Affordable Care Act or ACA
The Patient Protection and Affordable Care Act, Public Law 111- 148, as amended by the Healthcare and Education Reconciliation Act, Public Law 111-152, collectively referred to as the Affordable Care Act or ACA.
The amount a Participating Provider has agreed to accept as payment in full for the provision of 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.
See Section 4.
See Section 4.
Health Care Services primarily intended to preserve, change or improve the Enrollee’s appearance or are furnished for psychiatric or psychological reasons.
See Section 4.
Health Care Services performed, prescribed, directed or authorized by a Provider and for which the Group Contract provides Benefits. To be a Covered Service, the Health Care Service must be all of the following:
- Medically Necessary.
- Within the scope of the license of the Provider.
- Rendered while coverage under the Group Contract is in force.
- Not experimental/investigative.
- Authorized in advance by us if Precertification is required under the Group Contract.
- Not excluded or limited by the Group Contract.
Any type of care provided according to Medicare guidelines, including Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn't pay for custodial care. Custodial care is not covered.
See Section 4.
An individual you have appointed to assist or represent you with a Grievance, Appeal, or External Review. This person may include Providers, attorneys, friends, or family members. You must identify your Designated Representative to us in writing in order to prevent disclosure of your medical information to unauthorized persons. If you would like to designate a representative, you will need to complete a Designation of Representation form. The form is available online at iuhealthplans.org or, upon your request, we will forward a form to you for completion. If we do not obtain a completed Designation of Representation form, we will proceed in our investigation of your Grievance, Appeal or External Review, however, all communication related to such review will be directed to you and we will respond to inquiries submitted by you only.
With respect to an Emergency Medical Condition, a medical screening examination that is within the capability of the Emergency department of a Hospital or a Freestanding Independent Emergency Department, including ancillary services routinely available to the Emergency department to evaluate such Emergency Medical Condition and within the capabilities of the staff and facilities available at the Hospital or Independent Freestanding Emergency Department, and such further medical examination and treatment to stabilize the patient. The term “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. With respect to a pregnant person who is having contractions, the term “stabilize” also includes the delivery (including the placenta) if there is inadequate time to effect a safe transfer to another Hospital before delivery or a transfer may pose a threat to the health or safety of the pregnant person or the unborn Child.
Experimental or Investigational Services
We will deem any drug, biologic, device, Diagnostic, product, equipment, procedure, treatment, service, or supply to be Experimental/Investigative if we determine that one or more of the following criteria apply when the Health Care Service is rendered with respect to the use for which benefits are sought. The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply satisfies any or all of the following listed below:
- Cannot be legally marketed in the United States without the final approval of the FDA, or other licensing or regulatory agency, and such final approval has not been
- Has been determined by the FDA to be contraindicated for the specific use.
- Is provided as part of a clinical research protocol or clinical trial or is provided in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or
- Is subject to review and approval of an Institutional Review Board (IRB) or other body serving a similar
- Is provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply as Experimental/Investigative, or otherwise indicate that the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation.
Emergency Medical Condition or Emergency
A medical condition, including a mental health condition or substance abuse disorder. that arises suddenly and unexpectedly and manifesting itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in any of the following:
- Placing a person’s health (or, with respect to a pregnant person, the health of such pregnant person or the unborn Child of the pregnant person) in serious jeopardy.
- Serious impairment to a person’s bodily functions.
- Serious dysfunction of a bodily organ or part of a person.
The entity to which the Group Contract has been issued.
the Subscriber or any Dependent:
- Who meets all applicable eligibility requirements for coverage under the Group Contract;
- Who is enrolled as provided in the Contract; and,
- For whom the required premium payment has been received by us.
Enrollees are also referred to as “you” and “your” in this Evidence of Coverage.
The contract between Indiana University Health Plans, Inc. and the Employer that provides Benefits for Covered Services for Subscribers and enrolled Dependents. The Group Contract consists of the Evidence of Coverage, the Schedule of Benefits and any amendments or riders to any of these documents. The Summary of Benefits and Coverage and marketing materials are not considered a part of the Group Contract.
Health Care Services
Medical or health care services, including services for Behavioral Health, whether or not covered under the Group Contract, which include but are not limited to: medical evaluations, diagnoses, treatments, procedures, drugs, therapies, devices and supplies.
An institution that is operated and licensed under law and is primarily engaged in providing Health Care Services on an Inpatient basis.
Receipt of Health Care Services as a registered bed patient in a Hospital or other Provider where room and board charge is made.
Medical Food is a food that is Medically Necessary and prescribed by a Provider for the treatment of an inherited metabolic disease or inherited metabolic disorders for the primary or sole source of nutrition. Medical Food means a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a physician.
Those Health Care Services that we determine to be all of the following:
- Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the Enrollee’s illness, injury or disease.
- Required for the direct care and treatment or management of the Enrollee’s illness, injury or disease.
- If not provided, the Enrollee’s condition would be adversely affected.
- Provided in accordance with generally accepted standards of medical practice.
- Not primarily for the convenience of the Enrollee, the Enrollee’s family, the physician or another prescribing Provider.
- Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the Enrollee’s illness, injury or disease.
We will decide whether a Health Care Service is Medically Necessary. We will base our decision in part on a review of the Enrollee’s medical records and will also consider reports in peer reviewed medical literature, reports and guidelines published by nationally recognized health care organizations that include supporting scientific data, professional standards of safety and effectiveness, which are generally recognized in the United States for diagnosis, care or treatment, the opinion of health professionals in the generally recognized health specialty involved, the opinion of the attending physicians and other medical Providers, which have credence but do not override contrary opinions and any other relevant information brought to our attention.
The definition of Medically Necessary under the Group Contract relates only to coverage and may differ from the way a Provider engaged in the practice of medicine may use the term. The fact that a Provider has furnished, prescribed, ordered, recommended or approved the Health Care Service does not make it Medically Necessary or mean that we must provide coverage for it.
Minimum Essential Coverage (MEC)
Any of the following types of coverage.
- Government Sponsored programs (such as Medicaid, Medicare, CHIP, Veteran’s health care programs, Refugee Medical Assistance and student health coverage).
- An Employer sponsored health benefit plan.
- Individual health coverage.
- State health benefits high risk pool.
- Other programs recognized by the U.S. Department of Health and Human Services as Minimum Essential Coverage.
Health Care Services that are not covered under the terms of the Group Contract.
Non-Participating Provider or Non-Participating Pharmacist/Pharmacy
A Provider that has not entered into a contractual agreement with us or is not otherwise engaged by us to provide Health Care Services to Enrollees under the Group Contract.
Receipt of Health Care Services while not an Inpatient.
The maximum amount Enrollees will pay for Covered Services in a Calendar Year. The Out-of-Pocket Maximum includes the Deductible, Copayments and Coinsurance Percentage. The Out-of-Pocket Maximum is shown in the Schedule of Benefits and applies as follows:
- The “Per Enrollee” Out-of-Pocket Maximum is the amount that must be satisfied by each Enrollee, except as provided under the “Per Family” Out-of-Pocket Maximum provision.
- The “Per Family” Out-of-Pocket Maximum is the maximum Out-of-Pocket amount that applies if the Subscriber has Family Coverage. Each Enrollee can satisfy the entire “Per Enrollee” Out-of-Pocket Maximum until the total “Per Family” Out-of-Pocket Maximum is met for the Calendar Year. The “Per Enrollee” Out-of-Pocket amounts accumulate until the “Per Family” Out-of-Pocket Maximum is satisfied. The “Per Family” Out-of-Pocket Maximum can be satisfied by any combination of Cost Sharing paid by or for the Enrollees. At no time will the combined ”Per Enrollee” Out-of-Pocket Maximum amounts exceed the “Per Family” Out-of-Pocket Maximum.
Participating Provider or Participating Pharmacy/Pharmacist
A Provider that has entered into a contractual agreement or is otherwise engaged by us or another Provider that has an agreement with us to provide Health Care Services to Enrollees under the Group Contract.
Any claims that are not pre-service claims. In other words, post-service claims are those claims were treatment has been performed and the claims have been sent to us in order to apply for benefits.
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.
Precertification or Prior Authorization
A required review of a Health Care Service for a Benefit coverage determination which must be done prior to the Health Care Service start date.
||Health care services designed for prevention and early detection of illnesses in average risk people, generally including routine physical examinations, tests and immunizations.|
Primary Care Physician (PCP)
A Participating Provider practicing and duly licensed as a physician practicing in family practice, internal medicine, gynecology, obstetrics or pediatrics and who has agreed to assume primary responsibility for managing the Enrollee’s medical care under the Group Contract.
A doctor, Hospital, pharmacy, or other health care institution or practitioner licensed, certified or otherwise authorized to provide Health Care Services pursuant to the law of the jurisdiction in which care or treatment is received including but not limited to an Independent Freestanding Emergency Department.
|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.|
Routine Care Costs
The cost of Medically Necessary Health Care Services related to the care method that is under evaluation in an Approved Clinical Trial. Routine Care Costs do not include any of the following:
- The Health Care Service that is the subject of the Approved Clinical Trial.
- Any treatment modality that is not part of the usual and customary standard of care required to administer or support the Health Care Service that is the subject of the Approved Clinical Trial.
- Any Health Care Service provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient.
- An investigational drug or device that has not been approved for market by the federal Food and Drug Administration.
- Transportation, lodging, food, or other expenses for the patient or a family member or companion of the patient that is associated with travel to or from a facility where an Approved Clinical Trial is conducted.
- A Health Care Service that is provided by the sponsor of the Approved Clinical Trial free of charge for any new patient.
- A Health Care Service that is eligible for reimbursement from a source other than this Group Contract, including the sponsor of the Approved Clinical Trial.
Serious and Complex Condition
In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm. In the case of a chronic illness or condition, a condition that is:
(1) life-threatening, degenerative, potentially disabling, or congenital; and
(2) requires specialized medical care over a prolonged period of time.
Skilled Nursing Facility
A Provider licensed under state law to provide Inpatient care for recovery from a Sickness or injury, supervised by a physician, providing 24 hour per day nursing care supervised by a full-time registered nurse, and not primarily custodial or domiciliary care.
Step Therapy Protocol
A protocol that sets forth an order in which certain Prescription Drugs must be used to treat an Enrollee’s condition.
An employee of the Employer who is eligible for and enrolled in coverage under the Group Contract.
Health Care Services delivered by use of interactive electronic communications and technology in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), including:
- Secure video conferencing;
- Store and forward technology;
- Remote patient monitoring technology;
Between a Participating Provider in one location and a patient in another location and this is identified by us as secure and appropriate for use in the delivery of certain Health Care Services including, medical exams and consultations and Behavioral Health evaluations and treatment.
For purposes of this definition, “store and forward technology” means transferring data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation.
Urgent Care Claims
A request for a Health Care Service that, if subject to the time limits applicable to Post-Service Claims or Pre-Service Claims (as defined in Article 7 Section B) meets either of the following:
- Would seriously jeopardize the Enrollee’s life, health or ability to reach and maintain maximum function.
- In the opinion of physicians familiar with the Enrollee’s condition, would subject the Enrollee to severe pain that cannot be adequately managed unless we approve the Claim.
Indiana University Health Plans, Inc.
The term “you” refers to you, the Subscriber. The term “Enrollee” refers to you, the Subscriber and your Dependents who are enrolled for coverage under the Group Contract.