Glossary
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Accidental Bodily Injury
Any accidental bodily injury caused by external forces under unexpected circumstances and which does not arise out of or in the course of the employment of a Covered Person. Sprains and strains will not be considered accidental Bodily Injury for purposes of benefit determination.
Active Employment
With respect to any eligible Employee, active performance of all customary duties of the Employee’s occupation, at the Employee’s usual place of employment, for a specified number of hours per week as determined by that employer, and not on a temporary basis.
Ambulatory Surgical Center
Any public or private establishment with an organized medical staff of Physicians, with permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures; with continuous Physician services and registered professional nursing services whenever a patient is in the facility; and which does not provide services or other accommodations for patients to stay overnight.
Annual Enrollment Period
The period designated by the Employer during which the Employee or Dependent who did not enroll in the Plan when first eligible may enter the Plan.
Benefit Percentage
The percentage of a Covered Expense which the Plan pays (as shown in the Schedule of Benefits).
Birthing Center
Any licensed health facility, place, or institution which is not a Hospital, where births are planned to occur away from the mother’s usual residence, following a normal, uncomplicated pregnancy.
Calendar Year
The period beginning on January 1st and ending the following December 31st. When a person first becomes covered, the first calendar year begins on the effective date of coverage and ends on December 31st.
Certified Nurse Midwife
A licensed, registered nurse who has been certified by the American College of Nurse Midwives as a nurse Midwife.
Co-insurance
The percentage of a Covered Expense which the Covered Person is responsible for paying.
Contract Administrator
The organization providing administrative services to the Employer in connection with the operation of the Plan and performing such other functions, including processing and payment of claims as may be delegated to it.
Convalescent Hospital
See Extended Care Facility
Co-Pay or Co-Payment
An amount a Covered Person must pay per service or visit,in most cases not attributable to Deductibles or Co-insurance.
Covered Expense
Any expense listed in the Covered Expense section under your Plan, to the extent such expense is not excluded or otherwise limited by your Plan.
Covered Person
Any eligible Employee or their eligible Dependent whose coverage became effective and has not terminated.
Creditable Coverage
Includes coverage under most group health plans, individual health insurance, Medicare, Medicaid, church plans, medical coverage provided by the government for uniformed services, medical coverage through the Indian Health Service or a tribal organization and state sponsored health insurance coverage or public health plan. Creditable Coverage does not include liability, dental, vision, specified disease and/or other supplemental type plans.
Custodial Care
Services (including room and board) or supplies provided to a person which consist primarily of basic care given to maintain life and/or comfort with no reasonable expectation of cure or improvement of the Illness and which can generally be provided by an individual without special training.
Deductible
An amount which each Covered Person must contribute toward payment of Covered Expenses each Calendar Year or Plan Year as set forth in the Schedule of Benefits.
Dependent
A properly enrolled person who is an Employee’s lawful spouse, an unmarried child under the age specified in the plan; or an unmarried student under the age specified in the plan if such child is primarily dependent upon the employee for financial support and is in full-time school attendance at any accredited high school, trade school, college or university. Children include:
1) Naturally or legally adopted children;
2) Step-children if:
a) they have a permanent parent-child relationship with you; and
b) you pay at least 50% of their support, and
c) they live with you or are a student as described above.
3) Other children if:
a) you are a legal guardian of the child(ren); and
b) you pay 100% of their support; and
c) they live with you or are a student as described above.
* Some plans also cover other children if they are the natural child of a covered Dependent. Please refer to your plan of coverage for specific language.
Coverage can be continued beyond the limiting age for a dependant child who is incapable of self support because of a Developmental Disability or physical handicap.
The term Dependent does not include any Dependent who is on active duty in a military service , except for temporary active duty of thirty-one(31) days or less, or a child who is eligible for coverage under this Plan as an Employee.
Developmental Disability
A child’s substantial Disability which results from mental retardation, cerebral palsy, epilepsy, neurological disorder, or physical handicap that renders the dependent incapable of self-support and is diagnosed by a Physician as a permanent or long term continuing condition.
Disability or Totally Disabled
With reference to an Employee, it is Disability resulting solely from an Illness which prevents an Employee from engaging in any employment or occupation for which he/she is or becomes qualified by reason of education, training, or experience and only when such Employee is, in fact, not engaged in any employment or occupation for wage or profit. For a Dependent, it is Disability which prevents a Dependent from engaging in substantially all the normal activities of a person in good health of like age and sex. A Covered Person must also be under the care of a Physician in order to be Totally Disabled for benefit purposes.
Durable Medical Equipment
Equipment which (a) can withstand repeated use, (b) is primarily and customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of Illness or injury, (d) is appropriate for use in the home, and (e) has been prescribed by a Physician.
Emergency Admission
An Emergency Admission is hospitalization for a condition which, unless promptly treated, would put the patient’s life in danger, or cause serious damage to a bodily function of the patient.
Employee
A person employed by the Employer. The term Employee shall not include independent contractors or leased employees.
Employer
The entity usuall considered to be the Plan Sponsor of your benefit plan.
Enrollment Date
Means the first day of coverage under your Plan or, if there is a Waiting Period, the first day of the Waiting Period.
Extended Care Facility
An institution which is duly licensed as a Convalescent Hospital, Extended Care Facility, Skilled Nursing Facility, or Intermediate Care Facility and is operated in accordance with governing laws and regulations; is primarily engaged in providing accommodations and skilled nursing care 24 hours a day for convalescing persons, is under the full-time supervision of a Physician or a registered graduate nurse; admits patients only upon the recommendation of a Physician (other than the patient’s own Physician), maintains complete medical records, and has available at all times the services of a Physician; has established methods and procedures for the dispensing and administering of drugs; has an effective utilization review plan; has a written transfer agreement in effect with one or more Hospitals; and is not, other than incidentally, a place of rest, for custodial care, for the aged, for drug addicts, for alcoholics, for the care of the mentally ill or persons with nervous disorders, for the care of senile persons, a nursing home, a hotel, a school or a similar institution.
Fiduciary
The person or organization that has the authority to control and manage the operation and administration of the Plan. The fiduciary has discretionary authority to determine eligibility for benefits or to construe the terms of the Plan.
Home Health Care Agency
A Hospital, Home Health Care service organization or agency possessing a valid operating certificate issued in accordance with public health law authorizing such organization or agency to provide Home Health Care services.
Hospice Facility
An establishment which complies with all licensing, staffing, operating, and legal requirements in the state where it is located and, in any other state where it provides services, and is mainly engaged in providing Palliative Care for the terminally ill on a continuous 24-hour basis under the supervision of a duly licensed Physician or a registered nurse.
If the care is not supervised by a Physician, the Hospice Facility must have a duly licensed Physician available on a pre-arranged basis, maintain clinical records on all terminally ill individuals, and not be mainly be a place for the aged, a nursing or convalescent home, a custodial or a rest home.
A Hospice Facility may operate by itself, or as part of a Hospital, and must be located in the United States.
Hospital
An institution which is accredited as a Hospital under the Hospital Accreditation Program of the Joint Commission on the Accreditation of Hospitals; complies with all licensing and other legal requirements and is operating lawfully in the jurisdiction where it is located; is primarily engaged in providing medical treatment to sick and injured persons as registered bed patients and maintains permanent facilities for five or more such patients; has a Physician in regular attendance 24 hours a day; continuously provides 24 hour a day nursing service by registered graduate nurses; maintains a daily medical record for each patient; maintains permanent facilities for major surgical operations on its premises; and, is not, other than incidentally, a place of rest, for custodial care, for the aged, for drug addicts or alcoholics, for the care of senile persons, a nursing home, a hotel, a school or similar institution.
An institution specializing in the care and treatment of psychiatric conditions, which would qualify as a Hospital, except that it lacks organized facilities on its premises for major Surgery shall nevertheless be deemed a Hospital.
For an emotionally handicapped Dependent child, it also means a state licensed residential treatment center.
For treatment of alcoholism, drug addiction or chemical dependency, a residential treatment facility specializing in the care and treatment of alcoholism, drug addiction or chemical dependency will be considered a Hospital provided the facility is licensed as a treatment facility in the state in which it is operating.
A facility which is licensed and approved by the state in which it is operating as a rehabilitation facility whose primary purpose is to provide diagnosis, therapy, and restoration for persons who are disabled will be deemed a Hospital.
Hospital Average Semi-Private Charge
The standard charge by a Hospital for semi-private room and board accommodations, or the average of such charges where the Hospital has more than one established level of such charges, or the lowest charge by the Hospital for single bed room and board accommodations where the Hospital does not provide any semi-private accommodations.
Hospital Pre-Admission Certification
Approval by the Plan’s designated utilization review provider for a proposed Hospital admission.
Illness
An Illness shall be deemed to mean a bodily disorder, disease, mental infirmity or bodily injury. However, bodily injuries sustained in any one accident shall be considered one Illness, and all bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Illness. Pregnancy is considered an Illness.
In-patient
A person physically occupying a Hospital room to which the person has been assigned on a 24 hour a day basis without being issued passes to leave the Hospital premises.
Intensive Care Area
A Hospital area or accommodation exclusively reserved for critically and seriously ill patients requiring constant observation as prescribed by the attending Physician, which provides room and board, specialized registered professional nursing and other nursing care and special equipment and supplies on a stand-by basis and which is separated from the rest of the Hospital’s facilities.
Late Enrollee
An Employee or Dependent who enrolls for coverage after their initial Eligibility Date as described under Eligibility and Effective Dates. A Special Enrollee shall not be considered a Late Enrollee.
Maximum Lifetime Benefit
Means the Maximum Lifetime Benefit payable during an individual’s life while covered under the Plan. The Plan may provide for a Maximum Lifetime Benefit for specific types of medical treatment (sub-maximums) as well as for total benefits provided by the Plan. The Maximum Lifetime Benefit and sub-maximums, include any one or a combination of benefit Plan options provided by the Plan.
Medically Necessary
Services and supplies provided to a Covered Person which, in the judgment of the Plan Sponsor, (a) are appropriate and consistent with the diagnosis or treatment of the Illness, and (b) are customarily and reasonably recognized as appropriate throughout the Physician’s profession, and (c) could not have been omitted without adversely affecting the patient’s condition or the quality of medical care rendered, and (d) are not solely for the convenience of a Covered Person, Physician, Hospital or other provider.
For confinement in a Hospital, Medically Necessary also means that the treatment of the Illness could not have been provided in a Physician’s office, in the Out-patient department of a Hospital, or in a lesser facility, without adversely affecting the patient’s condition or the quality of medical care rendered. In regard to the type of accommodation, Medically Necessary shall mean that all semi-private or less expensive accommodations are occupied and the patient needs hospitalization immediately and such In-patient treatment cannot be deferred until less expensive accommodations become available or that the patient’s condition requires him to be isolated for his own health or that of others.
Treatment that is Experimental/Investigational, or done primarily for research will not be considered as Medically Necessary.
Out-of-Pocket Maximum
Means the maximum amount of Deductible and Co-insurance a Covered Person and/or covered Dependents must pay for Covered Expenses during a Calendar Year before the Benefit Percentage increases to 100%.
Expenses incurred for the following generally will not be applied toward the Out-of-Pocket Maximum: (a) Co-pays; (b) any penalty amounts; (c) any charges defined under Limitations and Exclusions; and (d) Co-insurance for Mental Health and Chemical Dependency treatment.
Out-patient
Hospital services rendered on other than an In-patient basis or services rendered at a covered non-hospital facility.
Palliative Care
A course of treatment directed toward lessening or controlling pain. It makes no attempt to cure a terminal Illness or to prolong the life of a patient.
Partial Hospitalization
Means continuous treatment for at least four hours, but not more than 12 hours, in any 24-consecutive-hour period in a Hospital.
One day of In-patient care reduces the available number of partial hospitalization days by two; two days of partial hospitalization reduces the available number of In-patient care days by one.
Physician
A person, other than the Covered Person or a Relative of the Covered Person, licensed to practice medicine or Surrgery as a Doctor of Medicine, (M.D.) or as a Doctor of Osteopathy, (D.O.). Physician shall include a person licensed to practice as a Dentist (D.D.S. or D.M.D.), Podiatrist (D.P.M.), Chiropractor (D.C.), Optometrist (O.D.), Licensed Psychologist or Licensed Consulting Psychologist, Licensed Social Worker (or equivalent as defined by state statutes), or a Licensed Community Health Center or Clinic as defined by state statutes. Physician shall also include a registered graduate nurse (R.N.) who is licensed as certified to engage in advanced nursing practice as a nurse anesthetist, nurse midwife or nurse practitioner, acting within the scope of such license.
Plan
Plan or Employee Benefit Plan means the benefits the Plan Sponsor has agreed to provide for Covered Persons. The term Plan generally includes the current Plan as well as any prior self-funded medical Plan maintained by the Plan Sponsor.
Plan Sponsor
The person/organization/Employer responsible for the day-to-day functions and management of the Plan. The Plan Sponsor may employ persons or firms to process claims and perform other Plan-connected services. The Plan Sponsor is the named plan administrator within the meaning of Section 414(g) of the Internal Revenue Code of 1986, as amended, and is the named Administrator within the meaning of Section 3(16)(A) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended.
Pre-existing Condition
A Pre-existing Condition is any condition, Illness or injury which is diagnosed or for which treatment is received or recommended prior to the Covered Person’s Enrollment Date, subject to the Plan’s Pre-existing Conditions Limitation.
Preferred Pharmacy(ies)
Participating stores and designated mail order providers according to the list provided by the Employer.
Preferred Provider Organization (PPO)
Hospitals, Physicians and medical service providers who have contracted with the Plan Sponsor. A directory of Preferred Providers is available from the Plan Sponsor or Contract Administrator. Inquiries concerning a particular provider can also be directed to the Contract Administrator.
Click here for a directory of PPO Links
Professional Services
Services received from or under the direction of a Physician.
Relative
A spouse, or a parent, brother, sister, or child of the Covered Person.
Schedule of Benefits
The Schedule of Benefits is a summary of the benefit levels available under your Plan. It provides the amounts of any Deductible, Co-pay, Out-of-pocket expense maximum, lifetime maximum and Co-insurance level which applies to your Plan. The Schedule of Benefits is found in the Summary Plan Description.
Special Enrollment
If an eligible Employee or Dependent waives coverage under the Plan at the time of initial eligibility (and states in writing at that time that coverage was waived because of alternative health coverage) but subsequently loses coverage under the other health plan and makes application for coverage under the Plan available to them through their Employer within thirty-one (31) days of the loss, such individual shall be a Special Enrollee provided such person: (a) was under a COBRA (Consolidated Omnibus Budget Reconciliation Act) continuation provision and the coverage under such provision was exhausted; or (b) was not under such a provision and either the coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment, or loss of Dependent status) or Employer contributions toward such coverage were terminated. Individuals who lose other coverage due to nonpayment of premium or for cause (e.g., filing fraudulent claims) shall not be considered Special Enrollees.
An eligible Employee or Dependent who waives coverage under this Plan at the time of initial Eligibility and seeks to enroll in this Plan as a result of the acquisition of a new Dependent through marriage, birth, adoption or placement for adoption shall be a Special Enrollee hereunder if the eligible Employee or Dependent enrolls within thirty-one (31) days of the acquisition of the new Dependent.
Coverage for a Special Enrollee shall be effective: (a) in the event an Employee or Dependent waived coverage for the sole reason of the existence of alternative health coverage, and loses such coverage as described above, not later than the first day of the first calendar month following the date the completed request for enrollment is received by the Plan; or (b) in the event of marriage, the first day of the first calendar month following the date the completed request for enrollment is received by the Plan; or (c) in the event of birth, adoption or placement for adoption, the date of such birth, adoption or placement for adoption.
Special Enrollee
An Employee or Dependent who is entitled to and requests Special Enrollment as described under Eligibility and Effective Dates: (a) within thirty-one (31) days of losing other Creditable Coverage; or (b) within thirty-one (31) days of marriage, birth, adoption, or placement for adoption.
Surgery
The following procedures when performed by a Physician: Cutting, Suturing, reduction of fracture, reduction of dislocation, electrocauterization, tapping (paracentesis), administration of artificial pneumothorax, removal of stone or foreign body by endoscopic means, debridement, or injection of sclerosing solution, or any other procedures commonly considered Surgery.
Urgent Care Facility
A facility or Hospital unit which is primarily engaged in providing minor emergency and episodic medical care to a Covered Person. A legally qualified Physician, a registered graduate nurse (R.N.) and a registered x-ray technician must be in attendance at all times that the clinic is open. The clinic’s facilities must include x-ray and laboratory equipment and a life support system.
Usual and Customary
A charge made by a provider of service which does not exceed the general level of charges made by other providers of similar standing rendering or furnishing such services, medicines, or supplies within the area in which the charge is incurred, for an Illness or injury comparable in severity and nature to the Illness or injury being treated. The term “area” as it would apply to any particular service, medicine, or supply means a county or such greater area as is necessary to obtain a representative cross section of the level of charges.
Waiting Period
Means the period of time that must pass under the Plan (or for purposes of determining Creditable Coverage, any other health plan) before an Employee or Dependent is eligible to enroll in the Plan. As an exception to the above with regard to determining Creditable Coverage, the time between the date a Later Enrollee or Special Enrollee first becomes eligible for enrollment under the Plan and the first day of coverage shall not be treated as a Waiting Period.