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.)
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 approved by the Board of Trustees.
Balance Billing – when a provider bills 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 for the remaining $30. A preferred provider may not balance bill for covered 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.
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.
Co-insurance or Participant Portion – your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the Plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The Plan pays the rest of the allowed amount.
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.
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.
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.
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.
Emergency Services – evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
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.
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.
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.
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.
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’ll pay more to see a non-participating provider.
Participating – an entity that is a part of the participating provider network and accepts as payment in full the allowance.
Patient’s Portion or Co-Insurance – your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. (See Co-Insurance and copayment above)
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.
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.
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.
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.
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.
Work – a job you perform in covered employment for an employer who makes contributions to the Fund on your behalf.