“Accidental Injury” - Physical harm, which is sudden and traumatic in nature, caused by the intervention of an external force.

“Area Administrative Office” - The Administrative Offices that have been retained by the Trust to provide administrative services.

“Coinsurance” - The percentage of the charge you are responsible for paying (i.e. if you use a non-PPO provider, you pay 15% and the Plan pays 85%).

“Convalescent Nursing Home” - A legally operated institution that (a) for a fee provides convalescents with room, board and 24-hour care by one or more professional nurses and other nursing personnel needed to provide adequate medical care; (b) is under full-time supervision of a doctor or registered nurse (R.N.); (c) keeps adequate medical records; (d) if not operated by a doctor, has the services of one available under an established agreement; and (e) is not an institution, or part of one, used mainly as a rest facility, a facility for the aged or for treatment of chemical dependency.

“Copay” - The pre-set amount you pay at the time of service.

“Cosmetic Surgery” - Surgery performed to alter the texture or configuration of the skin, or the configuration of relationship with contiguous structures of any feature of the human body. It is performed primarily for psychological purposes and does not correct or materially improve a bodily function or treat an illness or accident.

“Custodial Care” - Any portion of a service, procedure, or supply which, in the judgment of the Trust, is provided primarily:

• For ongoing maintenance of the patient’s health and not for its therapeutic value in treatment of an illness or accidental injury.
• To assist the patient in meeting the activities of daily living. Examples are help in walking, bathing, dressing, eating, preparation of special diets, and supervision over self-administration of medication not requiring constant attention of trained medical personnel.
• Any services, procedures or supplies that, in the reasonable opinion of this Plan, is given to sustain a patient without attempting to treat an illness or injury.

“Deductible” - The amount of eligible non-PPO medical expenses under the Medical Plan that must be paid by you before medical benefits are payable.

“Doctor or Provider” - A licensed practitioner of the healing arts acting within the scope of his or her license.

“Durable Medical Equipment” - Equipment which can stand repeated use (with the exception of cer tain consumable medical supplies), is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is ordered and/or prescribed by a physician for the exclusive use of the patient.

“Experimental and Investigational” - Any service, including a treatment, procedure, facility, equipment, drug, drug usage, medical device, or supply that, as determined by the Trust or its medical consultants, meets one or more of the following criteria:

• A drug or device that cannot be lawfully marketed without the approval of the United States Food and Drug Administration, and has not been granted such approval on the date it is furnished.
• A facility or provider who has not demonstrated proficiency in the service, based on experience, outcome, or volume of cases.
• Reliable evidence shows the service is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety, or efficacy.
• Reliable evidence shows the service is not as safe and effective for a particular medical condition, as compared to other generally available services, and that it poses a significant risk to the patient’s health or safety.

Reliable evidence means only published reports and articles in authoritative medical and scientific literature, scientific results of the provider of care’s written protocols, or scientific data from another provider studying the same service.

“Home Health Aide” - A person, other than a registered nurse, who provides medical or therapeutic care under the supervision of a home health care agency.

“Home Health Care Agency” - A hospital, agency or other service that is certified by the proper authority of the state in which it is located to provide home health care.

“Home Health Care Treatment Plan” - A program of home care that:

• Is required as the result of sickness or injury;
• Is established and reviewed at least every 60 days by the attending physician; and
• Is certified by the attending physician as a replacement for hospital confinement or confinement in a skilled nursing facility that would otherwise be necessary.

The plan of treatment must also describe the services and supplies for the medically necessary home health care to be provided to the patient by the approved home health care agency or approved providers of service. Such plan of care is subject to periodic review by your Utilization Review company and your Area Administrative Office.

“Hospice” - A facility which provides short periods of stay for a terminally ill person in a home-like setting for either direct care or respite care. This facility may be either free-standing or affiliated with a hospital. It must operate as an integral part of the hospice care program. If such a facility is required by a state to be licensed, certified, or registered, it must also meet that requirement to be covered.

“Hospice Care Program” - A formal program directed by a doctor to help care for a terminally ill person. This may be through either:

• A centrally-administered, medically directed and nurse-coordinated program which: (a) provides a coherent system primarily of home care; (b) uses a hospice team; and (c) is available 24 hours a day, seven days a week; or
• Confinement in a hospice.

The program must meet standards set by the National Hospice Organization and be approved by the Trust or its medical consultants. If such a program is required by a state to be licensed, certified, or registered, it must also meet that requirement to be considered a hospice care program.

“Hospital” - A legally operated institution which meets either of these tests:

1. Is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on the Accreditation of Hospitals, or
2. Is supervised by a staff of doctors, has 24-hour-a-day nursing service and is primarily engaged in providing either:
   • General inpatient medical care and treatment through medical, diagnostic and major surgical facilities on its premises or under its control; or
   • Specialized inpatient medical care and treatment through medical and diagnostic facilities (including X-ray and laboratory) on its premises, or under its control, or through a written agreement with a hospital (which itself qualifies under 1 or 2 of this definition) or with a specialized provider of these facilities.

In no event will the term “hospital” include a nursing home or an institution or part of one which: (a) is primarily a facility for convalescence, nursing, rest, the aged, or for treatment of chemical dependency; (b) furnishes primarily domiciliary or custodial care, including training in daily living routines; or (c) is operated primarily as a school.

“Indemnity Medical Benefits” - The term Indemnity medical benefits, as used in this booklet, refers to the benefits provided that are medical in nature and provided by medical practitioners. It does not include prescription, mental health or substance abuse treatment, which are part of the health and welfare plan for active regular employees.

“Medical Consultant” - A qualified medical professional whose services have been retained by the Trust to give medical advice to determine covered services and supplies and medical necessity.

“Medically Necessary” (also medical necessity) - Medically necessary means that services or supplies (a) must be ordered through a physician or other qualified provider, (b) must be commonly and customarily recognized as appropriate in the treatment of the patients’ diagnosed injury or sickness as specified by authoritative medical or scientific literature and (c) must be the least costly of the alternative services or supplies which can be safely provided. Medical necessity does not include maintenance or supportive type treatment or services, or custodial care. Such services or supplies must not be educational or experimental in nature, or provided primarily for the purpose of medical or other research. The fact that services or supplies were furnished, prescribed or approved by a physician or other qualified provider does not in itself mean it was medically necessary. A medical service, supply or setting may be medically necessary in part only.

“Network or Preferred Provider” - A provider who has contracted with the Trust’s PPO Program. See your booklet insert for a description of your PPO provider network.

“Non-Network or Non-Preferred Provider” - A provider who has not contracted with the Trust’s PPO Program. See your booklet insert for a description of your PPO provider network.

“Nurse” - Includes Licensed Registered Nurses (R.N.’s), Licensed Practical Nurses (L.P.N.’s), and Certified Nurse Practitioners (C.R.N.’s).

“Out-of-Pocket Maximum” - The maximum amount you could pay each year for covered expenses. The out-of-pocket maximum does not include deductibles, copayments or amounts over UCR.

“Outpatient Care” - Treatment in a non-hospital facility or during a hospital stay of less than 23 hours where there were no room and board charges.

“Outpatient Surgical Center” - A physician’s office, a medical clinic or legally operated institution which is engaged primarily in providing surgical services on an outpatient basis at the patient’s expense, and which meets all of the established standards of this kind of facility.

“Physical Therapy” - Treatment of an illness, injury or condition by physical means, such as massage, hydrotherapy, heat or similar modalities when performed by a licensed or registered physical therapist or certified occupational therapist. The treatment must be prescribed or referred to the physical or occupational therapist by your Physician.

“Physician Visit” - A physician’s visit means a personal interview and will not include any interview in which the physician does not see the patient in person. Telephone consultations are not considered a visit.

“PPO Allowed Amount” - Pre-set charges for PPO services. The PPO provider cannot charge the patient more for any service than the PPO allowed amount.

“Preferred Provider Organization (PPO)” - A network of doctors, hospitals, and other health care providers who are members of the PPO organization. These providers furnish medical services to Trust participants at negotiated rates.

“Pregnancy” - Pregnancy, including resulting childbirth, abortion or miscarriage, shall be treated as a sickness for employees and dependent wives. Expenses in connection with the pregnancy of a dependent child are not covered.

“Remission” - A halt in the progression of a terminal disease; or an actual reduction in the extent to which the disease has already progressed.

“Temporomandibular Joint Dysfunction (TMJ)” - A disorder of the temporomandibular joint (the joint that connects the mandible or jawbone to the temporal bone) that is generally characterized by:

• Pain or muscle spasms in one or more of the following areas: face, jaw, neck, head, ears, throat or shoulders;
• Popping or clicking of the jaw;
• Limited jaw movement or locking;
• Malocclusion, overbite or underbite; and/or
• Chewing difficulties.

“Terminally Ill Person” - A person whose life expectancy is six months or less, as certified by the primary attending doctor.

“Totally Disabled” - A person is considered totally disabled when, because of an accident or illness, (including pregnancy and its complications), the person is not able to perform the normal duties of his or her occupation, not engage in any occupation for wage or profit, and is under the regular care of a physician for that injury or sickness. A dependent is considered totally disabled when, because of the disability, the person is unable to engage in the normal activities of a person of the same age and gender.