Definitions

The following definitions apply to the Medical Plan. See "Definitions" for the Health Care Program for additional definitions that apply.

Allowable Charge (AC) - for In-Network Plus (INP) and Preferred Provider Organizations (PPO) providers, this means the actual charge made by the provider of the care or supply, or the amount to which the provider has agreed by participating in the network, whichever is less. For Out-of-Network (OON) providers, this means the actual charge made by the provider of the care or supply, or if less, the amount determined by the Plan Administrator or its designee to be usual, customary, and reasonable (UCR) based on what other providers charge for the same service. Any reduction or discount credited to the participant by the provider will reduce the Allowable Charge, potentially causing an overpayment that the Plan may recover from you (see "Recovering Overpayments" for more information).

Allowable Charges do not include any charge determined by the Plan to be the result of fraud, waste, or abuse, including but not limited to charges that are determined to be excessive (see “Exclusions Related to Fraud, Waste, and Abuse”).

In all cases, Allowable Charges for air ambulance will not exceed 200% of the Medicare-approved amount, and Allowable Charges for an implant or device will not exceed 110% of the original manufacturer’s invoice price.

Annual deductible - means the amount of Allowable Charges you pay out-of-pocket in a calendar year before the Plan pays any expenses. Copays do not apply to satisfy the annual deductible. See "Annual Deductible" for more information.

Care Coordination - means services provided by the Plan to help participants with complex or chronic health conditions receive medically necessary treatment and avoid gaps in care. These services may include Center of Expertise coordination, health monitoring, and treatment plan review and coordination. See “Preauthorization, Concurrent Review, Case Management, and Care Coordination” for more information.

Center of Expertise - means a facility approved by the Plan for designated procedures, based on the facility's experience, success rate, and treatment options available. See "Centers of Expertise" for more information.

Coinsurance - means the percentage of the Allowable Charge that is your responsibility for an eligible expense. For emergency room services, any coinsurance required applies to the ER facility charge and other ER-related charges, such as physician, radiologist, and lab.

Combined Medical/Prescription Out-of-Pocket Limit - see “Annual Out-of-Pocket Limits."

Copay - means the flat-dollar amount you pay at the time you visit the provider. For emergency room services, if only a copay is specified in “Benefit Summary," the copay covers the ER facility charge and other ER-related charges, such as physician, radiologist, and lab.

Custodial care - means care that is primarily for the purpose of assisting the individual in the activities of daily living, rather than medically necessary treatment of an illness or injury. Custodial care includes:

  • Sitters' or homemakers' services,
  • Care in a place that serves you primarily as a residence when you do not require substantial skilled nursing,
  • Long-term residential or inpatient care for convalescent or chronically ill individuals whose medical condition is unlikely to substantially improve, or
  • Similar care that is not primarily therapeutic.

Experimental/Investigational - means a drug, device (or combination of drugs and/or devices), biological product, or medical treatment or procedure that the Plan determines:

  • Cannot be lawfully marketed without approval of the appropriate governmental or regulatory agency and approval for marketing has not been given at the time the drug, device, biological product, or medical treatment or procedure is furnished,
  • Is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis, or
  • Based on the prevailing opinion among evidence-based analysis or authoritative medical and scientific literature regarding the drug, device, biological product, or medical treatment or procedure, 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 a standard means of treatment or diagnosis.

Note: Routine patient costs, as identified under "Clinical Trials" in the "Eligible Expenses" section, may not be excluded when provided to a qualified individual in connection with an approved clinical trial.

HealthCheck - means a cardiovascular health screening, administered by Raymond D. Wells PSC and certain INP providers. All information provided through the HealthCheck will be maintained pursuant to the privacy and security policies of the Plan (see "Notice of Privacy Practices for Protected Health Information") and of Raymond D. Wells PSC, in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Participants' individual information will be available to Raymond D. Wells PSC, the Plan, and any health care providers whom the participant approves for the release of information. All information from the HealthCheck results, including any indication of high-risk levels, is intended for the participant’s general knowledge only and is not a substitute for medical advice, diagnosis, or treatment. Participants should seek prompt medical care for any specific health issues and should consult their health care provider for confirmation of HealthCheck results.

In-Network - means providers that are members of one of the Plan's contracted networks, also referred to as Preferred Provider Organization (PPO).

In-Network Plus (INP) - means providers that have contracted directly with the Plan and are willing to coordinate with Raymond D. Wells PSC and the Plan's Care Coordination Services to help achieve improved health outcomes of participants.

Inpatient - means care as a registered bed patient in a hospital or other provider where a room and board charge is made. Preauthorization requirements apply for inpatient admissions.

Medical Necessity - see “Definition of Medical Necessity

Medical Out-of-Pocket Limit - see “Annual Out-of-Pocket Limits

Observation - means charges for keeping the patient in the emergency room or observation unit for monitoring or testing.

Out-of-Network (OON) - means providers that are not members of any of the networks contracted by the Medical Plan. 

Outpatient - see "Outpatient Care"

Period of care - means the time period beginning when a patient is admitted to a skilled nursing facility and ending when the patient has not been confined for 90 consecutive days in a hospital, skilled nursing facility, or other place that provides nursing care.

Preauthorization - means certification from the Plan Administrator before the services or products provided are rendered that, based upon the information presented by the participant or his or her provider at the time preauthorization is requested, the proposed treatment meets the Plan’s guidelines for medical necessity. For more information about preauthorization (which is sometimes referred to as “precertification”), see “Preauthorization, Concurrent Review, Case Management, and Care Coordination.” A separate definition of preauthorization applies for certain transplant services; see “Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services.”

Preferred Provider Organization (PPO) - means the Plan's contracted provider networks. Also referred to as In-Network.

Residential Treatment Center - means a facility that provides 24 hour-per-day, 7 day-per-week treatment for chemical dependency, drug and substance abuse or mental health problems on an inpatient basis. It must provide at least the following: room and board; medical services; nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services. A residential treatment center is recognized if it is accredited for its stated purpose and carries out its stated purpose in compliance with all relevant state and local laws. The Plan’s coverage does not include services provided in a community-based residential facility or group home. Preauthorization requirements apply for inpatient admissions.

Urgently needed care - means medical care or treatment that, if substantially delayed (e.g., 15 days), could:

  • Seriously jeopardize the life or health of the covered individual or the ability for the individual to regain maximum function, or
  • Subject the covered individual (in the opinion of a physician with knowledge of the individual's medical condition) to severe pain that cannot be adequately managed without the specified care or treatment.