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The ProblemRising Health Care Benefits Costs. One of the biggest problems faced by employers today is finding affordable and comprehensive health benefits coverage for employees.Despite the advent of HMOs, PPOs and other plan payment options, medical insurance costs continue to rise and so do the demands from employees who want access to the latest medical technology and physicians they know.Navigating through the sea of payment options, medical industry innovations and changing government regulations can be daunting for an employer struggling to create an affordable benefits plan.The SolutionInsurance Design Administrators. For an increasing number of employers The Solution to the health benefits dilemma is a Self-Funded Health Benefits Program.Self-funding gives employers flexibility over traditional fully insured, premium-paid insurance programs. Self-funding provides employers cost efficiency, greater control over their cash resources and coverage options that reflect the needs of their industry and the demands of their work force. To navigate throughout the risks and rewards of self-funding requires an experienced Third Party Administrator (TPA), such as Insurance Design Administrators.Insurance Design Administrators tailors the health benefit solutions that employers seek, whether the company has 50 employees or 50,000, whether they are located in one area or spread from coast to coast.IDA is a recognized national leader in designing and administering self-funded health benefits plans, delivering what employers want most: manageable health benefit costs, without the headaches and hassles of managing a benefits plan.
Program ServicesIDA’s complete package design includes medical plans, dental plans, prescription drug plans, vision plans, group disability insurance, life insurance, Section 125, Flexible Spending Accounts and billing services.IDA produces all documents necessary to implement the new self funded health benefits plan — including: employee handbooks explaining the plan, I.D. cards, physician referral lists and claim forms.Start up services consist of the following elements:1. Enrollment Procedures - Loading eligibility into system, checking for accuracy and completeness.2. Production of ID Cards - Actual cost of cards and mailing additional.3. System Orientation - Building plan parameters into system for complete and accurate adjudication of all claims, as well as any billing formulas, etc.IDA clients get a complete turn key health benefits operation that places virtually no burdens on an employer's Human Resources staff.
DISCLAIMER: The following links are provided as a service to our clients, IDA has no control over accuracy of content contained on individual sites. For confirmation on specific questions, check with your plan administrator.
Customer Service is Available:From 8:30 AM - 4:30 PM Mon - FriTo Assist You With Any Questions or Concerns Regarding Your ClaimsIDA utilizes a sophisticated IVR system which gives24 Hours a day, 7 Days a Week, 365 Days a Year, including:Claims Status Verification of benefits Eligibility
For Sales Assistance in:New York, Northern or Central New JerseyPlease Contact Paul Sabina at 201.337.0555 Ext. 311or e-mail at firstname.lastname@example.orgSouthern New Jersey, Pennsylvania or DelawarePlease Contact Jason Moorman at 201.337.0555 Ext. 233or e-mail at email@example.comTexas, Midwest and SoutheastPlease Contact Scott W. Andalman at 281.794.5050or e-mail at firstname.lastname@example.orgCustomer Service can be reached at 201.337.0555from 8:30 am - 4:30 pm, Monday through Friday.Claims Status and Verification of Benefits information can be obtained24 Hours a day through our Interactive Voice Response (IVR) system.
How To Submit A ClaimWhen a Covered Person has a claim to submit for payment that person must:(1) Obtain a claim form from the Personnel, Benefits' Office or the Plan Administrator.(2) Complete the Employee portion of the form. ALL QUESTIONS MUST BE ANSWERED.(3) Have the Physician complete the provider's portion of the form.(4) For expediting claim processing and Plan reimbursement, all claims must be submitted and accompanied by a completed, signed claim form and full size (8.5" x 11") itemized bills illustrating the following:•Name of Plan•Group number of Plan (if applicable)•Employee's name•Name of Covered Person/patient•Name, address, telephone number of the provider of care•Diagnosis•Type of services rendered, with diagnosis and/or procedure codes•Date of services•Charges(5) Bills for the services of private duty nurses must show that the nurse is either a Registered Nurse (R.N.), or a Licensed Practical Nurse (L.P.N.). The nurse's license number must be included, as well as a letter from the Attending Physician certifying that the nursing services were Medically Necessary and not provided for the convenience of the Covered Person.(6) Bills for prescription drugs must also show the name of the Covered Person/patient, theprescription number, the name of the prescription drug, and the quantity of the drug that was dispensed.(7) If payment has been made by any other source (including Medicare), for any of the expenses being submitted for payment under this Plan, a Covered Person must include a copy of the explanation of benefits from the carrier along with the claim submission and itemized bills.(8) Send the above information to the Claims Supervisor at the appropriate address as indicated on your I.D. CardFor Claim Questions Call:•201.337.0555•800.225.1345
When Claims Should be FiledBenefits are based on the Plan provisions at the time the charges are incurred. Charges are considered incurred when a treatment or care is given or a procedure performed. Claims should be filed with the Claims Supervisor within ninety (90) days of the date charges for the service were incurred. Claims filed later than that date may be declined unless:(1) It's not reasonably possible to submit the claim in that time; and(2) the submission was made as soon as possible under the circumstances.(3) Except in the absence of legal capacity, in no event will an expense be considered if proof of the expenses and/or charges is submitted more than one (1) year after the date the expenses/charges were incurred.The Claims Supervisor will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested.
Claim Denial and NotificationA request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. If a claim is wholly or partially denied, the Claims Supervisor will furnish the Plan Participant with a written notice of the denial. This written notice will be provided within ninety (90) days after receipt of all information required to process the claim. The written notice will contain the following information:(1) the specific reason or reasons for the denial;(2) the specific reference to those Plan provisions on which the denial is based;(3) description of any additional information or material necessary to correct the claim and an explanation of why such material or information is necessary; and(4) appropriate information as to the steps to be taken if a Plan Participant wishes to submit the claim for review.If special circumstances require an extension of time for processing the claim, the Claims Supervisor, shall send written notice of the extension to the Plan Participant. The extension notice will indicate the circumstances requiring the extension of an additional ninety (90) days at which time this Plan expects to render a decision on the claim.
Claims Review ProceduresIn cases where a claim for benefits payment is denied in whole or in part, the Plan Participant may appeal the denial. This appeal provision will allow the Plan Participant to:(1) Request from the Plan Administrator a review of any claim payment. Such request must include: the name of the Employee, his or her Social Security number, the name of the Covered Person/patient and the Group Identification Number, if any.(2) File the request for review in writing, stating in clear and concise terms the reason or reasons for this disagreement with the handling of the claim.The request for review must be directed to the Plan Administrator or Claims Supervisor within sixty (60) days after the claim payment date or the date of the notification of denial of benefits.A review of the denial will be made by the Plan Administrator. The Plan Administrator will provide the Plan Participant with a written response within sixty (60) days of the date the Plan Administrator receives the Plan Participant's written request for review. If, because of extenuating circumstances, the Plan Administrator is unable to complete the review process within sixty (60) days, the Plan Administrator shall notify the Plan Participant of the delay within the sixty (60) day period and shall provide a final written response to the request for review within one hundred twenty (120) days of the date the Plan Administrator received the Plan Participant's written request for review.The Plan Administrator's written response to the Plan Participant shall, if the denial is upheld, cite the specific Plan provision(s) upon which the denial is based.Refer to "Appealing A Claim" in your specific SPD for further appeal procedures.
Coordination of BenefitsCoordination of benefits refers to the set of rules used when two (2) or more plans cover charges incurred by a Covered Person. These rules determine which plan should pay first, then second, etc. These situations arise when a Covered Person is covered by more then one plan, or the Covered Person's Spouse is covered by more then one plan, or the couple's covered Dependent children are covered under two (2) or more plans.The plan that pays first according to the rules will pay as if there were no other plan involved.Benefit PlanThis provision will coordinate the health benefits of the plan. The term benefit plan means the Plan covering you or any one (1) of the following plans:1.Group or group-type plans, including franchise or blanket benefit plans.2.Blue Cross and Blue Shield group plans.3.Group practice and other group prepayment plans.4.Federal government plans or programs. This includes Medicare.5.Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that, by its terms, does not allow coordination.6.No-Fault Auto Insurance, or Out-of-State Automobile Insurance Coverage (OSAIC), by whatever name it is called, when not prohibited by law.Allowable ChargeFor a charge to be allowable it must be a Usual and Reasonable Charge and at least part of it must be covered under this Plan.In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Allowable Charge.In the case of HMO (Health Maintenance Organization) plans: This Plan will not consider any charges in excess of what an HMO provider has agreed to accept as payment in full. Also, when an HMO is primary and the Covered Person does not use an HMO provider, this Plan will consider as an Allowable Charge any charge that would have been covered by the HMO had the Covered Person used the services of an HMO provider.Benefit Plan Payment OrderWhen two (2) or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules.1. Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision will be considered after those without one.2. Plans with a coordination provision will pay their benefits by these rules up to the Allowable Charge.(a) The benefits of the plan which covers the person directly (that is, as an Employee, Member or Subscriber), "Plan A", (that is, other than as a Dependent) are determined before those of the plan which covers the person as a Dependent, "Plan B".Special Rule: As a result of the rules established by Title XVIII of the Social Security Act and implementing regulations, (i) if the person who is covered directly is a Medicare beneficiary, and (ii) Medicare is secondary to the plan covering the person as a Dependent, "Plan B", and (iii) Medicare is primary to the "Plan A" (for example, the person is retired), THEN "Plan B" will pay before "Plan A".(b) The benefits of a benefit plan which covers a person as an Employee who is neither laid-off nor retired are determined before those of a benefit plan which covers that person as a laid-off or Retired Employee. The benefits of a benefit plan which covers a person as a Dependent of an Employee who is neither laid-off nor retired are determined before those of a benefit plan which covers a person as a Dependent of a laid-off or Retired Employee.If the other benefit plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply.(c) The benefits of a benefit plan which covers a person as an Employee who is neither laid-off nor retired or a Dependent of an Employee who is neither laid-off nor retired are determined before those benefits of a plan which covers the person as a COBRA beneficiary.(d) When a child is covered as a Dependent and the parents are not separated or divorced, these rules will apply:1.The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before those of the benefit plan of the parent whose birthday falls later in that year;2.If both parents have the same birthday, the benefits of the benefit plan which has covered the parent for the longer time are determined before those of the benefit plan which covers the other parent.(e) When a child's parents are divorced or legally separated, these rules will apply:1.This rule applies when the parent with custody of the child has not remarried. The benefit plan of the parent with custody will be considered before the benefit plan of the parent without custody.2.This rule applies when the parent with custody of the child has remarried. The benefit plan of the parent with custody will be considered first. The benefit plan of the stepparent that covers the child as a Dependent will be considered next. The benefit plan of the parent without custody will be considered last.3.This rule will be in place of items (i) and (ii) above when it applies. A court decree may state which parent is financially responsible for the health benefits of the child. In this case, the benefit plan of that parent will be considered before other plans that cover the child as a Dependent.4.If the specific terms of the court decree state that the parents shall share joint custody, without stating that one (1) of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are not separated or divorced.(f) If there is a conflict after these rules have been applied, the benefit plan which has covered the person for the longer time will be considered first.(g) If there is still a conflict in the coordination of benefits and none of the preceding rules determine which plan would be the primary plan, the Allowable Expenses shall be shared equally between the plans.3. Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare is to be the primary payer, this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A and B, regardless of whether or not the person was enrolled under both of these parts.4. If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will pay first and this Plan will pay second.5. Please review your benefit plan for any other provisions regarding coordination of benefits.
Third Party Recovery ProvisionRight of subrogation and refundWhen this Provision AppliesA Covered Person may incur medical or dental charges due to injuries caused by the act or omission of a third party and/or a third party may be responsible for payment. In such circumstances, the Covered Person may have a claim against that third party, or insurer, for payment of the medical or dental charges.Reimbursement/Refund RightsAs a condition of receiving benefits under the Plan, if the plan contains a subrogation provision a Covered Person automatically assigns and transfers to the Plan any rights the Covered Person may have to recover payments from any third party or insurer (including, but not limited to such Covered Person's own insurer(s)), for funds paid or payable under the Plan as a result of personal injury or reimbursement of medical expenses. Further, in the event the Covered Person receives any funds from a judgment, settlement or otherwise from any other person, business entity or any other source, the Covered Person shall first repay the Plan in full as the first priority party, for any benefits paid by this Plan.Subrogation RightsAs a condition of receiving benefits under the Plan, a Covered Person recognizes, transfers, conveys and otherwise authorizes the Plan to directly pursue any claim which the Covered Person has against any third party, or insurer, whether or not the Covered Person or Dependent chooses to pursue that claim.Plan's Priority Over FundsThe Covered Person agrees to recognize the Plan's right to subrogation and reimbursement. These rights provide the Plan with a priority over any funds paid by a third party to a Covered Person relative to the Injury or Sickness, including a priority over any claim for non-medical or dental charges, attorney fees, or other costs and expenses. This priority shall be enforceable even if the Covered Person is not made whole by the available recoveries, and shall be considered a lien against such recoveries until the Plan is repaid in full.Amount Subject to Subrogation or RefundThe Plan's priority to funds, subrogation and refund rights, and any/all rights assigned to it, is limited to the extent to which the Plan has made, or will make, payments for medical or dental charges as well as any costs and fees associated with the enforcement of its rights under the Plan.Agreement to Assist In Enforcing RightsCovered Person(s) under the Plan agree to: (1) inform the Plan in writing within sixty (60) days of their claim against third parties, entities and/or insurers for benefits; (2) furnish information and assistance regarding the existence and status of such claims; and (3) to execute any documents as the Plan may require to enforce its rights under this Plan. Covered Person(s) also agree to take no action which may prejudice the rights or interest of the Plan under the Plan Document.Failure to comply with these provisions will be considered a material breach of the PlanDocument and may result in the Covered Person(s) being personally responsible for reimbursing the Plan, and/or lead to a denial of all further Plan benefits.
The following terms and phrases shall have the following meanings, unless a different meaning is plainly required by the context. These are general definitions and the presence of any definition in this section is not, in and of itself, the indication of the existence of a benefit.A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | ZActive Employee: is an Employee who is on the regular payroll of the Employer and who is scheduled to perform the duties of his or her job with the covered Employer on a permanent full-time basis or part-time basis, (if part-time employment is applicable).Activities of Daily Living: are the day-to-day activities, such as continence, dressing, feeding, toileting and transferring.Alcoholism (Substance Abuse [Alcohol Related]): is the condition caused by regular excessive compulsive drinking of alcohol that results in a chronic disorder affecting physical health and/or personal or social functioning.Alcoholism (Substance Abuse [Alcohol Related]) Treatment Facility: is a facility which primarily engages in providing Detoxification and Rehabilitation Treatment of Alcoholism1) Detoxification Facility is a health care facility licensed by the state in which it operates, as a Detoxification Facility for the treatment of Alcoholism.(2) Residential Facility is a health care facility licensed, certified or approved by the state in which it operates, as a Residential Facility for the treatment of Alcoholism.Allowable Charges/Expenses: is any Usual and Reasonable Charge(s) incurred:(1) for a Medically Necessary service or supply; when(2) the charge, service or supply is covered at least in part by one (1) or more plans of the same type (dental or medical) covering the person making the claim.(3) In the event that payments have been made by this Plan in amounts in excess of those necessary to satisfy the intent of this Plan, the Plan Administrator reserves the right to recover such excess payments from the individual and/or entity to which the payments were made.Ambulance: is a specially designed vehicle transporting the sick or injured that contains a stretcher, linens, first aid supplies, oxygen equipment and other life saving equipment required by the state and local law and that is staffed by personnel trained to provide first aid treatment.Ambulatory Surgical Center: is a licensed facility that is used mainly for performing outpatient surgery, has a staff of Physicians, has continuous Physician and nursing care by Registered Nurses (R.N.s) and does not provide for overnight stays.Amendment: is the formal process and resulting document that changes the provisions of this Plan Document, duly signed by the authorized person(s) as designated by the Plan AdministratorArea: means a county or larger geographic area, if a larger area is required, needed to obtain a representative level of Usual and Reasonable Charges.TOPBaseline:shall mean the initial Test Results to which the results in future years will be compared in order to detect abnormalities.Basic Benefit: means that portion of this Plan that provides coverage for eligible charges paid according to a "first-dollar" basis either in full or at a specific fee schedule.Benefit Percentage/Coinsurance: means that portion of eligible expenses to be paid by this Plan in accordance with the coverage provisions as stated in this Plan. It is the basis used to determine any out-of-pocket expenses in excess of the annual deductible which are to be paid by the Plan Participant, if any.Birthing Center: means any freestanding health facility, place, professional office or institution which is not a Hospital or in a Hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located. The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-time supervision of a Physician and either a Registered Nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement.TOPCalendar Year: means January 1st through December 31st of the same year.Certified Registered Nurse Anesthetist (CRNA): is a Registered Nurse certified to administer anesthesia, who is employed by and under the personal supervision of a Physician AnesthesiologistCOBRA: means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.Cognitive Rehabilitation Therapy: is the retraining of the brain to perform intellectual skills which it was able to perform prior to disease, trauma, surgery, or previous therapeutic process; or the training of the brain to perform intellectual skills it should have been able to perform if there were not a congenital anomaly.Coinsurance: means the percentage of charges that a Covered Person is required to pay for eligible charges/expenses under the Plan.Cosmetic Dentistry: means unnecessary dental procedures.Cosmetic Surgery: means medically unnecessary surgical procedures, usually, but not limited to, plastic surgery directed toward preserving beauty or correcting scars, burns or disfigurements.Coverage: is the plan design of payment for medical expenses under the Plan.Covered Person: means the Plan Participant and any/all covered Dependents.Creditable Coverage: is prior coverage of an eligible person which counts toward reducing or eliminating a Pre-Existing Conditions limitation, if any, applies to the Plan. "Creditable Coverage" includes most health coverage such as, coverage under a group health plan (including COBRA continuation coverage, HMO membership, an individual health insurance policy, Medicaid or Medicare). Creditable coverage does not include coverage consisting solely of "expected benefits", such as coverage solely for dental or vision benefits.Custodial Care: is care (including room and board needed to provide that care) that is given principally for personal hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over medication which could normally be self-administered.TOPDay and Night Psychiatric Facility: is a facility which is primarily engaged in providing diagnostic and therapeutic services for the treatment of Mental Disorders/Substance Abuse (Drug Related) only during the day or during the night.Day Care: refers to services, supplies and treatment in an approved facility for not less than four (4) hours or more than sixteen (16) hours in any twenty-four (24) hour period.Deductible(s): is the amount of covered charges for which no benefit will be paid. Before benefits can be paid in a Calendar Year a Covered Person must meet the deductible (the dollar amount indicated) shown in the Schedule of Benefits. The actual deductible amount per Covered Person varies with the type of coverage selected.Dentist: is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license.Diagnostic Services: are procedures ordered by a Physician or professional because of a specific symptom to determine a definite condition or disease.Drug Abuse: is physical, habitual dependence on drugs. This includes (but is not limited to) dependence on drugs that are medically prescribed. This does not include dependence on alcohol, tobacco and ordinary caffeine-containing drinks.Durable Medical/Surgical Equipment and Supplies: are (1) primarily and customarily used for medical purposes and are not generally useful in the absence of Sickness or Injury; (2) can effectively be used in a non-medical facility (home); (3) are expected to make a significant contribution to the treatment of Sickness or Injury; (4) are used solely for the care and treatment of the Covered Person/patient; and (5) are priced so that the cost of the equipment/supplies is proportionate to the therapeutic benefits which can be derived from the use of the equipment/supplies.TOPElective Surgical Procedure or Surgery: is a non-emergency surgical procedure which is scheduled at the Covered Person's convenience without endangering the Covered Person's life or without causing serious impairment to the Covered Person's bodily functions.Eligible Charges: are the charges that may be used as the basis for a claim. They are the charges for certain services and supplies to the extent the charges meet the terms as outlined in the Plan.Employee: means any Employee of the Employer who meets the eligibility criteria as set forth in the Eligibility section of the Plan. For the purposes of the Plan, former Employees and Retirees of the Employer may be eligible for coverage, if so designated by the Employer as set forth in the Eligibility section of the Plan.Enrollment Date: is the first day of coverage. If there is a Waiting Period, the first day of the Waiting Period.Experimental and/or Investigational: means services, supplies, care and treatment which do not constitute accepted medical practice properly within the range of appropriatee medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered. In determining coverage under a Plan, the Plan Administrator shall make an independent evaluation of the experimental status of specific technologies and shall be guided by a reasonable interpretation of Plan provisions. The decision(s) shall be made in good faith and will be rendered following a detailed factual background investigation of the claim and the proposed treatment. In making such a determination, the Plan Administrator will be guided by the following principles:(1) if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or(2) if the drug, device, medical treatment or procedure, or the Covered Person/patient informed consent document utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review or approval; or(3) if Reliable Evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I or phase II clinical trials, is the research, experimental, study or investigational arm of on-going phase III clinical trials, or is otherwise 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 (4) if Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device, 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 a standard means of treatment or diagnosis.Explanation of Benefits (EOB): is a document that accompanies a claims check and summarizes how reimbursement was determined.TOPFacility Charges: are charges from an approved medical institution such as a Hospital, Residential Treatment Center, Detoxification Center, Ambulatory or Freestanding Surgical Center. These charges are generally paid under the Medical provisions of the Plan.Family Unit: is the covered Employee or Retiree and the family members who are covered as Dependents under the Plan.First-Dollar Basis: is a provision of a benefit plan that provides reimbursement for incurred health care costs "from the first dollar" with no deductible.Foster Child: means an unmarried child under the age shown in the Dependent Eligibility Section of the Plan for whom a covered Employee has assumed a legal obligation, and who meets all of the following criteria: (1) the child is being raised as the covered Employee's; and (2) the child depends on the covered Employee for primary support; and (3) the child lives in the home of the covered Employee; and (4) the covered Employee may legally claim the child as a federal income tax deduction. A covered Foster Child is not a child temporarily living in the covered Employee's home; one placed in the covered Employee's home by a social service agency which retains control of the child; or whose natural parent(s) may exercise or share parental responsibility and control.Freestanding Dialysis Facility: is a facility which is primarily engaged in providing dialysis treatment, maintenance or training to patients on an outpatient or home care basisTOPGeneric Drug: means a Prescription drug which has the equivalency of the brand name drug with the same use and metabolic disintegration. The Plan will consider as a Generic Drug any Food and Drug Administration approved generic pharmaceutical dispensed according to the professional standards of a licensed Pharmacist and clearly designated by the Pharmacist as being generic.Genetic Information: means information about genes, gene products and inherited characteristics that may derive from an individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes.TOPHealth Maintenance Organization (HMO): is a prepaid medical group practice plan that provides a comprehensive predetermined medical care benefit package to enrolled groups at a predetermined price. The HMO can be sponsored by the government, medical schools, Hospitals, employers, labor unions, consumer groups, insurance companies, and Hospital-Medical plans. HMOs are both insurers and providers of health care. HMOs provide well-care and preventive medicine, and the enrolled participants' health care is managed by Primary Care Physicians.Home Health Care Agency: is an agency that meets all of the following tests: (1) its main function is to provide Home Health Care Services and Supplies; and (2) it is federally certified as a Home Health Care Agency; and (3) it is licensed by the state in which it is located, if licensing is required.Home Health Care Aide: means a person who provides care of a medical or therapeutic nature and reports to and is under the direct supervision of a Home Health Care Agency.Home Health Care Plan must meet the following tests: (1) it must be a formal written plan made by the Covered Person/patient's Attending Physician; (2) it must be reviewed at least every thirty (30) or sixty (60) days (as applicable); (3) it must state the diagnosis; (4) it must certify that the home health care is in place of Hospital confinement; and (5) it must specify the type and extent of home health care required for the treatment of the Covered Person/patient.Home Health Care Services and Supplies: include: part-time or intermittent nursing care by or under the supervision of a Registered Nurse (R.N.); part-time or intermittent home health aide services provided through a Home Health Care Agency (this does not include general housekeeping services); physical, occupational and speech therapy; medical supplies; and laboratory services by or on behalf of the Hospital.Hospice Agency: is an agency that provides Hospice Care Services and Supplies and is appropriately credentialed and licensed by the state(s) in which it located and operates to provide such services.Hospice Care Plan: is a plan of terminal Covered Person/patient care that is established and conducted by a Hospice Agency and supervised by a Physician.Hospice Care Services and Supplies: are those provided through a Hospice Agency and under a Hospice Care Plan and includes: inpatient care in a Hospice Unit or other licensed facility, home care, and family counseling during the bereavement period.Hospice Unit: is a facility or separate Hospital Unit that provides treatment under a Hospice Care Plan and admits at least two (2) unrelated persons who are expected to die within six (6) months.Hospital: is an institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the Covered Person/patient's expense and which fully meets these tests: (1) it is accredited as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations; (2) it is approved by Medicare as a Hospital; (3) it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of Physicians; (4) it continuously provides on the premises twenty-four (24) hour-a-day nursing services by or under the supervision of Registered Nurses (R.N.s); and (5) it is operated continuously with organized facilities for operative surgery on the premises.The definition of "Hospital" shall be expanded to include the following:(1) A facility operating legally as a psychiatric Hospital and licensed as such by the state in which the facility operates.(2) A facility operating primarily for the treatment of Substance Abuse if it meets these tests: maintains permanent and full-time facilities for bed care and full-time confinement of at least fifteen (15) resident patients; has a Physician in regular attendance; continuously provides twenty-four (24) hour a day nursing service by a Registered Nurse (R.N.); has a full-time Psychiatrist or Psychologist on the staff; and is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse.(3) It is licensed as an Ambulatory or Freestanding Surgical Center. The center must mainly provide outpatient surgical care and treatment.(4) It is an institution for the treatment of Alcoholism which is:(a) a licensed Hospital; or(b) a licensed Detoxification Facility; or(c) a Residential Treatment Facility which is approved by a state under a program that meets standards of care equivalent to those of the Joint Commission on Accreditation of Hospitals.(5) It is a Birthing Center that is licensed, certified or approved by a department of health or other regulatory authority in the state where it operates or meets all of the following tests:(a) it is equipped and operated mainly to provide an alternative method of childbirth;(b) it is under the direction of a Physician;(c) it allows only Physicians to perform surgery;(d) it requires an exam by an Obstetrician at least once before delivery;(e) it offers prenatal and postpartum care;(f) it has at least two (2) birthing rooms;(g) it has the necessary equipment and trained people to handle foreseeable emergencies. The equipment must include a fetal monitor, incubator, and resuscitator;(h) it has the services of registered graduate nurses;(i) it has written agreements with one (1) or more Hospitals in the area and will immediately accept patients who develop complications or require post-delivery confinements;(j) it provides for periodic review by an outside agency;(k) it maintains proper medical records for each patient.The definition of a "Hospital" shall not include a nursing home. Neither does it include an institution, nor part of one, that:(a) is used mainly as a place for convalescence, rest, nursing care, or for the aged or drug addicts;(b) is used mainly as a center for the treatment and education of children with Mental Disorders; or(c) provides homelike or custodial care.Hospitalization Benefits: are benefits provided under a Plan for Hospital charges incurred by a Covered Person because of a Sickness or Injury.Hospital Confinement or Confined in a Hospital: means a Covered Person is:(1) a registered bed patient in a Hospital upon recommendation of a Physician;(2) an outpatient in a Hospital because of (a) chemotherapy treatment; (b) surgery; (c) planned tests ordered by a Physician before inpatient admission to the same Hospital; or (d) treatmentof Alcoholism;(3) receiving emergency care in a Hospital for an Injury on his/her first visit as an outpatient within forty-eight (48) hours after the Injury is received;(4) partially confined for treatment of Mental Disorders, Substance Abuse (Drug Related) or other related Sickness. Two (2) days of being partially confined will be equal to one (1) day of being confined in a Hospital.TOPIllness: is any disorder of the body or mind of a Covered Person, but not an Injury; pregnancy of a Covered Person, including abortion, miscarriage or childbirth.Inherited Metabolic Disease: means a disease caused by an inherited abnormality of body chemistry, defined further as the disease of phenylketonuria (PKU), the body's failure to oxidize an amino acid; galactosemia, the inability to convert glucose; and hypothyroidism, a deficiency of thyroid secretion resulting in lowered basal metabolism, defined a an amount of energy needed for maintenance of life.Injury: means an accidental physical Injury to the body caused by unexpected external means.Intensive Care Unit: is defined as a separate, clearly designated service area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill. This definition includes what is referred to as a "coronary care unit" or "acute care unit" or "neonatal care unit" or "burn care unit". In any event, all Intensive Care Units shall have: facilities for special nursing care not available in regular rooms and wards of the Hospital; special life saving equipment which is immediately available at all times; at least two (2) beds for the accommodation of the critically ill; and at least one (1) Registered Nurse (R.N.) in continuous and constant attendance twenty-four (24) hours a day.TOPLate Enrollee: means a Plan Participant who enrolls under a Plan other than during the first thirty-one (31) day period in which the individual is eligible to enroll under a Plan or during a Special Enrollment Period.Legal Guardian: means a person recognized by a court of law as having the duty of taking care of the person and managing the property and rights of a minor child.Lifetime: is a word that appears in a Plan in reference to benefit maximums and limitations. Lifetime is understood to mean while covered under a Plan. Under no circumstances does Lifetime mean during the lifetime of the Covered Person.Low Protein Modified Food Product: means a food product that is specially formulated to have less than one (1) gram of protein per serving and is intended to be used under the direction of a Physician for dietary treatment of an Inherited Metabolic Disease, but does not include a natural food that is naturally low in protein, and "medical food" means a food that is intended for dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administrated entirely under direction of a Physician.TOPMedicaid:is Title XIX (grants to states for medical assistance programs) of the United States Social Security Act, as amended.Medical Care: is the professional services rendered by a Physician or professional provider for the treatment of a Sickness or Injury.Medical Care Facility: Means a Hospital, a facility that treats one (1) or more specific ailments, or any type of Skilled Nursing Facility/Extended Care Facility.Medical Emergency: means the sudden and unexpected onset of a condition with acute symptoms requiring immediate medical care. Medical Emergencies shall include conditions as found in heart attacks, cardiovascular accidents, loss of consciousness or respiration, convulsions, poisonings, acute abdominal pain, or other such medical conditions. In addition, Medical Emergency includes a mental health or chemical dependency condition when the lack of medical treatment could reasonably be expected to result in the Covered Person harming oneself and/or other persons.Medically Necessary: means services or supplies furnished by a provider not excluded under a Plan, to treat or diagnose a Sickness or Injury, and which as determined by the Plan Administrator, are:(1) consistent with the symptoms or diagnosis; and(2) not primarily for the convenience of the Covered Person or provider; and(3) is the most appropriate level of services which can be safely provided to the Covered Person; and(4) is not conducted for experimental, educational or research purposes; and(5) is medically proven to be effective treatment of the condition; and(6) commonly and customarily recognized by the medical profession as appropriate in the diagnosis and treatment of the Sickness or Injury.Note: The fact that a Physician may prescribe, recommend, order or approve a service or supply does not, of itself, determine it to be Medically NecessaryMedicare: is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security Act, as amended.Mental Disorder: means any disease or condition that is classified as a Mental Disorder in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.Morbid Obesity: is a diagnosed condition in which the body weight exceeds the medically recommended weight by either one hundred (100) pounds or is twice the medically recommended weight in the most recent Metropolitan Life Insurance Co. tables for a person of the same height, age and mobility as the Covered Person.TOPNo-Fault Auto Insurance: is the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.Non-Occupational Disease or Injury: means a Sickness or Injury which does not arise out of, and which is not caused or contributed to by, nor is a consequence of, or in the course of, any employment or occupation for compensation or profit.Non-Participating Provider or Non-network Provider: is a provider, such as a Physician, Hospital, or other health facility or provider who is not under a contractual agreement with a Plan to provide care or services to Covered Persons.TOPOutpatient Care and/or Services: is treatment including services, supplies and medicines provided and used in the following circumstances: (1) at a Hospital under the direction of a Physician to a Covered Person not admitted as a registered bed patient; (2) services rendered in a Physician's office, laboratory, x-ray facility, or at an Ambulatory Surgical Center; or (3) at the Covered Person/patient's home.TOPPartial Hospitalization (Day Care): is the process of unused inpatient days being exchanged for Partial Hospitalization visits on a two-for-one basis (One (1) inpatient day equals two (2) Partial Hospitalization visits.)Participating Provider or Network Provider: is a provider, such as a Physician, Hospital, or other health facility or provider who is under a contractual agreement with a Plan to provide care or services to Covered Persons.Peer Review: is the process whereby a provider's suggested or already rendered services to a patient are reviewed by a provider of similar profession and licensing. The review seeks: (a) to gauge the treatment against accepted practice guidelines of the applicable profession; (b) to determine the necessity/appropriateness of the indicated procedure and modality (considering alternative intervention); and (c) to assess the reimbursement of the procedure according to the terms of the applicable Plan Document.Period of Hospital Confinement: is the period a Covered Person is confined as a bed patient in a Hospital.Pharmacy: means a facility where covered Prescription drugs are filled and dispensed by a Pharmacist(s) licensed under the laws of the state in which the facility operates. As applicable, the facility itself is to comply with all federal and/or state credentialing and licensing requirements.Physician: means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Psychologist (Ph.D.), Licensed Professional Physical Therapist, Physiotherapist, Occupational Therapist, Optometrist (O.D.), Certified Nurse Anesthetist, Midwife, Licensed Professional Counselor, Psychiatrist, Audiologist, Speech Language Pathologist, and any other practitioner of the healing arts that is licensed and/or regulated by a state or federal agency and is acting within the scope of their license (as applicable).Plan Participants: are, for purposes of a Plan, Active Employees, former Employees or Dependents (COBRA participants), Retirees of the Employer, and Dependents, who may be eligible for coverage, if so designated by the Employer as set forth in the Eligibility section of the Plan, and have elected to be covered under the Plan.Plan Year: is the twelve (12) month period beginning on either the Effective Date of this Plan or on the day following the end of the first Plan Year which is a short Plan Year.Preferred Provider: as may be applicable to this Plan, means a Physician, group of Physicians, Hospital, or other healthcare provider (including a Pharmacy, if any) which participates in a Network, PPO or HMO that offers services to Covered Persons under a Plan.Preferred Provider Organization (PPO): is a provider arrangement between a Plan and certain Hospitals, Physicians and other health care providers (who are called Network Providers or Preferred Providers), to offer services to a Plan and its Covered Persons at pre-negotiated rates. Through this arrangement, fees charged by Preferred Providers are generally lower than charges made by Non-Participating Providers.Pregnancy: is childbirth and conditions associated with Pregnancy, including Complication of Pregnancy.Prescription Drug: shall mean: (1) any drug or medicine which, under federal law, is required to bear the legend: "Caution: Federal law prohibits dispensing without prescription"; and (2) is approved for sale and use in the United States at the dosage and indications approved by the Food and Drug Administration; and (3) is Medically Necessary in the treatment of a Covered Person's Sickness or Injury; and (4) shall also include injectable insulin and hypodermic needles/syringes, but only when dispensed upon a written prescription.Psychologist: means a person who is licensed or certified as a Clinical Psychologist, or a person without a license who is qualified as a Clinical Psychologist by a recognized psychological association. It will also include any other licensed counseling practitioner whose services are required to be covered by law in the locality where the policy is issued if they are operating within the scope of their license.TOPRehabilitation Hospital: is a facility which is primarily engaged in providing rehabilitation care services on an inpatient basis. Rehabilitation care consists of the combined use of medical, social, educational and vocational services to enable patients disabled by Sickness or Injury to achieve the highest possible level of functional ability. Services are to be provided by or under the supervision of an organized staff of Physicians. Continuous nursing services are to be provided under the supervision of a Registered Nurse.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, medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure.Residential/Detoxification Facility: means an institution which is licensed, certified or approved pursuant to state and local laws as a facility for the treatment of Alcoholism.Retired Employee/Retiree: means a former Active Employee of the Employer who retired while employed by the Employer under the formal written plan of the Employer and meets the eligibility requirements of the Employer for continuation of coverage under a Plan.Right of Recovery: A Plan may pay benefits that should be paid by another benefit plan. Under such circumstances, the Plan may recover the amount paid from the other benefit plan or the Covered Person. That repayment will count as a valid payment under the other benefit plan.TOPSchedule of Benefits: refers to the outline of Covered Benefits as described in this Medical Benefits Plan.Semi-Private: means "semi-private" room accommodations of at least two (2) beds.Sickness: is a Covered Person's Illness, disease or Pregnancy (including complications).Skilled Nursing Facility/Extended Care Facility: is a facility that meets all of the following tests:(1) It is licensed to provide professional nursing services on an inpatient basis for persons convalescing from Injury or Sickness.(2) Its services are provided for compensation from its patients and under the full-time supervision of a Physician or a Registered Nurse.(3) It provides twenty-four (24) hour per day nursing services by licensed nurses, under thedirection of a full-time Registered Nurse. The service must be rendered by a Registered Nurse (R.N.) or by a Licensed Practical Nurse (L.P.N.) under the direction of a Registered Nurse.(4) It provides services to assist patients in attaining a higher degree of body functioning, and provides services to help restore patients' self care skills in essential daily living activities.(5) It maintains a complete medical record on each patient.(6) It has an effective utilization review plan.(7) It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mental retardates, custodial or educational care or care of Mental Disorders.(8) It is approved and licensed by Medicare.(9) "Hospital" shall be interpreted to include an Extended Care Facility.Special Care Facility: means a facility other than as a Skilled Nursing Home or Hospital as defined under this Plan, which:(1) Specializes either in physical rehabilitation or in the diagnosis and treatment of Mental Disorders; or(2) Qualifies as a Skilled Nursing Facility/Extended Care Facility or provider of services under Medicare; but only if that institution:(a) maintains on the premises facilities necessary for medical treatment;(b) provides such treatment for compensation, under the supervision of Physicians; and(c) provides nurses' services.All such facilities must be credentialed and/or licensed by federal and/or state authorities to provide the services to which the incurred charges relate.Spinal Manipulation/Chiropractic Care: means skeletal adjustments, manipulation or other treatment in connection with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human body. Such treatment is done by a Physician to remove nerve interference resulting from, or related to distortion, misalignment or subluxation of, or in, the vertebral column.Spouse: means the legally recognized marital partner of an Employee.Substance Abuse: is the condition caused by regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs that results in a chronic disorder affecting physical health and/or personal or social functioning. This does not include dependence on tobacco or ordinary caffeine-containing drinks.Surgical Center: is an Ambulatory Care Facility licensed by a state to provide same day surgical services.Surgical Expense Benefit: means the payment(s) a Plan will make for surgical procedures, upon the proof (satisfactory to the Plan Administrator) that the services were Medically Necessary, recommended and approved by a Physician. On such terms, the Plan will pay allowances for the procedure(s) according to the Usual and Reasonable Charges, or according to a fee schedule (as applicable).Surgical Procedure: refers to medical procedures which involve: incising, excising, suturing, electro-cauterization, treatment of burns, correction of fracture, reduction of dislocation, manipulation of joint under general anesthesia, application of plaster casts, tapping, aspiration, administration of pneumothorax, endoscopy, or injection of sclerosing solution.TOPTemporomandibular Joint Syndrome (TMJ): is the treatment of jaw joint disorders including conditions of structures linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the temporomandibular joint. Coverage under this Plan requires a complete treatment plan be forwarded to the Plan Administrator.(1) Care and treatment includes, but is not limited to diagnostic testing and evaluation, Physician office visits, physical therapy, and any non-orthodontic, removable appliance that is attached to or rests on the teeth.(2) Services which are orthodontic or orthognathic in nature are not covered.Therapy Services: are services supplied by a licensed Physician or professional provider acting within the scope of their license(s) and certification(s) (as applicable) and used for the treatment of a Sickness or Injury to promote the recovery of a Covered Person.(1) Chemotherapy is the treatment of malignant diseases by chemical or biological antineoplastic agents.(2) Dialysis Treatment is the treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body to include hemodialysis and peritoneal dialysis.(3) Physical Therapy is the treatment by physical means, hydrotherapy, heat or similar modalities, physical agents, biomechanical and neurophysiological principles and devices to relieve pain, restore maximum function and prevent disability following Sickness, Injury, or loss of body part.(4) Occupational Therapy is the treatment of a physically disabled person by means of constructive activities designed and adapted to promote the restoration of the Covered Person's ability to satisfactorily accomplish the ordinary tasks of daily living and those required by the Covered Person's particular occupational role.(5) Radiation Therapy is the treatment of disease by x-ray, radium or radioactive isotopes.(6) Respiration Therapy is the treatment of introducing dry or moist heat (and/or gases, including oxygen) into the lungs for therapeutic purposes.(7) Speech Therapy is the treatment for the correction of a speech impairment resulting from disease, Injury, surgery, congenital and developmental abnormalities, or for previous therapeutic purposes.Total Disability (Totally Disabled): In the case of an Active Employee, as the result of an Injury or Sickness, the complete inability to perform any and every duty of their occupation or of a similar occupation for which the person is reasonably capable of performing, accounting for their education, training and experience.In the case of a Dependent or Retired Employee, it means the complete inability as the result of Injury or Sickness to perform the normal activities of a person of like age and gender in good health.TOPUsual and Reasonable Charge: is the basis of payment by this Plan for various services provided to a Covered Person. Generally, this term shall refer to charges for services or supplies:(1) Which is not higher than the usual charge made by the provider of the care or supply; and(2) Does not exceed the usual charge made by(a) a certain percentage of the providers in the same area; or(b) most providers of like service in the same area.(3) The Plan Administrator, in its discretion, shall determine the usual and reasonable level of charges. Such determination shall be made in good faith and on a reasonable basis. This determination may also consider the nature and severity of the condition being treated, and may also consider medical complications or unusual circumstances that require more time, skill or experience.