A pre-established payment that must be made by the Member under the particular Plan Option of benefits, e.g., for an office visit, emergency, etc.
- Covered Service or Covered Expense
A service or charge that is allowable under the Plan for a service or supply specified in the Plan, which is Medically Necessary and which is rendered by an eligible Provider or supplier.
A specified amount of Covered Services, usually expressed in dollars as the sum of out-of-pocket expenses that must be paid by the Member before the Plan will assume liability for all or part of the remaining Covered Service provided.
A person who meets the eligibility requirements of the Plan and has been enrolled by the PEBTF as an eligible dependent.
- HMO (Health Maintenance Organization)
An HMO appropriately approved and licensed by relevant authorities, with whom the PEBTF has established a relationship obligating the HMO to offer to eligible PEBTF Members benefits and services.
- In Network
Under the PPO, HMO, CDHP, Mental Health and Substance Abuse Plan, Dental HMO and DMEnsion, care received from the Member's Primary Care Physician or from an In-Network specialist.
A Member who is treated as a registered bed patient in a Hospital or Facility Other Provider and for whom a room and board charge is made.
- Medically Necessary (or Medical Necessity)
Services or supplies provided by a Hospital or Other Facility Provider, or by a Physician or Other Professional Provider that the Claims Payor - PPO, HMO, CDHP, Blue Cross or Mental Health and Substance Abuse Plan Provider, or the PEBTF - determines are:
(a) appropriate for the symptoms and diagnosis or treatment of the Member's condition, Illness, disease, or Injury;
(b) provided for the diagnosis, or the direct care and treatment of the Member's condition, Illness, disease, or Injury;
(c) in accordance with standards of good medical practice;
(d) is not primarily for the convenience of a Member or the Member's Provider; and
(e) the most appropriate supply or level of service that can be provided safely to the Member. When applied to hospitalization, this further means that the Member requires acute care as a bed patient due to the nature of the services rendered or the Member's condition, and the Member cannot receive safe or adequate care as an Outpatient.
The health insurance benefits provided under Title XVIII of the Social Security Act of 1965 (Federal Health Insurance for the Aged Act), as presently constituted or as hereafter amended.
Any enrolled person eligible for benefits under the Plan and includes eligible employees, their eligible dependents, eligible COBRA beneficiaries, and eligible surviving spouses.
The group of providers of medical care, services and supplies approved by the particular PPO, HMO, CDHP, Dental HMO or DMEnsion as eligible providers under the PPO, HMO or CDHP Options. It shall also mean the group of providers approved by the Mental Health and Substance Abuse Plan and Dental Plans as well.
- Open Enrollment
That period of time specified by the PEBTF during which Members may, in accordance with the established eligibility rules of the PEBTF, change the Plan Option in which they are enrolled.
Under the PPO, CDHP, Mental Health and Substance Abuse Plan of DMEnsion, care received without the Member contacting the Primary Care Physician or received from a non-Network provider. Out-of-Network care and Plan payment are subject to deductibles, co-payments and UCR limits. There is no Out-of-Network benefit for HMO Members.
- Out-of-Pocket Maximum
Under the PPO and CDHP, the amount the Member pays out of pocket before the Plan begins to cover 100% of the eligible Out-of-Network costs. Out-of-pocket maximum also applies under PEBTF Major Medical.
A person who receives services or supplies while not an Inpatient.
- PPO (Prefered Provider Organization)
The statewide plan that offers both a network and an out-of-network benefit. In order to receive the highest level of benefits, members must choose one of the network providers or facilities.
- Primary Care Physician (PCP)
Under the HMO Option, the doctor the Member chooses to coordinate his care. PCP's are family practice doctors, general practitioners, internists, pediatricians and, if approved by the particular HMO, obstetrician-gynecologists. The Member also chooses a Primary Dental Office (PDO) under the Dental HMO Option.
- Usual, Customary and Reasonable (UCR) Allowance
The fee determined and payable by the Claims Payor (under the applicable Plan Option) for Covered Services in accordance with:
(a) The usual fee which an individual Professional Provider most frequently charges to the majority of patients for the procedure performed;
(b) The customary fee determined by the Claims Payor based on charges made by Providers of similar training and experience in a given geographic area for the procedure performed; or
(c) The reasonable fee (which may differ from the usual or customary charge) determined by the Claims Payor by considering unusual clinical circumstances; the degree of professional involvement; or the actual cost of equipment and facilities involved in providing the service.