A bodily injury sustained through external and accidental means, such as broken bones, animal bites, poisonings and injuries to sound natural teeth. Masticating (chewing) incidents are not considered to be accidental injuries.
The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day.
An authorization by an enrollee or spouse for the Plan to issue payment of benefits directly to the provider. The Plan reserves the right to pay the member directly for all covered services.
January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.
A comprehensive exercise, education, and behavioral modification program designed to improve the physical and emotional conditions of patients with heart disease. There are four phases of cardiac rehabilitation:
- Phase I begins in the hospital (inpatient) after experiencing a heart attack or other major heart event. During this phase, individuals receive a visit by a member of the cardiac rehabilitation team who provides education about their disease, recovery, personal encouragement, and nutritional counseling to prepare them for discharge.
- Phase II begins after leaving the hospital. As described by the U.S. Public Health Service, it is a comprehensive, long-term program that includes medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling. Phase II refers to constant medically supervised programs that typically begin one to three weeks after discharge and provide appropriate electrocardiographic monitoring. Phase 2 may last 3 to 6 months.
- Phase III utilizes a supervised program that encourages exercise and healthy lifestyle and is usually performed at home or in a fitness center with the goal of continuing the risk factor modification and exercise program learned in phase II.
- Phase IV is based on an indefinite exercise program. These programs encourage a commitment to regular exercise and healthy habits for risk factor modification, such as tobacco cessation, stress reduction, nutrition and weight loss, to establish lifelong cardiovascular fitness. Some programs combine phases III and IV.
Clinical trials cost categories
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.
If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:
- Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy
- Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
- Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.
Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See Section 4.
A condition existing at or from birth which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include protruding ear deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes, and other conditions that the Plan may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intraoral structures supporting the teeth.
Convenient care clinic
A small healthcare facility, usually located in a high-traffic retail outlet, with a limited pharmacy, that provides non-emergency health care on a walk-in basis. Examples include MinuteClinics in CVS retail stores and Take Care Health clinics at Walgreen's. Convenient care clinics are different from Urgent care centers (See Urgent care center at the end of this section.)
A copayment is a fixed amount of money you pay when you receive covered services. See Section 4.
|Cost-sharing||Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.|
Services we provide benefits for, as described in this brochure.
The Plan determines what services are custodial in nature. Custodial care that lasts 90 days or more is sometimes known as Long term care. For instance, the following are considered custodial services:
- Help in walking; getting in and out of bed; bathing; eating (including help with tube feeding or gastrostomy) exercising and dressing;
- Homemaking services such as making meals or special diets;
- Moving the patient;
- Acting as companion or sitter;
- Supervising medication when it can be self-administered; or·
- Services that anyone with minimal instruction can do, such as taking a temperature, recording pulse, respiration or administration and monitoring of feeding systems.
A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See Section 4.
Experimental or investigational services
A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trial 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 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product 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, biological product, 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, biological product, or medical treatment or procedure.
If you wish additional information concerning the experimental/investigational determination process, please contact the Plan.
||The diagnosis, prognosis, management, and prevention of genetic disease for those patients who have no current evidence or manifestation of a genetic disease and those who we have not determined to have an inheritable risk of genetic disease.|
||The diagnosis and management of genetic disease for those patients with current signs and symptoms, and for those who we have determined to have an inheritable risk of genetic disease.|
Group health coverage
Health care coverage that a member is eligible for because of employment, by membership in, or connection with, a particular organization or group that provides payment for hospital, medical, or other health care services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.
|Health care professional||A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.|
Hospice care program
A formal program directed by a doctor to help care for a terminally ill person. The services may be provided through either a centrally-administered, medically-directed, and nurse-coordinated program that provides primarily home care services 24 hours a day, seven days a week by a hospice team that reduces or abates mental and physical distress and meets the special stresses of a terminal illness, dying and bereavement, or through confinement in a hospice care program. The hospice team must include a doctor and a nurse (R.N.) and also may include a social worker, clergyman/counselor, volunteer, clinical psychologist, physical therapist, or occupational therapist.
An expense is incurred on the date a service or supply is rendered or received unless otherwise noted in this brochure.
|Infertility||The inability to conceive after 12 months of unprotected intravaginal sexual relations (or 12 cycles of artificial insemination) for women under age 35, and 6 months of unprotected intravaginal sexual relations (or 6 cycles of artificial insemination) for women age 35 and over.|
Inpatient care is rendered to a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that the patient will remain at least overnight and occupy a bed. The hospital bills for inpatient room and board charges for each day (24 hour period) of the inpatient confinement as well as for hospital incidental services. Inpatient hospital benefits apply to services provided by the hospital during an inpatient admission. We make our determination based on nationally recognized clinical guidelines and standard criteria sets.
Intensive outpatient treatment
Intensive outpatient treatment programs must be licensed to provide mental health and/or substance use treatment. Services must be provided for at least two hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive psychiatric medication management.
The sudden and unexpected onset of a condition requiring immediate medical care. The severity of the condition, as revealed by the doctor’s diagnosis, must be such as would normally require emergency care. Medical emergencies include heart attacks, cardiovascular accidents, loss of consciousness or respiration, convulsions and such other acute conditions as may be determined by the Plan to be medical emergencies.
Services, drugs, supplies, or equipment provided by a hospital or covered provider of health care services that the Plan determines:
- are appropriate to diagnose or treat the patient’s condition, illness, or injury;
- are consistent with standards of good medical practice in the United States;
- are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
- are not a part of or associated with the scholastic education or vocational training of the patient; and
- in the case of inpatient care, cannot be provided safely on an outpatient basis.
The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary.
Mental health/substance use disorder
Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as Mental, Behavioral, and Neurodevelopmental disorders.
A diagnosed condition in which the bodymass index is 40 or greater, or 35 or greater with co-morbidities such as diabetes, coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, pulmonary hypertension, weight-related degenerative joint disease, or lower extremity venous or lymphatic obstruction. Eligible members must be age 18 or older.
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are provided while a decision is being made regarding whether a patient will require further treatment as a hospital inpatient or whether the patient will be able to be discharged from the hospital. Observation services are commonly ordered for a patient who presents to the emergency room department and who then requires a significant period of treatment or monitoring in order to make a decision regarding their inpatient admission or discharge. Some hospitals will bill for observation room status (hourly) and hospital incidental services.
If you are in the hospital for more than a few hours, always ask your physician or the hospital staff if your stay is consider inpatient or outpatient. Although you may stay overnight in a hospital room and receive meals and other hospital services, some hospital services-including “observation care”- are actually outpatient care. Since observation services are billed as outpatient care, outpatient facility benefit levels apply and your out-of-pocket expenses may be higher as a result.We make our determination based on nationally recognized clinical guidelines and standard criteria sets.
Any custom fitted external device used to support, align, prevent, or correct deformities, or to restore or improve function.
Partial hospitalization programs must be licensed to provide mental health and/or substance use treatment. Services must be at least four hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive medication management.
Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We determine our allowance as follows:
Network allowance: an amount that we negotiate with each provider or provider group who participates in our network. For these Network allowances, the Network provider has agreed to accept the negotiated reduction and you are not responsible for the discounted amount. In these instances, the benefit we pay plus any applicable deductible, copayment or coinsurance you are responsible for equals payment in full.
Non-Network allowance: the amount the Plan will consider for services provided by Non-Network providers. Non-Network allowances are determined as follows:
Our Plan allowance is the lesser of: (1) the provider’s billed charge; or (2) the Plan’s Non-Network fee schedule amount. The Plan’s Non-Network fee schedule amount is equal to the 80th percentile amount for the charges listed in the Prevailing Healthcare Charges System, administered by Fair Health, Inc. The Non-Network fee schedule amounts vary by geographic area in which services are furnished. We base our coinsurance of this Non-Network fee schedule amount. This applies to all benefits in Section 5 of this brochure.
For certain services, exceptions may exist to the use of the Non-Network fee schedule to determine the Plan’s allowance for Non-Network providers, including, but not limited to, the use of Medicare fee schedule amounts. For claims governed by OBRA ’90 and ’93, the Plan allowance will be based on Medicare allowable amounts as is required by law. For claims where the Plan is the secondary payer to Medicare (Medicare COB situations), the Plan allowance is the Medicare allowable charge.
If you do not have adequate choice in selecting Network providers, please contact us prior to receiving services at 800-410-7778 for more information about Non-Network providers.
For all dialysis services and all urine drug testing services, the Non-Network allowance is the maximum Medicare allowance for such services.
Other Non-Network Participating Provider allowance:
This Plan offers you access to certain other Non-Network health care providers that have agreed to discount their charges. Covered services at these participating providers are considered at the negotiated rate subject to applicable deductibles, copayments, and coinsurance. Since these other participating providers are not Network providers, Non-Network benefit levels will apply. Contact us at 800-410-7778 for more information about other Non-Network participating providers.
For services received from other participating providers (see Other Participating Providers), the Plan’s allowance will be the amount the provider has negotiated and agreed to accept for the services and/or supplies. Benefits will be paid at Non-Network benefit levels, subject to the applicable deductibles, coinsurance and copayments.
Network retail pharmacy allowance: the amount negotiated by the Plan’s pharmacy benefit manager with the pharmacy or pharmacy group at which the drug is purchased.
Non-Network retail pharmacy allowance: the guaranteed discounted price for the drug negotiated by the Plan in its contract with its pharmacy benefit manager.
Allowance for drugs provided by Network providers: the amount negotiated with each Network provider or provider group.
Allowance for drugs provided by Non-Network providers:
- 80% of the Average Wholesale Price (AWP) of the drug (or its equivalent if AWP data is no longer published)
We apply Aetna claim editing criteria and/or the National Correct Coding Initiative (NCCI) edits published by the Centers for Medicare and Medicaid Services (CMS) in reviewing billed services and making Plan benefit payments for them.
For more information, see Section 4, Differences between our allowance and the bill.
|Post-service claims||Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.|
|Pre-service claims||Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.|
An artificial substitute for a missing body part such as an arm, eye, or leg. This appliance may be used for a functional or cosmetic reason, or both.
|Reimbursement||A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.|
||Services that are not related to any specific illness, injury, set of symptoms or maternity care.|
A power-operated vehicle (chair or cart) with a base that may extend beyond the edge of the seat, a tiller-type control mechanism which is usually center mounted and an adjustable seat that may or may not swivel.
Sound Natural Tooth
A tooth that has sound root structure and an intact, complete layer of enamel or has been properly restored with a material or materials approved by the ADA and has healthy bone and periodontal tissue.
|Subrogration||A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.|
|Urgent care center||An ambulatory care center, outside of a hospital emergency department, that provides treatment for medical conditions that are not life-threatening, but need quick attention, on a walk-in basis.|
Urgent care claims
A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:
- Waiting could seriously jeopardize your life or health;
- Waiting could seriously jeopardize your ability to regain maximum function; or
- In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Urgent care claims usually involve pre-service claims and not post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.
If you believe your claim qualifies as an urgent care claim, please contact our Customer Service department at 800-410-7778. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.
|Us/We||Us and We refer to MHBP (Mail Handlers Benefit Plan).|
You refers to the enrollee and each covered family member.