Accumulation Period: This period is 12 months beginning January 1st and ending the following December 31st.
Actively at Work (Active Work): Performing compensated services for the Employer for 30 or more hours per week.
Allowable Charge: The maximum expense covered by this Plan for a service or supply. The Allowable Charge for a given service or supply will vary by the degree of complexity of the service or supply provided, as well as the area of the country in which the service or supply is provided, as determined by the Claims Administrator.
Annual Enrollment Period: The period designated each year by the Employer prior to the beginning of each Plan Year, during which Employees make coverage elections for the next Plan Year. These include Section 125 Plan elections. Deletions to coverage may be made during the annual enrollment; however, additions to coverage may only be made if they correspond with “Family Status” changes.
Annual Maximum Amount: The maximum payable for each Covered Person for all Covered Expenses for the Calendar Year. The annual maximum amount shall not exceed the aggregate Annual Maximum for all covered services incurred in the Calendar Year.
Approved Transplant Services: Medically Necessary services and supplies which are related to a: heart, kidney, liver or bone marrow or other human tissue transplant procedure; are approved in writing under the Pre-Certification process; and include but are not limited to:
- pre-transplant patient evaluation for the Medical necessity of the transplant; and
- Hospital charges; and
- Physician charges; and
- tissue typing and ancillary services.
Calendar Year: The period from January 1 through December 31 of the same year.
Claims Administrator: Medova Healthcare Financial Group, LLC
Covered Charges: That part of necessary expenses incurred which is (a) for care of a Covered condition; and (b) incurred while a person’s coverage is in force; and (c) does not exceed the Allowable Charge for the service or supply; and (d) is shown as a Covered Expense listed in the Comprehensive Medical Benefit Section. Covered Charges are considered incurred on the date a service is rendered or a supply is furnished.
Covered Condition: Any Non-Occupational Sickness or Injury for which a person is covered by this Benefit.
Covered Person: An Eligible Employee or Eligible Dependent whose coverage is effective under this Plan.
Creditable Coverage: Coverage under a group plan including a government or church plan, individual or group health insurance coverage, Medicare, Medicaid, state provided health care including risk pools, military sponsored health care, Peace Corps health benefit plans, a health program of the Indian Health Service or a tribal organization, and any other public health plan.
Dependent: Includes (1) the Employee’s Eligible Dependent who has coverage in force under the
Contract: (2) the Employee’s child, stepchild or adopted child who has coverage in force under the Contract, who has reached the limiting age for Dependents but who cannot earn his own living due to mental or physical handicap. All other requirements for Dependents must be met. The Employee must furnish the Company with proof of the child’s incapacity and dependency within 31 days after the date the limiting age is reached. The Company may also require proof of continuing incapacity and dependency. If proof is not given within 60 days of a request, coverage for the Dependent will end 60 days after the request is made.
Disability: You are Disabled if, due to Non-Occupational Sickness or Injury, you are unable to do the substantial and material duties of your regular job. A Dependent is Disabled if, due to Sickness or Injury, he is unable to do his normal activities.
Eligible Dependent: Includes (1) the Employee’s legal spouse of the opposite sex; (2) the Employee’s natural child up to age 26, adopted child (see also adopted child provisions on page 28); or stepchild up to age 26; and (3) children who are named as “alternate recipients” in a Qualified Medical Child Support Order approved by this Plan.
Eligible Dependent will not include: (1) a foster child; (2) a child or spouse who lives outside of the USA or from whom the Employee is legally separated or divorced; (3) a child or spouse who is covered as an Employee. The Plan Administrator reserves the right to require whatever documentation necessary to establish a Dependent’s eligibility status.
Eligible Employee: a) A person working for the Employer who has satisfied their waiting period, or b) a person who was covered under the Plan on their last day of active work and on an approved leave of absence until employment is terminated by the Employer.
Emergency: The sudden and unexpected onset of a medical condition, a severe injury or the acute exacerbation of a chronic condition, which is threatening to life, limb or sight and which requires immediate medical or surgical treatment. The determination of Emergency will be made by the Utilization Review Organization contracting with the Company at the time of occurrence.
Enrollment Date: A. For someone who enrolls during their Waiting Period, Enrollment Date, usually their date of hire, is the start of their Waiting Period. B. For someone who enrolls after their Waiting Period, Enrollment Date, usually due to a change in family status is the date the employee actually enrolls himself and/or his eligible dependents in the Group Health Plan. See section entitled “Late Requests”.
Experimental: A service, drug or supply not accepted or approved by a relevant segment of the medical community or government oversight agencies as beneficial for the diagnosis or treatment of the Sickness or Injury at the time services were rendered. The Claims Administrator will make determination based on reliable evidence related to federal law, clinical trials, written protocols and reports published in authoritative medical and scientific literature.
Free-Standing Surgical Center: A facility licensed as a free-standing or ambulatory surgical center.
Hospital: 1. An institution which: (a) is operated lawfully; and (b) mainly and continuously provides medical, diagnostic, and surgical facilities; these facilities may be on the premises or available on a prearranged basis supervised by a staff of one or more licensed Physicians; and (c) provides inpatient care for which a charge is made; and (d) provides 24-hour nursing care by, or supervised by, a registered graduate nurse (R.N.); or 2. An institution which is accredited as a Hospital by the Joint Commission on Accreditation of Health Care Organization; or 3. Any other institution required to be recognized as a Hospital for benefit payment purposes under
the law of the state in which the Employee lives. A “private” room is a room with one bed. A “semi-private” room is a room with two beds. A “ward” is a room with more than two beds.
Injury: Accidental bodily injury or injuries which cause a covered loss. The Injury must be the direct cause of the loss, independent of disease, bodily infirmity or other cause.
Late Enrollee: An Employee or Dependent who enrolls for coverage more than 31 days after their initial eligibility period, except as indicated below:
- An Employee or Dependent who waived coverage because that person had other Creditable Coverage, who enrolls within 31 days after the other coverage terminates.
- An Employee or Dependent who enrolls for coverage within 31 days of marriage, birth, adoption or placement for adoption. If a spouse does not enroll at the time of marriage, the spouse will not be considered a Late Enrollee if application is made within 31 days of the birth or adoption of a child when the child is added as a Dependent.
Medicare: Title XVIII of the Social Security Act of 1965, as amended. A person is eligible for Medicare on and after the date he is eligible for any Medicare coverage.
Non-occupational Sickness or Injury: Any Sickness or Injury other than an Occupational Sickness or Injury.
Occupational Sickness or Injury: Accidental bodily injury or sickness arising out of or in the course of any employment for wage or profit to the extent you are covered or are required to be covered by Worker’s Compensation or Occupational Disease Act or Law.
Physician: A legally licensed Physician who is acting within the scope of their license, and any other licensed practitioner required to be recognized for benefit payment purposes under the laws of the state in which they practice and who is acting within the scope of their license. The definition of Physician includes, but is not limited to: Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Chiropractor, Dentist (DDS), Licensed Consulting Psychologist, Licensed Psychologist, Licensed Clinical Social Worker, Occupational Therapist, Optometrist, Ophthalmologist, Physical Therapist, Podiatrist, Advanced Registered Nurse Practitioner (ARNP), Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.), Speech Therapist, Speech Pathologist, Licensed Midwife. An employee of a Physician who provides services under the direction and supervision of such Physician will also be deemed to be an eligible provider under the Plan.
Plan Administrator: Employer as stated in Attachment #1
Preferred Provider: Any Physician, laboratory, or other provider (other than a Hospital) contracting with the Preferred Provider Organization as of the day the Covered Charge is incurred.
Preferred Provider Hospital: Any Hospital contracting with the Preferred Provider Organization as of the day the Covered Charge is incurred.
Prevailing Fee: The maximum amount of billed charge the Plan will consider when determining Covered Charges as determined by the Claims Administrator. Benefit payments of Covered Charges are based on what the Claims Administrator determines to be the Prevailing Fee amount. Amounts billed in excess of the Prevailing Fee are not payable under this Plan.
Prior Plan: The Employer’s former policy of group insurance for its employees in effect on the day immediately preceding the Employer’s effective date of coverage under this plan.
Sickness: Illness, disease or pregnancy which cause a covered loss while a person’s coverage is in force; and congenital defects, birth abnormalities and prematurity of a covered newborn child.
Waiting Period: The length of time a newly hired employee must wait before he is eligible to be covered under this plan.
Year: The period from January 1st through December 31st of the same calendar year.