CalCPA ProtectPlus

Pre-Existing Condition means an illness, injury or condition which existed during the six-month period immediately prior to either: (i) your effective date; or (ii) the first day of any waiting period, whichever is earlier. A condition is considered to have existed when you: (i) sought or received medical advice for that condition; (ii) received medical care or treatment for that condition; or (iii) received medical supplies, drugs or medicines for that condition.

To review more health care terms, click here to visit the ProtectPlus Medical Plan glossary.

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.

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.

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.

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.

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.

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.

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.

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.

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.