Tri-State Plan SPD >> Glossary

Allowed amount means the maximum the Fund will pay for a covered service. When you go in-network, the allowed amount is based on an agreement with the provider. When you go out-of-network, the allowed amount is based on the Fund's payment rate of allowed charges to a network provider.

Ambulette means ground transportation to or from a licensed medical facility. This is covered only as a home health care expense, meaning you need to be eligible for home health care in order to receive coverage for the ambulette.

Co-insurance means the 50% you pay toward eligible out-of-network medical expenses for the hospital and medical benefits; or the 20% or 50% you pay towards eligible dental plan expenses.

Contributing employer (or "employer") is a person, company or other employing entity that has signed a collective bargaining agreement or participation agreement with the union or trust, and the agreement requires contributions to the Health Fund for work in covered employment.

Co-payment means the flat-dollar fee you pay for office visits and certain covered services when you use in-network providers. The Plan then pays 100% of remaining covered expenses.

Covered employment means work in a classification for which your employer is required to make contributions to the Fund.

Covered services are the services for which the Fund provides benefits under the terms of the Plan.

Deductible means the dollar amount you must pay each calendar year before benefits become payable for covered out-of-network services.

Doctor means a licensed and qualified provider (M.D., D.O., D.C., or D.P.M.) who is authorized to practice medicine, perform surgery and/or prescribe drugs under the laws of the state or jurisdiction where the services are rendered, acts within the scope of his or her license and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

EAP means the Employee Assistance Program which includes benefits for behavioral and substance abuse treatment.

Emergency means a condition whose symptoms are so serious that someone who is not a doctor–but who has average knowledge of health and medicine–could reasonably expect that, without immediate medical attention, the following would happen:

• the patient's health would be placed in serious jeopardy
• there would be serious problems with the patient's body functions, organs or parts
• there would be serious disfigurement, or
• the patient or those around him or her would be placed in serious jeopardy, in the event of a behavioral health emergency.

Severe chest pains, extensive bleeding and seizures are examples of emergency conditions.

In-network benefits are benefits for covered services delivered by providers and suppliers who have contracted with the Fund, Empire, MHN, Medco or with any other administrators under contract to the Fund, to provide services and supplies at a pre-negotiated rate. Services provided must fall within the scope of their individual professional licenses.

Medically necessary, as determined by the applicable insurance carrier or the Fund, means services, supplies or equipment that satisfy all of the following criteria:

• are provided by a doctor, hospital or other provider of health services

• are consistent with the symptoms or diagnosis and treatment of an illness or injury; or are preventive in nature, such as annual physical examinations, well-woman care, well-child care and immunizations, and are specified by the Plan as covered
• are not experimental, except as specified otherwise in this booklet
• meet the standards of good medical practice
• meet the medical and surgical appropriateness requirements established under Empire BlueCross BlueShield medical policy guidelines
• provide the most appropriate level and type of service that can be safely provided to the patient
• are not solely for the convenience of the patient, the family or the provider, and
• are not primarily custodial.

The fact that a network provider may have prescribed, recommended or approved a service, supply or equipment does not, in itself, make it medically necessary.

For EAP purposes, medically necessary is subject to additional conditions. See the "EAP" section for information.

Mental disorder means a mental or nervous condition that meets all of the following conditions:

• it is a clinically significant behavioral or psychological syndrome or pattern
• it is associated with a painful symptom, such as distress
• it impairs a patient's ability to function in one or more major life activities, and
• it is a condition listed as an Axis I disorder (excluding V Codes) in the most recent edition of the "Diagnostic and Statistical Manual of Mental Disorders" by the American Psychiatric Association.

Network means the same as in-network.

Out-of-network provider/supplier means a doctor, other professional provider, or durable medical equipment, home health care or home infusion supplier who is not in the Plan's network for medical/hospital, vision, dental or behavioral health services. Out-of-network benefits are benefits for covered services provided by out-of-network providers and suppliers. (Under the Hospital/Medical Plan, this does not apply to members and their families covered by the EPO who do not have an out-of-network benefit as explained in the "About the Empire Networks" section .)

Participating provider means a provider that has agreed to provide services, treatment and supplies at a pre-negotiated rate under the dental, prescription drug and vision plans.

TRI-CARE (formerly CHAMPUS) is the health services and support program for U.S. Military Personnel on active duty, U.S. Military retirees, and their families.