A
Accident – a violent, external, unexpected and unintentional event.
Allowance or Allowed Amount – a pre-determined cost agreed upon by the Plan for a particular service. This also 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.)
Ancillary Services, with respect to an in-network Health Care Facility, means the following:
- Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner,
- Items and services provided by assistant surgeons, hospitalists, and intensivists;
- Diagnostic services, including radiology and laboratory services; and
- Items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility.
Appeal – a request by a Plan participant or beneficiary that the 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 is considered to be an approved facility by the Fund’s applicable network provider.
B
Balance Billing – when a provider bills the patient 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 the patient for the remaining $30. A preferred provider may not balance bill a patient for covered services beyond the Patient Responsibility. Further, a non-participating provider may not balance bill a patient beyond the Patient Responsibility for any No Surprises Services.
Benefit Navigation – a process to help the participant obtain, or be referred to, clinically appropriate treatment for mental health or substance use disorder issues by a qualified and covered mental health professional.
C
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.
Continuing Care Patient means an individual who is: (1) receiving a course of treatment for a “serious and complex condition”, (2) scheduled to undergo non-elective surgery (including any post-operative care); (3) pregnant and undergoing a course of treatment for the pregnancy; (4) determined to be terminally ill and receiving treatment for the illness; or (5) is undergoing a course of institutional or inpatient care from the provider or facility.
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 or for a service as specified under the Plan 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 as provided under the terms of this Plan.
D
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.
E
Emergency Condition is a medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could 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 the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.
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 or any facility that is geographically separate and distinct from a hospital and is licensed under state law to provide Emergency Services.
Emergency Services –with respect to an Emergency Condition, means any of the following:
- An appropriate medical screening examination that is within the capability of the emergency department of a hospital or of an Independent Freestanding Emergency Department, including Ancillary Services routinely available to the emergency department to evaluate such emergency medical condition,
- Such further medical examination and treatment as are required to stabilize the patient (regardless of the department of the hospital in which such further examination or treatment is furnished),
- Services provided by an out-of-network provider or facility as part of outpatient observation or an inpatient or outpatient stay related to the emergency visit, until:
- The provider or facility determines that you are able to travel using nonmedical transportation or nonemergency medical transportation; and
- You are supplied with a written Notice, as required by federal law, that the provider is an out-of-network provider with respect to the Plan, of the estimated charges for your treatment and any advance limitations that the Plan may put on your treatment, of the names of any in-network providers at the facility who are able to treat you, and that you may elect to be referred to one of the in-network providers listed; and
- You give informed Consent to continued treatment by the nonparticipating provider, acknowledging that you understand that continued treatment by the out-of-network provider may result in greater cost to you.
Excluded Services – services that the Plan does not pay for or cover.
Experimental – A drug, device, medical treatment, or procedure is considered Experimental or investigative unless:
1. The approval of the U.S. Food and Drug Administration and approval for marketing the drug or device has been given at the time the drug or device is furnished;
2. The drug, device, medical treatment, or procedure, or the patient informed consent document utilized with the drug, device, medical treatment, or procedure, was reviewed and approved by the treating facility’s institutional review board or other such body serving a similar function, if federal law requires such review or approval;
3. Reliable evidence shows that the drug, device, medical treatment, or procedure is not the subject of on-going Phase I or Phase II clinical trials, or the research, experimental study, or investigational arm of ongoing Phase III clinical trials, or is not 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 not 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.
Reliable Evidence shall mean only published reports and articles in authoritative medical and scientific literature; the written protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment, or procedure; or the written informed consent document used by the treating facility or by another facility studying substantially the same drug, device, medical treatment, or procedure.
Notwithstanding the above, a drug, device, medical treatment or procedure that is administered as part of a clinical trial is not considered Experimental to the extent the Fund is required by law to cover it.
F
Final internal adverse benefit determination means the decision of the Board of Trustees on appeal regarding an adverse benefit determination.
G
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.
H
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 therapy, including physical therapy provided in the form of aqua therapy, occupational therapy, speech-language pathology and other services for people with disabilities in a variety of impatient and/or outpatient settings.
Health Care Facility (for non-emergency services) means each of following:
1. A hospital;
2. A hospital outpatient department;
3. A critical access hospital; or
4. An ambulatory surgical center.
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 for 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, or hours worked in a month in which you work less than 135 hours, 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.
I
Independent Freestanding Emergency Department means a facility that is geographically separate and distinct from a hospital under applicable state law and provides, and is licensed under state law to provide, Emergency Services.
M
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 be medically appropriate. In addition, the treatments, services and supplies must be:
- Consistent with the diagnosis and treatment of the condition
- In accordance with 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 medically appropriate 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 medically appropriate. Further, the fact that a provider labels a treatment, service or supply as medically appropriate does not make a treatment, service, or supply automatically covered under the Plan.
N
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.
Non-Participating Provider – a provider who doesn’t have a contract with your Plan to provide services to you. You may pay more to see a non-participating provider, depending on the type of services.
No Surprises Services means the following, to the extent covered under the Plan: (1) out-of-network Emergency Services, (2) out-of-network air ambulance services; (3) non-emergency ancillary services for anesthesiology, pathology, radiology, neonatology and diagnostics, when performed by an out-of-network provider at an in-network Health Care Facility; and (4) other out-of-network non-emergency services performed at an in-network Health Care Facility with respect to which the provider does not comply with federal Notice and Consent requirements.
Notice and Consent, with respect to out-of-network services provided at an in-network Health Care Facility, means: (1) that at least 72 hours before the day of the appointment (or 3 hours in advance of services rendered in the case of a same-day appointment), you are provided with a written notice, as required by federal law, that the provider is an out-of-network provider with respect to the Plan, the estimated charges for your treatment and any advance limitations that the Plan may put on your treatment, the names of any in-network providers at the facility who are able to treat you, and that you may elect to be referred to one of the in-network providers listed; and (2) you give informed Consent to continued treatment by the out-of-network provider, acknowledging that you understand that continued treatment by the out-of-network provider may result in greater cost to you. The Notice and Consent exception does not apply to Ancillary Services and items or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the out-of-network provider satisfied the Notice and Consent criteria.
P
Participating – an entity that is a part of the participating provider network and accepts as payment in full the allowance.
Patient’s Portion, Patient’s Responsibility or Co-Insurance – your share of the costs of a covered health care service, generally calculated as a percent (for example, 20%) of the allowed amount for the service. You pay the Patient’s Portion plus any deductibles you owe. Effective January 1, 2022, the Patient’s Portion applicable to No Surprises Services is based on the lesser of the Qualifying Payment Amount payable for such Services or the amount billed by the provider. Your Patient’s Portion for No Surprises Services will be counted towards your Deductible and Out-of-Pocket maximum.
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 also are referred to as “formulary drugs.”
Participating Provider – a provider who has a contract with your network to provide services to you at a discount.
Prescription Drugs – drugs and medications that by law require a prescription.
Pre-Determination or Prior Authorization – a finding, prior to the receipt of a health care service or supply, regarding whether a 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.
Provider – the entity who provides the service, treatment or procedure for the patient.
Q
Qualifying Payment Amount generally means the median contracted rates of the Plan for the item or service in the geographic region. This amount is determined by the Plan and is subject to change.
R
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 therapy, including physical therapy provided in the form of aqua therapy, occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
S
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 for the services you receive under the Plan. The EWTF Plan makes the final decisions about what is covered and what is paid and EWTF writes the checks to pay benefits.
Serious and Complex Condition means (1) In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or (2) in the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital; and requires specialized medical care over a prolonged period of time.
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.
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.
U
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.
W
Work – a job you perform in covered employment for an employer who makes contributions to the Fund on your behalf.