CalCPA ProtectPlus

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.