CalCPA ProtectPlus

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.

Out-of-Pocket Amount is the amount for which a member is responsible when the claims administrator’s allowance, as appropriate, for covered services is paid. The member’s out-of-pocket amount does not include:

1. Any expense incurred which exceeds covered expense or prescription drug covered expense;

2. Any expense incurred because the member did not obtain pre-authorization, pre-admission review or concurrent  review when required to do so under the heading Medical Management Program.

3. Any expense incurred because of plan limitations on the number of visits, days of treatment, or dollar limitations on days of treatment or other similar limitations on specific benefits;

4. Any amount for which a member is responsible when the maximum benefits of this plan are paid;

5. Any amount for which the member is responsible for prescription drugs; or

6. Any co-payment for covered services.

A Participating Provider is one of the following providers which has a claims administrator’s Participating Provider Agreement in effect with the claims administrator at the time services are rendered:

 1.   A hospital;
 2.   A physician;
 3.   An ambulatory surgical center;
 4.   A home health agency;
 5.   A facility which provides diagnostic imaging services;
 6.   A durable medical equipment outlet;
 7.   A skilled nursing facility;
 8.   A clinical laboratory; or
 9.   A home infusion therapy provider.

Participating providers agree to accept the negotiated rate as payment for covered services. A directory of participating providers is available upon request.

Mental Or Nervous Disorders, for the purposes of this plan, are conditions that affect thinking and the ability to figure things out, perception, mood and behavior, including severe mental disorders. A mental or nervous disorder is recognized primarily by symptoms or signs that appear as distortions of normal thinking, distortions of the way things are perceived (e.g., seeing or hearing things that are not there), moodiness, sudden and/or extreme changes in mood, depression, and/or unusual behavior such as depressed behavior or highly agitated or manic behavior.

Contracting Hospital is a hospital which has a Standard Hospital Contract in effect with the claims administrator to provide care to beneficiaries. A contracting hospital is not necessarily a participating provider. A list of contracting hospitals will be sent on request.

Hospice is an agency or organization primarily engaged in providing palliative care (pain control and symptom relief) to terminally ill persons and supportive care to those persons and their families to help them cope with terminal illness. This care may be provided in the home or on an inpatient basis. A hospice must be: (i) certified by Medicare as a hospice; (ii) recognized by Medicare as a hospice demonstration site; or (iii) accredited as a hospice by the Joint Commission on Accreditation of Hospitals. A list of hospices meeting these criteria is available upon request.

Facility-Based Care is care provided in a hospital, psychiatric health facility, residential treatment center or day treatment center for the treatment of mental or nervous disorders, severe mental disorders, or substance abuse.

Centers of Expertise Negotiated Rate (COE Negotiated Rate) is the fee COEs agree to accept as payment for covered services. It is usually lower than their normal charge. COE negotiated rates are determined by Centers of Expertise Agreements.

Participating Hospital is a hospital which has a claims administrator’s Participating Agreement in effect with the claims administrator, as appropriate, at the time services are rendered. Participating hospitals agree to accept the negotiated rate as payment in full for covered services. Participating hospitals agree to participate in procedures established to review the utilization of hospital services. Hospital services determined to be unnecessary, according to these utilization review procedures, are not covered by the plan. A list of participating hospitals is available upon request from the plan administrator, as appropriate.

An emergency is a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain) which the beneficiary reasonably perceives could permanently endanger health if medical treatment is not received immediately. Final determination as to whether services were rendered in connection with an emergency will rest solely with the claims administrator.

Deductible is the amount of charges a member must pay for any covered services before any benefits are available to the member under the plan. Amounts applied to the deductible do not apply to or reduce any co-insurance/co-payment, or the percentage of any covered expense or prescription drug covered expense which the member must pay.

A Generic Prescription Drug (Generic Drug) is a pharmaceutical equivalent of one or more brand name drugs and must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength, and effectiveness as the brand name drug.

COBRA

means the medical plan related provisions of the Consolidated Budget Reconciliation Act of 1985, as such provisions have been subsequently amended.

COBRA Administrator

means a COBRA participating employer or third party (not the Trustees or the plan administrator) appointed by the COBRA participating employer to act as the COBRA Administrator.

Claims Administrator refers to BC Life & Health Insurance Company. On behalf of BC Life & Health Insurance Company, Anthem Blue Cross of California shall perform all administrative services in connection with the processing of medical claims under the plan.

If you have registered with the State, please fax a copy of your registration and a completed Policy Change form to Banyan Administrators (cpaprotectplus@banyan-llc.com), LLC 877-237-4519.

Class I Transplants are any of the following: liver, heart, heart-lung, kidney, kidney-pancreas or bone marrow, including autologous bone marrow transplant, peripheral stem cell treatment and similar procedures.

Ambulatory Surgical Center is a freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It must also meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.

Mental Or Nervous Disorders for the purposes of this plan, are conditions that affect thinking and the ability to figure things out, perception, mood and behavior, including severe mental disorders. A mental or nervous disorder is recognized primarily by symptoms or signs that appear as distortions of normal thinking, distortions of the way things are perceived (e.g., seeing or hearing things that are not there), moodiness, sudden and/or extreme changes in mood, depression, and/or unusual behavior such as depressed behavior or highly agitated or manic behavior.

Non-Participating Provider is one of the following providers which does NOT have a claims administrator’s Participating Provider Agreement in effect with the claims administrator at the time services are rendered:

1. A hospital;
2. A physician;
3. An ambulatory surgical center;
4. A home health agency;
5. A facility which provides diagnostic imaging services;
6. A durable medical equipment outlet;
7. A skilled nursing facility;
8. A clinical laboratory; or
9. A home infusion therapy provider.

They are not participating providers. Remember that only a portion of the amount which a non-participating provider charges for services may be treated as covered expense under this plan. See your medical benefits: how covered expense is determined.

A participating pharmacy is a pharmacy which has a Participating Pharmacy Agreement in effect with the claims administrator at the time services are rendered. Call your local pharmacy to determine whether it is a participating pharmacy or call the toll-free customer service telephone number. Many participating pharmacies display a Rx decal with the claims administrator’s logo in their window so that you can easily identify them.