional Dental Plan pre m i u m s will result in the loss of Optional Supplemental B e n e fi t s, but not Disenrollment from Secure H o rizons Medicare+Choice Plan. Health Plan Premium (if applicable) I n c reases in Health Plan Premiums and/or d e c reases in the level of cove rage are only p e rmitted at the beginning of each contract ye a r ( w h i ch is usually the Calendar Year) and must be a p p roved by CMS. You will re c e i ve written notice in the Fall of the year befo re ch a n ges to yo u r Health Plan Premium become effe c t i ve. (Please note: Rate ch a n ges for Group Retire e M e m b e rs enrolled through an employer group or t rust administrator are subject to contra c t u a l a rra n gements between Pa c i fi C a re and your fo rm e r e m p l oyer or trust administra t o r. Your fo rm e r e m p l oyer or trust administrator is re s p o n s i ble fo r notifying you of any Secure Hori z o n s M e d i c a re+choice Plan premium ch a n ge s, c o n t ribution ch a n ges or employer sponsore d b e n e fit ch a n ges thirty (30) days befo re they become e ffe c t i ve. ) Pa c i fi C a re may Disenroll you for fa i l u re to pay Health Plan Pre m i u m s. P rior to such action h oweve r,pa c i fi C a re will: ( a ) contact you within twenty (20) days after the due date of the delinquent ch a rge s ( b ) p rovide an explanation of the Disenro l l m e n t p ro c e d u res ( c ) advise you that fa i l u re to pay the Health Plan P remiums within a ninety (90) day grace peri o d m ay result in your Disenro l l m e n t ( d ) gi ve you a written notice of Disenro l l m e n t, i n cluding an explanation of your right to a h e a ring under the Gri evance pro c e d u re s. Until you are notified of your Disenro l l m e n t, you are still a Member of Secure Horizons Medicare + C h o i c e Plan and must continue to use Contracting Medical P rov i d e rs except for Emergency Services or U rge n t ly Needed Serv i c e s. If you re c e i ve serv i c e s f rom Non-Contracting Medical Prov i d e rs without

65 P rior Au t h o rization from Pa c i fi C a re, n e i t h e r Pa c i fi C a re nor Medicare will pay for those serv i c e s. If you are Disenrolled for non-payment of Health Plan Premiums and you later decide to re - e n roll in S e c u re Horizons Medicare+Choice Plan,you mu s t p ay any Health Plan Premiums due from yo u r p revious enrollment in Secure Hori z o n s M e d i c a re+choice Plan. Medicare Part A Premium For Members with Secure Hori z o n s M e d i c a re+choice Plan Pa rt A equiva l e n t, failing to pay the Pa rt A Premium payments within a ninety (90) day grace period will result in yo u r D i s e n ro l l m e n t. If you are not entitled to Medicare Pa rt A, you may not enroll in any other Medicare+Choice Plan. I f you wish to enroll with another Medicare + C h o i c e O rg a n i z a t i o n, you must purchase Medicare Pa rt A. ( You we re able to remain enrolled with Secure H o rizons Medicare+Choice Plan because individuals with Pa rt B only who we re enrolled in an HMO befo re Ja nu a ry 1,1999 are gra n d fa t h e re d, and may remain enrolled with the same organization.) For instructions on how to p u rchase Medicare Pa rt A, please see Section 7. Medicare Part B Premium As a Secure Horizons Medicare+Choice Plan M e m b e r,you must continue to pay your Medicare Pa rt B Pre m i u m. If you re c e i ve a Social Securi t y A d m i n i s t ration or Railroad Retirement Board a n nuity ch e ck, this premium is automatically deducted from your ch e ck. O t h e r w i s e, yo u r p remium is paid dire c t ly to Medicare by you or someone on your behalf as Medicaid or Medi-Cal. Member Non-Liability In the event Pa c i fi C a re fails to re i m b u rse a C o n t racting Medical Prov i d e r s ch a rges for C ove red Services or in the event that Pa c i fi C a re fa i l s to pay a Non-Contracting Medical Provider for Prior Au t h o rized services occurring when you we re active ly enrolled in Secure Hori z o n s M e d i c a re+choice Plan,you will not be liable for any sums owed by Pa c i fi C a re. H o w e v e r, you will be liable if you re c e i v e services from Non-Contracting Medical P roviders without Prior Authorization. Neither PacifiCare nor Medicare will pay for those services except for: E m e rgency Services U rgently Needed Services O u t - o f - a rea and routine travel renal dialysis (in the United States at a Medicare certified facility) or C o v e red Services for which Secure Horizons M e d i c a re+choice Plan allows you to selfrefer to Contracting Providers. In addition, if you enter into a private contract with a Non-Contracting Medical Pro v i d e r, neither PacifiCare nor Medicare will pay for those services. In the event a Contracting Medical Prov i d e r s c o n t ract with Pa c i fi C a re is terminated while you are under a Contracting Medical Prov i d e r s care, Pa c i fi C a re will pay for the continuation of re l a t e d C ove red Services as long as you retain eligi b i l i t y, until the Cove red Services are completed, u n l e s s Pa c i fi C a re makes a re a s o n able and medically a p p ro p riate arra n gement for those services to be p rovided by another Contracting Medical Prov i d e r. A Pa c i fi C a re Medical Director or designee (entity or p e rson selected for this purpose) shall determ i n e when the Contracting Medical Prov i d e r s serv i c e s a re completed and what is a re a s o n able and m e d i c a l ly appro p riate arra n gement for the p rovision of the services by another Contra c t i n g Medical Prov i d e r. Third Party Liability In the case of injuries caused by any act or omission of a third part y, and any complications incident t h e re t o, Pa c i fi C a re shall furnish all Cove red Serv i c e s. H oweve r, you agree to fully re i m b u rse Pa c i fi C a re or its designee for the cost of all such services and b e n e fits prov i d e d, i m m e d i a t e ly upon obtaining a m o n e t a ry re c ove ry,whether due to settlement or j u d g m e n t, as a result of such injuri e s. 57

66 You agree to cooperate in protecting the intere s t s of Pa c i fi C a re or its designee under this prov i s i o n. You shall not settle any cl a i m, or release any p e rson from liab i l i t y, without the written consent of Pa c i fi C a re, w h e rein such release or settlement will extinguish or act as a bar to Pa c i fi C a re s right of re i m b u rs e m e n t. Reimbursement of Third Party Medical Expenses If you re c e i ve medical services under your Secure H o rizons Medicare+Choice Plan cove rage after being injured through the actions of another pers o n (a third party) for which you re c e i ve a monetary re c ove ry,you will be re q u i red to re i m b u rs e Pa c i fi C a re, or its designee, to the extent perm i t t e d under State and fe d e ral law,for the cost of such medical services and benefits provided and the re a s o n able costs actually paid to perfect any lien. You must obtain the written consent of Pa c i fi C a re or its nominee (entity or person authorized to gi ve consent) prior to settling any cl a i m, or releasing any t h i rd party from liab i l i t y, if such settlement or release would limit the re i m b u rsement rights of Pa c i fi C a re or its nominee. You are re q u i red to cooperate in protecting the i n t e rests of Pa c i fi C a re or its nominee by prov i d i n g all liens, assignments or other documents necessary to secure re i m b u rsement to Pa c i fi C a re or its n o m i n e e. Fa i l u re to cooperate with Pa c i fi C a re or its nominee in this re g a rd could result in term i n a t i o n of your Secure Horizons Medicare+Choice Plan m e m b e rs h i p. Should you settle your claim against a third part y and compromise the re i m b u rsement rights of Pa c i fi C a re or its nominee without Pa c i fi C a re s w ritten consent, or otherwise fail to cooperate in p rotecting the re i m b u rsement rights of Pa c i fi C a re or its nominee, Pa c i fi C a re may initiate legal action against yo u. A t t o rn ey fees will be awa rded to the p revailing part y. Non-Duplication of Benefits With Automobile, Accident or Liability Coverage If you are receiving benefits as a result of other a u t o m o b i l e, accident or liability cove rage, Pa c i fi C a re will not duplicate those benefi t s. It is your responsibility to take whatever action is n e c e s s a ry to re c e i ve payment under automobile, a c c i d e n t, or liability cove rage when such pay m e n t s can re a s o n ably be ex p e c t e d, and to notify Pa c i fi C a re of such cove rage when ava i l abl e. If Pa c i fi C a re happens to duplicate benefits to which you are entitled under other automobile, accident or l i ability cove rage, Pa c i fi C a re may seek re i m b u rsement of the re a s o n able value of those b e n e fits from yo u, your insurance carri e r, or yo u r health care Provider to the extent permitted under State and/or fe d e ral law. S e c u re Horizons Medicare+Choice Plan will p rovide benefits over and above your other automobile, accident or liability coverage, if the cost of your health care services exceeds such coverage. You are re q u i red to cooperate with Pa c i fi C a re in obtaining payment from your automobile, a c c i d e n t or liability cove rage carri e r, and your fa i l u re to do so m ay result in termination of your Secure Hori z o n s M e d i c a re+choice Plan members h i p. Acts Beyond the Control of PacifiCare I f, due to a natural disaster, wa r, ri o t, c i v i l i n s u rre c t i o n, complete or partial destruction of a fa c i l i t y, o rd i n a n c e, l aw or decree of any gove rn m e n t or quasi-gove rnmental age n c y, l abor dispute (when said dispute is not within Pa c i fi C a re s contro l ), o r a ny other emergency or similar event not within the c o n t rol of Pa c i fi C a re, C o n t racting Medical Prov i d e rs m ay become unava i l able to arra n ge or prov i d e health services pursuant to this Evidence of C ove rage and Discl o s u re Info rm a t i o n, t h e n Pa c i fi C a re shall attempt to arra n ge for Cove re d S e rvices insofar as practical and according to 58

67 Pa c i fi C a re s best judgment. Neither Pa c i fi C a re nor a ny Contracting Medical Provider shall have any l i ability or obligation for delay or fa i l u re to prov i d e or arra n ge for Cove red Services if such delay is the result of any of the circumstances described ab ove. Contracting Medical Providers Are Independent Contractors The relationships between Pa c i fi C a re and its C o n t racting Medical Prov i d e rs and Contra c t i n g Hospitals are independent contra c t o r re l a t i o n s h i p s. None of the Contracting Medical P rov i d e rs or Contracting Hospitals or their p hysicians or employees are employees or age n t s of Pa c i fi C a re. An agent would be anyo n e a u t h o rized to act on Pa c i fi C a re s behalf. N e i t h e r Pa c i fi C a re nor any employee of Pa c i fi C a re is an e m p l oyee or agent of the Contracting Medical P rov i d e rs or Contracting Hospital. PacifiCare Contracting Arrangements In order to obtain quality service in an effi c i e n t m a n n e r, Pa c i fi C a re pays its Prov i d e rs using va ri o u s p ayment methods, i n cluding capitation, per diem, i n c e n t i ve and discounted fe e - fo r - s e rv i c e a rra n ge m e n t s. Capitation means paying a fi xe d dollar amount per month for each Member assigned to the Prov i d e r. Per diem means paying a fi xed dollar amount per day for all serv i c e s re n d e re d. I n c e n t i ve means a payment that is based on appro p riate medical management by the P rov i d e r. Discounted fe e - fo r - s e rvice means pay i n g the Provider's usual, c u s t o m a ry and regular fe e discounted by an agreed-to perc e n t age. You are entitled to ask if Pa c i fi C a re has special financial arra n gements with the Contra c t i n g Medical Prov i d e rs that can affect the use of R e fe rrals and other services that you might need. To obtain this info rm a t i o n, call Customer Serv i c e and request info rmation about the Contra c t i n g Medical Prov i d e r s payment arra n ge m e n t s. How PacifiCare Contracting Providers Are Compensated The fo l l owing is a brief description of how Pa c i fi C a re pays its Contracting Medical Prov i d e rs : Pa c i fi C a re typically contracts with medical gro u p s / I PAs to provide medical services and with Hospitals to provide Hospital services to Members. The Contracting Medical Gro u p s / I PAs in turn, e m p l oy or contract with individual phy s i c i a n s. Most of the Contracting Medical Gro u p s / I PA s, re c e i ve an agreed upon monthly payment fro m Pa c i fi C a re to provide services to Members. T h e m o n t h ly payment may be either a fi xed dollar amount for each Member or a perc e n t age of the m o n t h ly plan premium re c e i ved by Pa c i fi C a re. The monthly payment typically cove rs p ro fessional services dire c t ly provided by the C o n t racting Medical Gro u p / I PA, and may also c over certain Refe rral serv i c e s. Some of Pa c i fi C a re's Contracting Hospitals re c e i ve similar m o n t h ly payments in re t u rn for arra n gi n g Hospital services for Members. Other Hospitals a re paid on a discounted fe e - fo r - s e rvice or fi xe d ch a rge per day of hospitalization. E a ch ye a r, Pa c i fi C a re and the Contracting Medical G ro u p / I PA agree on a budget for the cost of s e rvices cove red under the pro gram for all Secure H o rizons Medicare+Choice Plan Members tre a t e d by the Contracting Medical Gro u p / I PA. At the end of the ye a r, the actual cost of services for the ye a r is compared to the agreed upon budge t. If the actual cost of services is less than the agreed upon b u d ge t, the Contracting Medical Gro u p / I PA share s in the sav i n g s. The Contracting Hospital and the C o n t racting Medical Gro u p / I PA typically p a rticipate in pro grams for Hospital serv i c e s similar to that described ab ove. Stop-loss insurance protects the Contra c t i n g Medical Gro u p s / I PAs and Contracting Hospitals f rom large financial losses and helps the Prov i d e rs with re s o u rces to cover necessary tre a t m e n t. Pa c i fi C a re provides stop-loss protection to the C o n t racting Medical Gro u p s / I PAs and Contra c t i n g 59

68 Hospitals that re c e i ve capitation pay m e n t s. If a ny capitated Prov i d e rs do not obtain stop-loss p rotection from Pa c i fi C a re, t h ey must obtain stop-loss insurance from an insurance carri e r a c c e p t able to Pa c i fi C a re. You may obtain additional info rmation on compensation a rra n gements by contacting Customer Service or your Contracting Medical Gro u p / I PA. Physician-Patient Relationship You are re s p o n s i ble for selecting a Contra c t i n g Medical Gro u p / I PA. The phy s i c i a n - p a t i e n t relationship between you and your Contra c t i n g Medical Gro u p / I PA shall be maintained by the C o n t racting Medical Gro u p / I PA. S e c u re Hori z o n s M e d i c a re+choice Plan is not a health care Prov i d e r. Pa c i fi C a re does not prohibit or otherwise re s t rict a P rov i d e r, acting within the lawful scope of pra c t i c e, f rom advising, or advocating on your behalf ab o u t : 1. Your health status,medical care or tre a t m e n t o p t i o n s 2. The ri s k, b e n e fi t s, and consequences of t reatment or non-tre a t m e n t 3. The opportunity for you to refuse treatment and to ex p ress pre fe rences about future tre a t m e n t d e c i s i o n s. Facility Locations Medical services are provided to Secure Hori z o n s M e d i c a re+choice Plan Members thro u g h C o n t racting Medical Prov i d e rs, C o n t ra c t i n g P hy s i c i a n s, C o n t racting Hospitals, C o n t ra c t i n g Facilities and Contracting Pharm a c i e s. For a complete list of Prov i d e rs, please re fer to the Secure H o rizons Medicare+Choice Plan Provider Dire c t o ry. If you have any questions re g a rding the Contra c t i n g P rov i d e rs listed in the dire c t o ry, please contact Customer Service or visit the web site at w w w. s e c u re h o ri z o n s. c o m For twe n t y - four (24) hour Emergency and/or Urge n t C a re telephone nu m b e rs, re fer to either the Secure H o rizons Medicare+Choice Plan Provider Dire c t o ry or your membership card. Practitioners and Utilization Review Utilization Rev i ew decision-making is based only on a p p ro p riateness of care and serv i c e. Pa c i fi C a re does not compensate pra c t i t i o n e rs or other individuals conducting utilization rev i ew for denials of c ove rage or serv i c e. Financial incentives fo r Utilization Rev i ew decision-make rs do not e n c o u rage denials of cove rage or serv i c e. Notices A ny notice re q u i red to be gi ven under this Evidence of Cove rage and Discl o s u re Info rmation shall be in w riting and either delive red pers o n a l ly or by United States mail at the addresses set fo rth below or at s u ch other address as the parties may designate: If to Pa c i fi C a re : Pa c i fi C a re A t t n : Customer Serv i c e P. O. B ox 489 C y p re s s, CA If to yo u, to your last address known to Pa c i fi C a re. Public Policy Participation Pa c i fi C a re / S e c u re Horizons Medicare+Choice Plan a ffo rds its Members the opportunity to part i c i p a t e in establishing the public policy of Secure Hori z o n s. O n e - t h i rd of Pa c i fi C a re of Califo rn i a s Board of D i re c t o rs is comprised of Pa c i fi C a re / S e c u re H o rizons Medicare+Choice Plan Members. If yo u a re interested in participating in the establ i s h m e n t of the Pa c i fi C a re / S e c u re Horizons Medicare + C h o i c e Plan public policy, please call or write Pa c i fi C a re, A t t n : Customer Serv i c e, P. O. B ox 489, C y p re s s, C A Important Information About Organ and Tissue Donations Transplantation has helped thousands of people s u ffe ring from organ fa i l u re, or in need of corn e a s, s k i n, bone or other tissue. The need for donated o rgans and tissues continues to outpace the supply. At any gi ven time,n e a r ly 50,000 A m e ricans may be waiting for organ transplants while hundreds of 60

69 thousands more need tissue tra n s p l a n t s. O rg a n and tissue donation provides each of us with a special opportunity to help others. Almost Anyone Can Be a Donor Almost eve ryone can be a donor. T h e re is no age limit and the number of donors age 50 or older has i n c re a s e d. If you have questions or concerns ab o u t o rgan donation, speak with your fa m i ly, doctor or cl e rgy Member. T h e re are many re s o u rces that can p rovide the info rmation you need to make a re s p o n s i ble decision. Be Sure to Share Your Decision S h a ring your decision to be an organ and tissue donor with your fa m i ly is as important as making the decision itself. Your organs and tissue will not be donated unless a fa m i ly member gi ves consent at the time of your death,even if you have signed your dri ver's license or a donor card. A simple fa m i ly conve rsation may help to prevent confusion or uncertainty about your wishes. It is also helpful to document your decision by completing a donor c a rd in the presence of your fa m i ly and hav i n g them sign as witnesses. The donor card serves as a reminder to your fa m i ly and medical staff of yo u r p e rsonal decision to be a donor. C a rry it in yo u r wallet or purse at all times. How to Learn More To obtain your donor card and info rmation on o rgan and tissue donation, call SHARE or Request Donor Info rmation from your local D e p a rtment of Motor Ve h i cles (DMV). On the Intern e t, c o n t a c t : All About Transplantation and Donation at w w w. t ra n swe b. o rg D e p a rtment of Health and Human Services at h t t p : / / w w w. o rg a n d o n o r. gov Sign the donor card in your fa m i ly's pre s e n c e. H ave your fa m i ly sign as witnesses and pledge to c a rry out your wishes. Keep the card with you at all times where it can be easily fo u n d. Keep in mind that even if yo u ' ve signed a donor c a rd, you must info rm your fa m i ly so they can act on your wishes. As a Secure Horizons Medicare+Choice Plan M e m b e r, you have the right to request info rm a t i o n on the fo l l ow i n g : G e n e ral cove rage and compara t i ve plan i n fo rm a t i o n Utilization control pro c e d u re s Quality Control Pro gra m s Statistical data on Gri evances and Ap p e a l s The financial condition of Pa c i fi C a re S u m m a ry of Provider compensation a rra n ge m e n t s You may write to Pa c i fi C a re s Corporate Offices at: Pa c i fi C a re, 5701 Katella Ave nu e, C y p re s s, CA Section 14 S e c u re Horizons Medica re + C h o i ce Plan Service Area You are eligi ble for enrollment and continu e d c ove rage as long as you reside in the areas listed below : Fre s n o, Ke rn*, Los A n ge l e s,** Ora n ge, S a c ra m e n t o, Santa Clara, Santa Cru z, and Stanislaus * E x cluding 93527, I nyo ke rn, and 93558, Jo h a n n e s b u rg, , R a n d s b u rg, and and , R i d ge c re s t ** Excluding 90704, Ava l o n, Catalina Island You are also eligi ble for enrollment and continu e d c ove rage as long as you reside in one of the fo l l owing zip codes in the counties listed below : County: Alameda Zip Codes: , , , , , 61

70 , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , County: Contra Costa Zip Codes: , , , , , , , , , , , , , , , County: Madera Zip Codes: , , , , , , County: Placer Zip Codes: , , , , , , , , , , , , , , , , , , , , County: Riverside Zip Codes: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , County: San Bern a rd i n o Zip Codes: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , County: San Diego Zip Codes: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , County: San Luis Obispo Zip Codes: , , , , , , , , , , , , , , , , , , , , , , , , , , County: San Mateo Zip Codes: , , , , , , , , , , , , , , , , , , , , , , , , , , , , County: Santa Barbara Zip Codes: , , , , , 62

71 , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , County: Ve n t u r a Zip Codes: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Notice of Privacy Practices Effective April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMAT I O N. PLEASE REVIEW IT CAREFULLY. NO ACTION IS REQUIRED ON YOUR PA RT. At Pa c i fi C a re the protection of our members p ri va c y and the confidentiality of medical info rmation has a lways been a top pri o ri t y. We recognize that yo u depend upon us to safe g u a rd your pers o n a l i n fo rmation and uphold your pri vacy ri g h t s. T h i s d o c u m e n t, w h i ch is based on state and fe d e ral law, as well as our own company code of ethics, o ffe rs a d e cl a ration of our commitment to pre s e rv i n g member confidentiality and pri va c y. Our Privacy Practices This notice describes Pa c i fi C a re s pri vacy pra c t i c e s for both current and fo rmer members. It ex p l a i n s h ow we use health info rmation about you and when we may share that health info rmation with o t h e rs. It also info rms you about your rights with respect to your health info rmation and how yo u m ay exe rcise these ri g h t s. We are re q u i red by law to maintain the pri vacy of your health info rmation and to send you a copy of this notice so that you are awa re of how we maintain the pri vacy of yo u r health info rm a t i o n. Pa c i fi C a re employees are re q u i red to comply with our policies and pro c e d u res to protect the c o n fidentiality of health info rm a t i o n. A ny employe e who violates our pri vacy policy is subject to a d i s c i p l i n a ry pro c e s s. E m p l oyee access to health i n fo rmation is limited on a business n e e d - t o - k n ow b a s i s, s u ch as: to make benefit determ i n a t i o n s, p ay cl a i m s, m a n age care, u n d e r w rite cove rage, p e r fo rm quality assessment measure m e n t s, administer a plan or provide customer serv i c e. Pa c i fi C a re maintains phy s i c a l, e l e c t ronic and pro c e s s s a fe g u a rds that re s t rict unauthorized access to yo u r health info rm a t i o n. S u ch safe g u a rds include secure d o ffice fa c i l i t i e s, l o cked file cab i n e t s, and contro l l e d computer netwo rk systems and passwo rd accounts. This notice applies to all applicable companies within the Pa c i fi C a re fa m i ly of companies, w h i ch i n cludes businesses owned or controlled by Pa c i fi C a re Health Systems, I n c. ( Pa c i fi C a re ). Please share this notice with eve ryone cove red by your policy or contra c t. You have a right to re c e i ve a c o py of this notice upon request at any time. If yo u would like additional copies of the notice,or have questions related to the info rmation contained within the notice,please call Member/ Customer S e rvices at the toll-free number on your health plan i d e n t i fication card. You may also view a copy of this notice on our Web sites at www. p a c i fi c a re.com and w w w. s e c u re h o ri z o n s. c o m. Should any of our pri vacy practices ch a n ge, we re s e rve the right to ch a n ge the terms of this notice and to make the new notice effe c t i ve for all health i n fo rmation that we maintain. We will provide you a c o py of the revised notice and post the rev i s e d notice on our Web sites. Health Care Information Maintained at PacifiCare When we re fer to i n fo rm a t i o n or h e a l t h i n fo rm a t i o n in this notice,we mean info rm a t i o n about yo u, i n cluding demographic info rm a t i o n, t h a t m ay identify you and that relates to your past, 63

72 p resent or future physical or mental health and related health care serv i c e s. Health info rm a t i o n m ay be transmitted or shared in any fo rm or medium (ora l, w ri t t e n, or electro n i c ). The health info rmation we re c e i ve may va ry by p ro d u c t ; t h e re fo re, the examples that fo l l ow may not apply to all members, but are designed to re p resent the ge n e ral catego ries of info rm a t i o n that may be re c e i ved and maintained by Pa c i fi C a re : I n fo rmation provided by you on applications, fo rm s, s u rveys and our Web sites, s u ch as yo u r n a m e, a d d ress and date of birt h I n fo rmation from phy s i c i a n s, hospitals or other health care prov i d e rs, cl i n i c s, medical groups or health care service plans I n fo rmation provided by your employe r, b e n e fits plan sponsor or association,re g a rd i n g a ny group product that you may have I n fo rmation about your transactions and ex p e riences with our affi l i a t e s, o t h e rs, and us, s u ch as products or services purch a s e d, a c c o u n t b a l a n c e s, p ayment history, claims history, p o l i c y c ove rage and pre m i u m s I n fo rmation from consumer or medical re p o rting agencies or other third part i e s, i n cluding medical and demographic info rmation H ow We May Use or Share Your Info r m a t i o n The fo l l owing catego ries describe how we may use and share your health info rm a t i o n. For each c a t e go ry we provide examples that help illustra t e e a ch type of use or discl o s u re. Not eve ry use or d i s cl o s u re in a catego ry will be listed. H oweve r, the ways in which we are permitted to use and s h a re health info rmation will fall into one of these catego ri e s. For Tre a t m e n t We may share health info rmation with yo u r d o c t o rs or hospitals to help them provide medical c a re for yo u. For ex a m p l e, if you are hospitalized, we may allow the hospital staff access to any medical re c o rds sent to us by your doctor. We may also use or share your health info rmation with o t h e rs to help coordinate and manage your health c a re. For ex a m p l e, we may talk to your doctor to s u g gest a disease management or wellness pro gra m that can help improve your health. For Payment We may use your health info rmation when pay i n g your medical bills submitted to us by you or yo u r health care prov i d e rs, s u ch as doctors and h o s p i t a l s. Examples of payment activities incl u d e b i l l i n g, claims management and other re l a t e d a d m i n i s t ra t i ve functions. For Health Care Operations We may use or share certain health info rmation fo r n e c e s s a ry health care opera t i o n s. Examples of health care operations include the fo l l ow i n g : Pe r fo rming quality assessment and i m p rovement activities E valuating provider and health plan p e r fo rm a n c e P roviding underwriting cove rage Conducting or arra n ging medical rev i ews to d e t e rmine medical necessity,l evel of care or j u s t i fication of serv i c e s Pe r fo rming auditing functions Resolving internal gri eva n c e s, s u ch addre s s i n g p ro blems or complaints about your access to c a re or satisfaction with serv i c e s Making benefit determ i n a t i o n s, a d m i n i s t e ring a b e n e fit plan and providing customer serv i c e Other uses specifi c a l ly authorized by law We may also share your health info rmation with other individuals or entities,also known as business associates, that perfo rm payment or health care operations on behalf of Pa c i fi C a re. H oweve r, we will not share your health i n fo rmation with these business associates unless t h ey agree in writing to protect the pri vacy of that i n fo rm a t i o n. To Make Certain Communications to You We may use or share your health info rmation with a t h i rd party acting on behalf of Pa c i fi C a re in order to i n fo rm you about altern a t i ve medical tre a t m e n t s and pro grams or about health-related products and 64

73 s e rvices that may be of value to yo u. We may also i n fo rm you about enhancements, replacements or substitutions to your health plan cove rage. For members that reside in Ore gon and Neva d a, if you do not want Pa c i fi C a re to share health i n fo rmation as described ab ove, you may o p t - o u t by calling the Member/Customer Service tollf ree number on your health plan identifi c a t i o n c a rd during normal business hours. For members that reside in Tex a s, ex c ept fo r c o m munications about treatment or health care o p e ra t i o n s, Pa c i fi C a re may not use or share yo u r health info rmation for marketing purposes unless you provide written permission for us to do so. Information Not Personally Identifiable We may use or share your health info rm a t i o n when it has been d e - i d e n t i fi e d. H e a l t h i n fo rmation is considered to be de-identifi e d when it does not pers o n a l ly identify yo u. We may also use a limited data set that does not contain any info rmation that can dire c t ly identify yo u. This limited data set may only be used fo r the purposes of re s e a rch, p u blic health matters or health care opera t i o n s. For ex a m p l e, a limited data set may include your city, county and zip c o d e, but not your name or street addre s s. To the Employee Benefit Plan Under certain circ u m s t a n c e s, we may share limited health info rmation about you with the e m p l oyee benefit plan through which yo u re c e i ve health benefi t s. For ex a m p l e, we may s h a re summary health info rmation with the e m p l oyee benefit plan so that they may obtain bids from other health plans, or modify, a m e n d, or terminate cove rage with Pa c i fi C a re. We may also share health info rmation related to yo u r e n ro l l m e n t, d i s e n rollment and/or participation in a Pa c i fi C a re health plan. We will not share i n d i v i d u a l lyidentifi able health info rmation with your benefit plan unless they agree to maintain the pri vacy of your info rm a t i o n. For members that reside in Califo rnia and O k l a h o m a, Pa c i fi C a re may not share yo u r health info rmation with your employer or b e n e fit plan unless you provide wri t t e n p e rmission for us to do so. Special Circumstances and State and Federal Laws Special situations and certain state and federal laws may require us to use or release your health information. For example, we may be obligated to release your health information for the following reasons: To comply with state and fe d e ral laws that re q u i re us to release your health info rmation to others To re p o rt info rmation to state and fe d e ra l agencies that regulate our business, s u ch as the U. S. D e p a rtment of Health and Human S e rvices and your state s re g u l a t o ry age n c i e s To assist with public health activities; fo r ex a m p l e, we may re p o rt health info rmation to the Food and Drug A d m i n i s t ration for the purpose of investigating or tra cking a p re s c ription drug and medical dev i c e m a l f u n c t i o n s To re p o rt info rmation to public health age n c i e s if we believe there is a serious threat to yo u r health and safety or that of the public or another pers o n ; this includes disaster re l i e f e ffo rt s To re p o rt certain activities to health ove rs i g h t age n c i e s ; for ex a m p l e, we may re p o rt activities i nvolving audits, i n s p e c t i o n s, l i c e n s u re and peer rev i ew activities To assist court or administra t i ve age n c i e s ; fo r ex a m p l e, we may provide info rmation purs u a n t to a court ord e r, s e a rch wa rrant or subpoena To support law enforcement activities; for example, we may provide health information to law enforcement agents for the purpose of identifying or locating a fugitive, material witness or missing person To correctional institutions or law enforcement officials if you are an inmate or 65

74 under the custody of a law enfo rcement offi c i a l To report information to a government authority re g a rding child ab u s e, neglect or domestic violence To share information with a coroner or medical examiner as authorized by law (we may also share information with funeral directors, as necessary to carry out their duties) To use or share information for procurement, banking or transplantation of organs, eyes or tissues To report information regarding job-related injuries as required by your state worker compensation laws To share information related to specialized government functions, such as military and veteran activities, national security and intelligence activities and protective services for the President and others To researchers when their research has been approved by an institutional review board that has approved the research proposal and established protocols to ensure the privacy of your health information To a family member or friend under any of the following circumstances: (1) if you provide a verbal agreement to allow such a disclosure; (2) if you are given an opportunity to object to such a disclosure and you do not raise an objection; or (3) if it can be inferred from the circumstances, based on PacifiCare s professional judgment, that you would not object Written Permission to Use or Share Your Information For any other activity or purpose not listed ab ove or as otherwise permitted by law we mu s t obtain your written perm i s s i o n, k n own as an a u t h o ri z a t i o n, p rior to using or sharing yo u r health info rm a t i o n. If you provide a wri t t e n a u t h o rization and you ch a n ge your mind, you may revo ke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share the health information as outlined in the authorization form; however, you should be aware that we may not be able to retract a use or disclosure that was previously made based on a valid authorization. Other Restrictions Regarding Use and Disclosure of Your Information Depending on the state in which you reside, there may be additional laws related to the use and disclosure of health information related to HIV status, communicable diseases, reproductive health, genetic test results, substance abuse, mental health and mental retardation. Your Rights Regarding Your Health Information The following are your rights with respect to your health information. If you would like to exercise the following rights, please call Member/Customer Services at the toll-free number on your health plan identification card. You have the right to ask us to restrict how we use or share your health information for treatment, payment or health care operations. You also have the right to ask us to restrict health information that we have been asked to give to family members or to others who are involved in your health care or payment for your health care. Please note that while we will try to honor your requests, we are not required by law to agree to the type of restrictions described above. You have the right to request confidential communications of health information. For example, if you believe that sending your information to your current mailing address would put your safety at risk (e.g., in situations involving domestic disputes or violence), you may ask us to send the information by alternative means (such as by fax) or to an alternate address. We will accommodate reasonable requests for confidential communication of your information. 66

75 You have the right to inspect and obtain a copy of the health information we maintain about you in a designated record set. A designated record set refers to a group of records that includes enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for PacifiCare. The types of health information included in a designated record set may vary depending on the state in which you reside. This right does not obligate us to grant you access to certain types of health information. Please note that under most circumstances we will not provide you with copies of the following information: Psychotherapy notes Information compiled in reasonable anticipation of, or for use in, a civil or criminal administrative action or proceeding Information subject to certain federal laws governing biological products and clinical laboratories Medical information compiled and used for quality assurance or peer review purposes If you request a copy of your designated record set, a fee for the costs of copying, mailing or other associated supplies may be charged. Additionally, under certain circumstances we may deny your request to inspect or obtain a copy of your health information. If we deny your request, we will notify you in writing and may provide you the option to have the denial reviewed. If you would like to request access to review or copy your patient medical records, please directly contact your Primary Care Physician or the health care provider who created the records. Patient medical records include records in any form or medium maintained by, or in the custody or control of, a health care provider relating to health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient. You have the right to ask us to make changes to the health information that we maintain about you in your designated record set. These changes are referred to as amendments. We may require that your request be in writing and that you provide a reason for your request. If we make the amendment, we will notify you that it was made. If we deny your request to amend, we will notify you in writing of the reason for denial. This written notification will explain your right to file a written statement of disagreement. In return, we have a right to rebut your statement. Furthermore, you have the right to request that your initial written request, our written denial and your statement of disagreement be included with your health information for any future disclosures. You have the right to re c e i ve an accounting of c e rtain discl o s u res of your health info rm a t i o n made by us during the six ye a rs prior to yo u r re q u e s t. We may re q u i re that your request for an accounting be in writing. Your first accounting is free. Subsequently, you are allowed one free accounting upon request every 12 months. If you request an additional accounting within 12 months of receiving your free accounting, we may charge you a fee. We will inform you in advance of the fee and provide you with an opportunity to withdraw or modify your request. Please note that, under most circumstances, we are not required to provide you with an accounting of disclosures of the following information: Any information collected prior to April 14, 2003 Information shared for treatment, payment or health care operations Information already disclosed to you Information shared as part of an authorization request Information that is incidental to a use or disclosure that is otherwise permitted 67

76 I n fo rmation provided for use in a fa c i l i t y d i re c t o ry I n fo rmation that was provided to pers o n s i nvo l ved in your care or for other notifi c a t i o n purposes Information shared for national security or intelligence purposes Information that was shared or used as part of a limited data set for research, public health or health care operation purposes I n fo rmation disclosed to correctional i n s t i t u t i o n s, law enforcement officials or health oversight agencies Questions Regarding Use and Disclosure and Your Privacy Rights How to File a Privacy Complaint If you believe that your privacy rights have been violated, you may file a complaint with us by calling PacifiCare s Privacy Line at You may also direct your complaints to the Secretary of the U.S. Department of Health and Human Services. PacifiCare will not penalize you or take any action against you for filing a complaint. How to Obtain More Information Regarding Your Rights as Well as the Use and Disclosure of Your Health Information. If you have any questions about how we use or share your health information or your rights regarding your health information, you may call Member/Customer Services at the toll-free number on your health plan identification card during normal business hours. PacifiCare Family of Companies includes: Antero Health Plans, Inc. PacifiCare of Arizona, Inc. PacifiCare of California PacifiCare Behavioral Health of California, Inc. PacifiCare of Colorado, Inc. PacifiCare Behavioral Health, Inc. PacifiCare of Nevada, Inc. PacifiCare of Oklahoma, Inc. PacifiCare Dental PacifiCare of Oregon, Inc. PacifiCare Dental of Colorado, Inc. PacifiCare of Texas, Inc. PacifiCare of Washington, Inc. Rx Solutions, Inc. PacifiCare Life and Health Insurance Company PacifiCare Life Assurance Company 68

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