Definitions
A - C D - G H - L M - R S - Z
Accident
A violent, external, unexpected and unintentional event.
Accident & Sickness (A&S) Benefit
A weekly dollar benefit paid to the employee if he/she is off work due to an accident or sickness.
Adverse Benefit Determination
A claim that is denied in whole or in part.
Allowance
The allowance is the amount the Plan has determined to be the cost for a particular service. If you use OneNet PPO providers EWTF's "allowances" are the same as the OneNet "allowances."
Appeal
An appeal is a request by a Fund participant or beneficiary that the Fund and/or Board of Trustees reconsider the claim under circumstances in which the initial claim was denied in whole or in part.
Approved Facility
An approved facility is a legally operated institution, other than a hospital, that provides care and treatment through medical, diagnostic or surgical facilities on the premises, under supervision of a physician and approved by the Board of Trustees. This term may include: ambulatory surgery centers, walk-in medical centers, birthing centers, hospices and substance abuse rehabilitation facilities, acute care facilities and facilities for the treatment of mental or nervous condition. A determination by the Board of Trustees as to whether or not an institution constitutes an approved facility is definite.
Beneficiary
For the purposes of this plan a beneficiary is someone who is chosen by you to receive the Death Benefits.
Note: The Department of Labor (DOL) uses the word "beneficiary" to describe what the Fund Office defines as Spouses and Dependents.
Claim
A claim for benefits is a request by a participant or beneficiary that certain benefits, which the participant or beneficiary believes are covered under the terms of the Fund, be paid by the Fund.
COB
Coordination of Benefits. If you are entitled to other health care coverage in addition to EWTF coverage (including Medicare), your benefits are coordinated by submitting your claim first to what is called the primary plan. If any charges remain to be paid, then they are submitted to the secondary plan. It is the participant's responsibility to keep the Fund Office informed of any changes in any other health care coverage.
COBRA
Acronym for the federal law "Consolidated Omnibus Budget Reconciliation Act of 1985". This law allows you and your eligible dependents to continue health care coverage at your own expense under certain circumstances when health care coverage would otherwise end.
Coinsurance
Coinsurance is the portion of covered medical expenses that you must pay in addition to the annual deductible. Typically, the Plan's share is 80% of the allowance and your coinsurance is 20% of the allowance. However, for some expenses, the Plan pays more or less of the allowance.
Covered Medical Expense
Covered medical expenses are expenses for medically necessary treatments, services and supplies relating to the benefits provided by this Plan that are performed, recommended, approved or prescribed by the attending physician and are not excluded under the terms of the Plan.
Deductible
This is 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. The current deductibles are:
| Type of Benefit | Type of Deductible | Amount of Deductible |
| Medical | Individual | $150 |
| Medical | Family | $300 |
| Dental | Individual | N/A |
| Dental | Family | N/A |
Dependent Children
For the purposes of this plan dependent children are your fully dependent unmarried children under age 19, or 23 if full-time students and not employed for more than 30 hours a week except during school vacations.
"Children" includes natural children, stepchildren, adopted children, children placed with you for adoption, foster children, and those children for whom you are the legally appointed guardian, provided you can show proof of full parental responsibility.
EOB
Explanation of Benefit(s).
ERISA
This federal law ensures that you have certain rights and protections under the Employee Retirement Income Security Act of 1974. Refer to the Summary Plan Description or the Department of Labor (DOL) website for more information.
Formulary
A list of drugs that health plans use to administer prescription benefits. Formulary drugs are also known as preferred brand drugs.
Generic
Generic drugs contain the same active ingredients in the same dosage forms and strengths as their brand alternatives but are significantly less expensive. The U.S. Food and Drug Administration approves both generic and brand drugs before they are marketed in the United States.
H Plan Employees
The Plan provides benefits for employees whose classification is house wiring specialists. Their employers are contributing to the Plan on their behalf under the residential CROP agreement.
HCCCC
This is the acronym for Health Care Cost Containment Coalition. This coalition was formed to have more bargaining power when negotiating different fees with the PPO's, PBM's, Vision and Dental groups. Currently there are over 60 groups in the HCCCC and include most of the building trades in the Washington, DC area.
HIPAA
Health Insurance Portability and Accountability Act of 1996. This federal law requires that the Plan provide you with a Certificate of Creditable Coverage that indicates the period of time you and/or your dependents were covered under the Plan. This law also provides regulations on privacy, security and standards for electronic transmissions.
Home Health Care
Nursing care or special therapy in the home usually following hospitalization.
Hospice
A recognized institution which provides care for the terminally ill.
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.
Limited Term Plan
This is a group health plan that the Board of Trustees determines is temporary and does not provide adequate and similar coverage to that which is available under the EWTF plan, nor does it have continuation rights that are substantially similar to the rights under this Plan. This definition is used in determining coverage for a Surviving Spouse.
Medically Necessary
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 "medically necessary." In addition, the treatments, services and supplies must be:
- consistent with the diagnosis and treatment of the condition;
- in accordance with good medical practices;
- required other than for the convenience of the patient or provider; and
- the most appropriate treatments, services or supplies that may be provided safely.
Care as a hospital inpatient is considered medically necessary only if the care cannot be provided safely on an outpatient basis.
Non-preferred brand
These are brand drugs that are not on the preferred list maintained by Caremark. These drugs typically cost more than their preferred brand alternatives, and are often more expensive because their manufacturer markets them heavily.
Out-of-Pocket
The out of pocket maximum is a catastrophic benefit. The plan limits the amount of eligible expenses you have to pay each year. After you pay the out of pocket maximum of $10,000 per family, EWTF will pay 100% up to the allowance of your eligible expenses for the rest of the calendar year.
Period of Disability
A period of disability normally begins at the time you become disabled and ends when you are no longer disabled.
Permanently and Totally Disabled
Permanent and total disability is 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 physician is a doctor, chiropractor, podiatrist, psychologist, optometrist or surgeon licensed to practice medicine or perform surgery under the laws of the state where such services are performed, and who is acting within the scope of his license. A duly licensed practitioner, who, under the supervision of a physician, performs services that would be covered under this Plan if performed by the physician, is also treated as a "physician."
Post Service Claim
Most claims are post-service claims where you are requesting payment to your doctor or other medical provider, or reimbursement to yourself of some or all of the charges previously incurred for medical services that have already been rendered.
Pre-certification
Pre-certification is a requirement that certain services are pre-approved before EWTF will pay benefits. Currently all mental health and substance abuse treatment must be pre-certified by Business Health Services, your EAP provider.
Pre-determination
The dental benefits under this Plan require that a pre-determination is made when the billed amount is $600 or higher.
Pre-notification
Anytime you and/or your family memembers require inpatient hospitalization, you should contact UHC 48 hours prior to a scheduled hospital admission. For emergency admissions, call within two business days following the admission.
Services for physical, occupational, speech therapy and chiropractic care require pre-noification by UnitedHealthcare.
Preferred Brand
Preferred brand drugs are "formulary" drugs that health plans use to administer prescription benefits which give the greatest value for your dollar.
Preferred Provider Organization (PPO)
A Preferred Provider Organization is an organization that has a network of participating medical providers that have agreed to negotiated rates for services rendered. OneNet PPO is EWTF's current Preferred Provider Organization. These negotiated rates are passed on to the participants so that their out-of-pocket expense is less. By using a medical or dental provider in a PPO network you are also saving the Fund money.
Pre-Service Claim
These are claims that are submitted before services are rendered, but do not meet the definition of "urgent care claims." A pre-service claim may be submitted orally or in writing by a participant or authorized representative, including a participant or beneficiary's doctor.
Protected Health Information (PHI)
Protected Health Information is a provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Spouse
Your legally married spouse who resides with you.
Surviving Spouse
A widow or widower of an Active Employee, Retired Participant or a Non-Bargaining Unit Employee.
Urgent Care Claims
An urgent claim is a claim for medical care or treatment that, if normal pre-service standards are applied:
- would seriously jeopardize the life or health of the claimant; or
- the ability of the claimant to regain maximum function; or
- in the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.