Health Medical Plan Glossary
Accidental Injury is physical harm or
disability which is the result of a specific unexpected incident
caused by an outside force. The physical harm or disability must
have occurred at an identifiable time and place. Accidental
injury does not include illness or infection, except infection
of a cut or wound.
Surgical Center is a freestanding outpatient surgical facility. It must be
licensed as an outpatient clinic according to state and local laws and must
meet all requirements of an outpatient clinic providing surgical services. It
must also meet accreditation standards of the Joint Commission on Accreditation
of Health Care Organizations or the Accreditation Association of Ambulatory
Brand Name Prescription Drug (Brand Name Drug) is a prescription drug that
has been patented and is only produced by one manufacturer.
CalCPA means the California Society of Certified
of Expertise (COE) are health care providers which have a Centers of
Expertise Agreement in effect with the claims administrator at the time
services are rendered. COE agree to accept the COE negotiated rate
as payment in full for covered services. A participating provider in
the plan network is not necessarily a COE. A provider‘s
participation in the plan network or other agreement with the claims
administrator is not a substitute for a Centers of Expertise Agreement.
of Expertise Negotiated Rate (COE Negotiated Rate) is the fee COEs
agree to accept as payment for covered services. It is usually lower than
their normal charge. COE negotiated rates are determined by Centers of
meets the plan’s eligibility requirements for children as outlined under
how coverage begins and ends.
Administrator refers to BC Life & Health Insurance Company. On behalf
of BC Life & Health Insurance Company, Anthem Blue Cross of California shall
perform all administrative services in connection with the processing of
medical claims under the plan.
Class I Transplants are any
of the following: liver, heart, heart-lung, kidney, kidney-pancreas or bone
marrow, including autologous bone marrow transplant, peripheral stem cell
treatment and similar procedures.
COBRA means the medical plan related provisions of
the Consolidated Budget Reconciliation Act of 1985, as such provisions have
been subsequently amended.
COBRA Administrator means a COBRA participating
employer or third party (not the Trustees or the plan administrator)
appointed by the COBRA participating employer to act as the COBRA
Co-Insurance is the amount expressed as a percentage,
payable by the member for covered expenses.
Comprehensive Benefits means all benefits payable by
the plan for services and supplies other than benefits available under
the heading Prescription Drug Benefits.
Concurrent Review occurs
during the member’s hospital stay to determine if continued
inpatient care is medically necessary.
Hospital is a hospital which has a Standard Hospital Contract in
effect with the claims administrator to provide care to beneficiaries.
A contracting hospital is not necessarily a participating provider.
A list of contracting hospitals will be sent on request.
Co-Payment is the amount payable by the member
for office visits and certain other services. The prescription drug co-payments
are fixed dollar amounts payable for prescription drugs. The term “co-payment”
does not include the portion of covered expenses, expressed as a
percentage, payable by the member for covered services.
Cosmetic Surgery is performed to reshape normal
structures of the body and is intended solely to improve the appearance of the
Expense is the expense you incur for a covered service or supply, but not
more than the maximum amounts described in your
medical benefits: how covered expense is determined. Expense is incurred on the date you receive the
service or supply.
Coverage is coverage under any individual or group plan that provides
medical, hospital and surgical coverage, including continuation or conversion
coverage, coverage under a publicly sponsored program such as Medicare
or Medicaid, CHAMPUS, the Federal Employees Health Benefits Program, programs
of the Indian Health Service or of a tribal organization, a state health
benefits risk pool, or coverage through the Peace Corps. Creditable
coverage does not include accident only, credit, coverage for on-site
medical clinics, disability income, coverage only for a specified disease or
condition, hospital indemnity or other fixed indemnity insurance, Medicare
supplement, long-term care insurance, dental, vision, workers‘
compensation insurance, automobile insurance, no-fault insurance, or any medical
coverage designed to supplement other private or governmental plans.
You are considered to have been covered under a creditable
coverage if you:
- Were covered under a creditable coverage on the
date that coverage terminated;
- Were in an
eligible status under this plan within 63 days of termination of the creditable
enrolled for coverage within 31 days of the eligibility date.
You are also considered to have been covered under a creditable
coverage if your employment ended, the availability of medical coverage
offered through employment or sponsored by an employer terminated, or an
employer‘s contribution toward medical coverage terminated, provided
- Were covered under a creditable coverage
on the date that coverage terminated;
- Were in an
eligible status under this plan within 180 days of termination of the creditable
- Properly enrolled for coverage within 31 days of
the eligibility date
and Reasonable Charge, as determined annually by the claims
administrator, is a charge which falls within the common range of fees
billed by a majority of physicians for a procedure in a given geographic
region. If it exceeds that range, the expense must be justified based on the
complexity or severity of treatment for a specific case.
Day Treatment Center is an
outpatient psychiatric facility which is licensed according to state and local
laws to provide outpatient programs and treatment of mental or nervous disorders,
severe mental disorders, or substance abuse under the supervision
Deductible means the amount of charges a member
must pay for any covered services before any benefits are available to the member
under the plan. Amounts applied to the deductible do not apply
to or reduce any co-insurance/co-payment, or the percentage of
any covered expense or prescription drug covered expense which
the member must pay.
meets the plan’s eligibility requirements for dependents as
outlined under how coverage begins and
Partner meets the plan’s eligibility requirements for domestic
(Prescription Drug) means a prescribed drug approved by the State of
California Department of Health or the Food and Drug Administration for general
use by the public. For the purposes of this plan, insulin will be
considered a prescription drug.
Limited Fee Schedule represents the maximum amounts the plan will
allow as prescription drug covered expense for prescriptions
filled at non-participating pharmacies. These amounts are the lesser of
billed charges or the average wholesale price.
Date is the date your coverage begins under this plan.
is a sudden, serious, and unexpected acute illness, injury, or condition
(including without limitation sudden and unexpected severe pain) which the beneficiary
reasonably perceives could permanently endanger health if medical treatment is
not received immediately. Final determination as to whether services were
rendered in connection with an emergency will rest solely with the claims
Services are services provided in connection with the initial treatment of
a medical or psychiatric emergency.
procedures are those that are mainly limited to laboratory and/or animal
Facility-Based Care is care provided in
a hospital, psychiatric health facility, residential treatment
center or day treatment center for the treatment of mental
or nervous disorders, severe mental disorders, or substance
Family Member is the plan participant’s
enrolled spouse, or enrolled domestic partner, and each enrolled
Generic Prescription Drug (Generic Drug)
is a pharmaceutical equivalent of one or more brand name drugs
and must be approved by the Food and Drug Administration as meeting
the same standards of safety, purity, strength, and effectiveness
as the brand name drug.
Group Enrollment Agreement means the agreement by
which a plan participant enrolls in the plan.
Home Health Agencies are home health care
providers which are licensed according to state and local laws
to provide skilled nursing and other services on a visiting basis
in your home, and recognized as home health providers under Medicare
and/or accredited by a recognized accrediting agency such as the
Joint Commission on the Accreditation of Healthcare Organizations.
Infusion Therapy Provider is a provider licensed according to state and
local laws as a pharmacy, and must be either certified as a home health care
provider by Medicare, or accredited as a home pharmacy by the Joint
Commission on Accreditation of Health Care Organizations.
is an agency or organization primarily engaged in providing palliative care
(pain control and symptom relief) to terminally ill persons and supportive care
to those persons and their families to help them cope with terminal illness.
This care may be provided in the home or on an inpatient basis. A hospice
must be: (i) certified by Medicare as a hospice; (ii) recognized
by Medicare as a hospice demonstration site; or (iii) accredited as a
hospice by the Joint Commission on Accreditation of Hospitals. A list of hospices
meeting these criteria is available upon request.
is a facility which provides diagnosis, treatment and care of persons who need
acute inpatient hospital care under the supervision of physicians. It
must be licensed as a general acute care hospital according to state and local
laws. It must also be registered as a general hospital by the American
Hospital Association and meet accreditation standards of the Joint Commission
on Accreditation of Health Care Organizations.
For the limited purpose of
inpatient care for the acute phase of a mental or nervous disorder, severe
mental disorder, or substance abuse, “hospital” also includes psychiatric
Infertility is: (i) the presence of a
condition recognized by a physician as a cause of infertility;
or (ii) the inability to conceive a pregnancy or to carry a pregnancy
to a live birth after a year or more of regular sexual relations
services or visits provided by a COE and by participating providers
(but not including services or visits covered only on an in-network
basis if provided by a COE).
procedures or medications are those that have progressed to limited use on
humans, but which are not widely accepted as proven and effective within the
organized medical community.
means either or both of the following: diseases or conditions where the
likelihood of death is high unless the course of the disease is interrupted; diseases
or conditions with potentially fatal outcomes, where the endpoint of clinical
intervention is survival.
and necessary for the diagnosis or treatment of the medical condition;
for the diagnosis or direct care and treatment of the medical condition;
standards of good medical practice within the organized medical community;
primarily for your convenience, or for the convenience of your physician
or another provider; and
- The most
appropriate procedure, supply, equipment or service which can safely be
provided. The most appropriate procedure, supply, equipment or service must
satisfy the following requirements:
- There must
be valid scientific evidence demonstrating that the expected health benefits
from the procedure, supply, equipment or service are clinically significant and
produce a greater likelihood of benefit, without a disproportionately greater
risk of harm or complications, for you with the particular medical condition
being treated than other possible alternatives;
accepted forms of treatment that are less invasive have been tried and found to
be ineffective or are otherwise unsuitable; and
- For hospital
stays, acute care as an inpatient is necessary due to the kind of services
you are receiving or the severity of your condition, and safe and adequate care
cannot be received by you as an outpatient or in a less intensified medical
- There must
Medically Necessary Hospital Days are those days for
which inpatient care is determined to be medically necessary.
Medical Plan Document and
Disclosure Form is the written description of the benefits provided under
Medicare means those hospital benefits and other
health care benefits covered under the supplemental medical insurance program
of Title XVIII of the Social Security Act 42 U.S.C. §§ 1395 et seq.
Medicare Beneficiary means an individual enrolled in
Mental Or Nervous Disorders, for the purposes of this
plan, are conditions that affect thinking and the ability to figure
things out, perception, mood and behavior, including severe mental disorders.
A mental or nervous disorder is recognized primarily by symptoms or signs that
appear as distortions of normal thinking, distortions of the way things are
perceived (e.g., seeing or hearing things that are not there),
moodiness, sudden and/or extreme changes in mood, depression, and/or
unusual behavior such as depressed behavior or highly agitated or manic
Rate is the amount participating providers agree to accept as
payment in full for covered services. It is usually lower than their normal
charge. Negotiated rates are determined by claims administrator’s
Participating Provider Agreements. With respect to non-participating
providers, the negotiated rate means the typical fee participating
hospitals and participating physicians agree to accept as payment in
full of covered services as determined by the claims administrator, as
appropriate, in its discretion.
Pharmacy is a pharmacy which does not have a Participating Pharmacy
Agreement in effect with the claims administrator at the time services
are rendered. In most cases, you will be responsible for a larger portion of
your pharmaceutical bill when you go to a non-participating pharmacy.
Provider is one of the following providers which does NOT have a claims
administrator’s Participating Provider Agreement in effect with the claims
administrator at the time services are rendered:
- A hospital;
- A physician;
- An ambulatory surgical center;
- A home health agency;
- A facility which provides diagnostic imaging services;
- A durable medical equipment outlet;
- A skilled nursing facility;
- A clinical laboratory; or
- A home infusion
They are not participating providers.
Remember that only a portion of the amount which a non-participating
provider charges for services may be treated as covered expense
under this plan. See your
medical benefits: how covered expense is determined.
Other Health Care Providers are neither
physicians nor hospitals. They are mostly free-standing
facilities or service organizations, such as ambulance
companies. Other health care providers are not part of
the plan provider network.
Other health care provider is one of the
- A certified registered nurse anesthetist;
- A licensed ambulance company; or
- A hospice.
The provider must be licensed
according to state and local laws to provide covered medical services.
Out-of-Network describes services or visits rendered
by non-participating hospitals, non-participating physicians and other non-participating
providers, and with respect to services or visits covered on an in-network
basis only if provided by COE, services or visits provided by any
Provider other than a COE.
Out-of-Pocket Amount is the amount for which a member
is responsible when the claims administrator’s allowance, as
appropriate, for covered services is paid. The member’s out-of-pocket
amount does not include:
- Any expense incurred which exceeds covered expense or prescription
drug covered expense;
- Any expense incurred because the member did not obtain
pre-authorization, pre-admission review or concurrent review
when required to do so under the heading Medical Management Program.
- Any expense incurred because of plan limitations on the number
of visits, days of treatment, or dollar limitations on days of treatment or
other similar limitations on specific benefits;
- Any amount for which a member is responsible when the maximum
benefits of this plan are paid;
- Any amount for which the member is responsible for prescription
- Any co-payment
for covered services.
Participating Employer is a firm participating
in the plan, where more than 50 percent of all the participating
employer’s owners (i.e., principals, proprietors, partners,
shareholders or other owners) are Certified Public Accountants
and all Certified Public Accountant-owners are members of CalCPA
in good standing or a candidate applying for CalCPA membership.
Specific qualifications of a participating employer are
stipulated in the subscription agreement between the
trust and the participating employer.
Participating Hospital is a hospital
which has a claims administrator’s Participating Agreement in effect
with the claims administrator, as appropriate, at the time services are
rendered. Participating hospitals agree to accept the negotiated
rate as payment in full for covered services. Participating hospitals agree
to participate in procedures established to review the utilization of hospital
services. Hospital services determined to be unnecessary, according to
these utilization review procedures, are not covered by the plan. A
list of participating hospitals is available upon request from the plan
administrator, as appropriate.
Pharmacy is a pharmacy which has a Participating Pharmacy Agreement
in effect with the claims administrator at the time services are
rendered. Call your local pharmacy to determine whether it is a participating
pharmacy or call the toll-free customer service telephone number. Many
participating pharmacies display a “Rx” decal with the claims
administrator’s logo in their window so that you can easily identify them.
Participating Provider is one of
the following providers which has a claims administrator’s Participating
Provider Agreement in effect with the claims administrator at the time
services are rendered:
- A hospital;
- A physician;
- An ambulatory surgical center;
- A home health agency;
- A facility which provides diagnostic imaging services;
- A durable medical equipment outlet;
- A skilled nursing facility;
- A clinical laboratory; or
home infusion therapy provider.
providers agree to accept the negotiated rate as payment for
covered services. A directory of participating providers is available
means a licensed retail pharmacy.
Physical Therapy, Physical
Medicine and Occupational Therapy (including Chiropractic Care) means the
benefits described under the heading Physical Therapy, Physical Medicine and
Occupational Therapy (including Chiropractic Care).
- A doctor
of medicine (M.D.) or doctor of osteopathy (D.O.) who is licensed to practice
medicine or osteopathy where the care is provided; or
- One of the
following providers, but only when the provider is licensed to practice where
the care is provided, is rendering a service within the scope of that license,
is providing a service for which benefits are specified in this booklet, and
when benefits would be payable if the services were provided by a physician
as defined above:
podiatrist or chiropodist (D.P.M., D.S.P. or D.S.C.)
certified registered nurse anesthetist
- An acupuncturist (A.C.)
clinical social worker (C.S.W. or L.C.S.W.)
marriage, family and child counselor (M.F.C.C.)
- A physical therapist (P.T. or R.P.T.)*
- A speech pathologist*
- An occupational therapist (O.T.R.)*
respiratory care practitioner (R.C.P.)*
psychiatric mental health nurse
registered dietitian (R.D.)* for the provision of diabetic medical nutrition
- A registered nurse practitioner
* Note. The providers indicated
by asterisks (*) are covered only by referral of a physician as defined
in 1 above.
** If there is
no nurse midwife who is a participating provider in your area, you may
call the Customer Service telephone number on your ID card for a referral to an
is the set of benefits described in the Medical Plan Document and Disclosure
Form and in the amendments to the Medical Plan Document and Disclosure
Form, if any. These benefits are subject to the terms and conditions of
the plan. If changes are made to the plan, an amendment or
revised Medical Plan Document and Disclosure Form will be issued to each
plan participant affected by the change. (The word “plan” here
does not mean the same as “plan” as used in ERISA.)
Plan Administrator refers to
GROUP INSURANCE TRUST OF THE CALIFORNIA SOCIETY OF CERTIFIED PUBLIC
ACCOUNTANTS, the entity which is responsible for the administration of the plan.
Plan Agent is the agent of the plan responsible
for administering enrollment, underwriting and premium collection functions.
Until replaced by the plan administrator, the plan agent is Banyan Administrators Insurance Program Management.
Plan Document is the Medical
Plan Document and Disclosure Form.
is any person enrolled in the plan that meets the eligibility
requirements as outlined in the subscription agreement.
Pre-Admission Review occurs before a proposed hospital
admission to determine if such an admission is medically necessary.
Condition means an illness, injury or condition which existed during the
six-month period immediately prior to either: (i) your effective date;
or (ii) the first day of any waiting period, whichever is earlier. A condition
is considered to have existed when you: (i) sought or received medical advice
for that condition; (ii) received medical care or treatment for that condition;
or (iii) received medical supplies, drugs or medicines for that condition.
means a written order or refill notice issued by a licensed prescriber.
Drug Covered Expense is the expense you incur for a covered prescription
drug, but not more than the maximum amounts described in items i. and ii.
below. Expense is incurred on the date you receive the service or supply.
Prescription drug covered expense does not include
any expense in excess of: (i) the drug limited fee schedule for drugs
dispensed by non-participating pharmacies; or (ii) the prescription
drug negotiated rate for drugs dispensed by participating pharmacies
or by the mail service program.
Drug Negotiated Rate is the rate that the claims administrator has
negotiated with participating pharmacies under a Participating Pharmacy
Agreement for prescription drug covered expense. Participating
pharmacies have agreed to charge beneficiaries no more than the prescription
drug negotiated rate. It is also the rate which Prescription Drug Program
– Mail Service has agreed to accept as payment in full for mail service prescription
Preventive Care means the benefits described under
the heading Preventive Care.
Principal Plan is the plan which will have its
benefits determined first.
Prior Plan is a plan sponsored by us which was replaced by this plan
within 60 days. You are considered covered under the prior plan if you: (i)
were covered under the prior plan on the date that plan terminated; (ii)
properly enrolled for coverage within 31 days of this plan’s effective
date; and (iii) had coverage terminate solely due to the prior plan‘s
Prosthetic Devices are appliances which replace all or part of a function of a
permanently inoperative, absent or malfunctioning body part. The term
“prosthetic devices” includes orthotic devices, rigid or semi-supportive
devices which restrict or eliminate motion of a weak or diseased part of the
Protected Health Information
means information about you and your medical case, the privacy of which is
protected under the Health Insurance Portability and Accountability Act of 1996
Psychiatric Health Facility is an acute 24-hour
facility as defined in California Health and Safety Code 1250.2. It must be:
- Licensed by the California Department of Health
- Qualified to provide short-term inpatient treatment
according to state law;
- Accredited by the Joint Commission on Accreditation of
Health Care Organizations; and
- Staffed by an organized medical or professional staff
which includes a physician as medical director.
Psychiatric Mental Health Nurse
is a registered nurse (R.N.) who has a master’s degree in psychiatric mental
health nursing, and is registered as a psychiatric mental health nurse with the
state board of registered nurses.
Qualified Beneficiary, for the purposes
of COBRA, is any of the following who is not entitled to
Medicare on the day before the qualifying event
and who on the date of the qualifying event is covered
under the plan pursuant to the Subscription Agreement of
a COBRA participating employer:
- The plan participant;
- A plan participant’s spouse;
- A plan participant’s
former spouse (or legally separated spouse); or
- A child, including a child
born to or placed for adoption with the plan participant during the COBRA
Qualified Beneficiary, for the purposes of CalCOBRA,
is any individual who on the date of the qualifying event is covered
under the plan pursuant to the Subscription Agreement of a CalCOBRA
participating employer and is not a CalCOBRA excluded member.
Qualified beneficiary also includes any child who is born to a
former plan participant of a CalCOBRA participating employer,
which plan participant is a qualified beneficiary who has
elected CalCOBRA coverage, or a child who is placed for adoption
with such a former plan participant so electing, if the child is
enrolled in the plan within 30 days after the child’s birth or
placement for adoption. Such entitlement to benefits, subject to applicable
terms and conditions, shall continue for the remainder of the period during
which the plan participant is covered under CalCOBRA.
Qualifying Event for the purposes of COBRA means any one of the following events that, but for election of coverage under COBRA or CalCOBRA, would otherwise result in a
loss of coverage under the plan to a qualified beneficiary:
- The death of the plan participant;
- Termination of employment or reduction in the plan participant’s employment, except
that termination for gross misconduct does not constitute a qualifying event;
- The divorce or legal
separation of the plan participant from the plan participant’s spouse;
- The loss of dependent status by a dependent child
enrolled in the plan; or
- With respect to any qualified beneficiary other than the plan participant,
the plan participant’s entitlement to benefits under Medicare.
Reasonable Charge is a charge the claims
administrator considers not to be excessive based on the circumstances
of the care provided, including: (i) level of skill; experience
involved; (ii) the prevailing or common cost of similar services
or supplies; and (iii) any other factors which determine value.
Referral Center functions as a contact point for the member.
The referral center answers questions and facilitates the Medical
Management Programs provisions of the plan.
Residential Treatment Center is an inpatient
treatment facility where the member resides in a modified community
environment and follows a comprehensive medical treatment regimen for treatment
and rehabilitation as the result of a mental or nervous disorder,
severe mental disorder, or substance abuse. The facility must be
licensed to provide psychiatric treatment of mental or nervous disorders,
severe mental disorders, or rehabilitative treatment of substance abuse
according to state and local laws.
Self-Administered Injectable Drugs are
injectable drugs which are self-administered by the subcutaneous
route (under the skin) by the beneficiary and labeled or
approved for self-administration by the Food and Drug Administration
Severe Mental Disorders include the following
psychiatric diagnoses specified in California Health and Safety Code section
1374.72: schizophrenia, schizoaffective disorder, bipolar disorder, major
depression, panic disorder, obsessive-compulsive disorder, pervasive
developmental disorder or autism, anorexia, and bulimia.
“Severe mental disorders” also includes serious
emotional disturbances of a child as indicated by the presence of one or more
mental disorders as identified in the Diagnostic and Statistical Manual (DSM)
of Mental Disorders, other than primary substance abuse or developmental
disorder, resulting in behavior inappropriate to the child’s age
according to expected developmental norms. The child must also meet one or more
of the following criteria:
- As a result
of the mental disorder, the child has substantial impairment in at least two of
the following areas: self-care, school functioning, family relationships, or
ability to function in the community and is at risk of being removed from the
home or has already been removed from the home or the mental disorder has been
present for more than six months or is likely to continue for more than one
year without treatment.
- The child is psychotic, suicidal, or potentially
- The child meets special education
eligibility requirements under California law (Government Code Section 7570).
Benefits for severe mental disorders will be provided
according to the plan’s benefits for medical conditions, and will not be
subject to plan provisions for mental or nervous disorders.
Nursing Facility is an institution that provides continuous skilled nursing
services. It must be licensed according to state and local laws and be
recognized as a skilled nursing facility under Medicare. For the purpose of
care provided for the treatment of mental or nervous disorders, severe
mental disorders, or substance abuse, the term “skilled nursing
facility” includes residential treatment center.
Care Units are special areas of a hospital which have highly skilled
personnel and special equipment for acute conditions that require constant
treatment and observation.
Sponsor means CalCPA.
meets the plan’s eligibility requirements for spouses as outlined under how coverage begins and ends.
is inpatient confinement which begins when you are admitted to a facility and
ends when you are discharged from that facility.
Subscription Agreement means the medical plan
Subscription Agreement entered into by a participating employer and
accepted by the trust.
Substance Abuse is abuse of a substance where the
abuse affects thinking or the ability to figure things out, perception, mood
and behavior. Treatment for substance abuse does not include smoking
cessation programs nor treatments for nicotine dependency or tobacco use.
Disabled Plan Participant is a plan participant who, because of
illness or injury, is unable to work for income in any job for which he or she
is qualified or for which he or she becomes qualified by training or
experience, and who is in fact unemployed.
Trust is the Group Insurance Trust of the California
Society of Certified Public Accountants.
Urgent Care is the services received for
a sudden, serious, or unexpected illness, injury or condition,
other than one which is life threatening, which requires immediate
care for the relief of severe pain or diagnosis and treatment
of such condition.