DEFINITIONS

As used in this Plan, the following terms shall have the meanings specified below:

Benefits means those services and supplies which are covered under the terms of the Plan.

Chiropractic treatment means services for correction by normal or mechanical means of structure unbalance or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of the vertebral column.

Coinsurance is the percentage amount you pay toward the cost of your care (your out-of-pocket expense) in addition to your deductible and copays.

Copays are the fixed dollar amounts you pay towards certain services.

Covered charges are negotiated charges by preferred providers or usual and customary charges by other providers, incurred by an eligible person for the medically necessary treatment of conditions covered under the Plan, when provided in accordance with Plan rules. The Plan pays a percentage of covered charges.

Covered dental charges mean the reasonable and customary charges or the negotiated fees, for services rendered or supplies furnished or recommended by a dentist or doctor.

Custodial Care is care primarily for the purpose of meeting personal needs which could be provided by persons without professional skills or training. This includes, but is not limited to help in walking, getting in and out of bed, bathing, dressing, eating and taking medicine.

Deductible is the amount you pay before the Plan pays benefits. Charges not considered “covered charges” cannot be used to satisfy the deductible.

Dental hygienist means an individual who:

1. is licensed to practice dental hygiene by the government authority which has the jurisdiction over the practice of dental hygiene; and
2. works under the supervision of a dentist.

Dentist refers to a person authorized by law and duly licensed to practice dentistry.

Doctor (see “Physician”).

Emergency means a sudden, serious and unexpected onset of acute illness or accidental injury for which the patient secures immediate care within 24 hours of the onset of symptoms and which, in the absence of immediate emergency medical treatment, could be reasonably expected to result in:

1. severe jeopardy to the patient’s health;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.

Experimental Procedures means:

1. any medical procedure, equipment, treatment or course of treatment, or drug or medicine that is under investigation or is limited to research;
2. techniques that are restricted to use at those centers which are capable of carrying out disciplined clinical efforts and scientific studies;
3. procedures which are not proven in an objective way to have therapeutic value or benefit; and
4. any procedure or treatment whose effectiveness is medically questionable.

HMO means Health Maintenance Organization, a prepaid medical plan in which you receive coverage only when using certain designated providers. This Fund offers Kaiser Permanente.

Home Health Care is medically necessary care provided in the patient’s home by a licensed organization primarily engaged in skilled nursing and other therapeutic services under the full-time supervision of a physician or registered nurse. Home health care must be recommended by a physician and Pre-Certified by the Plan.

Hospice means a facility that provides a Hospice Care Program and operates in accordance with the laws of the jurisdiction where it is located. It operates as a unit or program that only admits terminally ill patients. It is separate from any other facility but may be affiliated with a hospital, nursing home or home health care agency.

Hospice Care Program means a coordinated program of inpatient and home care which treats the terminally ill patient and the family as a unit. The Plan provides care to meet the special needs of the patient and the family during the final stages of terminal illness and during bereavement.

Hospital means an institution operated pursuant to law that is primarily engaged in providing, for compensation from its patients, medical, diagnostic and surgical facilities for the care, treatment and rehabilitation of disabled, injured and sick persons on an inpatient basis, which provides such facilities under the supervision of a staff of physicians and with 24- hour-a-day nursing service by registered graduate nurses. In no event, however, shall such term include any institution or part thereof that is used principally as a rest facility, nursing facility, convalescent facility or facility for the aged or the care and treatment of drug addicts or alcoholics, except as mandated by state law or any institution that makes a charge that the patient is not legally required to pay.

Hours of Employment are straight time hours worked for a participating employer.

Illness means all sicknesses existing concurrently which are due to the same cause or are pathologically related shall be considered one illness. Successive sicknesses due to the same cause or pathologically related causes are considered one. Pregnancy is considered an illness.

Incurred date refers to the date the care or service is rendered. However, the “insert” date of an appliance shall be considered the date such charge was incurred.

Injury means all injuries sustained by a covered person in one accident.

Interplan is a health cost management company employed under contract with the Board of Trustees.

Medically Necessary means appropriate for the condition being treated, in accordance with standards of good medical practice, and not for the convenience of the patient or provider of services. To be considered medically necessary, the service must be one that, if exceeded, would adversely affect the patient’s condition. The mere fact that a doctor orders the treatment does not mean that it is medically necessary.

Medical necessity also applies to the type of facility in which the patient receives care. For example, a hospitalization will not be considered medically necessary if the care could be provided at home or in a less expensive facility such as a skilled nursing facility or outpatient clinic.

Network or In-Network Provider means a Preferred Provider (see below).

Nurse means a graduate registered nurse.

Occupational Illness means an illness or injury for which the individual is entitled to benefits under the applicable Worker’s Compensation Law, occupational disease law, or similar legislation.

Out-of-Area means you live 30 miles or more from the nearest Interplan provider.

PBM see Pharmacy Benefit Manager.

Pharmacy Benefit Manager (PBM) means a firm used by the Plan to provide a network of retail and/or mail service pharmacies where prescriptions can be filled by the Plan participants at a cost that is less than “retail.”

Physician or Doctor means a licensed doctor of medicine authorized to perform a particular medical or surgical service within the lawful scope of his/her practice, and shall also include any other health care provider or allied health practitioner duly licensed in the state where services are provided.

Plan means the U.A. Local 447 Health and Welfare Plan and the program of benefits it provides, as amended from time to time.

PPO means Preferred Provider Organization, the Network of Preferred Providers used by the Plan.

Pre-Certification is a requirement that specified services must be approved in advance by the Plan. Failure to comply with the Plan’s Pre-Certification rules will result in benefit reductions or denial of payment.

Preferred Provider means a doctor, hospital, urgent care center, laboratory or x-ray facility providing services at reduced rates in accordance with direct or indirect agreement between Interplan and the Board of Trustees, or in accordance with an agreement directly with the Board of Trustees. A directory of preferred providers may be obtained from the Administrative Office.

Self-Payment is the amount you pay monthly to maintain coverage.

Specialty Drug is a medication or injection which costs $500 or more per prescription for a supply of 31 days or less.

Terminally Ill Patient means a patient who does not have a reasonable prospect for a cure and who has a life expectancy of six months or less.

Totally Disabled and Total Disability, for the purpose of health coverage, means:

1. If you are an employee, that you are prevented from engaging in your regular customary occupation or employment by injury or illness. A period of disability begins with the cessation of active employment and ends when you are able to return to active employment.
2. If you are a dependent, that you, due solely to injury or illness, are prevented from engaging in substantially all of the normal activities of a person of like age and sex who is in good health. Disability means all periods of disability arising from the same cause or causes, including any and all complications; however, if the dependent recovers for a period of six months and also resumes normal activities, expenses incurred for the same disability will be paid as for a new disability.

Usual and Customary Charges means the maximum amount that will be considered for payment, taking into account:

1. the usual fee charged by institutions, physicians, or dentists for the service or supply;
2. the range of usual fees charged by institutions with similar facilities and by physicians or dentists of like training and experience for the same service in a given area; or
3. unusual circumstances or complications requiring more time, skill or experience for the service or procedure.

Work-Related Illness or Injury means an illness or injury for which the individual is entitled to benefits under the applicable Workers’ Compensation Law, occupational disease law, or similar legislation.