Summary Plan Description
This section is an alphabetical listing of terms and their definitions which help describe plan benefits and provisions.
The following definitions apply to the plan:
- Ambulatory surgical center means any public or private establishment which fully meets all of the following criteria:
- Is licensed as such by the state.
- Is Medicare certified.
- Has an organized medical staff of physicians.
- Has permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures.
- Provides continuous physician and registered professional nursing services whenever a patient is in the facility.
- Maintains a medical record for each patient.
- Has a written agreement with a local acute care hospital for the immediate transfer of patients who require greater care than can be furnished at the facility.
- Complies with all licensing and other legal requirements.
- Is not the office or clinic of one or more physicians.
- Is the most appropriate supply or level of service needed to provide safe and adequate care as determined by the plan.
- American Dental Association (ADA) specialist means a specialist as approved by the ADA including practices limited to public health, endodontics, oral pathology, oral and maxillofacial surgery, orthodontics, pedodontics, periodontics, and prosthodontics. The specialists must also meet the general standard requirements set forth by the ADA as to education and licensing.
- Associate employee means a non-bargaining employee covered as an "associate employee" under a written contribution agreement between an Individual Employer and the Trustees. The acceptance of non-bargaining employees of any and every Individual Employer shall be entirely discretionary with the Trustees and shall be subject to whatever definitions, rules, terms and conditions the Trustees may impose.
- Benefit maximum means a maximum amount of benefits that will be paid by the plan for a specified type of covered charge incurred during a given period of time.
- Board of Trustees or Board means the Board of Trustees established by the Trust Agreement.
- Building and construction industry means the various trades and related positions associated with the building and construction industry including, but not limited to, the specific trades represented by the collective bargaining agreements and written contribution agreements recognized by the Board of Trustees.
- Calendar year means a period that starts on January 1 at 12:01 a.m. and ends on December 31 at midnight of each year.
- Carpenter, employee or participant means any individual for whom an employer (as defined by the Trust Agreement) makes contributions or has previously made contributions who qualifies for plan benefits in accordance with the eligibility provisions (as amended from time to time) and is still eligible for or is receiving benefits under the plan.
- Certified Nurse Midwife (CNM) means a registered nurse who has gained the special knowledge and skills of midwifery in an educational program accredited by the American College of Nurse-Midwives and who is licensed in the State of Washington by the Board of Registered Nursing as a nurse-midwife or the equivalent department of another state.
- Coinsurance means the percentage of covered expenses each participant, retiree and dependent pays each calendar year.
- Congenital anomaly or hereditary complication means a condition existing at or from birth that creates a functional problem and is a significant deviation from the common form or norm.
- Copayment means a specified dollar amount each participant, retiree and dependent pays each time certain covered charges are incurred.
- Cosmetic surgery or services (including any complications direct or indirect) means any operative procedure, any portion of an operative procedure or any other treatment performed primarily for the purpose of improving or reshaping structures of the body in order to enhance a patient's appearance and self-esteem, and is not needed to correct or improve a bodily function. Cosmetic procedures can have psychological benefits by improving a patient's body image and self-esteem and may also have some medical benefit, even if this is not the main reason for the treatment.
- Covered charges or expenses as determined by this plan, means the medically necessary and maximum allowable fee as determined by this plan for services or supplies covered by this plan and incurred while the patient is eligible under this plan. "Covered charges" and "covered expenses" do not include services or supplies that fall within the exclusionary provisions of this plan, exceed benefit maximums or are not covered as a result of a benefit reduction under the medical review program, even if that service or supply is recognized as a "covered charge" under any of the other plans involved or Medicare.
- Covered provider means any healthcare provider who is acting within the scope of that provider's license or certificate under applicable state law. Benefits for some types of services furnished by providers may be limited or excluded under this plan, including "Glossary of Terms" and "General Limitations and Exclusions." Certain licensed or certified professionals providing services covered by this plan may be required to be under the supervision of an MD, DO, DDS, or DMD as determined by the plan.
- Custodial care means care that consists of services and supplies that are given mainly to help a patient meet the activities of daily living, whether or not the patient is disabled, and that are not rendered mainly for their therapeutic value in the treatment of an illness or injury. Custodial care includes, but is not limited to, care such as:
- Care mainly to provide room and board.
- Preparation of special diets.
- Supervision of the administration of medications that can usually be self-administered.
- Care not requiring constant attention of trained medical personnel.
- Personal care such as helping a patient walk, get in and out of bed, bathe, dress, eat, or use the toilet.
- Deductible means the amount of covered charges the participant, retiree and dependent is responsible for each calendar year before the plan's medical benefits are considered.
- Dependent means the participant's or retiree's lawful spouse and dependent children who qualify for coverage under the provisions of this plan as defined. Please refer here for the definition of "dependent" that applies to retiree health reimbursement accounts.
- Employer contributions means the contributions that an Individual Employer is required to make to the Carpenters Health and Security Plan of Western Washington under the terms of a collective bargaining agreement recognized by the Board of Trustees or a written contribution agreement recognized by the Board of Trustees.
- Enrollment, enroll or enrolled means the receipt by Carpenters Trusts of the necessary enrollment forms and documents that have been properly completed and signed by the participant or retiree. It also means to become covered for benefits under a group health or other plan (that is, when coverage becomes effective) without regard to when the individual may have completed or filed any forms that are required in order to enroll in the plan.
- Experimental or investigative means:
- The drug or device cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and approval for marketing has not been given for regular nonexperimental or noninvestigational purposes at the time the drug or device is furnished; or
- The drug, device, medical treatment, or procedure has been determined to be an experimental or investigational procedure by the treating facility's institutional review board, treating practitioner, or other body serving a similar function, and the patient has signed an informed consent document acknowledging such experimental status; or
- Federal law classifies the drug, device, or medical treatment under an investigative program; or
- Reliable evidence shows the drug, device, medical treatment, or procedure is the subject of on-going phase I, II or III clinical trials or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis; or
- Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis.
Notwithstanding the foregoing, routine patient costs for items and services furnished in connection with an approved clinical trial will not be considered experimental or investigational if the item or service would otherwise be a covered charge for an individual who is not enrolled in the clinical trial. An approved clinical trial is a phase I, II, III, or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition. The individual must be eligible to participate in the approved clinical trial according to the trial protocol. The following are not covered:
- The actual clinical trial or the investigational team;
- Items and services solely for data collection that are not directly used in the clinical management of the patient; or
- Services that are clearly inconsistent with widely accepted and established standards of care for a particular condition.
The plan will investigate each claim for benefits which might include experimental or investigational treatment. The plan will consult with medical professionals to determine whether the treatment is excluded as experimental or investigational. The plan may rely on the advice of these medical professionals in deciding all claims and appeals related to experimental or investigational services or supplies.
- Extension of benefits means certain benefits are extended beyond the date dollar bank eligibility terminates under this plan.
- Full-time student means the dependent child is attending an educational organization which normally maintains a regular faculty and curriculum and normally has a regularly enrolled body of pupils or students in attendance at the place where its educational activities are regularly carried on. "Full-time" means 12 or more quarter, trimester, or semester hours. Students are also eligible during the summer months as long as they attend school full time before the summer and did not graduate. Proof of student status is required each quarter, trimester, or semester. The student must also primarily depend on you for support and maintenance. If a full-time student is required to reduce his or her class schedule below 12 hours because of a medically necessary leave of absence, the plan can extend coverage through the end of that quarter, trimester or semester. Similarly, if a student who was full-time during the spring but was required to reduce his or her class schedule below 12 hours in the fall, the plan can extend coverage through the summer. A leave of absence is deemed "medically necessary" only if the plan receives written certification from the student's treating physician stating that the student is suffering from a serious illness or injury and that the leave of absence or change of enrollment is medically necessary. The participant must be covered under the plan during the leave of absence for a student to qualify for the leave. Attendance at the following programs do not qualify the child as a full-time student:
- On-the-job training courses.
- Apprenticeship programs.
- Correspondence schools including web-based programs.
- Night schools.
- Job corp.
- General educational development (GED).
- Habilitative/habilitation services means health care services that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age or who has delayed speech articulation skills and has not been clinically diagnosed with a neurodevelopmental disorder.
- Home health care agency means a public or private agency or organization (or subdivision of such an agency or organization) that administers and provides home health care and is either a Medicare-certified home health care agency or certified as a home health care agency by the Washington State Department of Social and Health Services or the equivalent department of another state.
- Hospice agency means a public or private agency or organization that administers and provides hospice care and is either a Medicare-certified hospice agency or certified as a hospice care agency by the Washington State Department of Social and Health Services or the equivalent department of another state.
- Hospital means an institution which fully meets every one of the following criteria:
- Is primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic, surgical and therapeutic services for the diagnosis, treatment and rehabilitation of injured, disabled or sick persons.
- Maintains clinical records on all patients.
- Has bylaws in effect with respect to its staff of physicians.
- Has a requirement that every patient be under the care of a physician.
- Provides 24 hour nursing service rendered or supervised by a registered, professional nurse.
- Has in effect a hospital utilization review plan.
- Is licensed pursuant to any state or agency of the state responsible for licensing hospitals.
- Has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.
- Illness means a sickness, disorder or disease and all related symptoms and recurrent conditions resulting from the same causes. Only illnesses or injuries that are not employment related are considered for benefits under this plan.
- Incurred means the date the service or supply is received or the purchase is made rather than the date the bill is received.
- Injury means physical damage to the body caused by purely accidental means, such as external force, independent of all other causes requiring immediate medical attention. Only injuries that are not employment related are considered for benefits under this plan, except as provided for under "Life Insurance and Accidental Death and Dismemberment Benefits."
- Inpatient refers either to the setting in which medical care is given or to a person who is receiving care in that setting. Inpatient means that the care is furnished to a patient while the patient is confined in a facility as a registered bed patient.
- Intensive outpatient program (IOP) is a kind of treatment service and support program used primarily to treat eating disorders, depression, self harm, and chemical dependency that does not rely on detoxification. IOP operates on a small scale and does not require the intensive residential or partial day services typically offered by the larger, more comprehensive treatment facilities. The typical IOP offers group and individual services of 10-12 hours per week. IOP allows the individual to participate in his or her daily affairs such as work and then participate in treatment at an appropriate facility in the morning or at the end of the day.
- Maximum allowable fee means the following:
- For network providers, it is the contracted rates.
- For non-network providers, it is the 90th percentile of what like providers charge for the same service in their zip code.
- For network and non-network providers, it is the multiple surgical procedure reductions (100 percent for the first procedure/50 percent for the second procedure/25 percent for the third procedure). Assistant surgeon is limited to a percentage of the maximum allowable fee allowed by the plan for the surgeon.
- For RAP providers (e.g., a network facility but the emergency room doctor or radiology provider is non-network), it is 90th percentile of what like providers charge for the same service in their zip code.
- Medically necessary means those covered services and supplies which are, in the judgment of the plan, determined to meet all of the following requirements. They must be:
- Essential to the diagnosis or the treatment of an illness, injury or condition and could not have been diagnosed or treated without it.
- Consistent with the symptom or diagnosis and treatment of the condition.
- Generally recognized by the medical profession as tested and accepted medical practice in accordance with authoritative medical or scientific literature.
- The most appropriate supply or level of service that is vital to the patient's needs.
- Not primarily for research or data accumulation.
- Not primarily for the convenience of the patient, the patient's family, the patient's provider, or another provider.
- Neither experimental or investigative and not in conflict with accepted medical standards.
In administering the plan, the Board of Trustees has authorized Carpenters Trusts and any medical review organization used by the plan to utilize internal guidelines and medical protocols in determining whether or not specific services or supplies are covered under by the plan.
- Medicare means the program established under Title XVII of the Social Security Act (Federal Health Insurance for the Aged) as it is presently constituted or may hereafter be amended.
- Medicare-eligible retiree means a retiree or dependent who is eligible for Medicare and covered under Retiree Coverage.
- Medicare entitlement means receiving coverage from Medicare. Normally this is accomplished when a person who is age 65 signs up for Social Security benefits, which automatically enrolls the person in the Medicare program. Medicare coverage also is possible with end-stage renal disease, generally beginning three months after treatment begins, or for a person younger than age 65 who Social Security deems disabled, effective on the first day of the 25th month after the date the person's Social Security disability began. Social Security disability benefits do not begin until the sixth full month of disability.
- Myofascial pain dysfunction syndrome (MPDS) means a disorder involving muscles of the temporomandibular joint (TMJ) area which is generally characterized by:
- Preauricular, temporal, occiput, and/or jaw pain.
- Spasm and/or tenderness of the masticatory muscles.
- Limited jaw movement.
- The occasional sound of a click in the joint (TMJ).
- Participant means the employee or carpenter.
- Physician refers to a legally qualified physician or surgeon practicing within the scope of his or her license as a Medical Doctor (MD), Osteopath (DO), Naturopath (ND), Podiatrist (DPM), or Doctor of Dentistry (DDS, DMD).
- Plan means this document outlining benefits provided by the Carpenters Health and Security Plan of Western Washington.
- Residential treatment center means a facility which provides inpatient and partial day inpatient programs to treat alcohol and drug dependence or mental conditions, but that is not licensed to provide inpatient care. The center must be licensed or otherwise approved to provide this care by the state in which it is located.
- Retired carpenter or retiree means any person who meets the eligibility requirements for Retiree Coverage under this plan.
- Skilled nursing facility means an institution, or distinct part thereof, recognized as such by Medicare and approved by Medicare for payment which also fully meets every one of the following criteria:
- It is licensed to provide, and is engaged in providing, on an inpatient basis, for patients convalescing from an illness or injury, professional nursing services rendered by a registered nurse (RN) or by a licensed practical nurse (LPN) under the direction of a registered nurse; and physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential daily living activities.
- Its services are provided for compensation from its patients and under the full-time supervision of a physician or registered nurse.
- It provides 24-hour-per-day skilled nursing services by licensed nurses, under the direction of a full-time registered nurse.
- Has a contract for the services of a physician, maintains daily records on each patient and is equipped to dispense and administer drugs.
- It complies with all licensing and other legal requirements, and is recognized as an "extended care facility" by the Secretary of Health, Education and Welfare of the United States pursuant to Title XVIII of the Social Security Administration of 1965.
- Has transfer arrangements with one or more hospitals, a utilization review plan, and operating policies developed and monitored by a professional group that includes at least one physician.
Unless specifically provided, the term "skilled nursing facility" does not include any institution or part thereof which is used principally as a place for rest, for custodial care, as a home for the aged, for drug addicts, for alcoholics, for the care of patients with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient patients, or as a nursing home, hotel, or similar institution.
- Temporomandibular joint dysfunction or disease (TMJ) means a disorder of the temporomandibular joint (the joint which connects the mandible or jawbone to the temporal bone) which is generally characterized by:
- Pain or muscle spasms in one or more of the following areas: face, jaw, neck, head, ears, throat, or shoulders.
- Popping or clicking of the jaw.
- Limited jaw movement or locking.
- Malocclusion, overbite or underbite.
- Mastication (chewing) difficulties.
- Trust means the Carpenters Health and Security Trust of Western Washington, originally created and established on January 1, 1960, as amended.
- Trust Agreement means the Trust Agreement establishing the Carpenters Health and Security Trust of Western Washington and any modification, amendment, extension, or renewal thereof.
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