Managed Care POS Glossary

What Do the Benefit Terms Mean

Benefit terms have precise (and sometimes complex) meanings. Here are some terms that appear often in this site,

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Advance Approval The process of requiring the patient to contact Aetna to obtain authorization in advance for hospitalization, certain outpatient surgical and diagnostic procedures, and alternate care. Failure to obtain an advance authorization will result in a decrease in benefits payable under the plan. This process applies to out-of-network and out-of-area benefits only.

Alternate Care Care that can be provided less expensively than hospital confinement with equal effectiveness, such as skilled nursing facility care, home health care, and hospice care.

Annualized Base Pay The annualized rate of base pay for a covered employee. For purposes of the plan, annualized base pay does not include:

Any amounts exceeding straight-time pay such as bonuses or other similar pay based upon performance, output or product sales
Any amount resulting from rehabilitation or disability payments of less than 100% of base pay
Pay for vacation not taken
Company contributions to any benefit plan
Expense allowances
Overtime
Shift premium
Foreign service premiums
Relocation payments
Tuition payments
Patent awards
Other similar awards or payments.

Case Management A process to plan, organize, and approve the quantity and sequence of medical services and resources to respond to a covered person's health care needs. This may include alternative medical treatment in appropriate settings that are less expensive than acute care hospitals.

Coordination of Benefits A method of determining the amount Managed Choice POS coverage pays, and the order in which it pays, if there is other group coverage.

Copayment The payment the patient makes to a provider for a covered service or prescription drug.

Covered Expenses Expenses that may be used as the basis for the payment of benefits by the plan.

Covered Person Eligible employees and dependents. For medical coverage, dependents must be enrolled in the plan.

Custodial Care Care rendered to a patient that:

Provides a level of routine maintenance for the purpose of meeting personal needs
Can be provided by a nonprofessional who does not have professional qualifications, skills, or training, and
Includes, but is not limited to, help in walking, getting into or out of bed, bathing, dressing, eating, and other functions of daily living; administration of or help in using or applying medications, creams, or ointments; routine administration of medical gases after regimen of therapy has been set up; routine care and maintenance in connection with equipment and supplies, such as casts and braces, indwelling catheters, colostomy and ileostomy bags, routine tracheostomy care, and general supervision of exercise programs; and routine care of a patient, including functions such as changing dressings, diapers, and sheets and periodic turning and positioning in bed.

A custodial care determination is not precluded by the fact that a patient is under the care of a supervising or attending physician and that services are being ordered and prescribed to support and generally maintain the patient's condition, provide for the patient's comfort, or ensure the manageability of the patient. Further, a custodial care determination is not precluded because the ordered and prescribed services and supplies are being provided by an R.N.

Deductible That portion of covered expenses that each covered person must pay each calendar year before plan benefits begin. This applies to out-of-network and out-of-area benefits only.

Dependents Family members who may be eligible for coverage under the plan. This generally includes a spouse and all eligible children. If your spouse is employed by a company that provides employee health care benefits, he or she must be enrolled in that plan to be eligible for coverage under Managed Care POS.

Detoxification (Acute Inpatient Substance Abuse Treatment) Generally indicated in the following situations:

Life or vital bodily function is threatened as a result of acute, excessive use, or the consequences of withdrawal from a substance(s) and
Failure to use acute inpatient treatment can be expected to significantly increase the risk of loss of life or permanent impairment of bodily function once use has stopped.

Acute inpatient detoxification can occur in acute inpatient psychiatric units, acute inpatient medical-surgical units, and residential substance abuse rehabilitation programs.

This level of treatment requires comprehensive and intensive medical evaluation and treatment by experts within a 24-hour structured and supervised setting.

Disability A condition which entitles a covered employee to a benefit under the company disability plan for employees covered by a bargaining agreement or a mental or physical handicap which causes an enrolled dependent to be unable to earn a living.

Doctor See physician.

Educational or Vocational The primary purpose of a service or supply is to provide the patient with any of the following:

Training in the activities of daily living,
Instruction in scholastic skills such as reading and writing, or
Preparation for an occupation or treatment for learning disabilities.

ERISA The Employee Retirement Income Security Act (ERISA) of 1974 as amended from time to time.

Evidence of Good Health A prescribed statement or proof about a person's physical condition provided to Aetna to determine acceptance for coverage.

Experimental or Investigational The use of a service or supply which is under study and is not yet recognized throughout the physician's profession in the United States as safe and effective for diagnosis or treatment. This includes, but is not limited to, all phases of clinical trials, all treatment protocols based upon or similar to those used in clinical trials, drugs approved by the Federal Food and Drug Administration under its Treatment Investigational New Drug regulation, and Federal Food and Drug Administration approved drugs used for unrecognized treatment indications.

Explanation of Benefits (EOB) The detailed explanation of the amount of reimbursement for an out-of-network or out-of-area medical or dental claim

Home Health Care Agency A home health care service organization or agency possessing a valid certificate issued in accordance with such public health law, or similar legally valid credential, authorizing such organization or agency to provide home health care services.

Home Health Care Plan A plan for care and treatment of a patient in the home. To qualify, the plan must be established and approved in writing by a physician who certifies that the patient would require confinement in a hospital or skilled nursing facility without the care and treatment stated in the plan. The plan includes any or all of the following:

Part-time or intermittent skilled nursing by a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) under the supervision of an R.N.
Part-time or intermittent home health aide service under the supervision of an R.N. or a physical, occupational, speech or respiratory therapist
Physical, occupational, speech or respiratory therapy by a qualified therapist
Nutrition counseling furnished or supervised by a registered dietitian
Laboratory tests
Medical supplies and equipment, to the extent such items would have been covered if the patient had been hospitalized
Prescription drugs and medicines.

Hospice An organization that provides care for a terminally ill person in a homelike setting or at home. A hospice facility may be either freestanding or affiliated with a hospital.

Hospice Care Program A program provided by a hospice team of professionals and volunteers that:

Meets standards set by the National Hospice Organization and approved by Aetna,
Fulfills any licensing requirements of the state or locality in which it operates,
Is directed by a physician, and
Provides palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness.

Hospital An institution accredited as a hospital under the hospital accreditation program of the joint Commission on the Accreditation of Healthcare Organizations or any other institution operated pursuant to law, under the supervision of a staff of physicians and with 24-hour a day nursing services, and primarily engaged in providing:

General inpatient medical care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which must be provided on its premises or under, its control or
Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital or with a specialized provider of those facilities.

A hospital does not include an institution (or part thereof) which is principally a convalescent hospital, extended care facility, or skilled nursing facility or is operated primarily as a school or place of rest or furnishes primarily domiciliary or custodial care.

Illness A physical or mental ailment. This term includes pregnancy.

Injury Accidental damage to some part of the body.

Inpatient A person who has been admitted to a hospital as a registered bed patient and is receiving covered services under the direction of a physician.

Managed Choice POS The name of the company health care program that includes in-network, out-of-network, and out-of-area benefits through an administrative services contract with Aetna, and a separate psychiatric and substance abuse network through an administrative services contract with Value Options. There may be different carriers for prescription, dental, vision, and hearing aid programs.

Medicaid A state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.

Medically Necessary Services or Supplies Medical services or supplies that meet all of the following criteria:

They are appropriate and necessary for the symptoms the patient has and provide for the diagnosis or direct care and treatment of the medical condition.
They are within the standards of good medical practice in the organized medical community.
They are not primarily for the convenience of the patient or the health care provider.
They are the most appropriate level of service or supply that can be safely provided. (When applied to hospitalization the term “medically necessary” means that acute care as an inpatient is necessary because of the kind of services the patient is receiving or the severity of the patient's condition. It also means that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.)

Medicare Hospital insurance and supplementary medical insurance under Title XVIII of the Social Security Act of 1965 as amended.

Mental Health Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or substance abuse disorder.

Non-occupational Illness An illness that does not arise from (or in the course of) any work for pay or profit, nor in any way results from an illness which does. However, if proof is furnished that the individual is covered under a workers' compensation law or similar law but is not covered for a particular illness under such law, that illness will be considered non-occupational regardless of cause.

Nurse A professionally trained individual who is either a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), or a Licensed Vocational Nurse (L.V.N.), other than a nurse who resides in the covered person's home or is a member of the covered person's family

Oral Surgery Surgery of the oral mouth cavity (including teeth, tongue, or neck) that may be dental or nondental in nature.

Out-of-Pocket Maximum The most a patient will pay for covered expenses in a calendar year, including the deductible. After this amount, the plan pays 100% of any additional covered expenses for the rest of the plan year. This applies to out-of-network and out-of-area benefits.

Outpatient A person receiving covered services other than as a registered, admitted bed patient, under the direction of a physician.

Participant A covered employee or an enrolled dependent of that employee.

Physician Any professional practitioner who holds a lawful license authorizing the person to practice medicine or surgery in the locale in which the service is rendered, limited to a Doctor of Medicine (M.D.), a Doctor of Osteopathy (D.O.), a Doctor of Podiatric Medicine (D.P.M.), a Doctor of Dental Surgery (D.D.S.), a Doctor of Chiropractic (D.C.), a Doctor of Optometry (O.D.), or a psychologist (Ph.D). As used herein, the term 'psychologist' shall be limited to a practitioner licensed or certified in the state where the service is rendered, who has a doctorate degree in psychology and has had at least two years clinical experience in a recognized health setting, or has met the standards of the National Register of Health Service Providers in Psychology. For purposes of out-of-network benefits, physician will not include a Doctor of Chiropractic (D.C.). For purposes of the disability income program, some of the listed providers may not be able to certify disability. Refer to your disability plan description for more information.

Plan The Managed Choice POS Plan.

Plan Administrator The person or group of persons designated by the legal plan document responsible for most day-to-day activities of the plan. These activities include determining eligibility for benefits, processing claims and appeals regarding claims, maintaining plan records, and distributing plan information to participants through various communication materials. For Managed Choice POS, the plan administrator is Vought Aircraft.

Primary Care Physician The physician chosen from the Managed Choice POS Provider Directory to manage a participant's health care under Managed Choice POS network benefits.

Private Duty Nursing Services provided by an R.N., L.V.N., or L.P.N. And covered only when they are recommended by your PCP and medically necessary to the care and treatment of injury or illness. Custodial care is not covered.

Inpatient private duty nursing benefits may be payable in rare instances when ICU is not available or its services are not sufficient. Services must be over and above the care that could be rendered by the floor nurse or in the ICU unit of a hospital.

Provider For purposes of the Managed Choice POS mental health network, the following qualified mental health professionals: psychiatrist, licensed clinical psychologist legally licensed to practice where services are rendered, psychiatric social worker or psychiatric nurse specialist acting within the scope of his or her license, or, if approved by Value Options, a masters-level counselor. For the purposes of the Managed Choice POS medical and surgical network, provider means those professionals or facilities included in the Managed Choice POS Provider Directory. For out-of-network and out-of-area benefits, provider means a professional or facility that provides health services or supplies.

Second Surgical Opinion An opinion of a board-certified specialist, based on examination of the patient, of the advisability of a recommended non-emergency surgical procedure.

Sickness See illness.

Skilled Nursing Facility A specially qualified facility which has the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services. Skilled nursing care can only be performed by, or under the supervision of, licensed nursing personnel. Skilled rehabilitation services may include such services as physical therapy performed by or under the supervision of a professional therapist.

A skilled nursing facility does not include an institution, or part of one, that is used mainly as a place for rest or for the aged.

Usual and Prevailing Rates The allowable expense based on the usual charge for the service or supply when there is no benefits coverage and the range of charges generally made in the geographical area for a like service or supply. Expenses that exceed usual and prevailing rates are not covered.