Glossary

The following terms apply to all medical care benefits

Air Ambulance
Must be a specifically designed and equipped aircraft for transporting the sick or injured. Must have a crew of at least two (2) members.

Allowable Amounts
For out of network providers
For any service or supply, the Allowable Amount will not exceed:

  1. the amount customarily charged by the provider; or
  2. the charge for the service or supply made by providers of comparable services or supplies in the same locality where services are rendered; or
  3. if a Member receives Emergency Services outside the area where they reside, the charges will be covered only to the extent that they do not exceed usual and customary charges generally made in the same area under similar conditions; or
  4. for elective services rendered outside of the area where the patient generally resides charges will be covered only to the extent that they do not exceed the South Carolina usual and customary rates.

For in network providers
For any service or supply, the Allowable Amount will not exceed the PPO allowable amount.
A special provision will apply when there are no providers of comparable services or supplies in the same locality, or in the event of an unusual type of service or supply. When this happens, the SCMA/MIT will decide whether the charge is appropriate, based on:

  1. the complexity involved;
  2. the degree of professional skill required;
  3. the cost of supplies; and
  4. other pertinent factors.

The SCMA/MIT may decline to pay flat rate charges when procedures, fees and/or time involved are not itemized.

Ambulatory Surgical Center
A center approved and licensed as such by the state. If the state does not have license requirements, the center must meet all of the following criteria:

  1. it must have outpatient facilities for diagnosis or treatment of an injury or surgery;
  2. it must be supervised by a staff of physicians;
  3. it must provide nursing services by registered graduate nurses
  4. it must maintain medical records on all patients;
  5. it must have emergency equipment and supplies with medical personnel trained in the use of the equipment; and
  6. it must have a contract with a hospital for admission in the case of an emergency.

Annual Maximum
The maximum amount this Plan will pay in a calendar year on any participant, regardless of which plan option or combination of plan options the individual is covered.

Approved Treatment Facility
An institution that does not qualify as a hospital but that does provide a program of effective medical and therapeutic treatment of alcoholism or drug abuse, or mental/nervous disorders; and

  1. has been licensed and approved by the regulatory authority having responsibility for such licensing and approval under the law; or
  2. the center meets all of the following requirements:
    1. is established and operated in accordance with the applicable laws of the jurisdiction in which it is located.
    2. provides a program of treatment approved by the physician and the SCMA/MIT.
    3. has or maintains a written, specific and detailed regiment requiring full-time residence and full-time participation by the patient; and
    4. provides at least the following basic services:
      1. room and board;
      2. evaluation and diagnosis;
      3. counseling; and
      4. referral and orientation to specialized community resources.

Complications of Pregnancy

  1. Conditions requiring hospital confinement (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and
  2. Nonelective caesarean section, ectopic pregnancy which is terminated and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

Comprehensive Case Management
In the event of a serious or catastrophic Illness or Injury, the Plan provides for a comprehensive case management program. The comprehensive case management program is a, patient-centered approach to developing a comprehensive plan of cost effective health care. The services provided under the case management program include:

  1. Evaluation and assistance for the Employee, their Physician, and family to help develop a plan of services to meet specific needs;
  2. Assistance with obtaining unusual equipment or supply needs;
  3. Assistance in home care planning and implementation;
  4. Arrangements for needed nursing/caregiver services;
  5. Providing help with assessment of rehabilitation needs and Provider arrangements;
  6. Offering appropriate and effective alternative care/therapy suggestions for Mental and Nervous Treatment and/or treatment for Substance Abuse as determined by medical care review;
  7. Monitoring and assuring treatment programs and interventions for Mental and Nervous Treatment and/or treatment for Substance Abuse; and
  8. Functioning as an effective resource for information on treatment facilities and available care for Mental and Nervous Treatment and/or treatment for Substance Abuse.

Alternative Treatment Plan Under Case Management
In the course of the case management program, the Plan Administrator shall have the right to alter or waive the normal provisions of this Plan of Benefits when it is reasonable to expect a cost-effective result without a sacrifice to the quality of patient care.

Benefits provided under this section are subject to all other Plan of Benefits provisions. Alternative care will be determined on the merits of each individual case an any care or treatment provided will not be considered as setting any precedent or creating any future liability with respect to that Participant or any other Participant. Nothing contained in this Plan of Benefits shall obligate the Plan Administrator to approve an alternative treatment plan.

Covered Expenses
The items of expense for which comprehensive medical benefits may be paid. The full list of Covered Expenses is included in this booklet.

Custodial Care
Services, including room and board, or supplies provided to a person that consists primarily of that basic care given to maintain life and/or comfort with no reasonable expectation of cure or improvement of the Injury or Illness.

Deductible
The amount required to be paid by the covered person prior to benefits being payable under this plan.

The Deductible is shown in the Schedule of Benefits. The Deductible applies separately to each Covered person once each calendar year; except as provided under “Family Deductible” shown in the Schedule of Benefits.

The Deductible amount excludes physician visit copayments, emergency room copayments, pharmacy copayments and mental/nervous outpatient copayments.

Emergency Services
Emergency services are those health care services provided to evaluate and treat medical conditions of rapid onset and severity that would lead a prudent lay person who possesses an average knowledge of health and medicine to reasonably expect the absence of immediate medical attention to result in:

  1. placing the health of the individual or with respect to a pregnant woman, the health of a woman and her unborn child in serious jeopardy; or
  2. serious impairment to bodily functions; or
  3. serious dysfunction of any bodily organ or part, or
  4. other serious medical consequences.

The following examples in conjunction with the above definition would demonstrate the need for immediate or urgent medical care:

  •  Acute Severe Pain (Chest Discomfort, Abdominal)
  • Acute Injury (i.e., Burns, Lacerations, Fractures)
  • Sepsis or Severe Infection
  • Obstetrical Crisis
  • Sudden Onset of Bleeding
  • Acute Illness or Injury that would cause Loss or Impairment of Body Systems
  • Unconsciousness
  • Convulsions
  • Respiratory Distress
  • Acute Condition Resulting in Admission of the Patient to a Hospital
  • Severe Emotional Distress or Suspected Mental Illness Requiring Prompt Medical Attention to Prevent Possible Deterioration, Disability, or Death
  • Sudden Dehydration
  • Sudden Onset Blurred Vision, Difficulty Speaking, Walking and/or Numbness of Extremities

Effective ongoing care of minor Illness or Injury which could reasonably have been provided by a physician in his/her office setting in not considered an emergency.

Emotional Support Services
A program for meeting the special physical, psychological, spiritual and
social needs of a person.

Experimental and/or Investigational Services
Services, supplies, care and treatments that do not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical and dental community or government oversight agencies at the time services were rendered.

The SCMA/MIT will make an independent evaluation of the experimental/non-experimental standings of specific technologies. The SCMA/MIT will be guided by reasonable interpretations of plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment. The SCMA/MIT will be guided by the following principles:

  • 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
  • If the drug, device, medical treatment or procedure, or the patient informed consent document utilized with the drug, device, treatment or procedure, and 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
  • If reliable evidence shows that the drug, device, medical treatment or procedure is the subject of ongoing phase I or phase II clinic trials, in the research, experimental, study of investigational arm of ongoing phase III clinic 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 treatment or diagnosis; or
  • 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.

Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration in general use.

The SCMA/MIT reserves the right to make the final determination in the case if a dispute should arise, subject to appeal and grievance procedures

Hospice Care Plan
A plan, in writing, by the attending physician for home or inpatient hospice care which treats the special needs of the terminally ill person and his or her family. The Hospice Care Plan must be approved by the SCMA/MIT as meeting established standards, including any legal licensing requirements of the state or locality in which it operates.

Hospice Care Team
A group of trained medical personnel, homemakers and counselors that provides care for a terminally ill person and his or her family.

Hospital
An institution legally operating as a hospital that:

  1. is mainly engaged in providing inpatient medical care for diagnosis and treatment of an injury or illness, and routinely makes a charge for such care;
  2. is supervised by a staff of physicians on the premises;
  3. provides 24 hour nursing services on the premises by graduate registered nurses; and
  4. is licensed by the state as an acute care hospital.

In no event will “Hospital” include any institution that:

  1. is run mainly as rest, nursing or convalescent home or residential treatment center;
  2. is engaged in the schooling of its patients;
  3. is not licensed as an acute care facility; or
  4. for which any part is mainly for the care of the aged.

Illness
Sickness or disease, including mental disease, that requires treatment by a physician. Illness includes pregnancy with respect to a female employee and a dependent wife. However, elective abortions are not included unless the life of the mother would be in danger if pregnancy continued, or if the medical condition of the fetus makes it incompatible with life and there is medical documentation of the incompatibility.

Injury
Accidental bodily injury that requires treatment by a physician.

Intensive Care Unit
A unit that is reserved for seriously ill patients who need constant observation as prescribed by the attending physician. The unit must provide room and board, nursing care by nurses assigned only to the unit, and special equipment or supplies on an immediate standby basis for the unit only.

Late Enrollee
The term “Late Enrollee” means an individual who completes the required forms for coverage more than 31 days after becoming eligible for coverage or one who does not enroll during a 31 day Special Enrollment Period.

Lifetime Maximum
The maximum amount this Plan will pay on any participant regardless of which plan option or combination of plan options the individual is covered by during their participation in this Plan. Amounts accumulated toward the Lifetime Maximum Benefit will carry forward from one plan to another.

Maximum Out-of-Pocket Expense
The amount required to be paid by a covered person prior to benefits being payable at 100%.

The maximum Out-of-Pocket Expense is shown in the Schedule of Benefits. The maximum Out-of-Pocket is comprised of the Deductible plus the coinsurance. When these two items reach the maximum out-of-pocket amount, benefits will be paid at 100% of the Allowable Amount for the remainder of that calendar year.

The Maximum Out-of-Pocket Expense applies separately to each Covered Person each calendar year, except as provided under “Family Out-of-Pocket Expense,” shown in the Schedule of Benefits.

Out-of-Pocket maximums do not apply if there is other group coverage providing benefits. However, if this plan is secondary to another group plan, the payment percentage may increase to 100%.

Maximum Benefit
The total amount payable by this Plan. The Maximum Benefit is shown in the Schedule of Benefits. It applies separately to Covered Expenses for each
Covered Person.

Any benefits paid on behalf of a Covered Person whether covered as an employee or a dependent will be combined for purposes of determining the Maximum Benefit.

Medically Necessary
Those services, supplies or equipment that are required and appropriate to identify or treat the Illness or Injury your provider has diagnosed. Such services, supplies or equipment must be:

  1. consistent with the diagnosis and treatment of the patient’s condition;
  2. be in accordance with generally accepted standards of good medical practice in the community;
  3. be required for reasons other than the convenience of the patient, his family, or the provider and; excluding services for experimental, investigational or cosmetic purposes.

Medicare
Title XVIII of the Social Security Act (Federal Health Insurance for the Aged & Disabled) as it is now or as it may be amended.

Open Enrollment Period
The annual period from December 1 through December 31 in which an individual can make changes to his/her plan.

Physician
A person, other than an intern, resident, or house physician who is duly licensed as a medical doctor, dentist, oral surgeon, osteopath, or podiatrist legally entitled to practice medicine, surgery, or dentistry within the scope of his or her license, and who customarily bills for his or her services.

Pre-certification
The process of obtaining all necessary medical information in order to approve an inpatient hospital stay.

Prior Authorization
The process of obtaining all necessary medical information in order to approve certain health services prior to the service being performed or received.

Probationary/Waiting Period
The term “Waiting Period” means the period of continuous, full-time employment, as described in the “Eligibility for You” which is required before an individual becomes eligible for coverage under this plan. This period cannot exceed 90 days.

Regular Enrollee
The term “Regular Enrollee” means an individual who has completed and filed the necessary enrollment forms within thirty-one (31) days of completing any required Waiting Period

Special Enrollee
The term “Special Enrollee” means an individual:

  1. who did not enroll for coverage under this Plan due to being covered under another plan who later experiences a loss of eligibility for the other coverage; or
  2. who may or may not be enrolled who experiences a family status change.

Such events will give rise to a Special Enrollment Period.

Special Enrollment Period
The term “Special Enrollment Period” means the period of thirty-one (31) days during which an individual can enroll in this Plan. This Special Enrollment Period is triggered by an event such as:

  1. Acquisition of a new dependent as a result of marriage, birth of a child, adoption or placement for adoption of a child.
  2. Failure to meet the other plan’s definition of an eligible participant due to events such as, legal separation, divorce, a child ceasing to be an eligible dependent, termination or reduction in hours of employment, or death of an employee.
  3. Termination of contributions toward the employee’s or dependent’s coverage by the employer sponsoring the other plan.
  4. Meeting the other plan’s lifetime limit for benefits.
  5. Cessation of coverage for a certain group of employees, such as, part-time workers, or cessation of benefits for individuals who no longer reside, live or work in an HMO’s service area.
  6. Loss of eligibility for coverage under another plan due to an involuntary event which is not caused by:
    1. Failure of the participant to make timely contributions
    2. Requested cancellation of the other coverage by the participant
    3. Termination of the other coverage due to cause, or
    4. Failure to exhaust the maximum length of time as extended by COBRA Continuation of Coverage provisions.
  7. The term “Special Enrollment Period” also means the period of 60 days during which an individual can enroll in this plan if the event is triggered by the following:
    1. termination of Medicaid or SCHIP; or
    2. upon becoming eligible for premium assistance in the employer’s group health plan.

In these events, you must request coverage within sixty (60) days of termination or the date they are determined entitled to premium assistance.

Skilled Nursing Facility
A legally operating institution or a distinct part of one that:

  1. is supervised by a resident Physician or a resident registered graduate nurse;
  2. requires that the health care of each patient be under the supervision of a physician;
  3. requires that a Physician be available to furnish necessary medical care in emergencies;
  4. provides 24 hour nursing care;
  5. provides facilities for the full-time care of five or more patients; and
  6. keeps clinical records on all patients.

Terminally Ill Person
A person diagnosed by a Physician as having six months or less to live.