Healthcare 101

The definitions contained herein are common in the healthcare industry and may help you better understand your plan of benefits, explanation of benefits, and general understanding of the healthcare industry.

The term “Acute Inpatient Rehabilitation Services” or any reference thereto, shall mean services provided for the physical rehabilitation of an illness or injury subsequent to an inpatient hospital stay.

The term “Adverse Benefit Determination” or any reference thereto, shall mean a denial, reduction of, or a failure to provide or make payment, in whole or in part, for a benefit:

  • including those based on a determination of your eligibility to participate in the plan; or
  • resulting from the application of utilization review or failure to cover an item or service for which benefits are otherwise provided, because:
    1. it is determined to be experimental or investigational, or not medically necessary or appropriate; or
    2. the amount billed exceeds the allowed amount for such service or item or any other coverage limits of the plan.

The term “Allowed Amount,” also referred to as “Eligible Expense” or “Negotiated Rate,” or any reference thereto, shall mean the maximum amount the plan will pay for a covered healthcare service.

As it relates to dental care, the term “Allowed Amount” or any reference thereto, shall also include expenses incurred by, or on behalf of participants, for charges made by a dentist for the performance of a dental service listed in the dental services schedule herein.

The term “Ambulatory Surgery Center” or any reference thereto, shall mean any facility where elective same-day or outpatient surgical procedures that do not require hospital admission are performed.  Ambulatory Surgery Centers may perform surgeries in several specialties or dedicate their services to one specialty.

Ambulatory Surgery Centers do not include health clinics, urgent care centers or other facilities that provide emergency care, ambulatory care centers that provide diagnostic or primary healthcare services, physicians’ offices, dentists’ offices, or any other facility that provides accommodations for overnight stays.

Authorization. The term “Authorization,” also referred to as “Precertification” or “Prior Authorization,” or any reference thereto, shall mean the process of obtaining approval from the Plan for certain services or procedures that require it, as set forth herein, before such services can be provided or procedures performed.

The term “Certificate of Creditable Coverage” or any reference thereto, shall mean a written certificate that contains a statement regarding the period of time you are eligible for coverage under the plan or another health plan or health insurance issuer.  The plan is required to issue such a certificate to you, your dependents, or upon request, to a subsequent employer, plan, or health insurance issuer when your coverage under the plan is terminated.

The term “Clinic Visit” or any reference thereto, shall mean any visit to a physician in a hospital setting.

The terms “COBRA Continuation Coverage” or “COBRA” or any reference thereto, shall mean a participant’s right to continue health care coverage on a self-pay basis with the plan following coverage termination under certain circumstances.

The term “Coinsurance” or any reference thereto, shall mean the unreimbursed portion of a claim for Out-of-Network services after the deductible has been applied. Coinsurance is the responsibility of the patient.

The term “Copayment” or any reference thereto, shall mean a fixed amount payable by the patient to the provider of services rendered pursuant to the plan.

The term “Covered Person” or any reference thereto, shall mean any eligible member and/or eligible dependent.

The term “Custodial Care” or any reference thereto, shall mean all services and/or supplies, including room and board, that are provided primarily to assist in the activities of daily living not for purposes of recovery or rehabilitation.

Such services and/or supplies are considered Custodial Care without regard to the provider by whom they are prescribed, recommended, or performed.  Examples of such services and/or supplies include, but are not limited to, help walking, getting in and out of bed, bathing, dressing, eating, and taking medicine.

The term “Deductible” or any reference thereto, shall mean the amount that must be paid by the participant for Out-of-Network services before the plan will pay any other benefit expenses.

The term “Dentist” or any reference thereto, shall mean any individual duly licensed to practice dentistry or oral surgery.  A Dentist shall also include a physician operating within the scope of his license when he performs any of the dental services described in the plan.

The term “Dependent” or any reference thereto, shall mean any participant’s eligible spouse or child.

The term “Disability” or any reference thereto, unless otherwise defined by applicable law, shall mean the inability to perform each of the regular duties of your job, or other job available to you, pursuant to your employment, as a result of Injury, Illness, or disease.

For purposes of extending the eligibility of a dependent on account of disability, the term “Disability” shall mean a condition or set of circumstances where one is incapable of engaging in gainful employment as a result of illness or injury.

For purposes of Workers’ Compensation or state Disability law, the term “Disability” shall have the meaning as prescribed by the applicable law.

The term “Eligibility Date” or any reference thereto, shall mean the date on which a member or dependent gains coverage and becomes eligible for benefits under the plan.

The term “Emergency Hospitalization” or any reference thereto, shall mean a confinement in a hospital resultant from an unforeseen medical situation that requires immediate medical care or treatment, the absence of which could seriously jeopardize the life or health of a participant or the ability of the participant to regain maximum function.

The term “Emergency Treatment” or any reference thereto, as it relates to an illness or injury, shall mean the treatment for:

  1. said Illness or Injury which require immediate medical evaluation or treatment; or
  2. the onset of symptoms of sufficient severity that you reasonably believe that emergency medical evaluation or treatment is needed.

 

ERISA. The term “ERISA” or any reference thereto, shall mean the Employee Retirement Income Security Act of 1974, as amended from time to time, codified in part in Title 29 of the United States Code.

The term “Extended Care Facility” or any reference thereto, shall mean any institution, or distinct part of an institution, that:

  1. is licensed and operated pursuant to applicable law and is primarily engaged in providing skilled nursing care for patients who require such care as the result of injury or illness; and
  2. provides 24-hour nursing services under the supervision of a full-time employee who is either a physician or nurse; and
  3. maintains clinical records for all patients; and
  4. has a physician available to furnish necessary medical care in case of emergency; and
  5. provides appropriate methods and procedures for the dispensing and administering of drugs and biologics.

 

In no event shall an Extended Care Facility include any institution that is primarily engaged in the care of a mental health condition or substance abuse, or that is primarily engaged in providing residential, assisted living, custodial, educational care, or elder care.

The term “Freestanding Facility” or any reference thereto, shall mean any facility that furnishes healthcare services and is neither integrated with, nor a department of, a hospital.  Freestanding Facilities include physically separated facilities on the campus of a hospital, provided such physically separated facilities are neither integrated with, nor a department of, the hospital.

The term “Group Health Plan” or any reference thereto, shall mean an employee welfare benefit plan established or maintained by an employer or an employee organization, such as a Union, that provides medical benefits for their participants and eligible dependents.

The term “HIPAA” or any reference thereto, shall mean the Health Insurance Portability and Accountability Act of 1996.

The term “Home Healthcare Agency” or any reference thereto, shall mean any organization that:

  1. is primarily engaged in providing, by or under the supervision of Physicians, Inpatient diagnostic or therapeutic services for the diagnosis, treatment, or rehabilitation of injured, disabled, or sick persons;
  2. is licensed by the state agency, or similar body of authority, that is responsible for the issuance and oversight of the licensing of Hospitals;
  3. is accredited by one of the programs of the Joint Commission of Accreditation of Hospitals;
  4. maintains clinical records on all patients;
  5. has bylaws in effect with respect to its staff of Physicians;
  6. provides 24-hour nursing services rendered or supervised by a Nurse; and
  7. has in effect a Hospital utilization review plan.

The term “Home Healthcare Plan” or any reference thereto, shall mean a plan for the care and treatment of a person in his or her home.  To qualify as such, a Home Healthcare Plan must be established and approved, in writing, by a physician who certifies that the person would require confinement in a hospital or skilled nursing facility, if the person did not have the care and treatment stated in the Home Healthcare Plan.

The term “Hospital” or any reference thereto, shall mean any institution that:

  1. is engaged primarily in providing medical care and treatment to ill or injured persons on an Inpatient basis, at the patient’s expense;
  2. is licensed by the state agency, or similar body of authority, that is responsible for the issuance and oversight of the licensing of hospitals;
  3. is constituted and operated in accordance with all applicable laws and regulations of the governing body in the jurisdiction in which the hospital is located;
  4. maintains on its premises all the facilities necessary to provide for the diagnosis and medical or surgical treatment of an illness or injury;
  5. such treatment is provided by, or under the supervision of, physicians with continuous 24-hour nursing services by a nurse;
  6. qualifies as a hospital, psychiatric hospital, tuberculosis hospital, or alcoholic treatment center or facility for the treatment of drug addictions, and is licensed by the state agency, or similar body of authority, that is responsible for the issuance and oversight of the licensing of hospitals in the jurisdiction in which the hospital resides; and
  7. is a provider of services under Medicare.

 

Unless otherwise specifically provided, a hospital does not include any institution, or part thereof, that is used primarily as a rest facility, nursing facility, convalescent facility, facility for the elder, or facility for the care and treatment of substance abuse.

The term “Illness” or any reference thereto, shall mean any sickness, disorder, or disease that is not related to one’s employment.  An Illness shall be considered an “Emergency” if it requires immediate medical evaluation or treatment, or if the onset of symptoms is of sufficient severity that there is reasonable belief that immediate medical evaluation or treatment is needed.

The term “Injury” or any reference thereto, shall mean any physical damage to you or your dependent caused exclusively by accidental means, independent of all other causes.  An injury shall be considered an “Emergency” if it requires immediate medical evaluation or treatment, or if the onset of symptoms is of sufficient severity that there is reasonable belief that immediate medical evaluation or treatment is needed.

The term “In-Network” or any reference thereto, shall mean a provider that has either (i) a direct agreement or contract with the fund, or (ii) an agreement or contract with a Network or PPO that is contracted with the fund, to deliver products or services to participants under the plan.

The term “In-Network Physician” or any reference thereto, shall mean a duly licensed doctor of medicine, osteopathy, podiatry, chiropractic, nurse practitioner, or physician assistant authorized to perform medical or surgical services within the scope of his license, that has either (i) a contract with the fund, or (ii) an agreement with a network or PPO contracted with the fund, to deliver products or services to participants under the plan.

The term “In-Network Provider” or any reference thereto, shall mean a provider that has either (i) a contract with the fund, or (ii) an agreement with a Network or PPO contracted with the Fund, to deliver products or services to participants under the plan.

The term “Inpatient” or any reference thereto, shall mean the classification of a covered person when that person is admitted to a hospital, or hospice facility, for treatment, and charges are incurred for room and board of the covered person as a result of such treatment.

The term “Medicaid” or any reference thereto, shall mean any state sponsored program of medical aid for needy persons, established under Title XIX of the Social Security Act of 1965, as amended from time to time.

The term “Medical Condition” or any reference thereto, shall mean any condition, whether physical or mental, resulting from an illness or injury, whether accidental or not, including but not limited to pregnancy or congenital malformation.

The term “Medical Necessity” or any reference thereto, shall mean healthcare services, supplies, or treatments, which are appropriate and consistent with the respective diagnosis and which, in accordance with generally accepted medical standards, could not have been omitted without adversely affecting the patient’s condition or the quality of medical care rendered and is ordered by a provider.

The term “Medicare” or any reference thereto, shall mean the health insurance program set forth in Parts A and B under Title XVIII of the Social Security Act of 1965, as amended from time to time.

The term “Mental Health Condition” or any reference thereto, shall mean any mental, nervous, emotional, or psychological conditions, symptoms, or disorders, regardless of cause, or resulting from illness, injury, or disability.

The term “Necessary Services and Supplies” or any reference thereto, shall mean any charges:

  1. made by a hospital on its own behalf for medical services and supplies actually used during hospital confinement, except charges for room and board; and
  2. by whomever made, for licensed ambulance services to, or from, the nearest hospital where the needed medical care and treatment can be provided.

The term “Network” or any reference thereto, shall mean a managed care organization of medical providers, such as physicians, hospitals, and other providers, who contract with insurers and group health plans to provide healthcare services at reduced rates to the insurer’s clients or group health plans’ members.

The term “No-Fault Insurance” or any reference thereto, shall mean the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

The term “Nurse” or any reference thereto, shall mean a licensed registered nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed vocational nurse (L.V.N.) or any other nurse licensed to practice in the state in which it resides.

The term “Out-of-Network” or any reference thereto, shall mean a provider that does not have either (i) a direct agreement or contract with the fund, or (ii) an agreement or contract with a network or PPO that is contracted with the fund, to deliver products or services to participants under the plan.

The term “Out-of-Network Physician” or any reference thereto, shall mean a duly licensed doctor of medicine, osteopathy, podiatry, chiropractic, nurse practitioner, or physician assistant authorized to perform medical or surgical services within the scope of his license, that does not have either (i) a contract with the fund, or (ii) an agreement with a network or PPO contracted with the fund, to deliver products or services to participants under the plan.

Out-of-Network Physicians are reimbursed at a percentage of reasonable and customary charges and a deductible is usually applied.

The term “Out-of-Network Provider” or any reference thereto, shall mean a provider that does not have either (i) a contract with the fund, or (ii) an agreement with a network or PPO contracted with the fund, to deliver products or services to participants under the plan.

Out-of-Network Providers are reimbursed at a percentage of reasonable and customary charges and a deductible is usually applied.

The term “Out-of-Pocket Expense” or any reference thereto, shall mean those expenses paid by the patient.

The term “Outpatient” or any reference thereto, shall mean the classification of a covered person when that covered person received medical care, treatment, services, or supplies at a clinic, physician’s office, outpatient psychiatric facility, outpatient alcoholism treatment facility, or hospital (provided said covered person is not a registered bed patient at that hospital).

The term “Participant” or any reference thereto, shall mean a member or dependent who satisfies the eligibility requirements of the plan.

The term “Physician” or any reference thereto, shall mean a duly licensed doctor of medicine, osteopathy, podiatry, chiropractic, nurse practitioner, or physician assistant authorized to perform medical or surgical services within the scope of his license.

The term “Post-Service Claim” or any reference thereto, shall mean any claim for benefits where Authorization or other form of approval under the plan is not required.

A Post-Service Claim will usually be made after the service, treatment, or provision of goods, such as prescription drugs, has been provided; however, even if a benefit is not provided, it is still a Post-Service Claim unless Authorization is required by the terms of the plan.

The term “Predetermination” or any reference thereto, shall mean a review of a dentist’s proposed treatment plan.

The term “Pre-Service Claim” or any reference thereto, shall mean any claim for a benefit where Authorization or other form of approval under the plan is required in order to receive the benefit.

The terms “Preferred Provider Organization” or “PPO” or any reference thereto, shall mean a managed care organization of medical providers, such as physicians, hospitals, and other providers, who contract with insurers and group health plans to provide healthcare services at reduced rates to the insurer’s clients or group health plans’ members.

The term “Primary Plan” or any reference thereto, shall mean the plan of benefits that pays first under the plan’s coordination of benefits rules.

The term “Provider” or any reference thereto, shall mean any supplier of healthcare services, facilities, or supplies, such as a hospital, pharmacy, physician, or other healthcare professional or supplier of healthcare related services, facilities, or supplies, licensed or certified by the applicable authority to practice healthcare or healthcare related services.

The term “Qualified Medical Child Support Order” or “QMCSO,” shall mean a medical child support order that:

  1. creates or recognizes the right of an alternate recipient to receive benefits for which a participant or beneficiary is eligible under a group health plan or assigns to an alternate recipient the right of a participant or beneficiary to receive benefits under a group health plan; and
  2. is recognized by the group health plan as “qualified” because it includes information and meets other requirements of the QMCSO provisions.

 

A properly completed National Medical Support Notice is be treated as a QMCSO.

Reasonable and Customary Charges

The term “Reasonable and Customary Charges” or any reference thereto, shall mean the charges normally made by others who render or furnish such services or treatments in the same geographic area for the same Illness or Injury as determined by published industry data.

The term “Room and Board” or any reference thereto, shall mean any and all charges made by a hospital on its own behalf, for room and meals, and for all general services and activities needed for the care of registered bed patients.

The term “Spouse” or any reference thereto, shall mean a member’s lawful spouse.  This does not include a spouse who is legally divorced or separated from the member by judgment, decree, or signed separation agreement.

The term “Substance Abuse” or any reference thereto, shall mean an unhealthy pattern of the use of alcohol, drugs, or similar substances, leading to clinically significant impairment or distress.

The term “Surgery” or any reference thereto, shall mean any procedure involving the:

  1. incision, excision, or electro cauterization or laser, of any organ or part of the body;
  2. manipulative reduction of a fracture or dislocation;
  3. suturing of a wound; or
  4. diagnostic evaluation or removal of a stone or foreign body by endoscopic means.

The term “Treatment Facility” or any reference thereto, shall mean any institution, or distinct part thereof, that:

  1. is primarily engaged in providing, on a full-time basis, a program for the diagnosis, evaluation, and effective treatment of substance abuse or a mental health condition;
  2. has a written agreement with a hospital in the area to provide:
    1. emergency care services, including, but not limited to detoxification and medical treatment services on a continuous 24-hour basis; or
    2. diagnostic, x-ray, laboratory, and pharmaceutical services;
  3. is under the continuous supervision of a staff of physicians on a continuous 24-hour basis;
  4. provides skilled nursing services on a continuous 24-hour basis under the direction of a full-time Nurse, with licensed nursing personnel on duty at all times; and
  5. prepares and maintains a written plan for admission, care, treatment, and discharge for each patient, based on the diagnostic assessment of the patient’s medical, psychological, and social needs.

The term “Urgent Care Claim” or any reference thereto, shall mean a claim for which a benefit determination must be made quickly, because allowing a longer period of time for making the determination could:

  1. seriously jeopardize your life or your ability to regain maximum function;
  2. in your physician’s opinion, would subject you to severe pain that could not be adequately managed without the care or treatment being sought; or
  3. which a physician with knowledge of your condition determines meets the conditions of (a) or (b) above.

The term “Well-Baby Care” or any reference thereto, shall mean medical treatment, service, or supplies rendered to a child, or newborn, solely for the purpose of health maintenance and not for the treatment of an illness or injury.