| Active
Employee |
The
term "Active Employee" means any person who, by reason of his
employment, meets the eligibility requirements established and amended from time
to time by the Fund.
|
| Allowed
Charges |
The
term "Allowed Charges" or "Covered Expense" means that there
is a limit on the type of benefit that is covered by the Plan and the amount
payable by the Fund.
An example of the limitations is as follows:
|
(a) |
A
doctor's charge for an office call is $50.00. The Plan allowance is $35.00. The
Plan pays a maximum of $35.00 subject to application of deductible provisions.
|
|
(b)
|
The
doctor's bill includes a charge of $30.00 for an office call and a charge for a
flu shot of $15.00. The Fund would pay the $30.00
office call but would not pay the $15.00 flu shot.
Flu shots are not an allowed charge or covered expense, unless the
participant
is over 65 years of age.
|
|
| Ambulatory
Center |
The
term "Ambulatory Center" means a distinct entity that:
|
(a)
|
Operates
exclusively for the purposes of providing outpatient
surgical services and/or emergency care to patients, and
|
|
(b)
|
is operated under the supervision
of a Physician.
|
|
| Assignment
of Benefits |
An
assignment of benefits is an authorization to the Fund to pay
the physician, hospital or other provider of service directly for the
benefits received. The Plan
will accept assignment of benefits for all services except prescription drugs.
The Vision Service Plan will not accept assignment of benefits if an eligible
individual receives benefits from a physician other than a Vision Service Plan
provider.
|
| Birthing
Center |
The
term "Birthing Center" means a facility equipped and operated solely
as a setting for prenatal care, delivery and immediate postpartum care for
patients with low risk pregnancies.
A Birthing Center may be free-standing, hospital-based or hospital-
associated. It must be licensed and
operated under the direction of an
M.D. or D.O. specializing in obstetrics and gynecology.
It shall provide skilled nursing services under the direction of an R.N.
or certified nurse-midwife in the delivery and recovery rooms and have a written agreement with an
area hospital for immediate transfer in case of emergency. |
| Certified Nurse-Midwife |
A "Certified
Nurse-Midwife" is a Registered Nurse who has gained the special knowledge
and skills of midwifery in an educational program accredited by the American
College of Nurse-Midwives and who is licensed in the State of California by
the Board of Registered Nursing as a Nurse-Midwife.
|
| Co-payment |
The
term "co-payment" means any amount you are responsible to pay
after the Fund has provided benefits. This
is also called your "out-of-pocket" expense and is your portion of the
cost of care.
The "co-payment" for an HMO (Kaiser, Health Net, Health Plan of
Nevada) is the amount charged to you at the time of service.
This is your portion of the cost of care. |
| Cosmetic
Surgery |
The
term "Cosmetic Surgery" means surgery which is performed merely
for the purpose of improving the appearance of an individual. |
| Dentist |
The
term "Dentist" means a dentist licensed to practice dentistry in the
state or county in which he renders treatment and is not the spouse,
child, brother, sister or parent of the Active or Retired member or the
Member's dependent or spouse. |
| Dependent |
The term
"Dependent" means
|
(1)
|
The
Active or Retired member's legal spouse, but not a common-law
spouse, and;
|
|
(2)
|
the
Active or Retired member's child. The
Trustees provide coverage
for the Active or Retired member's natural children, step-children,
and legally adopted children. The
Trustees also provide for children
born out of wedlock if the Active or Retired member is legally
determined to be the parent. To be
covered, children must be unmarried and be less than 19 years of age or, if a
student, the child must be less than 26 years of age, attending a recognized
educational, technical or trade school on a full-time basis (as defined by the
school), continue to depend on the Active or Retired member for support and
maintenance, and reside in the member's household, or a judicial decree or
qualified medical child support order must require the member to
furnish medical overage.
In addition, the term "Dependent" shall include any person who is less
than 19 years of age and for whom the Active or Retired member has been appointed guardian of the person, pursuant to
applicable state law, during the period of such guardianship; and any person who
is less than 19 years of age for whom the Active or Retired member has been
appointed conservator, pursuant to applicable state law, during the period of
such conservator ship.
|
|
| Elective
Surgery |
The
term "Elective Surgery" means a surgery which is not a matter of
life or death. It means a surgery
which can be performed at any time. It
does not include any surgery which must be performed immediately in order to protect the health
and life of a person. |
| Eligible
Individual |
The
term "Eligible Individual" means each Active or Retired Employee
and each of his eligible Dependents, if any. |
| Extended
Care Facility |
The
term "Extended Care Facility" means an institution which is
primarily engaged in providing inpatients with (1) skilled nursing care
and related services for patients who require medical or nursing care, or
(2) rehabilitation services
for the rehabilitation of injured, disabled or sick persons which meets all of the following requirements:
|
(a)
|
it is regularly engaged in
providing skilled nursing care to sick and injured people under 24-hour-a-day
supervision of a physician and surgeon (MD) or a graduate Registered Nurse (RN);
|
|
(b)
|
it has available at all times the
services of a physician and surgeon (MD) who is a staff member of a general
hospital;
|
|
(c)
|
it has on duty 24 hours a day a
graduate Registered Nurse (RN), Licensed Vocational Nurse (LVN), or skilled
practical nurse, and it has a graduate Registered Nurse (RN) on duty at least
eight hours per day;
|
|
(d)
|
it maintains a clinical record for
each patient;
|
|
(e)
|
it is not, other than incidentally,
a place for custodial care, a place for aged, a place for drug addicts, a
place for alcoholics, a hotel, or a similar institution;
|
|
(f)
|
it complies with all licensing and
other legal requirements, and is recognized as a "extended care
facility" by the Secretary of Health, Education and Welfare of the United
States in accordance with the Social Security Amendments Act of 1965.
|
|
| HMO
- Health Maintenance Organization |
An
organization which contracts with the Fund to provide complete medical coverage
for Plan participants. The Fund has contracts with Kaiser, Health Net and
Health Plan of Nevada. |
| Home
Health Agency |
The
term "Home Health Agency" means an organization or agency
which meets the requirements for participation as a "home health
agency" under Medicare. |
| Hospital |
The
term "Hospital" means only an institution which meets all of the
following requirements:
|
(a)
|
Maintains a permanent full-time
facility for bed care of five or more resident patients;
|
|
(b)
|
has a physician in regular
attendance;
|
|
(c)
|
continuously provides 24-hour-a-day
nursing service by Registered Nurses;
|
|
(d)
|
is primarily engaged in providing
diagnostic and therapeutic facilities for medical and surgical care of injured
and sick persons on a basis other than as a rest home, nursing home,
convalescent home, a place for the aged or a place for drug addicts, and is
operating lawfully in the jurisdiction where it is located; or
|
|
(e)
|
is recognized, by the Board of
Trustees, by name on a specific basis, and is primarily engaged in
providing Physician prescribed inpatient medical treatment of alcoholism.
|
|
| Itemized
Bill |
An
itemized bill is a bill from a provider of service which has a breakdown for
each specific service rendered and an individual price for each service.
The itemized bill is provided for each individual patient. The Fund will
accept an itemized billing in lieu of a completed claim form as long as all of
the information indicated above is provided as well as the participant's name,
the patient's name, the participant's Social Security Number, the diagnosis, and
the provider's name, address and Tax I.D. Number.
|
| Medically
Necessary |
The
term "Medically Necessary" means that the service or supply fulfills
the following requirements:
|
(a)
|
It
is rendered for the treatment or diagnosis of an injury or disease (signs
and/or symptoms of the disease or injury must
be present); and |
|
(b)
|
It
is appropriate for the signs and symptoms present, is consistent with the
diagnosis, and is otherwise in accordance with generally accepted medical
practice and professionally recognized standards for injuries and/or diseases
comparable in nature and severity, including frequency and duration of therapy;
and |
|
(c)
|
It is not mainly for the
convenience of the patient or of the patient's physician or other provider; and
|
|
(d)
|
It is the most appropriate supply or
level of care needed to provide safe and adequate care. Also, the site of
the service must be the most appropriate due to the inherent clinical condition
of the patient or to the nature of the services provided.
|
|
| Panel
Dentist |
The
term "Panel Dentist" means any Dentist contracted by the Fund to
provide dental services and supplies at a fixed rate.
|
| Physician |
The
term "Physician" means a person who is licensed to practice medicine
and surgery as a doctor of medicine or as a doctor of osteopathy.
Physician shall also include a person licensed to practice as a Audiologist,
Chiropractor, Podiatrist, Psychologist, Certified Acupuncturist, or
Optometrist. A Physician cannot be the member or his dependents or any
person who is the spouse, parent, child, brother or sister of the member or his
dependents.
In other words, you cannot treat yourself or a family member and expect to be
reimbursed by the Fund. |
| Plan |
The
term "Plan" means the Rules and Regulations of the Operating Engineers
Health and Welfare Fund for Active and Retired Employees.
|
| Qualified
Medical Child Support Order |
The term
"Qualified Medical Child Support Order" means an order by a court
resulting from a divorce which designates one parent to pay for a child's health
coverage.
|
| Reasonable
Charges/Usual and Customary Charges |
The
term "Reasonable Charges" means the necessary, usual or customary
charges, in the area in which they are incurred. The term "area"
means a county or such greater area necessary to obtain a representative cross-section of
persons, hospitals, prescription pharmacies, institutions or other
entities furnishing medical care. A charge is considered to have been
incurred as of the date on which the service or supply for which the charge is
made is rendered or obtained.
|
| Registered
Nurse |
The term
"Registered Nurse" means a registered graduate nurse who does not
ordinarily reside in the participant's home and is not the spouse, child,
brother, sister or parent of the participant or his Dependent.
|
| Retiree |
The term
"Retiree" means any person who, by reason of his retirement, meets the
eligibility requirements established and amended from time to time by the Fund.
|
| Schedule
of Dental Procedures |
The term
"Schedule of Dental Procedures" means the description of dental
procedures and the maximum amounts payable as set forth by the Board of Trustees
and amended from time to time.
|
| Schedule
of
Operations/
Surgical Schedule |
The term "
Schedule of Operations" and "Surgical Schedule" means the
description of surgical procedures and the amounts payable as set forth by the
Board of Trustees and amended from time to time.
|
| Totally
Disabled (Health & Welfare Plan) |
The
term "Totally disabled" means, with respect to an Active Employee in
the Health & Welfare Plan, prevention by reason of bodily injury or sickness
from engaging in any occupation for wages or profit, and with respect to a
Dependent, prevention by reason of bodily injury or sickness, to engage in normal activities.
|
