CalCPA ProtectPlus

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.

Qualified Beneficiary, for the purposes of COBRA, is any of the following who is not entitled to Medicare on the day before the qualifying event and who on the date of the qualifying event is covered under the plan pursuant to the Subscription Agreement of a COBRA participating employer:

1. The plan participant;
2. A plan participant’s spouse;
3. A plan participant’s former spouse (or legally separated spouse); or
4. A child, including a child born to or placed for adoption with the plan participant during the COBRA continuation period.

Qualified Beneficiary, for the purposes of CalCOBRA, is any individual who on the date of the qualifying event is covered under the plan pursuant to the Subscription Agreement of a CalCOBRA participating employer and is not a CalCOBRA excluded member. Qualified beneficiary also includes any child who is born to a former plan participant of a CalCOBRA participating employer, which plan participant is a qualified beneficiary who has elected CalCOBRA coverage, or a child who is placed for adoption with such a former plan participant so electing, if the child is enrolled in the plan within 30 days after the child’s birth or placement for adoption. Such entitlement to benefits, subject to applicable terms and conditions, shall continue for the remainder of the period during which the plan participant is covered under CalCOBRA.

Psychiatric Health Facility is an acute 24-hour facility as defined in California Health and Safety Code 1250.2. It must be:

1. Licensed by the California Department of Health Services;
2. Qualified to provide short-term inpatient treatment according to state law;
3. Accredited by the Joint Commission on Accreditation of Health Care Organizations; and
4. Staffed by an organized medical or professional staff which includes a physician as medical director.

Protected Health Information means information about you and your medical case, the privacy of which is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Prior Plan is a plan sponsored by us which was replaced by this plan within 60 days. You are considered covered under the prior plan if you: (i) were covered under the prior plan on the date that plan terminated; (ii) properly enrolled for coverage within 31 days of this plan’s effective date; and (iii) had coverage terminate solely due to the prior plan‘s termination.

Prescription Drug Negotiated Rate is the rate that the claims administrator has negotiated with participating pharmacies under a Participating Pharmacy Agreement for prescription drug covered expense. Participating pharmacies have agreed to charge beneficiaries no more than the prescription drug negotiated rate. It is also the rate which Prescription Drug Program – Mail Service has agreed to accept as payment in full for mail service prescription drugs.

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.

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.

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.

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.

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.

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.

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.

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.