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