Accident – a violent, external, unexpected and unintentional event.
Allowance – a pre-determined cost for a particular service.
Allowed Amount – maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If the provider charges more than the allowed amount, the patient may have to pay the difference. (See Balance Billing.)
Appeal – a request by a Plan participant or beneficiary that the Plan and/or Board of Trustees reconsider the claim under circumstances in which the initial claim was denied in whole or in part.
Approved Facility – a legally operated institution, other than a hospital, that provides care and treatment through medical, diagnostic or surgical facilities on the premises, under the supervision of a physician and approved by the Board of Trustees.
Balance Billing – when a provider bills for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill for the remaining $30. A preferred provider may not balance bill for covered services.
Benefit Navigation – a process to help the participant obtain or be referred to clinically appropriate treatment for mental health or substance abuse issues by a qualified and covered mental health professional.
Clinical Guidelines for Medical Appropriateness – Only expenses for treatments, services and supplies provided by a hospital, physician or other appropriately licensed provider in the diagnosis or treatment of an illness or injury may be considered to meet clinical guidelines for medical appropriateness. In addition, the treatments, services and supplies must be:
- consistent with the diagnosis and treatment of the condition
- in accordance with good medical practice
- required other than for the convenience of the patient or provider
- the most appropriate treatments, services or supplies that can be provided safely
Also, care as a hospital inpatient is considered as meeting clinical guidelines for medical appropriateness only if the care cannot be provided safely on an outpatient basis.
Note: Simply because it is given by or on the orders of a doctor does not designate a treatment, service or supply as meeting clinical guidelines for medical appropriateness. Further, the fact that a provider labels it as meeting such clinical guidelines never makes a treatment, service, or supply automatically covered under the Plan. The Plan has the final determination on what constitutes clinical eligibility for coverage.
Co-Insurance – your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the Plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The Plan pays the rest of the allowed amount. (See Patient’s Portion)
Complications of Pregnancy – conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section are not complications of pregnancy.
Co-Payment – a fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. For example, your co-pay for a prescription drug is fixed. Your co-insurance for a medical visit is not fixed because it is a percentage of the charge.
Covered Medical Expenses – only those expenses for medically appropriate treatments, services, and supplies relating to the benefits provided by this Plan.
Deductible – an amount determined by the Board of Trustees that must be satisfied before EWTF pays a percentage of the allowed amount. A new deductible is effective each January 1.
Durable Medical Equipment (DME) – equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs and crutches.
Emergency Medical Condition – an illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency Medical Transportation – ambulance services for an emergency medical condition.
Emergency Room Care – emergency services you get in an emergency room.
Emergency Services – evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Excluded Services – health care services that the Plan does not pay for or cover.
Generic Drugs – a less expensive alternative to brand name drugs. The generic version of any drug contains identical active chemical ingredients and must meet the same manufacturing standards and federal requirements for safety and effectiveness as a brand name drug.
Habilitation Services – health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of impatient and/or outpatient settings.
Home Health Care – health care services a person receives at home.
Hospice Services – services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization – care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospitalization Outpatient Care – care in a hospital that usually doesn’t require an overnight stay.
Hours Bank – hours you work in excess of the required 135-hour minimum each month are credited to a “bank” so that you may apply those hours to maintain your coverage if you work fewer than 135 hours in a later month.
In-Network Co-Insurance – the percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your Plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
In-Network Co-Payment – a fixed amount (for example, $15) you pay for covered health care services to providers who contract with your Plan. In-network co-payments usually are less than out-of-network co-payments.
Medically Appropriate – only expenses for treatments, services and supplies provided by a hospital, physician or other appropriately licensed provider in the diagnosis or treatment of an illness or injury. Simply because it is given by or on the orders of a doctor does not make a treatment, service or supply medically appropriate. Further, just because a provider labels it as medically appropriate never makes a treatment, service or supply automatically covered under the Plan.
Network – the facilities, providers and suppliers your Plan has contracted with to provide health care services.
Non-Participating (non-par) – an entity that is not in the preferred provider network
Non-Preferred Brand – brand drugs that are not on the preferred list maintained by CVS Caremark. These drugs typically cost more than their preferred brand alternatives, and are often more expensive because their manufacturer markets them heavily.
Non-Preferred Provider – a provider who doesn’t have a contract with your Plan to provide services to you. You’ll pay more to see a non-preferred provider.
Notification – the clinical information necessary to determine eligibility for benefit coverage.
Out-of-Network Co-Insurance – the percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your Plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
Out-of-Network Co-Payment – a fixed amount (for example, $30) you pay for covered health care services to providers who do not contract with your Plan. Out-of-network co-payments usually are more than in-network co-payments.
Out-of-Pocket Limit – the most you pay during the year before your Plan begins to pay 100% of the allowed amount. This limit never includes items listed here.
Patient’s Portion – the portion of covered expenses that you must pay in addition to the annual deductible. (See Co-Insurance)
Period of Disability – begins at the time you become disabled and ends when you are no longer disabled.
Permanently and Totally Disabled – the inability to perform the duties of your job for 12 months and, beyond the first 12 months, the complete inability to engage in any occupation or employment for which you are fitted by reason of education, training or experience.
Physician – a doctor, chiropractor, podiatrist, psychologist, optometrist, or surgeon licensed to practice medicine or perform surgery.
Preferred Brand – brand drugs that are on the preferred list maintained by CVS Caremark. Preferred brands drugs are also referred to as “formulary drugs.”
Preferred Provider – a provider who has a contract with your network to provide services to you at a discount.
Prescription Drug Coverage – a Plan that helps pay for prescription drugs and medications.
Prescription Drugs – drugs and medications that by law require a prescription.
Pre-Determination – a finding, prior to the receipt of a health care service or supply, that the health care expense is covered under the Plan. Certain benefits under the Plan require a pre-determination to be covered.
Primary Care Physician – a physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under law, who provides, coordinates or helps a patient access a range of health care services.
Prior Authorization – a coverage requirement that UnitedHealthcare be consulted prior to the receipt of a health care service or goods for a pre-determination.
Provider – the entity who provides the service, treatment or procedure for the patient
Reconstructive Surgery – surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Rehabilitation Services – health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Self-Funded Plan – your employer’s contributions—and any income earned from investments of your employer’s contributions—pay for the health care expenses that you and your fellow participants incur. The EWTF Plan makes the final decisions about what is covered and what is paid and EWTF writes the checks to pay benefits.
Skilled Nursing Care – services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Specialist – a physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care such as a physical therapist or a nurse practitioner.
Specialty Pharmacy – a comprehensive and coordinated system of pharmacy care where patients with chronic illnesses and complex medical conditions receive expert therapy management services tailored to meet their unique needs.
Spell of Illness – a period beginning when you are first confined in a hospital, nursing home or other approved facility and ending when you are discharged and you recover completely from the condition causing the confinement or you go at least one year during which you are not confined again for the same condition.
UCR (Usual, Customary and Reasonable) – the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Urgent care – care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Work – a job you perform in covered employment for an employer who makes contributions to the Fund on your behalf.