Definitions
Certain terms have a special meaning under the Medical Care Plan. This section provides the exact meaning for those terms.
Accidental Injury - a severe injury that requires immediate attention by a doctor.
Benefits Committee - oversees the operation of the plan and interprets plan provisions.
Before-tax Premiums - your cost for coverage will be automatically deducted on a before-tax basis. Your taxable income will be reduced by the amount of your premiums. You won't pay any federal or state taxes (or Social Security or Medicare, if applicable) on your premium amounts. Since your taxable income will be lower, your taxes will be lower as well.
Claims Administrator - an organization employed by the plan to verify eligibility, determine medical necessity and administer plan provisions.
Custodial Care - care that is provided at a nursing facility or at home when a patient's condition is such that further progress is not expected and medical treatment is not provided, except that the patient is aided through supplies and services in normal daily life activities, such as walking, bathing, eating and dressing.
Custodial care also includes care that could be provided safely and reasonably by a person who is not medically skilled.
Doctor (or Physician) - a legally-qualified practitioner of the healing arts acting within the scope of his or her license.
Emergency Accident Care - the initial outpatient treatment of an accidental injury, including related diagnostic service.
Emergency Medical Care - the initial outpatient treatment, including related diagnostic service, of the sudden and unexpected onset of a medical condition which has severe symptoms. If immediate medical attention is not obtained, the symptoms could result in serious and permanent medical consequences. Examples of such symptoms are severe chest pains, convulsions or persistent, severe abdominal pains.
Experimental - treatment that is considered experimental in terms of generally-accepted medical practice.
Family Status Change - allows you to add or discontinue plan coverage for eligible dependents at a time other than the annual open enrollment period. Such changes include:
a change in marital status (marriage,
divorce or legal separation);
the birth or adoption of a child; the death of an
eligible dependent;
a change in your or your spouse's
employment status (i.e. reduction in hours) which includes
the loss of health insurance; and
a dependent child reaching the age limit
for the plan.
Home Health Care - a public or private agency or organization that provides skilled nursing and therapeutic services in the home by registered nurses under a physician's or registered nurse's supervision. The agency must keep clinical records on all patients.
Hospice - an organization that provides a centrally administered program of palliative (relief from pain) and support services to the terminally ill and their families. Services are provided by a medically supervised team of professionals and volunteers.
Hospital - an institution that:
is licensed as a hospital in the
jurisdiction where it is located;
provides 24-hour-a-day skilled nursing
services by registered nurses;
keeps a medical record of each patient;
keeps an ongoing quality assurance program
with review by doctors; charges for its services and supplies; and
although it provides medical or
psychiatric treatment, it is not mainly: - a nursing home,
convalescent or extended care facility;
- a place for rest or the aged;
- a place for drug addicts or alcoholics;
- a place that provides educational or behavioral modification services in a residential setting for children or adolescents with behavioral or social problems, mental retardation or autism;
- a place of career advice, job training or vocational rehabilitation; or
- a place to reside, play or exercise.
Infertility - the inability to achieve pregnancy after twelve months of unprotected intercourse despite purposeful attempts at pregnancy. The inability to sustain a successful pregnancy is defined as either the third miscarriage occurring before 12 weeks of gestation or the first spontaneous pregnancy loss occurring after 12 weeks of gestational age.
Maintenance Drugs - prescription drugs used on an ongoing basis for the treatment of chronic conditions, such as diabetes, ulcers or high blood pressure.
Medical Advisor Review Program - a health care function offered by the City to certify hospital confinements for you and your dependents, explain alternatives to hospital care and facilitate the early discharge of a hospital patient. Information shared with the medical advisor will be confidential medical information. This information may not be obtained by other employees, the City or any other individual or organization for any purpose unless the patient, or a person who the patient designates, authorizes the release of the information in writing. Refer to page PPOM-2 for a summary of the features of the medical advisor review program. More information starts on page PPOM-10.
Medical Care - medical care and treatment by a doctor, including the professional services of a radiologist, pathologist or other specialist acting within the scope of his or her license. The care or treatment must be for a service covered under the plan.
Medically Necessary - a service, supply or course of treatment that is customary for the treatment of an illness, injury or mental or nervous condition and is consistent with generally accepted medical standards. The service, supply or course of treatment must not involve the use of drugs which are not approved by federal authorities. The eligible expense must be certified as medically necessary.
The claims administrator will initially determine if a service or supply is medically necessary. The plan will not pay for the cost of hospitalization or any other health care services or supplies that are not medically necessary. The judgment of the claims administrator relates only to benefits coverage under this plan. You should not use the availability of benefits coverage to determine what medical care or treatment you or your dependents decide to receive.
Note: Hospitalization, for purposes of your benefit coverage only, will be determined to be medically necessary when the medical services you receive require a hospital inpatient setting. If services could appropriately be provided in your doctor's office, the outpatient department of a hospital or some other setting without adversely affecting your condition, hospitalization will be considered not medically necessary.
Here are some examples of hospitalization and other services and supplies that are not medically necessary:
hospital admissions for or consisting
primarily of observation and/or evaluation that could have
been provided safely and adequately in some other setting,
such as a doctor's office or hospital outpatient
department;
hospital admissions primarily for
diagnostic studies (x-ray, laboratory and pathology services
and diagnostic tests) which could have been provided safely
and adequately in some other setting, such as a doctor's
office or hospital outpatient department;
continued inpatient hospital care when the
patient's medical symptoms and condition no longer
require a continued hospital stay;
hospitalization or admission to a skilled
nursing facility, nursing home or other facility for the
primary purpose of providing custodial care, convalescent
care, rest cures or domiciliary care to the patient or for
the convenience of the patient or doctor;
hospitalization or admission to a skilled
nursing facility for the convenience of the patient or doctor
or because care in the home is not available or is
unsuitable; and
the use of skilled or private nurses to
assist in daily living activities, routine supportive care,
or to provide services for the convenience of the patient
and/or his or her family.
Modality - any physical agent applied to produce therapeutic changes to biologic tissue; includes but is not limited to thermal, acoustic, light, mechanical or electrical energy.
Nursing Care - medical care of an illness, injury or mental or nervous condition by a nurse:
who is not a member of your or your
dependent's immediate family; or
who does not live in your home or your
dependent's home.
Nurse means a registered graduate nurse (RN) or a licensed practical nurse (LPN).
Prescription Drugs - drugs or medicines that require a doctor's signature to dispense and are approved by the U.S.F.D.A. for use in treating the sickness or injury for which they are prescribed.
Residential Treatment Center - a facility that specializes in 24-hour-a-day mental health and substance abuse care and treatment. The center must:
be licensed for the type of treatment
provided;
be licensed by the state in which it is
located; and
have a Blue Cross and Blue Shield vendor
number.
To be eligible for coverage, the center cannot be primarily for patient education.
Skilled Nursing Facility - a licensed institution (other than a hospital) that specializes in inpatient physical rehabilitation, skilled nursing or medical care. The skilled nursing facility must:
maintain all facilities necessary for
medical treatment;
provide treatment under the supervision of
doctors;
provide nursing services 24 hours every
day; and
maintain daily clinical records on all
patients.
A skilled nursing facility does not include any institution or part of an institution that is used primarily for educational care, custodial care, or for the care and treatment of drug addiction or alcoholism.
Total Disability - means that you as the employee are prevented, solely by reason of a disease or accidental bodily injury, from engaging in your regular occupation and are performing no work for any kind of compensation or profit; or, as the dependent, you are prevented, solely by reason of a disease or accidental bodily injury, from engaging in substantially all of the normal activities of a person of similar age and sex in good health.
Usual and Customary Charge - the lowest of the following:
the usual charge by the doctor or provider
for the same or similar services or supplies;
the usual charge of doctors or providers
of similar training or experience in the same area or a
similar geographic area for the same or similar services or
supplies;
the actual charge for the service or
supplies; or
the allowable charge for services subject
to the PPO Network.
November 2002