ACTIVE LABOR - Means a labor at a time at which either of the following would occur:
(1) There is inadequate time to effect safe transfer to another hospital prior to delivery. (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. ACUTE CONDITION - A medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration.
ADVICE NURSE - Advice Nurse is an RN (Registered Nurse) capable of assessing and advising you about your health condition on the telephone.
AGREEMENT - This Evidence of Coverage (EOC), the appendices, all endorsements, all
enrollment in the Plan are the Agreement (Contract) issued by CCHP. This Agreement sets forth the benefits, things not covered, payment administration and other conditions under which CCHP will provide services to members of the Plan. If you are in the Kaiser Permanente Network, the benefits, things not covered, and other conditions are in the Kaiser Health Plan Evidence of Coverage. (See also Health Plan Contract).
AMENDMENT - A written description of additional provisions to the Health Plan Contract which CCHP will send to members when such changes occur. Any Amendment gotten from the Plan should be read and then attached to this Combined Evidence of Coverage & Disclosure Form booklet. AUTHORIZATION (AUTHORIZED or OKAYED) - The approval (okay) given by CCHP, in advance of a benefit or service being provided to a member. Even if authorization by the CCHP is not required for a certain service under this Evidence of Coverage, except for Emergency Services, Sensitive Services and other services for which you can self-refer (such as access to OB/GYN), those services which are listed in this Evidence of Coverage as benefits will not be covered by the CCHP unless you are referred for such services by your PCP. For members in Kaiser Permanente Network, authorization is the pre-approval and referrals given by Kaiser Permanente according to rules established by Kaiser Permanente.
BENEFITS (COVERED SERVICES) -
Those medically necessary services,
supplies and drugs which a member is entitled to get pursuant to the terms of this Evidence of Coverage, which is the Service Agreement and Disclosure Form. A service will not be covered as a benefit under this
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Plan, even if identified as a benefit in this Evidence of Coverage, if it is not medically necessary. All benefits must be provided by doctors within CCHP’s provider network, unless previously okayed by the Plan. BIC CARD - Beneficiary Identification Card that shows eligibility for Medi-Cal. CALENDAR YEAR - A period starting at 12:01 a.m. on January 1 and stopping at 12:00 a.m. January 1 of the following year. CCHP - Contra Costa Health Plan
CCS - Services covered by California Children’s Service
CENTERS FOR MEDICARE AND
MEDICAID SERVICES (CMS) - The new name for the Health Care Financing
Administration, the Federal agency
responsible for administering the Medicare and Medicaid Programs.
CHDP SERVICES - State of California Child Health Disability Prevention Program.
COMMUNITY PHYSICIAN - A
participating provider from the Community Provider Network (CPN). CPN providers are not employed by Contra Costa Health Services Department, and do not otherwise provide services at any of the Health Centers located in Antioch, Bay Point, Brentwood,
Concord, Martinez, Pittsburg, North
Richmond and San Pablo (referred to as the RMCN).
COMMUNITY PROVIDER - A
participating doctor, professional, or
ancillary provider from the CPN.
COMMUNITY PROVIDER NETWORK (CPN) - A network of providers contracted to provide covered services by CCHP that are not employed by Contra Costa Health
Services Department, and do not otherwise provide services at any of the Health Centers in the RMCN.
CONTRACT - See Health Plan Contract
CONTRACTING PROVIDER - See
Participating Provider
COSMETIC PROCEDURES - Any surgery, service, drug or supply designed to alter or reshape normal structures of the body in order to improve appearance.
COUNTY - Contra Costa County COVERED SERVICES - See Benefits CUSTODIAL CARE - See Long Term Care
DURABLE MEDICAL EQUIPMENT
(HOME MEDICAL EQUIPMENT) - Equipment that can withstand repeated use in the home, usually for a medical purpose. Generally, a person does not use Durable Medical Equipment in the absence of illness or injury. To qualify as a benefit under this Plan, Durable Medical Equipment must be medically necessary, prescribed by a participating doctor and okayed by the Plan for use in your home. These items may include oxygen equipment, wheelchairs, hospital beds, and other items that CCHP determines to be medically necessary. Durable Medical Equipment may be either purchased or rented by CCHP as determined by CCHP
EFFECTIVE DATE - The date, as shown in CCHP’s records and on which CCHP coverage starts for you under this contract. You will get written notification of your effective date once CCHP has confirmed your enrollment.
ELIGIBLE PERSON - A Medi-Cal beneficiary who meets the enrollment
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Medi-Cal Evidence of Coverage & Disclosure Form requirements of the Plan and the Department
of Health Care Services, whose county of residence for the purpose of Medi-Cal eligibility determination is Contra Costa County, and who resides in CCHP’s service area.
EMERGENCY (EMERGENCY MEDICAL CONDITION) - A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
(1) placing the health of the individual (or in the case of a pregnant woman, the health of the woman and her unborn child) in serious medical jeopardy; or
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
EMERGENCY SERVICES OR CARE - Medical screening, exam, and evaluation by a doctor or psychiatrist to determine whether an emergency medical or psychiatric emergency medical condition or active labor exists. To the extent permitted by applicable law and under the supervision of a doctor or psychiatrist, other appropriate personnel may conduct the examination or screening to determine if an emergency medical condition, psychiatric condition or active labor exists. Emergency services or care do not require prior authorization or referral by the Plan.
EPSDT SERVICES - State of California Early Periodic Screening, Diagnosis and Treatment Program.
EVIDENCE OF COVERAGE - The document that explains the services and benefits covered by CCHP and defines the
rights and responsibilities of the member and CCHP.
EXCLUSION - Services, equipment, supplies or drugs which are not benefits under this Plan.
EXPERIMENTAL PROCEDURES AND ITEMS (INVESTIGATIONAL SERVICES) - Services, drugs, equipment, and procedures (a Service) are considered to be experimental or investigational if:
(a) The service is not recognized
in accordance with generally accepted medical standards, as being safe and effective for treating the condition in question, whether or not the service is okayed by law for use in testing or other studies on human patients; or
(b) The service approval of any
governmental authority prior to use and such approval has not been granted when the service is to be rendered; or
(c) The service can only be
legally provided as part of a research or investigational program okayed by a governmental authority.
Off-label use of drugs, are not considered experimental or investigational just because they are prescribed for a different purpose from what they are approved by the FDA, as long as certain conditions are met in California law. Experimental services are not a benefit under this Plan, even if such service is recommended or referred by your doctor. Investigational services are not covered except when it is clearly documented that all of the following apply: (1) Conventional therapy will not adequately treat the intended
patient's condition;
(2) Conventional therapy will not prevent progressive disability or
premature death;
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service has a record of safety and success with it equivalent or superior to that of other providers of the investigational service;
(4) The investigational service is the lowest cost item or service that meets the patient's medical needs and is less costly than all conventional alternatives;
(5) The service is not being performed as a part of a research
study protocol;
(6) There is a reasonable expectation that the investigational service will significantly prolong the intended patient's life or will maintain or restore a range of physical and social function suited to activities of daily living.
All investigational services require prior authorization. Payment will not be authorized for investigational services that do not meet the above criteria, or for associated inpatient care when a beneficiary needs to be in the hospital primarily because she/he is receiving such non-approved investigational services. If you are denied an experimental or investigational service, you may access the Department of Managed Health Care’s Independent Medical Review (IMR) process. See Section 8 below for more about IMR.
FEE FOR SERVICE - A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as it is rendered and identified by a claim for payment.
GENERIC - A chemically equivalent copy designed from a brand-name drug whose patent has expired. Typically less expensive and sold under the common name for the drug, not the brand name.
HEALTH CARE OPTIONS (HCO) - The California Department of Health Care
Services’ Contractor who makes
presentations and provides information on managed care and enrolls Medi-Cal eligible beneficiaries in a managed care plan in Contra Costa County.
HEALTH PLAN - The Contra Costa Health Plan (CCHP).
HEALTH PLAN CONTRACT - (See also Agreement) The Combined Evidence of Coverage, Disclosure form and Service Agreement which sets forth the benefits, exclusion, payment administration and other conditions under which CCHP will provide services to members of the Plan under this
contract, including all amendments,
appendices, and applications for coverage. HOSPICE - Care and services provided in a home or facility by a licensed or certified provider that are:
(a) designed to provide palliative and supportive care to individuals who have gotten a diagnosis of terminal illness with one (1) year or less life expectancy;
(b) directed and coordinated by medical professionals; and
(c) okayed by CCHP. Hospice is not long term care.
HOSPITAL - A health care facility licensed by the State of California, and accredited by the Joint Commission on Accreditation of Health Care Organizations, as either an acute care hospital or a psychiatric hospital. A facility which is principally a rest home, nursing home or home for the aged, or a distinct part Skilled Nursing Facility portion of a hospital is not included as a hospital. IDENTIFICATION CARD – The “ID” card issued by the CCHP to each member. This card must be presented to all providers when health care services are gotten. You may
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Medi-Cal Evidence of Coverage & Disclosure Form also be issued a card from Kaiser
Permanente if you choose them to be your provider network.
INPATIENT – An individual who has been admitted to a hospital as a registered bed patient and is receiving services under the direction of a doctor.
INVESTIGATIONAL SERVICES – See Experimental Procedures and Items. KAISER PERMANENTE NETWORK – A
network of doctors, health care
professionals, hospitals, and other health care facilities that are employed by, owned, or contracted by Kaiser Permanente to provide covered services to Medi-Cal members who select the Kaiser Permanente Network.
LIFE THREATENING – Either:
(1) diseases or conditions where the likelihood of death is high unless the course of the disease or condition is interrupted; and/or
(2) diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival. LONG TERM CARE – The provision of health, personal and social services to individuals who lack some function capacity (for example, the chronically ill, the elderly, and the disabled). This care is provided on a long-term basis usually in institutions (i.e., nursing homes or at-home basis). Hospice is not long term care.
MEDICALLY NECESSARY – Includes all covered services that are reasonable and necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury including services necessary to correct or
illnesses and conditions discovered by the screening services.
MIDWIFE – A person licensed as a Registered Nurse, who is currently certified as a nurse by the California Board of Registered Nursing, under the supervision of a licensed physician, attends cases of normal childbirth and provides before, during and after pregnancy care, including family planning care, for mothers and immediate care for the newborn.
NETWORK – See Provider Networks OCCUPATIONAL THERAPY – Treatment under the direction of a participating doctor and provided by a certified occupational therapist, utilizing arts, crafts, or specific training in daily living skills, to improve and maintain a patient’s ability to function. OFF-LABEL USE OF PRESCRIPTION DRUGS - Use of Food and Drug Administration (FDA) okayed drug for purposes other than those okayed by the agency. Examples of off-label uses include prescribing for a disease, dose, route, or formulation not okayed by the FDA. Off- label use of medications is a benefit (for plans which cover prescription drugs) when used for a life-threatening or chronic and seriously debilitating condition. The use of the drug must be safe, effective, and medically necessary.
ORTHOSIS (ORTHOTIC) – An orthopedic appliance or apparatus used to support, align, prevent or correct deformities or to improve the function of movable body parts. OUT OF AREA COVERAGE – Emergency services gotten while a member is outside of the service area. No services are covered outside the United States, except for emergency services requiring hospitalization
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and out-of-state treatment plans may be covered out of area only under limited conditions.
OUTPATIENT – A person receiving services under the direction of a participating doctor, but not as an inpatient.
PARTICIPATING PHYSICIAN OR
DOCTOR – A physician who is a participating provider.
PARTICIPATING PROVIDER – A doctor, clinic, hospital, or other health care professional or facility under contract with CCHP to arrange or provide benefits to members.
PHARMACY BENEFIT MANAGER – Firms that contract with plans to manage pharmacy services.
PHYSICIAN OR DOCTOR – An individual licensed and okayed to engage in the practice of medicine or osteopathic medicine.
PLAN PHYSICIAN OR DOCTOR – A physician having an agreement with CCHP to provide medical services to CCHP members.
PREFERRED DRUG LIST (PDL) – A list of drugs that do not require Prior Authorization.
PRESCRIPTION MEDICATION – A drug which has been okayed for use by the Food and Drug Administration, and which can, under federal or state law, be dispensed only by a prescription order from a licensed doctor, nurse practitioner or dentist. In addition, insulin is included as a prescription medication under this Evidence of Coverage.
PRESCRIPTION ORDER OR
PRESCRIPTION REFILL – The
authorization for a prescription medication issued by a provider who is licensed to make such an authorization in the ordinary course of his or her professional practice.
PRIMARY CARE PHYSICIAN (PCP) (OR PROVIDER) – The doctor (or nurse practitioner working with your doctor) selected from CCHP’s list of PCPs for the member’s primary care. The PCP is responsible for supervising, coordinating and providing the member’s initial and primary care; for making referrals to Specialty Care Physicians and other specialist care; and for all of the member’s
health care needs as okayed by
CCHP.
PRIOR AUTHORIZATION – See
Authorization.
PROSTHESIS – An artificial part, appliance or device used to replace a missing part of the body.
PROVIDER NETWORKS – One of the three (3) health care provider networks described in this Evidence of Coverage. These networks are the Community Provider Network, Regional Medical Center Network and the Kaiser Permanente Network.
QUALIFIED HEALTH CARE
PROFESSIONAL (RE: SECOND
OPINION REQUESTS) – An appropriately qualified health care professional is a Primary Care Physician or a specialist who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to the particular illness, disease, condition or conditions associated with a request for a second opinion.
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Medi-Cal Evidence of Coverage & Disclosure Form RECONSTRUCTIVE SURGERY – Surgery
performed to correct or repair abnormal structures of the body caused by congenital
defects, developmental abnormalities,
trauma, infection, tumors or disease to do either of the following:
(a) To improve function;
(b) To create a normal appearance, to the extent possible.
REFERRAL PROVIDERS – Any health care provider who is under contract with CCHP to whom a member is specifically referred for health services by a PCP. A member may be referred to a provider not under contract to CCHP only when medically necessary, when an appropriate referral provider is not available, and with the prior authorization of CCHP’s Medical Director.
REGIONAL MEDICAL CENTER
NETWORK (RMCN) – Health Centers located in Antioch, Bay Point, Brentwood,
Concord, Martinez, Pittsburg, North
Richmond and San Pablo, the doctors who practice at those centers, and the hospitals and other health providers under contract to CCHP. (Referred to as the RMCN).
SENSITIVE SERVICES – Diagnosis and treatment of sexually transmitted diseases (STD), Family Planning Services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy, HIV testing and counseling, abortion, treatment for rape and sexual assault. These services are those which a member may self-refer (without referral by the PCP or authorization from CCHP), including to a Medi-Cal provider who is not under contract with the Plan.
SERIOUS CHRONIC CONDITION - A medical condition due to a disease, illness, or other medical problem or medical
disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration.
SERIOUSLY DEBILITATING – Diseases or conditions that cause major irreversible morbidity.
SERVICE AREA – The geographic area served by CCHP which is Contra Costa County.
SKILLED NURSING CARE – Services that can only be performed by licensed nursing personnel. For home care, these services are intermittent.
SKILLED NURSING FACILITY – A skilled nursing facility has two (2) levels of care:
(1) Skilled Care-Services
necessitating the daily intervention and supervision by a licensed individual (i.e., registered nursing personnel or a doctor) for long-term or acute illness; and