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Glossary

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A | B | C | D | E | F | G |H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Adverse Determination: A determination by the Health Plan that the Health Care Services furnished or proposed to be furnished to a member are not medically necessary as defined in the Evidence of Coverage.

Age of Ineligibility: The age at which dependents are no longer eligible for coverage, subject to the definition of Eligible Dependent. Unless amended by Your Group, Age of Ineligibility will be 26.

Agreement: The Scott & White Health Plan evidence of coverage and all attachments and riders.

Anniversary Date: The beginning of an employer group’s benefit year.

Annual Enrollment Period: A period during which You have an opportunity to select an alternate health plan. Most frequently, Annual Enrollment periods are held for one month every year. You are also allowed to add/remove Your dependents from the coverage during Annual Enrollment.

Appeal: An oral or written request for the Health Plan to reverse a previous decision.

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B

Behavioral Health Care: The assessment and treatment of mental and/or psychoactive substance abuse disorders.

Benefit Package: The services a plan offers to a group or an individual.

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C

Capitation: A stipulated dollar amount established to cover the cost of health care delivered for a person. The term usually refers to a negotiated per capita rate to be paid periodically, (usually monthly), to a health care provider. The provider is responsible for delivering or arranging for the delivery of all health services required by the covered person under the conditions of the provider contract.

Centers for Medicare & Medicaid Services (CMS): The Federal Agency responsible for administering Medicare (formerly known as the Health Care Financing Administration).

Chemical Dependency: The abuse of, psychological or physical dependence on, or addiction to alcohol or a controlled substance.

Chemical Dependency Treatment Center: A facility which is a Participating Provider and, which provides a program for the Treatment of chemical depen­dency pursuant to a written Treatment plan approved and monitored by a Participating Physician and which facility is also:

  1. Affiliated with a hospital under a contractual agreement with an established system for patient referral;
  2. Accredited as a chemical dependency treatment center by the Joint Commission on Accreditation of Health Care Organizations;
  3. Licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse; or
  4. Licensed, certified, or approved as a chemical dependency treatment program or center by any other agency of the state of Texas having legal authority to so license, certify, or approve.

Coinsurance: The portion of covered medical expenses that is shared by the Health Plan and the covered person in a specific ratio (i.e., 80%/20% and/or 50%/50%) after the deductible has been satisfied. The amount of coinsurance paid by the covered person is applied to satisfy the covered person's annual out-of-pocket maximum. The total out-of-pocket maximum includes coinsurance and copayments, not mutually exclusive from other out-of-pocket limits. This means that a Participant’s total out-of-pocket maximum could contain a combination of coinsurance and/or copayments. (For example, a Participant could pay up to $6,450 in copayments alone if there was no coinsurance paid throughout the year. If a Participant met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,450 in copayments, totaling $6,450 in overall out-of-pocket expense.)

Complainant: A member, or a physician, provider, or other person designated to act on behalf of a member, who files a complaint.

Complaint: Any oral or written expression of dissatisfaction with any aspect of the Health Plan's operation, including but not limited to dissatisfaction with plan administration, procedures related to review or appeal of an adverse determination, the denial, reduction, or termination of a service for reasons not related to medical necessity, the way a service is provided, or disenrollment decisions expressed by a Complainant. The term does not include a misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information. The term does not include dissatisfaction or disagreement with an adverse determination.

Contract Date: The date on which coverage for Your Employer’s Health Benefit Plan commences.

Contract Holder: The person or entity with whom the Health Plan has entered into an agreement to provide health care services. Under this evidence of coverage, the Group is the Contract Holder.

Contract Year: That period of time which begins at 12:00 midnight on the Contract Date and ends at 12:00 midnight one year later.

Controlled Substance: A toxic inhalant or a substance designated as a controlled sub­stance in the Texas Controlled Substances Act (Chapter 481 of Texas Health and Safety Code).

Coordination of Benefits: A provision in a contract that applies when a person is covered under more than one group medical program. It requires the payment of benefits to be coordinated by all programs to eliminate over-payment or duplication of benefits.

Copay: The dollar amount or the percentage of the cost of Health Care Services, if any, shown in the Schedule of Benefits payable by the Member to a Participating Hospital, Participating Physician, or Participating Provider, when Health Care Services are obtained from that Participating Hospital, Participating Physician, or Participating Provider. The amount of copay paid by the covered person is applied to satisfy the covered person's annual out-of-pocket maximum. The total out-of-pocket maximum includes coinsurance and copayments, not mutually exclusive from other out-of-pocket limits. This means that a Participant’s total out-of-pocket maximum could contain a combination of coinsurance and/or copayments. (For example, a Participant could pay up to $6,450 in copayments alone if there was no coinsurance paid throughout the year. If a Participant met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,450 in copayments, totaling $6,450 in overall out-of-pocket expense.)

Covered Dependent: A member of Your family who meets the eligibility provisions by Your employer, whom You have listed on the Enrollment Application, and for whom the Required Payments have been made.

Creditable Coverage: Any group health coverage or individual health coverage, including services from insurance or a health maintenance organization, that qualifies under regulations implementing the Federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), provided such coverage ended within the 63-day period directly preceding the applicant’s request to enroll in this Plan.

Crisis Stabilization Unit: An appropriately-licensed and accredited 24-hour residential program that is usually short-term in nature that provides intensive supervision and highly structured activities to Members who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe proportions.

Custodial Care: Care designed principally to assist an individual in engaging in the activities of daily living, or services which constitute personal care, such as help in walking and getting in and out of bed, assistance in bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication, which can usually be self-administered and which does not entail or require the continuing attention of trained medical or other paramedical personnel. Custodial Care is normally, but not necessarily, provided in a nursing home, convalescent home, rest home, or similar institution.

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D

Daughter or Son: A child as defined in the Act and whose eligibility requirements are stated in the Rules of the Board of Trustees of ERS.

Deductible: The dollar amount, if any, shown in the Schedule of Benefits payable by the Member for Health Care Services before benefits under the Health Care Plan will be payable.

Disenroll or Disenrollment: The process of ending your membership with Scott & White Health Plan. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).

Drug Formulary: A listing of prescription medications, which are preferred for use by the Health Plan and are dispensed through participating pharmacies. The list is subject to periodic review and modification by the Health Plan.

Durable Medical Equipment (DME): Equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. However, an institution may not be considered a member's home if it meets the basic requirements of a hospital or skilled nursing facility. DME includes items such as oxygen equipment, wheelchairs, hospital beds, and other items that are determined medically necessary. (For SeniorCare, in accordance with Medicare law, regulations and guidelines.)

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E

Effective Date: The date the coverage for You or Your Covered Dependent actually begins. It may be different from the Eligibility Date or the Contract Date.

Eligible Dependent: the spouse of an employee or retiree or any child who is either under 26 years of age or disabled; provided that in the case of a disabled child 26 years of age or older, such child is dependent upon the employee or retiree for care or support.

  • "Child" means the presence of a child as defined in the Act and whose eligibility requirements are stated in the Rules of the Board of Trustees of ERS.
  • "Disabled" means any medically determinable physical or mental condition which prevents the child from engaging in self-sustaining employment; provided that the disability commences and the child was covered immediately prior to such child's attainment of age 26 and that satisfactory proof of such disability and dependency is submitted by the employee or retiree within 31 days following such child's attainment of age 26 and at such intervals thereafter as may be required by ERS, but not more frequently than annually following the child's attainment of such limiting age.

Eligible Employee: Employees and retirees of the state of Texas who may enroll in an HMO, provided the HMO is approved by the Board of Trustees of the ERS.

Eligibility Date: The date the Member satisfies the definition of either Eligible Employee or Dependent and is in a class eligible for coverage under the Health Plan.

Emergency Care: Shall mean Health Care Services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

  1. Placing his or her health in serious jeopardy;
  2. Serious impairment to bodily functions;
  3. Serious dysfunction of any bodily organ or part;
  4. Serious disfigurement; or
  5. In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Emergency Medical Condition: A medical condition brought on by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that not getting immediate medical attention could result in:

  1. Serious jeopardy to the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child);
  2. Serious disfigurement;
  3. Serious impairment to bodily functions; or
  4. Serious dysfunction of any bodily organ or part.

Emergency Services: Covered services that are:

  1. Furnished by a provider qualified to furnish emergency services; and
  2. Needed to evaluate or stabilize an emergency medical condition.

Employer: See definition of Group.

Enrollee: Any person eligible for service as either a subscriber or a dependent in accordance with a contract.

Enrollment Application: Any document(s) which must be completed by or on behalf of a person in applying for coverage.

Evidence of Coverage and Disclosure Information: This document, along with your enrollment form, which explains the covered services, defines the plan's obligations, and explains your rights and responsibilities as a member.

Exclusion: Items or services that Scott & White Health Plan does not cover. You are responsible for paying for excluded items or services.

Experimental or Investigational: In the opinion of the Medical Director, Treatment that has not been proven successful in improving the health of patients. In making such determinations, the Medical Director will rely upon:

  1. Well-designed and well-conducted investigations published in recognized peer-reviewed medical literature, such as the New England Journal of Medicine or the Journal of Clinical Oncology, when such papers report conclusive findings of controlled or randomized trials. The Medical Director shall consider the quality of the body of studies and the consistency of the results in evaluating the evidence;
  2. Communications about the Treatment that have been provided to patients as part of an informed consent;
  3. Communications about the procedure or Treatment that have been provided from the physician undertaking a study of the Treatment to the institution or government sponsoring the study;
  4. Documents or records from the institutional review board of the hospital or institution undertaking a study of the Treatment;
  5. Regulations and other communications and publications issued by the Food and Drug Administration and the Department of Health and Human Services; and
  6. The Member's medical records.

As used above, peer-reviewed medical literature means one or more U. S. scientific publications which require that manuscripts be submitted to acknowledged experts inside or outside the editorial office for their considered opinions or recommendations regarding publication of the manuscript. In addition, in order to qualify as peer-reviewed medical literature, the manuscript must actually have been reviewed by acknowledged experts before publication.

Treatments referred to as experimental, experimental trial, investigational, investigational trial, trial, study, controlled study, controlled trial, and any other term of similar meaning shall be considered to be Experimental or Investigational.

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F

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G

Grievance: Any complaint or dispute other than one involving an Organization Determination. Examples of issues that involve a complaint that will be resolved through the Grievance rather than the Appeal process are:

  • Waiting times in physician offices;
  • Rudeness or unresponsiveness of customer service staff.

Group: Your Employer is the party contracting with the Health Plan to purchase coverage for its employees. The employees become Subscribers on an aggregate basis. Your Employer must pay the applicable Premium Contribution for the plan selected for each Eligible Employee who elects to be covered. No less than the applicable Participating Percentage of the Eligible Employees must be covered. Your Employer must be located within the Service Area.

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H

Health Benefit Plan: A group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services.

Health Care Services: Those Medically Necessary services which are included in the Summary of Benefits and any amendments or riders thereto, and which are performed, prescribed, or authorized by a Participating Physician, Participating Provider, Participating Hospital, or a Referral Physician.

Health Plan: Scott & White Health Plan.

Health Professionals: Those health care professionals, licensed in the state of Texas (or, in the case of Health Care Services rendered on referral, licensed in the state in which that care is provided) who are associated with, or engaged by, directly or indirectly, Medical Group or Referral Physicians to provide Health Care Services in the Service Area. Health Professionals include a Doctor of Dentistry, a Doctor of Podiatry, a Doctor of Optometry, a Doctor of Chiropractic, a Doctor in Psychology, Acupuncturists, a Licensed Audiologist, a Licensed Speech-Language Pathologist, a Licensed Hearing Aid Fitter and Dispenser, a Licensed Dietitian, a Licensed Master Social Worker-Advanced Clinical Practitioner, a Licensed Professional Counselor or a Licensed Marriage and Family Therapist, and other practitioners of the healing arts as specified in the Texas Insurance Code.

Health Maintenance Organization (HMO): The Scott & White Health Plan is an HMO. They provide both fully-insured plans as well as administrative services for self-insured plans. For fully-insured plans they provide coverage for designated health services needed by plan members for a fixed, prepaid premium. They provide administrative services for self-insured plans for an administrative fee.

Home Health Agency: A Medicare-certified agency that provides skilled nursing care and other therapeutic services in your home when medically necessary.

Hospice: A Medicare-certified organization or agency that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people and their families.

Hospital: A Medicare-certified institution licensed by the State, that provides inpatient, outpatient, emergency, diagnostic, and therapeutic services. The term "Hospital" does not include a convalescent nursing home, rest facility, or facility for the aged that primarily provides custodial care, including training in routines of daily living.

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I

Independent Review Organization (IRO): An organization selected as provided under Article 21.58C, Insurance Code.

Individual Treatment Plan: A Treatment plan prepared or approved by the Member's physician with specific attainable goals and objectives appropriate to both the Members and the Treatment modality of the program.

Initial decision: In general, a decision by Scott & White Health Plan or a person acting on Scott & White Health Plan's behalf, to approve or deny a payment for a service or a request for provision of service made by you or on your behalf.

Investigational or Experimental: In the opinion of the Medical Director, Treatment that has not been proven successful in improving the health of patients. In making such determinations, the Medical Director will rely upon:

  1. Well-designed and well-conducted investigations published in recognized peer-reviewed medical literature, such as the New England Journal of Medicine or the Journal of Clinical Oncology, when such papers report conclusive findings of controlled or randomized trials. The Medical Director shall consider the quality of the body of studies and the consistency of the results in evaluating the evidence;
  2. Communications about the Treatment that have been provided to patients as part of an informed consent;
  3. Communications about the procedure or Treatment that have been provided from the physician undertaking a study of the Treatment to the institution or government sponsoring the study;
  4. Documents or records from the institutional review board of the hospital or institution undertaking a study of the Treatment; and
  5. Regulations and other communications and publications issued by the Food and Drug Administration and the Department of Health and Human Services, and the Member's medical records.

As used above, peer-reviewed medical literature means one or more U. S. scientific publications which require that manuscripts be submitted to acknowledged experts inside or outside the editorial office for their considered opinions or recommendations regarding publication of the manuscript. In addition, in order to qualify as peer-reviewed medical literature, the manuscript must actually have been reviewed by acknowledged experts before publication.

Treatments referred to as experimental, experimental trial, investigational, investigational trial, trial, study, controlled study, controlled trial, and any other term of similar meaning shall be considered to be Experimental or Investigational.

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J

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K

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L

Life-Threatening Condition: A disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.

Lifetime Maximum: The maximum benefits for Chemical Dependency Treatment available under this Agreement during a Member's lifetime. Lifetime Maximums do not apply to all Health Care Services.

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M

Medical Director: Any Medical Group Physician designated by the Health Plan who shall have such responsibilities for assuring the continuity, availability, and accessibility of Health Care Services as shall be assigned. These responsibilities include, but are not limited to, monitoring the programs for quality assurance, utilization review and peer review, determining Medical Necessity, and determining whether or not a Treatment is Experimental or Investigational.

Medically Necessary or Medical Necessity: Those Health Care Services which, in the opinion of Member's primary care physician or referral physician, whose opinions are subject to the review, approval or disapproval, and actions of the Medical Director or the Quality Assurance Committee in their appointed duties, are:

  1. Essential to preserve the health of the Member;
  2. Consistent with the symptoms or diagnosis and Treatment of the Member's condition, disease, ailment, or injury;
  3. Appropriate with regard to standards of good medical practice within the surrounding community;
  4. Not solely for the convenience of the Member, Member's Physician, Hospital, or other health care provider; and
  5. The most appropriate supply or level of service which can be safely provided to the Member.

Medically Underwritten Health Plans: Refers to policies that are issued only after medical questions are answered or a physical is performed to make sure the applicant qualifies for the product.

Medicare: Title XVIII of the Social Security Act, and amendments thereto.

Medicare Cost Plan: A benefit package offered by a Medicare Cost Organization that offers a specific set of health benefits at a uniform premium and uniform level of cost-sharing to all people with Medicare residing in the service area covered by the Plan. A Cost Plan may offer more than one plan in the same service area. Members under this plan may access Original Medicare benefits from any Medicare Provider.

Member: You or Your Covered Eligible Dependent.

Member Services: A department within Scott & White Health Plan responsible for answering your questions about your benefits, grievances, and appeals. A Scott & White Health Plan Member Services representative is available to assist you during regular business hours at any of our Scott & White Health Plan locations.

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N

Non-Plan Provider or Non-Plan Facility: Any professional person, organization, health facility, hospital, or other person or institution licensed and/or certified by the state or Medicare to deliver or furnish health care services. This type of provider is not employed, owned, operated by, or under contract to deliver covered services to you.

Not mutually exclusive: Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a Participant’s total out-of-pocket maximum could contain a combination of coinsurance and/or copayments. (For example, a Participant could pay up to $6,450 in copayments alone if there was no coinsurance paid throughout the year. If a Participant met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,450 in copayments, totaling $6,450 in overall out-of-pocket expense.)

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O

Office Visit: A visit for covered services to a PCP, specialist, other plan provider, or non-plan provider upon referral.

Original Medicare: A plan that is available everywhere in the United States. It is the way most people get their Medicare Part A and Part B health care. (Original Medicare is also known as Fee-for-Service Medicare).

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P

Paralysis: Spinal cord injuries from a Sickness diagnosed or treated 30 days or more after the Effective Date of this policy or Injury that results in complete and total loss of use of two or more limbs for a continuous period of at least 30 days. The paralysis must be confirmed by your attending Physician.

Participating Hospital: An institution licensed by the state of Texas as a hospital which has contracted or arranged with the Health Plan to provide Health Care Services to Members and which is listed by the Health Plan as a Participating Provider.

Participating Physician: Anyone licensed to practice medicine in the state of Texas and who is employed by or has executed a contract with Medical Group to provide Health Care Services.

Participating Provider: Any person or entity that has contracted, directly or indirectly, with the Health Plan to provide Health Care Services to Members. Participating Providers includes but is not limited to: Medical Group, Participating Hospitals, Participating Physicians, Health Professionals, Urgent Care Facilities, and Contracted Pharmacies, within the service area.

Peer Review Organization (PRO): Groups of health care professionals who are hired by the Federal Government to review Medical Necessity, appropriateness and quality of medical care, and services provided to Medicare beneficiaries. Upon request, the PRO also reviews hospital discharges for appropriateness and quality-of-care complaints.

Permanent Legal Residence: The address at which a Member intends to reside during the Contract Year. For a student enrolled in an education, trade, or technical school, the Permanent Legal Residence is presumed to be that of the parent with whom the Dependent resided prior to attending school.

Plan Hospital: A hospital that has a contract with Scott & White Health Plan or your Plan Medical Group to give you services and/or supplies.

Plan Medical Group: Physicians organized as a legal entity to provide medical care. The Plan Medical Group has an agreement with the Scott & White Health Plan to provide medical services to you.

Plan Pharmacy: A pharmacy that has an agreement to provide you the medication(s) prescribed by your Plan Provider.

Plan Provider: A health professional, a supplier of health items, or a health care facility that has an agreement to provide or coordinate covered services to you.

Post delivery care: Postpartum health care services provided in accordance with accepted maternal and neonatal assessments including, but not limited to, parent education, assistance and training in breast-feeding and bottle-feeding, and the performance of any necessary and appropriate clinical tests.

Premium: Those periodic amounts required to be paid to the Health Plan for, or on behalf of, a Subscriber and Dependents, if any, as a condition of coverage under this Agreement.

Premium Contribution: The minimum percentage of premium which Your Employer must pay for Your coverage.

Primary Care Physician(PCP): A Participating Physician specializing in family medicine, community internal medicine, general medicine, or pediatrics selected by You or Your Covered Dependent to manage the Health Care Services which will be made available to You or Your Covered Dependent by the Health Plan. Scott & White is now an Open Access HMO. You and your covered dependents can go to any network provider without a referral. You and your covered dependents may choose a network primary care physician (PCP) if you would like to designate one, but PCPs are no longer required by the Scott & White Health Plan.

Prior Authorization: When a provider must obtain approval from SWHP Health Services Division before you can receive certain health care services.

Provider: A doctor, hospital, health care professional, or health care facility licensed and/or certified by the state or Medicare to deliver or furnish health care services.

Psychiatric Day Treatment Facility: A mental health facility, licensed by the state of Texas, which provides treatment for individuals suffering from acute, mental, and nervous disorders in a structured psychiatric program utilizing individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program and that is clinically supervised by a doctor of medicine who is certified in psychiatry by the American Board of Psychiatry and Neurology. The facility at which the treatment is performed must have a contract with the Health Plan to provide its services to Members, must treat its patients not more than eight hours in any twenty-four hour period, and must be accredited by the Program for Psychiatric Facilities, or its successor, of the Joint Commission on Accreditation of Health Care Organizations.

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Q

Qualified Medical Support Order: An order issued by a Texas Court or enforceable by a Texas Court which sets forth the responsibility for providing health care coverage for Eligible Dependents.

Quality Assurance Committee: A committee or committees used by the Health Plan to establish programs to monitor the appropriateness and effectiveness of the Health Care Services provided for or arranged by the Health Plan, record the outcome of Treatment, and provide a means for peer review.

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R

Reconsideration: Coverage decisions regarding such issues as payment for emergency services, post-stabilization care, urgently needed services, payments to non-plan medical providers or facilities, and discontinuation of services.

Rehabilitative Services: Services including physical, cardiac, speech, and occupational therapies that are rendered under the direction of a plan provider.

Required Payments: Any payment or payments required of the Group, an applicant for coverage hereunder, or a Member in order to obtain or maintain coverage under this health care Agreement, including application fees, copays, Deductibles, subrogation, Premiums, late fees, and any other amounts specifically identified as Required Payments under the terms of this Agreement.

Residential Treatment Center for Children and Adolescents: A child-care institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Healthcare Organizations, or the American Association of Psychiatric Services for Children.

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S

Summary of Benefits: The attachment to the Agreement which describes, among other things, the copays, Deductibles, and other information applicable to Your Health Plan and Health Care Services set forth in the Description of Benefits attachment to the agreement and any amendments or riders thereto.

Second Level Grievance: A request for the Health Plan to reverse a previous decision for a Grievance regarding such issues as quality of services, office waiting times, physician behavior, adequacy of facilities, and involuntary disenrollment.

Series of Treatments: A planned, structured, and organized program to promote chemical free status which may include different facilities or modalities. Such a program is considered complete when the covered Member:

  1. Is discharged on medical advice from inpatient detoxification, inpatient rehabilitation/Treatment, partial hospitalization, or intensive outpatient care or a series of these levels of Treatment without a lapse in Treatment, or
  2. Fails to materially comply with the Treatment program for a period of thirty (30) days.

Service Area: The geographic area more fully described in the Scott & White Health Plan Service Areas and provider locations attachment to the Agreement.

Short-term Therapy: The therapeutic service, or those therapeutic services, which, when applied to a covered injury or illness under the agreement, meet or exceed Treatment goals in accordance with the Individual Treatment Plan.

Skilled Nursing Care: Services that can only be performed by or under the supervision of licensed nursing personnel.

Skilled Nursing Facility: A facility (or distinct part of a facility) which is primarily engaged in providing to its residents skilled nursing or rehabilitation services and is certified by Medicare. The term "Skilled Nursing Facility" does not include a convalescent nursing home, rest facility, or facility for the aged which furnishes primarily custodial care, including training in routines of daily living.

Son or Daughter:

  1. A child born to You or Your legal spouse; or
  2. A child who is Your legally adopted child with legal adoption evidenced by a decree of adoption by a Texas court or court of another state, who is the object of a lawsuit for adoption and You are a party to such lawsuit, or who has been placed with You for adoption.

Specialist: A doctor who provides health care services for a specific disease or part of the body. Examples include oncologists (care for cancer patients), cardiologists (care for the heart), and orthopedists (care for bones).

Subscriber: The Eligible Employee or other person whose employment or other status, except family dependency, is the basis for eligibility under the terms, conditions, and limitations of this Agreement and for, or on behalf of, whom the Premiums are paid by the Group.

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T

Texas Department of Insurance (TDI): In Texas, the agency that insurance laws and regulations are administered by.

Time-Sensitive: A situation in which waiting for a standard decision or an authorization for a service could seriously jeopardize your life or health, or your ability to regain maximum function.

Total Out-of-Pocket Maximum: The total out-of-pocket maximum includes coinsurance and copayments, not mutually exclusive from other out-of-pocket limits. This means that a Participant’s total out-of-pocket maximum could contain a combination of coinsurance and/or copayments. (For example, a Participant could pay up to $6,450 in copayments alone if there was no coinsurance paid throughout the year. If a Participant met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,450 in copayments, totaling $6,450 in overall out-of-pocket expense.)

Toxic Inhalant: A volatile chemical under the Texas Controlled Substance Act (Chapter 481 of the Texas Health and Safety Code).

Treatment or Treatments: Services, supplies, drugs, equipment, protocols, procedures, therapies, surgeries, and similar terms used to describe ways to treat a health problem or condition.

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U

Urgent Care Clinic: Any licensed Facility that provides physician services for the immediate treatment only of an injury or disease, and which has contracted with the Health Plan to provide Members such services.

Urgent Care: Services provided for the immediate treatment of a medical condition that requires prompt medical attention but where a brief time lapse before receiving services will not endanger life or permanent health. Urgent conditions include, but are not limited to, minor sprains, fractures, pain, heat exhaustion, and breathing difficulties other than those of sudden onset and persistent severity. An individual patient’s urgent condition may be determined emergent upon evaluation by a Plan Provider.

Urgently Needed Services: Services needed immediately as a result of an unforeseen illness, injury, or condition; and it is not reasonable, given the circumstances, to get the services through your primary care physician or other plan providers. These services are provided when you are out of the service area not more than 90 days in a row.

Usual, Customary, and Reasonable Charges (UCR): The fee which a physician or other provider of a particular service usually charges his/her patients for the same service, and which is within the range of fees usually charged by other physicians or other providers located within the immediate geographic area where the service is received under similar or comparable circumstances. When applied to a Plan Provider, it means the amount allowed under a Plan Provider’s agreement with the Health Plan or Medical Group.

Utilization: The extent to which a given group uses services during a specified period of time. Usually expressed as the number of services used per year per 1,000 persons eligible for the services, but utilization rates may be expressed in other types of ratios.

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V

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W

Waiting Period: The period of time specified by Group that must pass before a person becomes eligible for coverage under this Agreement.

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Y

You: The Subscriber.

Your: Relating or pertaining to the Subscriber.

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Z