KEY HEALTH PLAN TERMS

Allowable Charges or Allowed Amount or Allowance. There is a maximum amount that the Plan will consider for each medical service or procedure. This amount is periodically set by the Board of Trustees and considers the location in which the charges are incurred but never exceeds the actually incurred charges. The Plan's Allowance may be less than the amount charged by the Provider. In no event will the Plan allow more than the Reasonable Charge (see below) for any service or supply.

Balance Billing. When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider bills $100 and the Plan's allowed amount is $70, you may be billed by the provider for the remaining $30. An in-network provider may not balance bill you for services covered by the Plan.

California Participant. You are considered a California participant if the address you most recently filed with the Plan Office is in the State of California or outside of the United States.

Case Management. A program in which a Blue Cross nurse coordinator works with the patient, their physician, family and the Health Plan to establish an appropriate treatment plan in the event of catastrophic or chronic sickness or injury.

Co-payment and Co-insurance. These refer to the amount you pay for provider services after the deductible has been satisfied. Co-payments are generally flat dollar amounts, such as the $15 or $25 co-payment for office visits to network physicians. Co-insurance is generally a percentage of the Plan's Allowance, such as the 20% co-insurance a Plan I participant who sees non-network physicians must pay.

Contract Allowance. The amount a network provider must accept as the total charge. Network providers cannot bill you for covered charges in excess of the Contract Allowance (balance billing).

Cosmetic Surgery. Any surgery or procedure which is directed at improving the patient's appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease. Cosmetic surgery is not covered by the Plan. Surgery to correct birth defects of individuals under age 19, or prompt repair of accidental injury, or mammoplasty following a mastectomy shall not be considered cosmetic under the Health Plan.

Custodial Care. Treatment or services, regardless of who recommends them or where they are provided, that could be given safely and reasonably by a person not medically skilled and are designed mainly to help the patient with daily living. Examples include help with walking, bathing, dressing and using the toilet.

Deductible. This refers to the amount of covered expenses you must pay before the Plan begins to pay. There are separate deductibles for hospital, major medical, prescription drug and dental coverage. Deductibles may be higher when you use non-network providers.

Dentist. A person duly licensed to practice dentistry by the governmental authority having jurisdiction over the licensing and practice of dentistry in the locality where the service is rendered.

Durable Medical Equipment. Includes medical supplies such as bandages and surgical dressings obtained in a physician's office, surgical supplies such as appliances to replace lost physical organs or parts or to aid in their functions when impaired, oxygen and equipment for the administration of oxygen, wheelchairs or hospital-type beds, mechanical equipment for the treatment of respiratory paralysis and blood and blood plasma. Payment will be made only if the supplies and/or equipment:

  1. Are prescribed by a covered provider; and

  2. Are used by the eligible individual for whom a claim has been made; and

  3. Cannot be used where sickness or injury is not present; and

  4. Can withstand repeated use; and

  5. Are not general use items which can be used by other family members.

Items like exercise bicycles, for example, are not covered.

Emergency Medical Condition. An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

ERISA. The Employee Retirement Income Security Act of 1974 (ERISA) spells out and protects the rights of all plan participants. :

Exclusions. Health care services that are not covered by the Plan. Examples include cosmetic surgery, Lasik eye surgery, experimental treatments and occupational drug testing. Please see the Summary Plan Description for a full listing of exclusions.

Experimental or Investigative Procedures. A drug, device, medical treatment or procedure is experimental or investigative if:

  1. 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. The drug, device, medical treatment or procedure, or the 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. Reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I or phase II clinical trials, or is the research, experimental, study or investigative arm of ongoing 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. 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.

Hospital. An institution legally operating as a hospital which is: 1) primarily engaged in providing, for compensation from its patients, inpatient medical and surgical facilities for diagnosis and treatment of sickness or injury and the care of pregnancy, and 2) operated under the supervision of a staff of physicians and continuously provides nursing services by graduate Registered Nurses for 24 hours of every day.

Hospital shall not include any institution which is operated primarily as a rest, nursing or convalescent home, or any institution or part thereof which is principally devoted to the care of the aged or the treatment of drug or alcohol abuse or any institution engaged in the schooling of its patients.

The Plan does not cover treatment in non-network hospitals, except in the case of medical emergency.

Medically Necessary. The Trustees determine at their discretion if a service or supply is medically necessary for the diagnosis or treatment of an accidental injury, sickness, pregnancy or other medical condition. This determination is based on and consistent with standards approved by the Plan's medical consultants. These standards are developed, in part, with consideration as to whether the service or supply meets the following:

  1. It is appropriate and required for the diagnosis or treatment of the accidental injury, sickness, pregnancy or other medical condition.

  2. It is safe and effective according to accepted clinical evidence reported by generally recognized medical professionals or publications.

  3. There is not a less intensive or more appropriate diagnostic or treatment alternative that could have been used in lieu of the service or supply given.

Mental or Nervous Disorders. Any condition listed in the Mental Disorders sections of the then current edition of the International Classification of Diseases, 9th Revision, Clinical Modification, regardless of the basis of the disorder.

Network. This refers to providers in one of the Plan's managed care networks which are outlined on page 29 of the Summary Plan Description. Services from network providers give you the best value for your health dollar.

Non-California Participant. You are considered a non-California participant if the address you most recently filed with the Plan Office is outside of the State of California but not outside of the United States.

Non-Network. This refers to providers who are not in one of the Plan's managed care networks. Your out of-pocket expenses are usually greater using these providers. Please note that the Plan does not cover treatment in non-network hospitals except in the case of medical emergency.

Performer Information Form. The Performer Information Form is one of the most important documents you will complete for the Plan. It is the Plan's record of your current mailing address and your current dependents. You must file a Performer Information Form with the Plan Office before any Health Plan claims for benefits can be processed.

Plan I and Plan II. These are the two tiers of benefits. The Plan for which Earned Eligible participants qualify is based on Covered Earnings or Days of Employment. A participant is either in Plan I or Plan II, but not both. For complete eligibility rules, please refer to pages 1 through 7 of the Summary Plan description.

Physician. A duly licensed doctor of medicine authorized to perform a particular medical or surgical service within the lawful scope of his practice.

Prescription Drug Coverage. The Plan's benefit that helps pay for prescription drugs and medications

Reasonable Charge. For services rendered by or on behalf of a physician, the Reasonable Charge is an amount not to exceed the amount determined by the Plan in accordance with the applicable fee schedule adopted by the Board of Trustees. For all other charges, the Reasonable Charge is an amount measured and determined by the Plan by comparing the actual charge for the services or supply with the prevailing charges made for it. In determining the prevailing charge the Plan takes into account all pertinent factors, including the complexity of the service, the range of services provided and the prevailing charge level in the geographic area where the provider is located and other geographic areas having similar medical cost experience.

While the Plan staff will do its best to answer any questions you have concerning the Reasonable Charge over the phone, you may not rely on any information obtained in that manner. Only information in writing signed on behalf of the Board of Trustees can be considered official.

Totally Disabled. With respect to an adult participant or adult dependent, a person who is prevented, solely because of sickness or accidental bodily injury, from engaging in any occupation. With respect to a minor participant or minor dependent, Totally Disabled means a person who is presently suffering from a sickness or accidental bodily injury, the effects of which are likely to be of long or indefinite duration and which will prevent him from engaging in most of the normal activities of a person of like age and sex in good health.