The following are definitions of specific terms and words used in this document or that would be helpful in understanding covered or excluded health care services. These definitions do not, and should not be interpreted to, extend coverage under the Plan.
Accident: A sudden and unforeseen event as a result of an external or extrinsic source, that is not work-related.
Active Employee: The term —active Employee— means an Employee who meets the eligibility provisions as an active hourly bargaining Employee or active monthly non-bargaining Employee, as defined in the Becoming a Plan Participant section of the Plan Document.
Allied Health Care Practitioner: The term —Allied Health Care Practitioner— means a licensed physical, occupational, or speech therapist, a Dentist (D.D.S.), licensed Podiatrist (D.P.M.), Psychologist, Physician Assistant, Marriage, Family, Child Counselor (MFCC), Licensed Clinical Social Worker (LSCW) , Registered Nurse (R.N.), Nurse Midwife, Nurse Practitioner or Certified Acupuncturist who are practicing within the scope of their licenses. The term shall not include any person who is the Spouse, Domestic Partner, child, brother, sister, or parent of the Active or Retired Employee.
Adverse Benefit Determination: See the Claim Filing and Appeal Information chapter for the definition.
Allowed Charge/Allowed Amount/Allowable Charge: means the amount this Plan allows for eligible medically necessary services or supplies. The allowed charge amount is determined by the Plan Administrator or its designee to be the lowest of:
- The dollar amount this Plan has determined it will allow for covered Medically Necessary services or supplies provided by Non-PPO Providers as determined by the Plan’s PPO based on appropriate and reasonable charges for the services in the geographical area where the services are provided. With respect to Non-PPO Hospitals or Facilities within the PPO Area for other than an Emergency Medical Condition, the allowed charge will be the same as the Schedule of Allowances (Non-Contract allowance provided by Anthem Blue Cross, American Health Holding, Accelera or other entity designated by the Fund for the allowable amount). The Plan’s Allowed Charge is not based on or intended to be reflective of fees that have traditionally been described as usual and customary (U&C), usual, customary and reasonable (UCR) or any other traditional term. Non-PPO Providers’ bills often exceed the Plan’s Allowed Charge, and in such cases the Plan’s benefits will be based on the Allowed Charge not the Non-PPO Providers billed rate. In cases of an Emergency Medical Condition, or when the Patient has not had a reasonable opportunity to select a PPO Provider, the Plan reserves the right to have the billed amount of a claim reviewed by an independent medical review firm to assist in determining the Allowed Charge for the submitted claim. When using Non-PPO Providers, the Participant is responsible for any difference between the actual billed charge and the Plan’s Allowed Charge, in addition to any copay and percentage coinsurance required by the Plan.
- The Non-Contract Provider’s actual billed charge.
Any amount in excess of the “allowed charge” amount does not count toward the Plan’s annual Out-of-Pocket Maximums. Participants are responsible for amounts that exceed —allowed charge— amounts by this Plan. With respect to Non-network Emergency Room services, the Plan allowance is the greater of: the negotiated amount for in-network providers, or 100% of the Plan’s Allowed Charge formula (reduced for cost-sharing) or the amount that Medicare would pay. Ambulatory Surgical Facility/Center The term —Ambulatory Surgical Facility— or —Outpatient Surgical Facility— means a health facility that is accredited by the Accreditation Association of Ambulatory Health Care.
Ancillary Services: Services provided by a Hospital or other Health Care Facility other than room and board, including but not limited to, use of the operating room, recovery room, intensive care unit, etc., and laboratory and x-ray services, drugs and medicines, and medical supplies provided during confinement.
Anesthesia: The condition produced by the administration of specific agents (anesthetics) to render the patient unconscious and without conscious pain response (e.g. general anesthesia), or to achieve the loss of conscious pain response and/or sensation in a specific location or area of the body (e.g. regional or local anesthesia). Anesthetics are commonly administered by injection or inhalation.
Assistant Surgeon: An assistant surgeon is also referred to as an assistant at surgery or first assistant. A person who functions as an assistant surgeon actively assists the physician in charge of a surgical case (the surgeon) in performing a surgical procedure. This Plan allows payment of an assistant surgeon under the following conditions:
- the individual functioning as an assistant surgeon is properly licensed as a Physician, Nurse Practitioner, Certified Nurse Midwife, Physician Assistant, Registered Nurse First Assistant (RNFA), but not an Employee of a hospital or surgical facility or a medical student, intern or other trainee; and
- the use of an assistant surgeon(s) is determined by the Plan Administrator or its designee to be medically necessary; and
- the assistant surgeon actively participated in the surgical procedure (was not stand-by).
Balance Billing: A bill from a health care provider to a patient for the difference (or balance) between this Plan’s Allowed Charges and what the provider actually charged (the billed charges). Amounts associated with balance billing are not covered by this Plan, even if the Plan’s Out-of-Pocket maximum limits are reached. See also the provisions related to the Plan’s Out-of-Pocket Expenses and the Plan’s definition of Allowed Charge. Remember, amounts exceeding the Allowed Charge do not count toward the Plan’s Out-of-Pocket maximum and may result in balance billing to you. Out-of-Network Health Care Providers commonly engage in balance billing a Plan participant for any balance that may be due in addition to the amount payable by the Plan. Typically, In-Network providers do not balance bill except in situations of third party liability claims. Generally, you can avoid balance billing by using In-Network providers.
Behavioral Health Disorder: A Behavioral Health Disorder is any illness that is defined within the mental disorders section of the current edition of the International Classification of Diseases (ICD) manual or is identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including a psychological and/or physiological dependence on or addiction to alcohol or psychiatric drugs or medications regardless of any underlying physical or organic cause. Behavioral health disorder includes, among other things, depression, schizophrenia, and substance abuse and treatment that primarily uses psychotherapy or other psychotherapist methods, and is provided by Behavioral Health Practitioners as defined in this chapter. Certain Behavioral Health Disorders, conditions and diseases are specifically excluded from coverage as noted in the Medical Plan Exclusions chapter of this document. See also the definitions of Chemical Dependency and Substance Abuse.
Behavioral Health Practitioners: A psychiatrist, psychologist, a mental health or substance abuse counselor or social worker who has a Master’s degree, or a nurse practitioner in independent practice who is qualified to perform behavioral health counseling and, who is legally licensed and/or legally authorized to practice or provide service, care or treatment of Behavioral Health Disorders under the laws of the state or jurisdiction where the services are rendered; and acts within the scope of his or her license; and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee.
Behavioral Health Treatment: Behavioral Health Treatment includes outpatient visits and inpatient services (including room and board given by a Behavioral Health Treatment Facility or area of a Hospital that provides behavioral or mental health or Substance Abuse treatment) for a mental disorder identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). If there are multiple diagnoses, only the treatment for the Illness that is identified under the DSM code is considered a Behavioral Health Treatment for the purposes of this Plan.
Behavioral Health Treatment Facility: A specialized facility that is established, equipped, operated and staffed primarily for the purpose of providing a program for diagnosis, evaluation and effective treatment of Behavioral Health Disorders and which fully meets one of the following two tests:
- It is licensed as a Behavioral Health Treatment Facility by the regulatory authority having responsibility for the licensing under the laws of the jurisdiction in which it is located; or
- Where licensing is not required, it meets all of the following requirements: has at least one Physician on staff or on call and provides skilled nursing care by licensed Nurses under the direction of a full-time Registered Nurse (RN) and prepares and maintains a written plan of treatment for each patient based on the medical, psychological and social needs of the patient.
A Behavioral Health Treatment Facility that qualifies as a Hospital is covered by this Plan as a Hospital and not a Behavioral Health Treatment Facility. A residential treatment facility, transitional facility, group home, halfway house or temporary shelter is not a Behavioral Health Treatment Facility under this Plan.
Benefit, Benefit Payment, Plan Benefit: The amount of money payable for a claim, based on the Allowed Charge, after calculation of all Deductibles, Coinsurance and Copayments, and after determination of the Plan’s exclusions, limitations and maximums.
Board: The term —Board— means the Board of Trustees of the District Council 16 Northern California Health and Welfare Trust Fund.
Calendar Year: The 12-month period beginning January 1 and ending December 31. For the Medical program, all annual Deductibles, Out-of-Pocket Maximums and Annual Maximum Plan benefits are determined during the calendar year.
Cardiac Rehabilitation: Cardiac Rehabilitation refers to a formal program of controlled exercise training and cardiac education under the supervision of qualified medical personnel capable of treating cardiac emergencies, as provided in a hospital outpatient department or other outpatient setting. The goal is to advance the patient to a functional level of activity and exercise without cardiovascular complications in order to limit further cardiac damage and reduce the risk of death. Patients are to continue at home, the exercise and educational techniques they learn in this program.
Chemical Dependency: This is another term for Substance Abuse/Substance Use Disorder. See also the definitions of Behavioral Health Disorders and Substance Abuse/Substance Use Disorder.
Child(ren): See the definition of Dependent Child(ren) and children of Domestic Partner.
Chiropractor: A person who holds the degree of Doctor of Chiropractic (DC); and is legally licensed and authorized to practice the detection and correction, by mechanical means, of the interference with nerve transmissions and expressions resulting from distortion, misalignment or dislocation of the spinal column (vertebrae); and acts within the scope of his or her license; and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee.
COBRA: means Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. and refers to temporary continuation of health care coverage.
Coinsurance: That portion of eligible expenses for which the covered person has financial responsibility to pay.
Concurrent Review: A managed care program designed to assure that Hospitalization and Health Care Facility admissions and length of stay, surgery and other health care services are medically necessary by having the Utilization Review Company conduct ongoing assessment of the health care as it is being provided, especially (but not limited to) inpatient confinement in a Hospital or Health Care Facility. Also called Continued Stay Review.
Coordination of Benefits (COB): The rules and procedures applicable to determination of how Plan benefits are payable when a person is covered by two or more health care plans. See also the Coordination of Benefits chapter.
Copayment, Copay: The fixed dollar amount you are responsible for paying for a service before the Plan pays the remaining Allowed Charge.
Corrective Appliances: The general term for appliances or devices that support a weakened body part (Orthotic) or replace a missing body part (Prosthetic). To determine the category of any particular item, see also the definitions of Durable Medical Equipment, Nondurable Supplies, Orthotic appliance (or Device) and Prosthetic appliance (or Device).
Cosmetic Surgery or Treatment: The term —Cosmetic Surgery or Treatment— means any surgery or medical treatment to improve or preserve physical appearance, but not physical function. Cosmetic Surgery or Treatment includes, but is not limited to, removal of tattoos, breast augmentation, or other medical, dental, or surgical treatment intended to restore or improve physical appearance without significantly improving physiological function, as determined by the Plan Administrator or its designee.
Cost-Efficient: See the definition of Medically Necessary for the definition of Cost-Efficient as it applies to medical services that are medically necessary.
Covered Individual: Any Employee, and/or Retiree and that person’s eligible Spouse or Dependent Child or Domestic Partner (as these terms are defined in the Plan) who has completed all required formalities for enrollment for coverage under the Plan and is actually covered by the Plan. A covered individual is also referred to as a Plan Participant.
Covered Medical and/or Dental Expenses: See the definition of Eligible Medical and/or Dental Expenses.
Custodial Care: Care and services given mainly for personal hygiene or to perform the activities of daily living. Some examples of Custodial Care are helping patients get in and out of bed, bathe, dress, eat, use the toilet, walk (ambulate), or take drugs or medicines that can be self-administered. These services are Custodial Care regardless of where the care is given or who recommends, provides, or directs the care. Custodial Care can be given safely and adequately (in terms of generally accepted medical standards) by people who are not trained or licensed medical or nursing personnel.
Deductible: The amount of Eligible Medical Expenses you are responsible for paying before the Plan begins to pay benefits. The amount of the Deductible is discussed in the Medical Expense Coverage chapter of this document.
Dependent: Any of the following individuals: Dependent Child(ren) or Spouse, or Domestic Partner as those terms are defined in the Plan Document. See also the definition of Eligible Dependent, Domestic Partner, Domestic Partner child. Note that the daughter-in-law or son-in-law or grandchild of an eligible Employee or Spouse or Domestic Partner is not an eligible Dependent under this Plan.
Dependent Child(ren): Please refer to the Eligibility section for a description of the Dependent children who are eligible for coverage under the Plan.
Disabled/Disability: The inability of a person to be self-sufficient as the result of a physically or mentally disabling injury, illness, or condition (such as mental retardation, cerebral palsy, epilepsy or another neurological disorder, or psychosis), and the person is permanently and totally disabled in that they are unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months and the condition was diagnosed by a Physician, and accepted by the Plan Administrator or its designee, as a permanent and continuing condition. See also the definition of Totally Disabled.
Domestic Partner: The term —Domestic Partner— means a domestic partner of an active or Retired Employee who provides a Certificate of Domestic Partnership issued by the California Secretary of State or another governmental sub-division within California that has developed regulations for the recognition of such relationships.
You should consult a tax advisor regarding the tax consequences of receiving benefits from the Trust Fund for your Domestic Partner, as these are considered —imputed income— to you under federal law. You must make payment to the Trust Fund Office for any taxes that are required to be paid on the value of this —imputed income.— Failure to do so will result in termination of coverage for your Domestic Partner and your Domestic Partner will NOT be eligible for any extension of coverage.
Durable Medical Equipment: The term —Durable Medical Equipment— means equipment that can withstand repeated use, is primarily and customarily used for a medical purpose and is not generally useful in the absence of an injury or illness, is not disposable or non-durable and is appropriate for use in the patient’s home. Durable Medical Equipment includes, but is not limited to, apnea monitors, blood sugar monitors, commodes, electric hospital beds with safety rails, electric and manual wheelchairs, nebulizers, oximeters, oxygen and supplies, and ventilators.
Emergency Services: means with respect to an Emergency Medical Condition (defined below), a medical screening examination within the emergency department of a hospital including ancillary services routinely available to the emergency department to evaluate the emergency medical condition, along with additional medical examination and treatment to the extent they are within the capabilities of the staff and facilities available at the hospital to stabilize the patient.
- The term —to stabilize— means, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition, to deliver a newborn child (including the placenta).
- The term —Emergency Medical Condition— means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the health of the individual (or for a pregnant woman, the health of the woman of her unborn child), serious impairment to bodily functions or serious dysfunction of any bodily organ or part. The Plan Administrator or its designee has the discretion and authority to determine if a service or supply is or should be classified as an Emergency Medical Condition.
Enroll, Enrollment: The process of completing and submitting a written enrollment form indicating that coverage by the Plan is requested by the Employee. An Employee may request coverage for an Eligible Dependent only if he or she is or will be covered by the Plan. See the Eligibility chapter for details regarding the mechanics of enrollment.
Essential Health Benefits: The Affordable Care Act defines essential health benefits to include the following: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Experimental and/or Investigational: The term —Experimental— shall mean any of the following:
- Any medical procedure, equipment, treatment or course of treatment, drug or medicine which is not normally and regularly used or prescribed by the medical community for the reason that it remains under clinical or laboratory investigation or has not been exposed to clinical/laboratory investigation; or
- Any drug, device or medical treatment or procedure which is the subject of on-going phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
- Reliable Evidence shows that the consensus among experts regarding the drug, device, or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis.
Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure.
Final determination as to whether services are —Experimental— will be made by the Plan Administrator or its designee. The Trustees may rely on the advice of medical consultants in determining whether a service or supply is —Experimental— under this definition.
Note that under this medical plan, experimental, investigational or unproven does not include routine costs associated with a certain “approved clinical trial” related to cancer or other life-threatening illnesses. For individuals who will participate in a clinical trial, precertification is required in order to notify the Plan that routine costs, services and supplies may be incurred by the eligible individual during their participation in the clinical trial. The routine costs that are covered by this Plan are discussed below:
- —Routine costs— means services and supplies incurred by an eligible individual during participation in a clinical trial if such expenses would be covered for a participant or beneficiary who is not enrolled in a clinical trial. However, the plan does not cover non-routine services and supplies, such as: (1) the investigational items, devices, services or drugs being studied as part of the approved clinical trial; (2) items, devices, services and drugs that are provided solely for data collection and analysis purposes and not for direct clinical management of the patient; or (3) items, devices, services or drugs inconsistent with widely accepted and established standards of care for a patient’s particular diagnosis.
- An —approved clinical trial— means a phase I, II, III, or IV clinical trial conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition. The clinical trial’s study or investigation must be (1) federally-funded; (2) conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or (3) a drug trial that is exempt from investigational new drug application requirements. —Federally funded— clinical trials include those approved or funded by one or more of: the National Institutes of Health ( NIH), the Centers for Disease Control and Prevention (CDC), the Agency for Health Care Research and Quality (AHCRQ), the Centers for Medicare and Medicaid Services (CMS), a cooperative group or center of the NIH, CDC, AHCRQ, CMS, the Department of Defense (DOD), the Department of Veterans Affairs (VA); a qualified non-governmental research entity identified by NIH guidelines for grants; or the VA, DOD, or Department of Energy (DOE) if the study has been reviewed and approved through a system of peer review that the Secretary of HHS determines is comparable to the system used by NIH and assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
- A participant or beneficiary covered under a group health plan is eligible to participate in a clinical trial and receive benefits from a group health plan for routine services if: (1) the individual satisfies the eligibility requirements of the protocol of an approved clinical trial; and (2) either the individual’s referring physician is a participating health care provider in the plan who has determined that the individual’s participation in the approved clinical trial is medically appropriate, or the individual provides the plan with medical and scientific information establishing that participation in the trial would be medically appropriate.
- The plan may require that an eligible individual use an in-network provider as long as the provider will accept the patient. This plan is only required to cover out-of-network costs for routine clinical trial expenses if the clinical trial is only offered outside the patient’s state of residence.
- The plan may rely on its Utilization Management Company or other medical review firm to determine, during a review process, if the clinical trial is related to cancer or a life-threatening condition, as well as to help determine if a person’s routine costs are associated with an —approved clinical trial.— During the review process, the person or their attending Physician may be asked to present medical and scientific information that establishes the appropriateness and eligibility for the clinical trial for his/her condition. The Plan (at no cost to the patient) reserves the right to have the opinion of a medical review firm regarding the information collected during the review process.
Federal Legend Drugs: See the definition of Prescription Drugs.
Food and Drug Administration (FDA): The U.S. government agency responsible for administration of the Food, Drug and Cosmetic Act and whose approval is required for certain Prescription Drugs and other medical services and supplies to be lawfully marketed.
Formulary: A formulary is a list of drugs approved by the pharmacy benefit manager and available for your doctor to use in prescribing your treatment. After careful review by a group of practicing doctors and pharmacists, drugs that offer value without sacrificing quality are placed in the formulary. Your doctor may still prescribe a non-formulary drug, but you pay the full cost for the drug. The formulary list includes the most cost-effective drugs for treating various classes of conditions and illnesses. The formulary list includes mostly generic medications and some brand name medications.
Fund: means the District Council No. 16 Northern California Health and Welfare Trust Fund.
Habilitative/Habilitation: Health care services, such as physical therapy, occupational therapy, and/or speech-language pathology, provided to individuals with developmental delays that have never acquired normal functional abilities. Examples of habilitative services includes physician-prescribed therapy for a child who is not walking or talking at the expected age.
Handicap or Handicapped (Physically or Mentally): See the definition of Disabled.
Health Care Facilities: For the purposes of this Plan, Health Care Facilities include Outpatient Ambulatory Surgical Facilities, Behavioral Health Treatment Facilities, Birthing Centers, Hospices, Skilled Nursing Facilities, and Subacute Care Facilities/Long Term Acute Care facilities as those terms are defined in this Definitions chapter.
Health Care Practitioner: A Physician, Behavioral Health Practitioner, Chiropractor, Dentist, a licensed physical, occupational, or speech therapist, a Dentist (D.D.S.), licensed Podiatrist (D.P.M.), Psychologist, Physician Assistant, Marriage, Family, Child Counselor (MFCC), Licensed Clinical Social Worker (LSCW), Registered Nurse (R.N.), Nurse Midwife, Nurse Practitioner or Certified Acupuncturist who are practicing within the scope of their licenses. The term shall not include any person who is the spouse, Domestic Partner, child, brother, sister, or parent of the Active or Retired Employee.
Health Care Provider: A Health Care Practitioner as defined above, or a Hospital, Ambulatory Surgical Facility, Behavioral Health Treatment Facility, Birthing Center, Home Health Care Agency, Hospice, Skilled Nursing Facility, or Subacute Care Facility/Long Term Acute Care facility, as those terms are defined in this Definitions chapter.
Home Health Care: Intermittent Skilled Nursing Care services provided by a licensed Home Health Care Agency as those terms are defined in this chapter.
Home Health Care Agency: An agency or organization that provides a program of home health care and meets all requirements of PPO Network for a Home Health Care Agency Provider.
Hospice: An agency or organization that administers a program of palliative care and supportive health care services providing physical, psychological, social and spiritual care for terminally ill persons assessed to have a life expectancy of 6 months or less. The Hospice Agency must be a licensed hospice Provider recognized as such by the Centers for Medicare and Medicaid Services.
Hospital: The term —Hospital— means a state or federally licensed institution that meets the following requirements:
- It is primarily engaged in providing diagnostic, surgical and therapeutic facilities for medical and surgical care of sick and injured persons on an inpatient basis at the patient’s expense.
- It continuously provides 24-hour-a-day supervision by a staff of Physicians licensed to practice medicine (other than physicians whose license limits their practice to one or more specified fields) and 24-hour-a-day nursing care by or under the supervision of registered nurses (R.N.s).
- It is not, other than incidentally, a place of rest, a nursing home, a convalescent home, a place for the aged, a pain clinic or a place for recovery from drug or alcohol addictions.
Illness: The term —Illness— means any bodily sickness or disease, including any congenital abnormality of a newborn child, as diagnosed by a Physician. However, infertility is not an Illness for the purpose of coverage under this Trust Fund. Pregnancy of a covered Employee or covered spouse or Domestic Partner will be considered to be an Illness only for the purpose of coverage under the Indemnity Medical Plan. Prenatal and postnatal visits for a pregnant dependent child will be an illness that is covered by this Plan, but not ultrasounds and other pregnancy-related services of the pregnant dependent child, the delivery and/or newborn expenses.
Injury: Any damage to a body part resulting from trauma from an external source.
In-Network Services: Services provided by a Health Care Provider that is a member of the Plan’s Preferred Provider Organization (PPO) as distinguished from Out-of-Network Services that are provided by a Health Care Provider that is not a member of the PPO.
Investigational: See the definition of Experimental and/or Investigational.
Life Threatening: The term —life threatening— means the onset of a medical emergency that is so severe that the patient is admitted to a Hospital as an inpatient for ongoing care.
Maximum Allowable Charge (MAC): The Maximum Allowable Charge (MAC) is the highest amount that the Fund will pay for routine total hip/knee replacements, arthroscopic surgeries, cataract surgeries and colonoscopies. The MAC will not apply to colonoscopies at an outpatient surgical center.
Maximum Plan Benefits: The maximum amount of benefits payable by the Plan (and described more fully in the Medical Expense Coverage chapter of this document) on account of medical expenses incurred by any covered Plan Participant. There are two general types of Plan maximums, described below:
- Limited Overall Maximum Plan Benefits are the maximum amount of benefits payable on account of certain covered medical services or supplies by the Plan during the entire time a Plan Participant is covered under this Plan and any previous medical expense Plan provided by Fund. The services or supplies that are subject to Limited Overall Maximum Plan benefits and the limits of those benefits are identified in the Schedule of Medical Benefits.
- Annual Maximum Plan Benefits are the maximum amount of benefits payable each Calendar Year on account of certain medical expenses incurred by any covered Plan Participant or family of the Plan Participant under this Plan. Annual Maximums are identified in the Schedule of Medical Benefits.
Medically Necessary/Medical Necessity:
Services and supplies are —Medically Necessary— or provided due to —Medical Necessity— if such service or supply is determined by the Plan Administrator or its designee to be:
- Appropriate and necessary for the symptoms, diagnosis or treatment of the injury or illness; and
- Provided for the diagnosis or direct care and treatment of the Illness or Injury; and
- Not Experimental, as defined above, or primarily educational; and
- Within the standards of good medical practice accepted and followed by the medical community; and
- Not primarily for the convenience of the Participant, the Participant’s family, any person who cares for the Patient, any health care practitioner, facility, or another provider; and
- The most appropriate supply or level of service that can be safely provided. For Hospital stays, this means that acute care as an inpatient is necessary due to the kind of services the Participant is receiving or the severity of the Participant’s condition, and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.
Medicare: The Health Insurance for the Aged and Disabled provisions in Title XVIII of the U.S. Social Security Act as it is now amended and as it may be amended in the future.
Mental Health; Mental Disorder; Mental and Nervous Disorder: See the definition of Behavioral Health Disorder.
Morbidly Obese, Morbid Obesity: The term —morbid obesity— means the presence of morbid obesity that has persisted for at least 5 years, defined as either:
- body mass index exceeding 40; or
- BMI greater than 35 in conjunction with ANY of the following severe co-morbidities:
- coronary heart disease; or
- type 2 diabetes mellitus; or
- (clinically significant obstructive sleep apnea (as determined by the Plan Administrator or its designee); or
- high blood pressure/hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);
- Individual has completed growth (18 years of age or documentation of completion of bone growth);
- Individual has participated in a physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record. This physician-supervised nutrition and exercise program must meet ALL of the following criteria:
- Participation in nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists; AND
- Nutrition and exercise program must be 6 months or longer in duration; AND
- Nutrition and exercise program must occur within the two years prior to surgery; AND
- Participation in physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who does not perform bariatric surgery. Note: A physician’s summary letter is not sufficient documentation.
- Individual has completed growth (18 years of age or documentation of completion of bone growth);
Nondurable Supplies: Goods or supplies that cannot withstand repeated use and/or that are considered disposable and limited to either use by a single person or one-time use, including, but not limited to, bandages, hypodermic syringes, diapers, soap or cleansing solutions, etc. See also the definitions of Corrective Appliances, Durable Medical Equipment, Orthotic appliance (or Device) and Prosthetic appliance (or Device). Only those nondurable supplies identified in the Schedule of Medical Benefits are covered by this Plan. All others are not.
Non-Network: See Out-of-Network.
Non-Participating Provider: A Health Care Provider who does not participate in the Plan’s Preferred Provider Organization (PPO). Also referred to as Non-PPO, Out-of-Network or non-network.
Occupational Therapist: A person legally licensed as a professional occupational therapist who acts within the scope of their license and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee, and acts under the direction of a physician to assess the presence of defects in an individual’s ability to perform self-care skills and activities of daily living (such as eating, bathing, dressing) and who formulates and carries out a plan of action to restore or support the individual’s ability to perform such skills in order to regain independence. Other occupational therapy services can include assessment of perceptual motor and sensory activity, the design, fabrication or application of selected support devices (orthotics) such as a wrist brace or ankle support, training on how to utilize prosthetic devices to maximize independence, guidance in the selection and use of adaptive equipment, teaching exercises to enhance functional performance and adaptation of environments for people with mental and physical disabilities.
Office Visit: A direct personal contact between a Physician or other Health Care Practitioner and a patient in the Health Care Practitioner’s office for diagnosis or treatment associated with the use of the appropriate office visit code in the Current Procedural Terminology (CPT) manual of the American Medical Association and with documentation that meets the requirement of such CPT coding. The following are not considered to be an office visit: a telephone discussion with a Physician or other Health Care Practitioner, internet/virtual office visit, a visit to a Health Care Practitioner’s office where no office visit code is billed or a visit to a Health Care Practitioner’s office for blood drawing, leaving a specimen, or receiving a routine injection.
Orthotic (Appliance or Device): A type of Corrective Appliance or device, either customized or available —over-the-counter,— designed to support a weakened body part, including, but not limited to, crutches, specially designed corsets, leg braces, extremity splints, and walkers. For the purposes of the Medical Plan, this definition does not include Dental Orthotics. See also the definitions of Corrective Appliance, Durable Medical Equipment, Nondurable Supplies and Prosthetic appliance (or Device).
Out-of-Network Services (Non-Network): Services provided by a Health Care Provider that is not a member of the Plan’s Preferred Provider Organization (PPO), as distinguished from In-Network Services that are provided by a Health Care Provider that is a member of the PPO.
Out-of-Pocket Maximum: The maximum amount of coinsurance each covered person or family is responsible for paying during a Calendar Year before the coinsurance required by the Plan ceases to apply. When the Out-of-Pocket Maximum is reached, the Plan will pay 100% of additional coinsurance related to most covered expenses for the remainder of the Calendar Year. See the section on Out-of-pocket Maximum in the Medical Expense Coverage chapter for details about what expenses do not count toward the Out-of-Pocket Maximum.
Participating Provider: A Health Care Provider who participates in the Plan’s Preferred Provider Organization (PPO).
Physical Therapist: A person legally licensed as a professional physical therapist who acts within the scope of their license and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee, and acts under the direction of a physician to perform physical therapy services including the evaluation, treatment and education of a person using physical measures, therapeutic exercise, thermal (hot/cold) techniques and/or electrical stimulation to correct or alleviate a physical functional disability/impairment. Physical therapists may also perform testing and retraining of muscle strength, joint motion, or sensory and neurological function along with balance, coordination, and flexibility in order to enhance mobility and independence.
Physical Therapy: Rehabilitation directed at restoring function following disease, injury, surgery or loss of body part using therapeutic properties such as active and passive exercise, cold, heat, electricity, traction, diathermy, and/or ultrasound to improve circulation, strengthen muscles, return motion, and/or train/retrain an individual to perform certain activities of daily living such as walking and getting in and out of bed.
Physician: A person legally licensed as a Medical Doctor (MD) or Doctor of Osteopathy (DO) and authorized to practice medicine, to perform surgery, and to administer drugs, under the laws of the state or jurisdiction where the services are rendered who acts within the scope of his or her license and is not the patient or the parent, Spouse, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee.
Physician Assistant (PA): A person legally licensed as a Physician Assistant, who acts within the scope of his or her license and acts under the supervision of a Physician to examine patients, establish medical diagnoses; order, perform and interpret laboratory, radiographic and other diagnostic tests; identify, develop, implement and evaluate a plan of patient care; prescribe and dispense medication within the limits of his or her license; refer to and consult with the supervising Physician; and bill and be paid in his or her own name under the laws of the state or jurisdiction where the services are rendered, and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee.
Placed for Adoption: For the definition of Placed for Adoption as it relates to coverage of adopted Dependent children, see the definition in the section on Adopted Dependent Children in the Eligibility chapter.
Plan, This Plan: The programs, benefits and provisions described in the Plan Document.
Plan Administrator: The Board of Trustees who has been designated as the Plan Administrator by the Plan Sponsor and who has the responsibility for overall Plan administration.
Plan Documents: The term —Plan Documents— refers to the Trust Agreement establishing this Trust Fund and all written documents, insurance policies, HMO policies, Evidence of Coverage documents, this Summary Plan Description, Collective Bargaining Agreements, Subscriber Agreements and all other legal documents setting forth the District Council 16 Northern California Health and Welfare Plan. It also includes written policy and procedure documents that have been formally adopted by the Board of Trustees.
Plan Participant: See the definition of Covered Individual.
Plan Sponsor: The Board of Trustees
Plan Year: The twelve-month period from January 1 to December 31 designated to be the Plan Year. The Contract Year is the same as the Plan Year.
Podiatrist: A person legally licensed as a Doctor of Podiatric Medicine (DPM) who acts within the scope of his or her license and who is authorized to provide care and treatment of the human foot (and in some states, the ankle and leg up to the knee) under the laws of the state or jurisdiction where the services are rendered and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee.
Prior Authorization: Prior Authorization is a review procedure performed by the Utilization Review Company before services are rendered, to assure that health care services meet or exceed accepted standards of care and that the service, admission and/or length of stay in a health care facility is appropriate and medically necessary. Prior Authorization is also referred to as pre-service review, precert, precertification, pre-authorization, or preapproval.
Preferred Provider Organization (PPO): An independent group or network of Health Care Providers (e.g. hospitals, physicians, laboratories) under contract with the Plan to provide health care services and supplies at agreed-upon discounted/reduced rates.
Prescription Drugs: For the purposes of this Plan, Prescription Drugs include:
- Federal Legend Drug: Any medicinal substance that the Federal Food, Drug and Cosmetic Act requires to be labeled, —Caution — Federal Law prohibits dispensing without prescription.—
- Compound Drug: Any drug that has more than one ingredient and at least one of them is a Federal Legend Drug or a drug that requires a prescription under state law.
- Brand drug: means a drug that has been approved by the U.S. Food and Drug Administration (FDA) and that drug has been granted a 20-year patent, which means that no other company can make it for the entire duration of the patent period. This patent protection means that only the company who holds the patent has the right to sell that brand drug. A brand drug cannot have competition from a generic drug until after the brand-name patent or other marketing exclusivities have expired and the FDA grants approval for a generic version.
- Generic drug: means a generic version of a brand-name drug (basically a copy of an FDA approved brand-name drug that contains the same active ingredients as the brand-name drug and is the same in terms of dosage, safety, purity, strength, how it is taken, quality, performance and intended use). Generic drugs work in the same way and in the same amount of time as brand-name drugs. The generic drug must be the same (or bio-equivalent) in several respects: the active ingredients (those ingredients that are responsible for the drug’s effects), the dosage amount, the way in which the drug is taken must be the same as the brand name drug, the safety must be the same and the amount of time the generic drug takes to be absorbed into the body must be the same as the brand name drug. A generic drug has been approved by the U.S. Food and Drug Administration (FDA). Generic drugs can have different names, shapes, colors and inactive ingredients than the original brand name drug.
- Specialty drug: Generally refers to high-cost, low volume, biotechnology-engineered FDA approved, non-experimental medications used to treat complex, chronic or rare diseases. These medications may also have one or more of the following qualities: are injected, infused, taken oral or inhaled, may need to be administered by a health care practitioner, have side-effects or compliance issues that need monitoring, require substantial patient education/support before administration, and/or have unique manufacturing, handling and distribution issues that make them unable to be purchased from a retail and/or mail order service. Examples of specialty drugs can include medications to treat hemophilia, immunity disorders, multiple sclerosis, rheumatoid arthritis, hepatitis or certain types of cancer. Specialty drugs may be managed by the Prescription Drug Program under contract to the Plan.
Prosthetic Appliance (or Device): A type of Corrective Appliance or device designed to replace all or part of a missing body part, including, but not limited to, artificial limbs, heart pacemakers, or corrective lenses needed after cataract surgery. See also the definitions of Corrective Appliances, Durable Medical Equipment, Nondurable Supplies and Orthotic appliance (or Device).
Pulmonary Rehabilitation: Pulmonary Rehabilitation refers to a formal program of controlled exercise training and respiratory education under the supervision of qualified medical personnel capable of treating respiratory emergencies, as provided in a hospital outpatient department or other outpatient setting. The goal is to advance the patient to their highest functional level of activity/endurance, decrease respiratory symptoms/complications, and encourage self-management and control over their chronic lung problems. Patients are to continue at home, the exercise and educational techniques they learn in this program. Pulmonary rehabilitation services are payable for patients who have a chronic respiratory disorder such as chronic obstruction pulmonary disease (COPD), emphysema, pulmonary fibrosis, asthma, etc.
Qualified Medical Child Support Order (QMCSO): A court order that complies with requirements of federal law requiring an Employee to provide health care coverage for a Dependent Child, and requiring that benefits payable on account of that Dependent Child be paid directly to the Health Care Provider who rendered the services or to the custodial parent of the Dependent Child. See also the Eligibility chapter of this document.
Reconstructive Surgery: A medically necessary surgical procedure performed on an abnormal or absent structure of the body to correct damage caused by a congenital birth defect, an accidental injury, infection, disease or tumor, or for breast reconstruction following a total or partial mastectomy.
Rehabilitation Services: Physical, occupational, or speech therapy that is prescribed by a Physician when the bodily function has been restricted or diminished as a result of illness, injury or surgery, with the goal of improving or restoring bodily function by a significant and measurable degree to as close as reasonably and medically possible to the condition that existed before the injury, illness or surgery, and that is performed by a licensed therapist acting within the scope of his or her license. Only care that demonstrates progressive improvement in the patient’s functional capacity is covered. No benefits are provided for pervasive developmental delay, learning disabilities or that are primarily provided to enhance academic achievement in Dependent children.
Retired Employee: The term —Retired Employee— means an Employee who meets the eligibility provisions as either a Retired hourly bargaining Employee or a Retired monthly non-bargaining Employee.
Skilled Nursing Facility: The term —Skilled Nursing Facility— means a public or private facility, licensed and operated according to law, that primarily provides skilled nursing and related services to people who require medical or nursing care and that rehabilitates injured, disabled or sick people, and that meets all of the following requirements:
- It is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a Skilled Nursing Facility or is recognized by Medicare as a Skilled Nursing Facility; and
- It is regularly engaged in providing room and board and continuously provides 24 hour-a-day Skilled Nursing Care of sick and injured persons at the patient’s expense during the convalescent stage of an Injury or Illness, maintains on its premises all facilities necessary for medical care and treatment, and is authorized to administer medication to patients on the order of a licensed Physician; and
- It provides services under the supervision of Physicians; and
- It provides nursing services by or under the supervision of a licensed Registered Nurse (RN), with one licensed Registered Nurse on duty at all times; and
- It maintains a daily medical record of each patient who is under the care of a licensed Physician; and
- It is not (other than incidentally) a home for maternity care, rest, domiciliary (non-skilled/custodial) care, or care of people who are aged, alcoholic, blind, deaf, drug addicts, mentally deficient, mentally ill, or suffering from tuberculosis; and
- It is not a hotel or motel.
A Skilled Nursing Facility that is part of a Hospital will be considered a Skilled Nursing Facility for the purposes of the Indemnity Medical Plan.
Speech Therapist: A person legally licensed as a professional speech therapist who acts within the scope of their license and is not the patient or the parent, Spouse, Domestic Partner, sibling (by birth or marriage, such as a brother-in-law), aunt/uncle, or child of the patient or covered Employee, and acts under the direction of a physician to perform speech therapy services including the application of principles, methods and procedures for the measurement, testing, evaluation, prediction, counseling, instruction, or rehabilitation related to disorders of speech, voice, language, swallowing or feeding.
Spinal Manipulation: The detection and correction, by manual or mechanical means, of the interference with nerve transmissions and expressions resulting from distortion, misalignment or dislocation of the spinal (vertebrae) column. Spinal Manipulation is commonly performed by Chiropractors, but it can be performed by Physicians.
Subrogation: This is a technical legal term for the right of one party to be substituted in place of another party in a lawsuit. See the Third Party Liability subchapter in the chapter on Coordination of Benefits for an explanation of how the Plan may use the right of subrogation to be substituted in place of a Covered Individual in that person’s claim against a third party who wrongfully caused that person’s injury or illness, so that the Plan may recover medical and/or dental benefits paid if the Covered Individual recovers any amount from the third party either by way of a settlement or judgment in a lawsuit.
Substance Abuse/Substance Use Disorder: A psychological and/or physiological dependence or addiction to alcohol or drugs or medications, regardless of any underlying physical or organic cause, and/or other drug dependency as defined by the current edition of the ICD manual or identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See the definitions of Behavioral Health Disorders and Chemical Dependency.
Total Disability, Totally Disabled: The term —total disability— or —totally disabled— means for active Employees, a disability caused by injury or illness that wholly and continuously prevents the active Employee from performing the substantial and material duties of his occupation or employment. For a Retired Employee or eligible Dependent, the term means a disability caused by injury or illness that wholly and continuously prevents the Retired Employee or the eligible Dependent from engaging in the substantial and material activities engaged in prior to the start of disability.
Value Based Site: The term —Value Based Site— means a PPO Hospital or ambulatory surgical center (ASC) in California that will hold costs under the Maximum Allowable Charge.
You, Your: When used in this document, these words refer to the Employee who is covered by the Plan. They do not refer to any Dependent of the Employee.