Allowed Amount means the maximum amount that HealthSpan will pay for Covered Services received by a Covered Person.
Ambulance Services means ambulance transportation from a patient’s home, from the scene of an accident, or medical emergency to the hospital; between hospitals; between the hospital and a skilled nursing Facility; and from the hospital or skilled nursing Facility to a patient’s home. Authorized Representative means an individual who represents a Covered Person in an internal appeal or external review process of an Adverse Benefit Determination who is any of the following:
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• A person to whom a Covered Person has given express, written consent to represent that individual in an internal appeal process or external review process of an Adverse Benefit Determination;
• A person authorized by law to provide substituted consent for a Covered Person;
• A family member or a treating health care professional, but only when the Covered Person is unable to provide consent.
Coinsurance is a Covered Person’s share of the payment by the Plan for Covered Services (a percentage of the Allowed Amount).
Copayment or Copay is a Covered Person’s share of the cost of some Covered Services. Copayment is a specific dollar amount. Copayments are due and payable at the time services are provided.
Cosmetic Services means those services that are primarily intended to preserve, change or improve appearance or are furnished for psychiatric or psychological reasons.
Covered Person means the Member and Dependents. A Covered Person is sometimes called “you” and “your.”
Covered Services means an authorized service described in this Evidence of Coverage as being eligible for benefits and is rendered by a Provider for which HealthSpan will provide benefits. To be a Covered Service, supply or treatment must be: (a) Medically Necessary or otherwise specifically included as a benefit under this Evidence of Coverage; (b) not subject to the restrictions and exclusions stated in this Evidence of Coverage; (c) within the scope of the license of the Provider performing the service; (d) performed while this Evidence of Coverage is in effect; (e) not an Experimental/Investigative Service or an Excluded Service; or (f) authorized in advance by HealthSpan if required.
Creditable Coverage means prior coverage from a group plan, individual insurance policy, state risk pool, public health plan, Medicare, Medicaid, Indian Health Service, or Peace Corps service. Prior coverage does not count as Creditable Coverage if there was a break in coverage of sixty- three (63) days or more prior to applying for this coverage. If a Covered Person’s coverage with HealthSpan ends for any reason, the Covered Person will receive a “Certificate of Creditable Coverage” indicating the length of time the Covered Person as covered by HealthSpan without a sixty-three (63) day lapse in coverage. If a Covered Person buys health insurance through another plan, this certificate may help the Covered Person obtain coverage without a pre-existing condition exclusion.
Custodial Care is treatment or services that could be learned and performed by a person not medically skilled, regardless of where they are to be provided. Custodial Care includes, but is not limited to:
a. personal care such as help in walking, getting in and out of bed, bathing, eating, tube or gastrectomy feeding, exercising, dressing, enema and using the toilet.
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b. homemaking, such as preparing meals or special diets; c. moving the patient;
d. suctioning; e. catheter care;
f. acting as a companion or sitter;
g. supervising medication which is usually self-administered, and
h. preparation/supervision over medical supplies and/or medical equipment not requiring constant attention of trained medical personnel.
Deductible is the amount a Member must pay for Covered Services within each contract year before benefits will be paid by HealthSpan. The individual Deductible is the amount each Member must pay; the family Deductible is the total amount any two or more family members must pay.
Dependent means any member of a Member’s family who meets all the applicable eligibility requirements, who has enrolled, and for whom the payment required actually has been received by HealthSpan.
Designated Representative means any entity appointed by HealthSpan to administer managed care and/or cost containment programs for HealthSpan.
Domiciliary Care is care provided in a residential institution, treatment center, halfway house, or school because a Covered Person’s home arrangements are not available or are unsuitable and consists chiefly of room and board, even if therapy is included.
Effective Date is the date a Member’s coverage beings under this Evidence of Coverage.
Eligible Person means a person who satisfies the Plan’s eligibility requirements and is entitled to apply to be a Member or Dependent.
Emergency Medical Condition, as defined in Section 1753.28 of the Ohio Revised Code, means a medical condition that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: (a) placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn Child, in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. An Emergency Medical Condition also includes a behavioral health emergency where the Covered Person is acutely suicidal or homicidal.
Emergency Care or Emergency Services means the following: (a) a medical screening examination, as required by federal law, that is within the capability of the emergency
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department of a hospital, including ancillary services routinely available to the emergency department, to evaluate an Emergency Medical Condition; and (b) such further medical examination and treatment that are required by federal law to Stabilize an Emergency Medical Condition and are within the capabilities of the staff and facilities available at the hospital, including any trauma and the burn center of the hospital.
Evidence of Coverage means this certificate issued to Covered Persons that sets out the coverage and other rights to which Covered Persons are entitled under the Plan.
Excluded Services means those services that are not Covered Services.
Experimental/Investigative Services is any treatment, procedures, Facility, equipment, drug, device or supply that the Plan does not recognize as accepted medical practice or which did not have required governmental approval when received by a Covered Person. This includes treatments and procedures that: (a) are still in the investigative research state; (b) have not been adopted for general clinical use; (c) have not been approved or accepted by the appropriate review body; or (d) are not generally accepted by the local medical community as safe, appropriate, and effective treatment. HealthSpan makes the determination of whether a service is experimental.
Facility is any hospital or other medical care center, agency or institution.
Final Adverse Benefit Determination means an Adverse Benefit Determination that is upheld at the completion of HealthSpan‘s internal appeal process.
Group means the employer or other entity that has entered into a Group Contract with HealthSpan.
Group Contract (or Contract) means the contract between the Group and HealthSpan, which includes this Evidence of Coverage, the Schedule of Benefits, the application, any supplemental application or change form, the Member I.D. Card, and any endorsements or riders.
Home Health Agency is a Facility or program that is licensed, certified or otherwise authorized pursuant to the laws of the State of Ohio as a home health agency and is under contract with HealthSpan to provide the home health care covered by this Evidence of Coverage.
Independent Review Organization or IRO means an entity that is accredited to conduct independent external reviews of Adverse Benefit Determinations. An IRO is generally an independent third party accredited by a nationally recognized private accrediting organization and the Superintendent.
Inpatient means a Covered Person who receives care as a registered bed patient in a hospital or other Provider where a room and board charge is made. An “Inpatient” does not include a Covered Person who is placed under observation for less than twenty-four (24) hours.
Limiting Age means the end of the month of the Dependent’s twenty-sixth (26th) birthday. See the Evidence of Coverage for optional extension to age twenty eight (28).
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Medicaid has the same meaning as in Section 5111.01 of the Ohio Revised Code.
Medically Necessary means those services determined by HealthSpan or its Designated Representative to be (a) preventative, diagnostic and/or therapeutic in nature; (b) specifically related to the condition which is being treated/evaluated; (c) rendered in the least costly medically appropriate setting, (e.g., Inpatient, Outpatient, office), based on the severity of illness and intensity of service required; (d) not solely for the Covered Person’s convenience or that of his or her Physician; (e) provided in accordance with applicable medical and/or professional standards; (f) known to be effective, as proven by scientific evidence, in materially improving health outcomes; (g) not an Experimental/Investigative Service; and (h) not otherwise an Excluded Service.
Medicare means the program established under Title XVIII of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C. 1395, as amended.
Member means a person who is an employee or member of the Group and who is eligible to receive benefits under the Group Contract. This person enrolls as the contract holder in accordance with those requirements, and is responsible for payment. A Member is sometimes called “you” and “your.”
Member Identification (“I.D.”) Card is a card that HealthSpan issues to each Member. The Member I.D. Card indicates the Covered Persons’ Copayment and Coinsurance.
Non-Covered Service means any health care item or service that is not a Covered Service or is excluded as a benefit under this Evidence of Coverage. Non-Covered Services include those items and services that HealthSpan determines, in its sole discretion, are not Medically Necessary.
Non-Participating Provider means a Physician, hospital, or other licensed health professional or licensed Facility who or which, at the time care is rendered to a Covered Person, does not have a contract with HealthSpan to furnish Covered Services to Covered Persons.
Outpatient means a Covered Person who receives services or supplies while not an Inpatient. Participating Hospital means any hospital with which HealthSpan has a contract or established arrangements to furnish covered services to Covered Persons.
Participating Pharmacy means a pharmacy that is a Participating Provider.
Participating Provider means a Physician, hospital, pharmacy, or other licensed health professional or licensed Facility, who or which, at the time care is rendered to a Covered Person, has a contract with HealthSpan to furnish Covered Services to Covered Persons.
Participating Specialist Physician means a Specialist Physician who is a Participating Provider. Physician means a doctor of medicine, doctor of osteopathy, podiatrist or surgical chiropodist, dental surgeon, chiropractor, or doctor of optometry, licensed under applicable state law.
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Plan means the health benefits plan sponsored by the Group for which benefits are provided Member and Dependents for Covered Services.
Premium means the periodic charges which the Member or Group must pay HealthSpan to maintain coverage.
Primary Care Provider or PCP means a Participating Provider who is designated by HealthSpan as a PCP to supervise, coordinate, or provide initial care or continuing care to a Covered Person, and who may be required by HealthSpan to initiate a referral for specialty care and to maintain supervision of health care services rendered to Covered Person. PCPs are those specializing in family practice, internal medicine, or pediatrics.
Provider means any natural person or partnership of natural persons who are licensed, certified, accredited, or otherwise authorized in the State of Ohio to furnish health care services, or any professional association organized under Chapter 1785 of the Ohio Revised Code.
Schedule of Benefits is the description of Covered Services and Benefits and Restrictions and Excluded Services.
Service Area means the geographical area in which Covered Services are available, as approved by state regulatory agencies.
Specialist Physician means a Physician who provides Covered Services to Covered Persons within the range of his or her medical specialty and who has chosen to be designated as a Specialist Physician by HealthSpan.
Spouse means the person who is legally married to a Member.
Stabilize means the provision of such medical treatment as may be necessary to assure, within reasonable medical probability, that no material deterioration of an individual’s medical condition is likely to result from or occur during a transfer, if the medical condition could result in any of the following: (a) placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. In the case of a woman having contractions, “Stabilize” means such medical treatment as may be necessary to deliver, including the placenta.
Superintendent means the Superintendent of the Ohio Department of Insurance.
Urgent Care Services means those health care services that are appropriately provided for an unforeseen condition of a kind that usually requires medical attention without delay but that does not pose a threat to the life, limb, or permanent health of the injured or ill person, and may include such health care services provided out of HealthSpan’s approved Service Area pursuant to indemnity payments or service agreements.
Urgent Medical Condition is an unexpected illness or injury that requires medical attention soon after it appears but that is not an Emergency Medical Condition.
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Working Actively means present and capable of carrying out the normal assigned job duties of the Group. Members who are absent from work due to a health related disability, maternity leave, or regularly scheduled vacation will be considered Working Actively.
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