CalCPA ProtectPlus

The following information is from the American Heart Association and explains how to understand blood pressure readings which is very important if we are to monitor our health. It is especially important to understand these numbers if we suffer from high or low blood pressure as well as other health conditions.

Step 1:  About High Blood Pressure – Understanding Blood Pressure Readings

What do the blood pressure numbers mean?

Blood pressure is typically recorded as two numbers, written as a ratio like this: 117/76 mm Hg (read as “117 over 76 millimeters of mercury”.

Systolic

The top number, which is also the higher of the two numbers, measures the pressure in the arteries when the heart beats (when the heart muscle contracts).

Diastolic

The bottom number, which is also the lower of the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood).

What is the AHA recommendation for healthy blood pressure?

This chart reflects blood pressure categories defined by the American Heart Association.

* Your doctor should evaluate unusually low blood pressure readings.

How is high blood pressure diagnosed?

Your healthcare providers will want to get an accurate picture of your blood pressure and chart what happens over time. Starting at age 20, the American Heart Association recommends a blood pressure screening at your regular healthcare visit or once every 2 years, if your blood pressure is less than 120/80 mm Hg.

Your blood pressure rises with each heartbeat and falls when your heart relaxes between beats. While BP can change from minute to minute with changes in posture, exercise, stress or sleep, it should normally be less than 120/80 mm Hg (less than 120 systolic AND less than 80 diastolic) for an adult age 20 or over. About one in three (33.5%) U.S. adults has high blood pressure.

If your blood pressure reading is higher than normal, your doctor may take several readings over time and/or have you monitor your blood pressure at home before diagnosing you with high blood pressure.

A single high reading does not necessarily mean that you have high blood pressure. However, if readings stay at 140/90 mm Hg or above (systolic 140 or above OR diastolic 90 or above) over time, your doctor will likely want you to begin a treatment program. Such a program almost always includes lifestyle changes and often prescription medication for those with readings of 140/90 or higher.

If, while monitoring your blood pressure, you get a systolic reading of 180 mm Hg or higher OR a diastolic reading of 110 mm HG or higher, wait a couple of minutes and take it again. If the reading is still at or above that level, you should seek immediate emergency medical treatment for a hypertensive crisis.

Even if your blood pressure is normal, you should consider making lifestyle modifications to prevent the development of HBP and improve your heart health.

Which number is more important, top (systolic) or bottom (diastolic)?

Typically more attention is given to the top number (the systolic blood pressure) as a major risk factor for cardiovascular disease for people over 50 years old. In most people, systolic blood pressure rises steadily with age due to increasing stiffness of large arteries, long-term build-up of plaque, and increased incidence of cardiac and vascular disease.

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Aggregate out-of-pocket maximum is met when the total of the out-of-pocket payments made by all family members exceeds two times the individual out-of-pocket amount.

Rights of Survivorship may apply to eligible family members following the death of a plan participant. These are rights to continued coverage under the deceased participant’s plan after the legally required rights provided under COBRA or CalCOBRA have expired. Family members who are eligible, and the conditions for continuation coverage, are set forth under the plan document. Rights of Survivorship do not apply to Anthem Blue Cross HMO Participants.

Prescription Drug Deductible is the amount of charges you have to pay for any covered brand-name prescription drug, before any brand-name prescription drug benefits are available to you. The prescription drug deductible does not apply to generic drugs and is not integrated with the medical deductible. It does not count toward the out-of-pocket maximum.

High Deductible Health Plan (HDHP) is a health insurance plan with minimum annual deductibles of $1,200 for individuals or $2,400 for family coverage. The annual out-of-pocket expense maximums (including deductibles and copayments but not including premiums) cannot exceed $5,950 for individuals or $11,900 for families. These amounts (for 2011) are indexed annually for inflation.

Usual, Customary and Reasonable (UCR) is a charge which falls within the common range of fees billed by a majority of physicians, hospitals, and other providers for a procedure in a given geographic region, or which is justified based on the complexity, or the severity of treatment for a specific case.

Health Savings Account (HSA) – is a special tax-sheltered savings account that is similar to a traditional Individual Retirement Account (IRA), but designated for medical expenses. An HSA allows you to pay for current health expenses and save for future qualified medical and retiree health care expenses on a tax-free basis. Contributions, earnings, and distributions all are exempt from federal income and Social Security (FICA) taxes when used to pay for qualified medical expenses.

Health Maintenance Organizations (HMOs) represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same regardless of types or levels of services provided by physicians who are employed by, or under contract with the HMO.

Home Infusion Therapy Provider is a provider licensed according to state and local laws as a pharmacy, and must be either certified as a home health care provider by Medicare, or accredited as a home pharmacy by the Joint Commission on Accreditation of Health Care Organizations.

Life-threatening means either or both of the following: diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted; diseases or conditions with potentially fatal outcomes, where the endpoint of clinical intervention is survival.

Medically necessary procedures, supplies equipment or services are those the claims administrator determines to be:

 1. Appropriate and necessary for the diagnosis or treatment of the medical condition;

 2. Provided for the diagnosis or direct care and treatment of the medical condition;

 3. Within standards of good medical practice within the organized medical community;

 4. Not primarily for your convenience, or for the convenience of your physician or another provider; and

 5. The most appropriate procedure, supply, equipment or service which can safely be provided.

The most appropriate procedure, supply, equipment or service must satisfy the following requirements:

 1. There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives;

 2. Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and

 3. For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care cannot be received by you as an outpatient or in a less intensified medical setting.

A Day Treatment Center is an outpatient psychiatric facility which is licensed according to state and local laws to provide outpatient programs and treatment of mental or nervous disorders, severe mental disorders, or substance abuse under the supervision of physicians.

Drug Limited Fee Schedule represents the maximum amounts the plan will allow as prescription drug covered expense for prescriptions filled at non-participating pharmacies. These amounts are the lesser of billed charges or the average wholesale price.

Non-Participating Pharmacy is a pharmacy which does not have a Participating Pharmacy Agreement in effect with the claims administrator at the time services are rendered. In most cases, you will be responsible for a larger portion of your pharmaceutical bill when you go to a non-participating pharmacy.

Co-Payment is the amount payable by the member for office visits and certain other services. The prescription drug co-payments are fixed dollar amounts payable for prescription drugs. The term co-payment does not include the portion of covered expenses, expressed as a percentage, payable by the member for covered services.

Hospital is a facility which provides diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of physicians. It must be licensed as a general acute care hospital according to state and local laws. It must also be registered as a general hospital by the American Hospital Association and meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations.

For the limited purpose of inpatient care for the acute phase of a mental or nervous disorder, severe mental disorder, or substance abuse, “hospital” also includes psychiatric health facilities.

Physician means:

1.  A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is licensed to practice medicine or osteopathy where the care is provided; or
2. One of the following providers, but only when the provider is licensed to practice where the care is provided, is rendering a service within the scope of that license, is providing a service for which benefits are specified in this booklet, and when benefits would be payable if the services were provided by a physician as defined above:

a)       A dentist (D.D.S.)

b)      An optometrist (O.D.)

c)       A dispensing optician

d)      A podiatrist or chiropodist (D.P.M., D.S.P. or D.S.C.)

e)      A psychologist

f)        A chiropractor (D.C.)

g)      A certified registered nurse anesthetist

h)      An acupuncturist (A.C.)

i)        A clinical social worker (C.S.W. or L.C.S.W.)

j)        A marriage, family and child counselor (M.F.C.C.)

k)      A physical therapist (P.T. or R.P.T.)*

l)        A speech pathologist*

m)    An audiologist*

n)      An occupational therapist (O.T.R.)*

o)      A respiratory care practitioner (R.C.P.)*

p)      A psychiatric mental health nurse

q)      A Physician assistant*

r)       A nurse midwife**

s)       A registered dietitian (R.D.)* for the provision of diabetic medical nutrition therapy only

t)       A registered nurse practitioner

* Note. The providers indicated by asterisks (*) are covered only by referral of a physician as defined in 1 above.
** If there is no nurse midwife who is a participating provider in your area, you may call the Customer Service telephone number on your ID card for a referral to an OB/GYN.

Negotiated Rate is the amount participating providers agree to accept as payment in full for covered services. It is usually lower than their normal charge. Negotiated rates are determined by claims administrator’s Participating Provider Agreements. With respect to non-participating providers, the negotiated rate means the typical fee participating hospitals and participating physicians agree to accept as payment in full of covered services as determined by the claims administrator, as appropriate, in its discretion.

A Participating Employer is a firm participating in the plan, where more than 50 percent of all the participating employer’s owners (i.e., principals, proprietors, partners, shareholders or other owners) are Certified Public Accountants and all Certified Public Accountant-owners are members of CalCPA in good standing or a candidate applying for CalCPA membership. Specific qualifications of a participating employer are stipulated in the subscription agreement between the trust and the participating employer.

Other Health Care Providers are neither physicians nor hospitals. They are mostly free-standing facilities or service organizations, such as ambulance companies. Other health care providers are not part of the plan provider network.

Other health care provider is one of the following providers:
1. A certified registered nurse anesthetist;
2. A blood bank;
3. A licensed ambulance company; or
4. A hospice.

The provider must be licensed according to state and local laws to provide covered medical services.