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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace   
How the Retiree Group Health Program Works
Glossary of Key Terms
Certain terms have special meaning under the Retiree Group Health Program. The definitions provided in this section apply to services you and your spouse/domestic partner receive while covered under the Retiree Group Health Program. The claims administrator may have additional definitions that may apply to the health care services you and your spouse/domestic partner receive, and will always have the discretionary authority to interpret the meaning of these terms and the benefits payable under the Retiree Group Health Program.
Allowable Charge – the amount of covered expense prior to any reductions due to coinsurance or deductible amounts.
Charges – the actual billed charges, except when the provider contracts directly or indirectly for a different amount.
Contract Amount – a predetermined amount to be covered or allowed for a service or procedure as outlined in the provider contract.
Covered Expenses – the expenses that the Retiree Group Health Program covers. To be considered a covered expense, an expense must qualify in each of the following ways:
 | The claims administrator must determine that the expense meets the definition of “medically necessary” for the specific illness or injury.
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| The expense cannot exceed the maximum reimbursable charge for the service as determined by the claims administrator.
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| The expense is not excluded from being a Covered Expense. |
Custodial Services – any service that is not intended primarily to treat a specific injury or sickness (including mental illness, alcohol abuse, or drug abuse). Custodial services include (but are not limited to):
| Watching or protecting a person;
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| Performing or assisting a person in performing any activities of daily living, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating, preparing foods, or taking medications that can be self-administered; and
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| Services not required to be performed by trained or skilled medical or paramedical personnel. |
Durable Medical Equipment – equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful for a person in the absence of sickness or an injury, and is appropriate for use in the home.
Emergency – medical, psychiatric, surgical, hospital, and related services and testing (including ambulance services) that a prudent layperson (with average knowledge of medical science) believes is needed to treat a sudden or unexpected onset of a bodily injury, a serious medical complication, loss of life, or permanent impairment to a bodily function. This is a condition that – if not treated immediately – might cause the loss of a limb or lead to a severe permanent disability. Examples of emergencies include:
| Seizure or loss of consciousness;
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| Loss of breathing;
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| Suspected overdose of medication or poisoning;
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| Broken bones;
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| Chest pain or a squeezing sensation in the chest;
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| Severe bleeding;
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| Burns or cuts;
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| Shortness of breath;
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| Sudden paralysis;
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| Slurred speech; or
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| Severe pain. |
Home Health Aide – a person who provides care of a medical or therapeutic nature. He or she reports to and is under the direct supervision of a home health care agency.
Home Health Care – short-term health care that is ordered by a physician and provided in the patient’s home by a licensed home health care agency. This type of care must be approved by the claims administrator.
Home Health Care Agency – a hospital or a nonprofit or public home health care agency that:
| Primarily provides therapeutic services under the supervision of a physician or a registered graduate nurse;
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| Is run according to rules established by a group of professional persons;
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| Maintains clinical records on all patients; and
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| Does not primarily provide custodial care, or care and treatment of the mentally ill. |
A home health care agency must be licensed and run according to the laws that pertain to agencies in jurisdictions where required.
Hospice – a program of care for a patient whose life expectancy is six months or less. The purpose of hospice care is to keep the patient as comfortable as possible and to provide support for the patient’s family. Qualified hospice care may be provided at an approved hospice facility, or in the home under the direction of a recognized hospice care program.
Hospital – an institution that:
| Is licensed as a hospital and maintains on its premises all facilities that are necessary for acute medical and surgical treatment;
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| Provides such treatment on an inpatient basis, for compensation, under the supervision of physicians; and
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| Provides 24-hour service by registered graduate nurses. |
A hospital may be accredited by the Joint Commission on Accreditation of Healthcare Organizations. A hospital can specialize in the treatment of mental illness, alcohol abuse, drug abuse, or other related illnesses. It can provide residential treatment programs, and it is licensed in accordance with the laws of the appropriate legally authorized authority. An institution that is primarily a place for rest, a place for the aged, or a nursing or convalescent home is not a hospital.
Hospital Confinement or Confined in a Hospital – a period of time during which a person is a registered bed patient in a hospital and is being treated upon the recommendation of a physician. In addition, a person is considered confined in a hospital if he or she is partially confined for the treatment of mental illness, alcohol abuse, drug abuse, or other related illness. “Partially confined” means that a person is continually treated for at least three hours (but not more than 12 hours in any 24-hour period).
In-Network Benefit Level – the benefit level payable when services are provided by participating providers and authorized by the claims administrator.
Maximum Reimbursable Charge – the maximum billed amount that is recognized for a covered service or supply, as determined by the claims administrator. This maximum is based on normal billed charges that are submitted by most doctors and other providers in the provider’s geographic area for comparable services and supplies. This means that the charge must be within the range of normal charges. These limits are adjusted periodically to reflect current charges.
If you or your spouse/domestic partner receives care from a participating provider, the reimbursable rates are already negotiated at a rate that does not exceed the maximum reimbursable charge(s). If, however, you or your spouse/domestic partner receives care from a non-participating provider (or if you or your spouse/domestic partner participates in the CIGNA Indemnity coverage option), you are responsible for paying any amount over the maximum reimbursable charge(s).
Any amount in excess of the maximum reimbursable charge does not count toward your annual deductible or your annual out-of-pocket limit.
Medically Necessary – the determination of whether a particular service or supply is medically necessary is based on whether the:
| Service or supply is for the treatment, diagnosis, or symptoms of an injury, disease, or condition (including pregnancy);
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| Service or supply is consistent with the diagnosis and is appropriate given the symptoms;
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| Type, level, and length of care; the treatment or medical supply; and the setting are needed to provide safe and adequate care; and
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| Care is not research-related or not generally regarded as experimental or investigational in nature. |
The claims administrator makes final determination as to whether a service or supply is medically necessary.
Mental Illness – any disorder, other than a disorder induced by alcohol or drug abuse, that impairs an individual’s behavior, emotional reaction, or thought process, regardless of medical origin. In determining benefits, charges made for the treatment of any physiological symptoms related to a mental illness are not considered as charges made for the treatment of a mental illness.
Necessary Services and Supplies – any charges, except for room and board, made by a hospital for medical services and supplies actually used while an individual is confined in a hospital. Necessary services and supplies do not include any charges for special nursing fees, dental fees, or medical fees.
Non-Participating Provider – a provider who does not have a contractual relationship with the claims administrator for the coverage option in which you or your spouse/domestic partner is enrolled.
Nurse – a registered nurse (R.N.), a licensed practical nurse (L.P.N.), or a licensed vocational nurse (L.V.N.).
Nurse-Practitioner – a licensed medical practitioner operating within the scope of his or her license in the state in which he or she is practicing medicine and performing a service for which benefits are provided under this Program.
Out-of-Network Benefit Level – the benefit level that is payable when services are provided by non-participating providers or when unauthorized by the claims administrator.
Outpatient Surgical Facility – an institution that has a staff of physicians, nurses, and licensed anesthesiologists and that maintains at least two operating rooms and one recovery room, a diagnostic laboratory, and X-ray facilities. It must have equipment for emergency care, it must maintain a blood supply, and it also must maintain medical records. The facility must have an agreement with hospitals for immediate acceptance of patients who need hospital confinement on an inpatient basis. It also must be licensed in accordance with the laws of the appropriate legally mandated agency.
Participating Provider – a provider who has a contractual relationship with the claims administrator for the coverage option in which you or your spouse/domestic partner is enrolled.
Physician (or Provider) – a medical practitioner who practices within the scope of his or her license and who is licensed to prescribe and administer drugs or to perform surgery. A provider is any other licensed medical practitioner whose services are required to be covered by law in a certain area if he or she is operating within the scope of his or her license and is performing a service for which benefits are provided under this Program.
Pre-Existing Condition – a condition for which an individual receives medical care, treatment, advice, or medication prior to the coverage effective date. Pre-existing condition limitations do not apply under the Retiree Group Health Program.
Private-Duty Nursing – skilled nursing services that are rendered by a registered nurse, a licensed practical nurse, or a licensed vocational nurse on a per-shift, part-time, or intermittent basis. Such services are part of a treatment plan that is supervised by a licensed physician. Private-duty nursing services may be provided as part of a confinement or as part of a home health plan.
Psychologist – a person who is licensed or certified as a clinical psychologist. Where no license or certification exists, this term means a person who is considered qualified as a clinical psychologist by a recognized psychological association. The term also can include any other licensed counseling practitioner whose services are required to be covered by law in a certain area if he or she is operating within the scope of his or her license and is performing a service for which benefits are provided under this Retiree Group Health Program when provided by a psychologist. The term also can include any psychotherapist while he or she is providing care authorized by the claims administrator if he or she is state-licensed or nationally certified by his or her professional discipline and is performing a service for which benefits are provided under this Retiree Group Health Program when provided by a psychologist.
Room and Board – all charges made by a hospital on its own behalf for room and meals, and for all general services and activities that are needed for the care of a registered bed patient.
Skilled Nursing and Rehabilitation Facility – an approved facility where an individual recovers from an illness or injury. The individual must be under the continuous care of a physician during the skilled nursing or rehabilitation facility confinement, and the physician must certify that 24-hour-a-day nursing care is essential.
Urgent Care Services – medical, surgical, hospital, and related health care services and testing that are not emergency services. Instead, a prudent layperson with average knowledge of medical science determines such services to be necessary to treat a condition that requires prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where the patient would ordinarily receive and/or was scheduled to receive services. Urgent care services can include severe sore throat, sprains and strains, ear or eye infections, or fever.
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