Section 18 – GENERAL PLAN DEFINITIONS
“Administrative Office” means the entity identified at in the Quick Reference Table at the front of this booklet.
An “Ambulatory Surgical Center” or “Outpatient Surgical Center” is a specialized facility established primarily for the purpose of performing surgical procedures, and which fully meets one of the following two tests:
- It is licensed as an Ambulatory Surgical Center under the laws of the jurisdiction in which it is located; or
- Where licensing is not required, it meets all of the following requirements:
- it is operated under the supervision of a licensed Physician who is devoting full time to supervision and permits a surgical procedure to be performed only by a duly qualified Physician who is privileged to perform the procedure in at least one Hospital.
- it requires in all cases, except those requiring only local infiltration anesthetics, that a licensed anesthesiologist administer the anesthetic or supervise the anesthetist who administers the anesthetic, and that the anesthesiologist or anesthetist remain present throughout the surgical procedure.
- it provides at least one operating room and at least one post-anesthesia recovery room, and has trained personnel and necessary equipment to handle emergency situations.
- it is equipped to perform diagnostic x-ray and laboratory examinations or has an arrangement to obtain these services, and has immediate access to a blood bank or blood supplies.
- it maintains an adequate written medical record for each patient.
- it provides full-time services of one or more registered nurses (RN) for patient care in the operating rooms and in the post-anesthesia recovery rooms.
An Ambulatory Surgical Center that is part of a Hospital will be considered an Ambulatory Surgical Center for the purposes of this Plan.
“Annual Out-of-Pocket Limit” is the maximum amount of Covered Expenses each Participant pays each calendar year. Once a Participant has reached their Annual Out-of-Pocket Limit, Covered Expenses during the remainder of that calendar year are payable at 100%. The calendar year deductible is included in the Annual Out-of-Pocket Limit.
“Collective Bargaining Agreement” means the labor agreement between Teamster Local 959 and a Contributing Employer, which provides for contributions to this Trust in accordance with the provisions of the Trust Agreement.
“Contributing Employer” or “Employer” means a business entity that is required by a Collective Bargaining Agreement with the Union to make payments into this Trust. A Contributing Employer shall also include a business entity whose participation is permissible under applicable laws (including the Union on behalf of its own employees) and which contributes to the Trust pursuant to a Written Agreement with Trust. The Board of Trustees may require an Employer to sign a Written Agreement or Collective Bargaining Agreement acceptable to it before crediting Covered Hours of an Employer’s Employees.
“Covered Expenses” mean the charges or expenses incurred by an eligible Participant while coverage is in force which are:
- made for care and treatment of an Illness or Injury as defined in the Plan; and
- Medically Necessary; and
- Usual, Customary and Reasonable; and
- covered under provisions of the Plan, or which are not expressly excluded.
“Covered Hour” means:
- an hour of work for which a Collective Bargaining Agreement or written agreement between the Trust and Employer obligates the Employer to contribute to the Trust on behalf of the Employee; or
- a unit that a Collective Bargaining Agreement states the Plan will credit to an Employee.
See also the special crediting rule under Flat Rate Contracts that applies exclusively for purposes of determining Retired Participant Status at Section 2.1.
“Custodial Care” means care or services provided family members for personal hygiene or to perform activities of daily living. People who are trained or licensed medical or nursing personnel can provide Custodial Care. Some examples of Custodial Care are training or helping patients get in and out of bed, as well as help with bathing, dressing, feeding, or eating, use of the toilet, ambulating, or taking drugs or medicines that can be self-administered. These services are Custodial Care regardless of where the care is given or who recommends, provides, or directs the care.
“Dependent” is an individual who has satisfied the eligibility rules described at Eligibility Rules for Dependents of Active and Retired Participants.
“Drug” or “Prescription Drug” is a Medically Necessary drug dispensed by a licensed pharmacist.
“Electronic Protected Health Information” means Protected Health Information that is transmitted or maintained in electronic media.
“Eligible Employee” is an Employee who has satisfied the eligibility rules of the Plan. An individual cannot be an Eligible Employee and a Retired Participant at the same time.
The term “Emergency” means an unforeseen Injury or acute Illness for which medical attention cannot be delayed without serious risk to the Participant’s or Dependent’s health, including situations where application of the normal time periods for deciding a claim 1) could seriously jeopardize life or health or ability to regain maximum function, or 2) in the opinion of a physician with knowledge of the medical condition, would subject the Participant or Dependent to severe pain that cannot adequately be managed without the care or treatment being sought.
The term “Emergency Services” is as defined under the Health Care Reform law, but generally means services at a hospital’s emergency department for an emergency medical condition, and any further services that are necessary to stabilize the patient.
“Employee” means an individual on behalf of whom an Employer is obligated to contribute to the Trust pursuant to a Collective Bargaining Agreement or written agreement between the Trust and the Employer.
“Employer” – Please refer to the definition of “Contributing Employer.”
“Experimental and/or Investigational.” The Plan or its designee has the discretion and authority to determine if a service or supply is or should be classified as “Experimental and/or Investigational.” A service or supply will be deemed to be Experimental and/or Investigational if, in the opinion of the Plan or its designee, (based on the information and resources available at the time the service was performed or at the time the supply was provided, or the service or supply was considered for precertification under the Plan’s Utilization Management Program), any of the following conditions were present with respect to one or more essential provisions of the service or supply:
- The service or supply is described as an alternative to more conventional therapies in written documents by the health care provider that performs the service or prescribes the supply;
- The prescribed service or supply may be given only with approval of an Institutional review Board as defined by federal law;
- There is an absence of authoritative medical or scientific literature on the subject, or that literature indicates that the service or supply is Experimental and/or Investigational or that more research is needed;
- Food and Drug Administration (FDA) has not approved marketing of the service or supply or has it under consideration;
- The service or supply is available only through clinical trials sponsored by the FDA, the National Cancer Institute or the National Institutes of Health.
“Flat Rate Contract” means a Collective Bargaining Agreement or Written Agreement that obligates an Employer to contribute a specified monthly amount to the Plan and does not base the amount of such contribution on the number of Covered Hours an Employee works. A Collective Bargaining Agreement that obligates an Employer to contribute a specified monthly amount to the Plan if an Employee works a minimum number of Covered Hours is a Flat Rate Contract.
“Health Care Provider” means only a person shown on the list below, if that person is: (1) licensed under the laws of the state or jurisdiction where services are rendered; (2) practicing within the scope of their license, and (3) not a Relative to the Participant.
- A dentist (DDS or DMD).
- A podiatrist (DPM).
- A psychologist (PhD), or licensed clinical social worker (LCSW).
- A registered nurse (RN), licensed practical nurse (LPN), licensed vocational nurse (LVN), registered nurse practitioner (RNP), psychiatric mental health nurse, or certified midwife.
- A certified registered nurse anesthetist (CRNA), registered nurse anesthetist (RNA), or nurse anesthetist (NA) authorized to administer anesthesia in collaboration with a Physician.
- An optometrist (OD).
- A registered physical therapist (RPT), occupational therapist (OT), or speech therapist (CST).
- A chiropractor (DC).
- A Pharmacist (RPh or PharmD).
- A certified audiologist (MS, ccc-a or MA, ccc-a).
- A physician assistant (PA).
- A certified mental health or substance abuse counselor or social worker, including a Licensed Professional Counselor (LPC) or a Licensed Psychological Associate (LPA), who has a master’s degree and is licensed/legally authorized to practice or provide services.
- Massage Therapist
The following is a partial listing of providers that are not recognized by the Plan:
- Christian Science Practitioner
- Non-certified midwife
“Hospice” or “Hospice Agency” shall mean a facility or organization which administers a program of palliative and supportive health care services providing physical, psychological, social and spiritual care during the final stages of terminal illness and during bereavement. The facility or organization must be certified by the National Hospice Organization, be approved by Medicare, and be licensed under the laws of the jurisdiction in which it is located. A Hospice that is a part of a Hospital will be considered a Hospice for the purposes of this Plan.
“Hospital” means a public or private facility or institution licensed and operating according to law, that:
- is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO);
- is approved by Medicare as a Hospital; and
- provides care and treatment by Physicians and Nurses on a 24-hour basis for Illness or Injury through the medical, surgical and diagnostic facilities on its premises.
For purposes of benefits provided for mental health treatment, an institution that lacks permanent facilities for surgery or where the patient is normally expected to remain at the facility, or under the direct supervision of facility staff, 24 hours a day, will be considered a Hospital and an institution that is primarily a place for care of persons with mental health conditions will be considered a Hospital, provided that such institutions meet all other requirements applied to Hospitals
Any portion of a Hospital used as an ambulatory surgical facility, birthing center, convalescent or extended care facility, hospice, skilled nursing facility, sub acute care facility, or other residential treatment facility or place for rest, custodial care or the aged will not be regarded as a Hospital for purposes of benefits provided by this Plan.
“Illness” means a bodily disorder, infection, or disease and all related symptoms and recurrent conditions resulting from the same cause. An Illness identified in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered to be a Mental Illness for the purposes of this Plan. If there are multiple diagnoses, only the treatment for the Illness identified under the DSM code is considered Mental Illness treatment. Illness does not include an illness incurred or aggravated while performing a job-related task, engaging in any activity for wage or profit, or for which compensation could be available if application were made under a workers’ compensation or occupational injury law or similar legislation.
“Injury” means physical harm sustained as the direct result of an accident, affected solely through external means, and all related symptoms and recurrent conditions resulting from the same accident. Injury does not include an injury incurred or aggravated while performing a job-related task, engaging in any activity for wage or profit, or for which compensation could be available if application were made under a workers’ compensation or occupational disease or injury law or similar legislation.
“Lag Month Eligibility Period (or) Lag Period” means the period of time after which an Employee satisfies the Plan’s eligibility requirements, and before coverage begins. See Section 1.1.
A “Licensed Home Health Care Agency” shall meet all of the following requirements:
- it must primarily provide skilled nursing services and other therapeutic services under the supervision of Physicians and Registered Nurses;
- it must operate according to policies established by a professional group, including Physicians and Registered Nurses, which governs the services provided;
- it must maintain written clinical records on all patients; and
- it must be licensed by the jurisdiction where it is located, operate according to the laws of that jurisdiction which pertain to agencies providing Home Health Care, and be certified as a Home Health Care Agency by Medicare.
“Life Insurance Provider” means the insurer, identified in the Quick Reference Table at the front of this booklet that provides benefits described at Section 12.
Services and supplies are “Medically Necessary” or provided due to “Medical Necessity” if such service or supply is determined by the Plan to be:
- appropriate and necessary for the symptoms, diagnosis or treatment of an Illness, Injury or condition; and
- not Experimental and/or Investigational; and
- not primarily for the convenience of the Participant, the Participant’s Physician or another provider; and
- not primarily for research or data accumulation; and
- within the standards of generally accepted medical practice and professionally recognized standards within the organized medical community in which services are provided; and
- the most appropriate supply or level of service which can safely be provided. When applied to hospitalization, Medically Necessary means that the symptoms or condition cannot safely and adequately be treated on an outpatient basis.
- Medical Necessity shall also encompasses dental necessity with respect to the Plan’s dental benefits.
The fact that a Physician or other Health Care Provider may prescribe, order, recommend or approve a service or supply does not mean that such a service or supply will be considered to be Medically Necessary for the coverage provided by this Plan.
“Medicare” means the insurance program established by Title XVIII, United States Social Security Act of 1965, as originally enacted and as subsequently amended.
A “Mental Illness” is an Illness defined within the mental disorders section of the current edition of the International Classification of Diseases (ICD-9-CM) manual or is identified in the current edition of the Diagnostic and Statistical manual of Mental Disorders (DSM), including a psychological and/or physiological dependence on or addiction to alcohol or psychiatric drugs or medications, regardless of any underlying physical or organic cause.
The term “Open Enrollment” shall mean the annual period specified by the Trustees in which you may elect to change your Plan Level of benefits.
“Orthopedic Surgery” means surgical procedures to treat conditions involving the musculoskeletal system, other than spinal surgery.
“Participant” shall mean any person eligible for benefits under the Plan, whether as an Eligible Employee, Retired Participant, or Dependent.
The terms “Physician,” “Surgeon” or “Doctor” mean a licensed Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.), licensed to practice in the state in which services are rendered and practicing within the scope of their license. For a list of additional recognized providers, refer to Health Care Providers.
“Payroll Month” means the four or six week payroll period ending in a calendar month that is ordinarily used by your Employer to report employees’ hours of work during a month to the Plan. For an Employer reporting hours of work on the basis of the bimonthly or monthly periods, the “Payroll Month” is the same as a calendar month.
“Pension Trust” means the Alaska Teamster-Employer Pension Trust.
“Pharmaceutical Provider” means the Prescription Drug Benefit administrator for the Plan, identified in the Quick Reference Table at the front of this booklet.
“Plan Level” means a type of coverage available under the Plan, as further described in Section 1. The cost of each Plan Level is determined by the Trustees. When beginning participation in the Plan, you have a choice about which Plan Level to select – or a Plan Level will be chosen for you. Plan Level selections can only be changed at yearly Open Enrollment, for coverage effective January 1 of the following year, or when certain qualifying events changes have occurred in your family.
“Plan” shall mean this document titled the Alaska Teamster-Employer Welfare Trust Summary Plan Description as adopted and thereafter amended by the Board of Trustees.
The term “Preferred Provider Organization” or “PPO” means a Hospital, Physician or other health professional, pharmacy, or other facility that has a contract for negotiated rates in effect with the Plan.
“Preferred Provider Plan” means a program whereby specific providers contract with the Plan to provide Medically Necessary services or supplies to Participants payable on a negotiated rate basis, approved by the Trustees and amended from time to time.
The term “Pregnancy” includes prenatal and postnatal care, childbirth, early termination of pregnancy, and complications of pregnancy for an Eligible Employee, Retired Participant, or Dependent Spouse, only. Pregnancy-related expenses are not provided for Dependent Children. Pregnancy will be covered as if it were an Illness.
The term “Complications of Pregnancy” means all physical effects suffered which have been directly caused by the pregnancy, but which would not be considered from a medical viewpoint the effects of a normal pregnancy. Complications of Pregnancy shall include, but are not limited to, conditions such as acute nephritis, nephrosis, cardiac compensation, missed abortion, ectopic pregnancy which terminated, caesarian section, spontaneous terminations of pregnancy which occur during a period of gestation in which a viable birth is not possible, and similarly medically diagnosed conditions. Complications of Pregnancy shall not include false labor, Physician prescribed rest during the period of pregnancy, morning sickness and similar conditions not constituting a classifiably distinct Complication of Pregnancy.
“Protected Health Information” means information that is created or received by the Plan that identifies a living or deceased participant or beneficiary, or for which there is a reasonable basis to believe the information can be used to identify the participant or beneficiary, and which relates to: the past, present, or future physical or mental health or condition of a participant or beneficiary; the provision of health care to a participant or beneficiary; or the past, present or future payment for the provision of health care to a participant or beneficiary. “Relative” means the Participant’s spouse, parents, children, siblings, or anyone residing in the same household as the Participant.
“Retired Participant” means an individual who has satisfied the eligibility and enrollment provisions at Eligibility Rules for Retired Participants.
“Security Incident” has the same meaning as in 45 CFR § 164.304.
“Skilled Nursing Facility” or “Extended Care Facility” means an institution primarily engaged in providing patients with (i) skilled nursing care and related services, or (ii) services for the rehabilitation of injured, disabled or sick persons, and which meets all of the following requirements:
- it is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF) as a Skilled Nursing Facility or is recognized by Medicare as a Skilled Nursing Facility; and
- it is regularly engaged in providing room and board and skilled nursing care for sick and injured persons under 24 hour-a-day supervision of a Physician or a Registered Nurse;
- it has available at all times a Physician who is a staff member of a Hospital;
- it has on duty 24 hours a day a Registered Nurse, licensed vocational nurse, or skilled practical nurse, and has on duty at least eight hours a day a Registered Nurse;
- it maintains a daily medical record for each patient who is under the care of a Physician;
- it is not (other than incidentally) a home for maternity care, rest, domiciliary care, or care of people who are aged, alcoholic, blind, deaf, drug addicts, or suffering from mental health conditions or tuberculosis; and
- it is not a hotel or similar facility.
“Spouse” means the person to whom an Eligible Employee or Retired Participant is legally married, as determined by applicable state law.
“Substance Abuse Facility” means a facility for treatment of abuse of alcohol or drugs which:
- is accredited by the Bureau of Alcohol and Drug Abuse in the Rehabilitation Division of the Department of Human Resources or a Hospital which is licensed by the Health Division of the Department of Human Resources (or analogous governmental entity that certifies Substance Abuse Facilities); and
- is accredited by the Joint Commission on Accreditation of Healthcare Organizations, providing a program for the treatment of substance abuse as part of its accredited activities.
For purposes of inpatient treatment for other than detoxification, Substance Abuse Facility means:
- a facility having either of the above accreditations; or
- a facility accredited by the Commission on Accreditation of Rehabilitation Facilities; or
- a Hospital.
“Summary Health Information” means information that (a) summarizes the claims history, claims expenses or type of claims experienced by individuals provided health benefits under the Plan; and (b) from which the information described at 42 CFR § 164.514(b)(2)(i) has been deleted, except that the geographic information described in 42 CFR § 164.514(b)(2)(i)(B) need only be aggregated to the level of a five-digit zip code.
“Summary Plan Description,” “Plan,” or this “Booklet” describes this document.
“Surviving Spouse” means the individual to whom an Eligible Employee or Retired Participant was legally married on the date of the Eligible Employee or Retired Participant’s death.
For Time Loss Benefits and for Extended Benefits for Total Disability, “Total Disability” or “Totally Disabled” means that as a result of an Injury or Illness, an Eligible Employee is absent from work and unable to engage in the duties of his/her customary occupation, and is performing no work of any kind for wage or profit.
The term “Trust Agreement” or “Trust” or “Welfare Trust” means the Trust Agreement establishing the Alaska Teamster-Employer Welfare Trust, and any modification, amendment, extension or renewal thereof.
“Trust Customer Service Office” means the Alaska Teamsters-Employer Welfare Trust.
“Trustees” shall mean any person(s) designated as Trustees pursuant to the terms of the Trust Agreement, and the successor of such persons from time to time in office. The term “Board of Trustees” and “Board” means the Board of Trustees established by the Trust Agreement.
An “Urgent Care Facility” is a public or private Hospital-based or free-standing facility, licensed as an Urgent Care Facility, that primarily provides minor Emergency and episodic medical care, in which one or more Physicians and Nurses are in attendance at all times when the facility is open, and that includes a life support system and an arrangement to provide x-ray and laboratory services.
“Usual, Customary and Reasonable” or “UCR” means the charge for a service or supply furnished by a covered provider, which meets the following criteria as determined by the Plan:
A charge is considered “usual” if it is the charge the provider most frequently makes to the majority of his or her patients for a given service or supply. A charge is considered “customary” when it is within the range of appropriate charges in the geographic area as determined by a third party service selected by the Plan to determine appropriate medical charges. A charge is within the range of appropriate charges if it is equal to or less than the 85th percentile rate established for the geographic area by the Plan’s third party service and no more than the amount determined by the Plan’s third party service as the then-current Medicare allowed charge for end-stage renal disease charges. With regard to end-stage renal disease charges, however, the Plan may pay charges up to the amount determined by the Plan’s third-party service to be no more than 125% of the then-current Medicare allowed charges. A charge is considered “reasonable” when the service or supply is within reasonable utilization limits, and is justifiable considering the circumstances involved.
“Utilization Management” is a managed care procedure to determine the Medical Necessity, appropriateness, location and cost-effectiveness of health care services. This review procedure can occur before, during or after services are rendered, and may include (but is not limited to):
- Precertification/Preauthorization Review for hospitalizations, surgery, diagnostic procedures, home health and IV therapy services, hospice care and rehabilitation services; and
- Medical Case Management.
“Utilization Management Organization” means the organization, identified in the Quick Reference Table at the front of this booklet that performs Utilization Management for the Plan.
“Written Agreement” means an agreement between an Employer and the Trust requiring employer contributions to the Trust on behalf of its employees.