Accidental Injury is physical harm or disability which is the result of a specific unexpected incident caused by an outside force. The physical harm or disability must have occurred at an identifiable time and place. Accidental injury does not include illness or infection, except infection of a cut or wound.
Ambulatory Surgical Center is a freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It must also meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.
Board of Trustees is the governing body of the trust.
Brand Name Prescription Drug (Brand Name Drug) is a prescription drug that has been patented and is only produced by one manufacturer.
CalCOBRA means California Insurance Sections 10128.50.
CalCPA means the California Society of Certified Public Accountants.
Centers of Expertise (COE) are health care providers which have a Centers of Expertise Agreement in effect with the claims administrator at the time services are rendered. COE agree to accept the COE negotiated rate as payment in full for covered services. A participating provider in the plan network is not necessarily a COE. A provider’s participation in the plan network or other agreement with the claims administrator is not a substitute for a Centers of Expertise Agreement.
Centers of Expertise Negotiated Rate (COE Negotiated Rate) is the fee COEs agree to accept as payment for covered services. It is usually lower than their normal charge. COE negotiated rates are determined by Centers of Expertise Agreements.
Child meets the plan’s eligibility requirements for children as outlined under how coverage begins and ends.
Claims Administrator refers to BC Life & Health Insurance Company. On behalf of BC Life & Health Insurance Company, Blue Cross of California shall perform all administrative services in connection with the processing of medical claims under the plan.
Class I Transplants are any of the following: liver, heart, heart-lung, kidney, kidney-pancreas or bone marrow, including autologous bone marrow transplant, peripheral stem cell treatment and similar procedures.
COBRA means the medical plan related provisions of the Consolidated Budget Reconciliation Act of 1985, as such provisions have been subsequently amended.
COBRA Administrator means a COBRA participating employer or third party (not the Trustees or the plan administrator) appointed by the COBRA participating employer to act as the COBRA Administrator.
Co-Insurance is the amount expressed as a percentage, payable by the member for covered expenses.
Comprehensive Benefits means all benefits payable by the plan for services and supplies other than benefits available under the heading Prescription Drug Benefits.
Concurrent Review occurs during the member’s hospital stay to determine if continued inpatient care is medically necessary.
Contracting Hospital is a hospital which has a Standard Hospital Contract in effect with the claims administrator to provide care to beneficiaries. A contracting hospital is not necessarily a participating provider. A list of contracting hospitals will be sent on request.
Co-Payment is the amount payable by the member for office visits and certain other services. The prescription drug co-payments are fixed dollar amounts payable for prescription drugs. The term “co-payment” does not include the portion of covered expenses, expressed as a percentage, payable by the member for covered services.
Cosmetic Surgery is performed to reshape normal structures of the body and is intended solely to improve the appearance of the individual.
Covered Expense is the expense you incur for a covered service or supply, but not more than the maximum amounts described in your medical benefits: how covered expense is determined. Expense is incurred on the date you receive the service or supply.
Creditable Coverage is coverage under any individual or group plan that provides medical, hospital and surgical coverage, including continuation or conversion coverage, coverage under a publicly sponsored program such as Medicare or Medicaid, CHAMPUS, the Federal Employees Health Benefits Program, programs of the Indian Health Service or of a tribal organization, a state health benefits risk pool, or coverage through the Peace Corps. Creditable coverage does not include accident only, credit, coverage for on-site medical clinics, disability income, coverage only for a specified disease or condition, hospital indemnity or other fixed indemnity insurance, Medicare supplement, long-term care insurance, dental, vision, workers’ compensation insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans.
You are considered to have been covered under a creditable coverage if you:
You are also considered to have been covered under a creditable coverage if your employment ended, the availability of medical coverage offered through employment or sponsored by an employer terminated, or an employer’s contribution toward medical coverage terminated, provided that you:
Customary and Reasonable Charge, as determined annually by the claims administrator, is a charge which falls within the common range of fees billed by a majority of physicians for a procedure in a given geographic region. If it exceeds that range, the expense must be justified based on the complexity or severity of treatment for a specific case.
Day Treatment Center is an outpatient psychiatric facility which is licensed according to state and local laws to provide outpatient programs and treatment of mental or nervous disorders, severe mental disorders, or substance abuse under the supervision of physicians.
Declination means the portion of the enrollment agreement acknowledging declination of coverage.
Deductible means the amount of charges a member must pay for any covered services before any benefits are available to the member under the plan. Amounts applied to the deductible do not apply to or reduce any co-insurance/co-payment, or the percentage of any covered expense or prescription drug covered expense which the member must pay.
Dependent meets the plan’s eligibility requirements for dependents as outlined under how coverage begins and ends.
Domestic Partner meets the plan’s eligibility requirements for domestic partners.
Drug (Prescription Drug) means a prescribed drug approved by the State of California Department of Health or the Food and Drug Administration for general use by the public. For the purposes of this plan, insulin will be considered a prescription drug.
Drug Limited Fee Schedule represents the maximum amounts the plan will allow as prescription drug covered expense for prescriptions filled at non-participating pharmacies. These amounts are the lesser of billed charges or the average wholesale price.
Effective Date is the date your coverage begins under this plan.
Emergency is a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain) which the beneficiary reasonably perceives could permanently endanger health if medical treatment is not received immediately. Final determination as to whether services were rendered in connection with an emergency will rest solely with the claims administrator.
Emergency Services are services provided in connection with the initial treatment of a medical or psychiatric emergency.
Experimental procedures are those that are mainly limited to laboratory and/or animal research.
Facility-Based Care is care provided in a hospital, psychiatric health facility, residential treatment center or day treatment center for the treatment of mental or nervous disorders, severe mental disorders, or substance abuse.
Family Member is the plan participant’s enrolled spouse, or enrolled domestic partner, and each enrolled eligible child.
Generic Prescription Drug (Generic Drug) is a pharmaceutical equivalent of one or more brand name drugs and must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength, and effectiveness as the brand name drug.
Group Enrollment Agreement means the agreement by which a plan participant enrolls in the plan.
Home Health Agencies are home health care providers which are licensed according to state and local laws to provide skilled nursing and other services on a visiting basis in your home, and recognized as home health providers under Medicare and/or accredited by a recognized accrediting agency such as the Joint Commission on the Accreditation of Healthcare Organizations.
Home Infusion Therapy Provider is a provider licensed according to state and local laws as a pharmacy, and must be either certified as a home health care provider by Medicare, or accredited as a home pharmacy by the Joint Commission on Accreditation of Health Care Organizations.
Hospice is an agency or organization primarily engaged in providing palliative care (pain control and symptom relief) to terminally ill persons and supportive care to those persons and their families to help them cope with terminal illness. This care may be provided in the home or on an inpatient basis. A hospice must be: (i) certified by Medicare as a hospice; (ii) recognized by Medicare as a hospice demonstration site; or (iii) accredited as a hospice by the Joint Commission on Accreditation of Hospitals. A list of hospices meeting these criteria is available upon request.
Hospital is a facility which provides diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of physicians. It must be licensed as a general acute care hospital according to state and local laws. It must also be registered as a general hospital by the American Hospital Association and meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations.
For the limited purpose of inpatient care for the acute phase of a mental or nervous disorder, severe mental disorder, or substance abuse, "hospital" also includes psychiatric health facilities.
Infertility is: (i) the presence of a condition recognized by a physician as a cause of infertility; or (ii) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.
In-Network describes services or visits provided by a COE and by participating providers (but not including services or visits covered only on an in-network basis if provided by a COE).
Investigative procedures or medications are those that have progressed to limited use on humans, but which are not widely accepted as proven and effective within the organized medical community.
Life-Threatening means either or both of the following: diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted; diseases or conditions with potentially fatal outcomes, where the endpoint of clinical intervention is survival.
Medically Necessary procedures, supplies equipment or services are those the claims administrator determines to be:
Medically Necessary Hospital Days are those days for which inpatient care is determined to be medically necessary.
Medical Plan Document and Disclosure Form is the written description of the benefits provided under the plan.
Medicare means those hospital benefits and other health care benefits covered under the supplemental medical insurance program of Title XVIII of the Social Security Act 42 U.S.C. §§ 1395 et seq.
Medicare Beneficiary means an individual enrolled in Medicare.
Mental Or Nervous Disorders, for the purposes of this plan, are conditions that affect thinking and the ability to figure things out, perception, mood and behavior, including severe mental disorders. A mental or nervous disorder is recognized primarily by symptoms or signs that appear as distortions of normal thinking, distortions of the way things are perceived (e.g., seeing or hearing things that are not there), moodiness, sudden and/or extreme changes in mood, depression, and/or unusual behavior such as depressed behavior or highly agitated or manic behavior.
Negotiated Rate is the amount participating providers agree to accept as payment in full for covered services. It is usually lower than their normal charge. Negotiated rates are determined by claims administrator’s Participating Provider Agreements. With respect to non-participating providers, the negotiated rate means the typical fee participating hospitals and participating physicians agree to accept as payment in full of covered services as determined by the claims administrator, as appropriate, in its discretion.
Non-Emergency Admission is an admission which is not due to an emergency.
Non-Participating Pharmacy is a pharmacy which does not have a Participating Pharmacy Agreement in effect with the claims administrator at the time services are rendered. In most cases, you will be responsible for a larger portion of your pharmaceutical bill when you go to a non-participating pharmacy.
Non-Participating Provider is one of the following providers which does NOT have a claims administrator’s Participating Provider Agreement in effect with the claims administrator at the time services are rendered:
They are not participating providers. Remember that only a portion of the amount which a non-participating provider charges for services may be treated as covered expense under this plan. See your medical benefits: how covered expense is determined.
Other Health Care Providers are neither physicians nor hospitals. They are mostly free-standing facilities or service organizations, such as ambulance companies. Other health care providers are not part of the plan provider network.
Other health care provider is one of the following providers:
The provider must be licensed according to state and local laws to provide covered medical services.
Out-of-Network describes services or visits rendered by non-participating hospitals, non-participating physicians and other non-participating providers, and with respect to services or visits covered on an in-network basis only if provided by COE, services or visits provided by any Provider other than a COE.
Out-of-Pocket Amount is the amount for which a member is responsible when the claims administrator’s allowance, as appropriate, for covered services is paid. The member’s out-of-pocket amount does not include:
Participating Employer is a firm participating in the plan, where more than 50 percent of all the participating employer’s owners (i.e., principals, proprietors, partners, shareholders or other owners) are Certified Public Accountants and all Certified Public Accountant-owners are members of CalCPA in good standing or a candidate applying for CalCPA membership. Specific qualifications of a participating employer are stipulated in the subscription agreement between the trust and the participating employer.
Participating Hospital is a hospital which has a claims administrator’s Participating Agreement in effect with the claims administrator, as appropriate, at the time services are rendered. Participating hospitals agree to accept the negotiated rate as payment in full for covered services. Participating hospitals agree to participate in procedures established to review the utilization of hospital services. Hospital services determined to be unnecessary, according to these utilization review procedures, are not covered by the plan. A list of participating hospitals is available upon request from the plan administrator, as appropriate.
Participating Pharmacy is a pharmacy which has a Participating Pharmacy Agreement in effect with the claims administrator at the time services are rendered. Call your local pharmacy to determine whether it is a participating pharmacy or call the toll-free customer service telephone number. Many participating pharmacies display a “Rx” decal with the claims administrator’s logo in their window so that you can easily identify them.
Participating Provider is one of the following providers which has a claims administrator’s Participating Provider Agreement in effect with the claims administrator at the time services are rendered:
Participating providers agree to accept the negotiated rate as payment for covered services. A directory of participating providers is available upon request.
Pharmacy means a licensed retail pharmacy.
Physical Therapy, Physical Medicine and Occupational Therapy (including Chiropractic Care) means the benefits described under the heading Physical Therapy, Physical Medicine and Occupational Therapy (including Chiropractic Care).
Physician means:
* Note. The providers indicated by asterisks (*) are covered only by referral of a physician as defined in 1 above.
** If there is no nurse midwife who is a participating provider in your area, you may call the Customer Service telephone number on your ID card for a referral to an OB/GYN.
Plan is the set of benefits described in the Medical Plan Document and Disclosure Form and in the amendments to the Medical Plan Document and Disclosure Form, if any. These benefits are subject to the terms and conditions of the plan. If changes are made to the plan, an amendment or revised Medical Plan Document and Disclosure Form will be issued to each plan participant affected by the change. (The word “plan” here does not mean the same as “plan” as used in ERISA.)
Plan Administrator refers to GROUP INSURANCE TRUST OF THE CALIFORNIA SOCIETY OF CERTIFIED PUBLIC ACCOUNTANTS, the entity which is responsible for the administration of the plan.
Plan Agent is the agent of the plan responsible for administering enrollment, underwriting and premium collection functions. Until replaced by the plan administrator, the plan agent is Seabury & Smith Insurance Program Management.
Plan Document is the Medical Plan Document and Disclosure Form.
Plan Participant is any person enrolled in the plan that meets the eligibility requirements as outlined in the subscription agreement.
Pre-Admission Review occurs before a proposed hospital admission to determine if such an admission is medically necessary.
Pre-Existing Condition means an illness, injury or condition which existed during the six-month period immediately prior to either: (i) your effective date; or (ii) the first day of any waiting period, whichever is earlier. A condition is considered to have existed when you: (i) sought or received medical advice for that condition; (ii) received medical care or treatment for that condition; or (iii) received medical supplies, drugs or medicines for that condition.
Prescription means a written order or refill notice issued by a licensed prescriber.
Prescription Drug Covered Expense is the expense you incur for a covered prescription drug, but not more than the maximum amounts described in items i. and ii. below. Expense is incurred on the date you receive the service or supply.
Prescription drug covered expense does not include any expense in excess of: (i) the drug limited fee schedule for drugs dispensed by non-participating pharmacies; or (ii) the prescription drug negotiated rate for drugs dispensed by participating pharmacies or by the mail service program.
Prescription Drug Negotiated Rate is the rate that the claims administrator has negotiated with participating pharmacies under a Participating Pharmacy Agreement for prescription drug covered expense. Participating pharmacies have agreed to charge beneficiaries no more than the prescription drug negotiated rate. It is also the rate which Prescription Drug Program - Mail Service has agreed to accept as payment in full for mail service prescription drugs.
Preventive Care means the benefits described under the heading Preventive Care.
Principal Plan is the plan which will have its benefits determined first.
Prior Plan is a plan sponsored by us which was replaced by this plan within 60 days. You are considered covered under the prior plan if you: (i) were covered under the prior plan on the date that plan terminated; (ii) properly enrolled for coverage within 31 days of this plan’s effective date; and (iii) had coverage terminate solely due to the prior plan’s termination.
Prosthetic Devices are appliances which replace all or part of a function of a permanently inoperative, absent or malfunctioning body part. The term “prosthetic devices” includes orthotic devices, rigid or semi-supportive devices which restrict or eliminate motion of a weak or diseased part of the body.
Protected Health Information means information about you and your medical case, the privacy of which is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Psychiatric Health Facility is an acute 24-hour facility as defined in California Health and Safety Code 1250.2. It must be:
Psychiatric Mental Health Nurse is a registered nurse (R.N.) who has a master's degree in psychiatric mental health nursing, and is registered as a psychiatric mental health nurse with the state board of registered nurses.
Qualified Beneficiary, for the purposes of COBRA, is any of the following who is not entitled to Medicare on the day before the qualifying event and who on the date of the qualifying event is covered under the plan pursuant to the Subscription Agreement of a COBRA participating employer:
Qualified Beneficiary, for the purposes of CalCOBRA, is any individual who on the date of the qualifying event is covered under the plan pursuant to the Subscription Agreement of a CalCOBRA participating employer and is not a CalCOBRA excluded member. Qualified beneficiary also includes any child who is born to a former plan participant of a CalCOBRA participating employer, which plan participant is a qualified beneficiary who has elected CalCOBRA coverage, or a child who is placed for adoption with such a former plan participant so electing, if the child is enrolled in the plan within 30 days after the child’s birth or placement for adoption. Such entitlement to benefits, subject to applicable terms and conditions, shall continue for the remainder of the period during which the plan participant is covered under CalCOBRA.
Qualifying Event for the purposes of COBRA means any one of the following events that, but for election of coverage under COBRA or CalCOBRA, would otherwise result in a loss of coverage under the plan to a qualified beneficiary:
Reasonable Charge is a charge the claims administrator considers not to be excessive based on the circumstances of the care provided, including: (i) level of skill; experience involved; (ii) the prevailing or common cost of similar services or supplies; and (iii) any other factors which determine value.
Referral Center functions as a contact point for the member. The referral center answers questions and facilitates the Medical Management Programs provisions of the plan.
Residential Treatment Center is an inpatient treatment facility where the member resides in a modified community environment and follows a comprehensive medical treatment regimen for treatment and rehabilitation as the result of a mental or nervous disorder, severe mental disorder, or substance abuse. The facility must be licensed to provide psychiatric treatment of mental or nervous disorders, severe mental disorders, or rehabilitative treatment of substance abuse according to state and local laws.
Self-Administered Injectable Drugs are injectable drugs which are self-administered by the subcutaneous route (under the skin) by the beneficiary and labeled or approved for self-administration by the Food and Drug Administration (excluding insulin).
Severe Mental Disorders include the following psychiatric diagnoses specified in California Health and Safety Code section 1374.72: schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia, and bulimia.
"Severe mental disorders" also includes serious emotional disturbances of a child as indicated by the presence of one or more mental disorders as identified in the Diagnostic and Statistical Manual (DSM) of Mental Disorders, other than primary substance abuse or developmental disorder, resulting in behavior inappropriate to the child's age according to expected developmental norms. The child must also meet one or more of the following criteria:
Benefits for severe mental disorders will be provided according to the plan's benefits for medical conditions, and will not be subject to plan provisions for mental or nervous disorders.
Skilled Nursing Facility is an institution that provides continuous skilled nursing services. It must be licensed according to state and local laws and be recognized as a skilled nursing facility under Medicare. For the purpose of care provided for the treatment of mental or nervous disorders, severe mental disorders, or substance abuse, the term "skilled nursing facility" includes residential treatment center.
Special Care Units are special areas of a hospital which have highly skilled personnel and special equipment for acute conditions that require constant treatment and observation.
Sponsor means CalCPA.
Spouse meets the plan’s eligibility requirements for spouses as outlined under how coverage begins and ends.
Stay is inpatient confinement which begins when you are admitted to a facility and ends when you are discharged from that facility.
Subscription Agreement means the medical plan Subscription Agreement entered into by a participating employer and accepted by the trust.
Substance Abuse is abuse of a substance where the abuse affects thinking or the ability to figure things out, perception, mood and behavior. Treatment for substance abuse does not include smoking cessation programs nor treatments for nicotine dependency or tobacco use.
Totally Disabled Dependent is a dependent who is unable to perform all activities usual for persons of that age.
Totally Disabled Plan Participant is a plan participant who, because of illness or injury, is unable to work for income in any job for which he or she is qualified or for which he or she becomes qualified by training or experience, and who is in fact unemployed.
Trust is the Group Insurance Trust of the California Society of Certified Public Accountants.
Urgent Care is the services received for a sudden, serious, or unexpected illness, injury or condition, other than one which is life threatening, which requires immediate care for the relief of severe pain or diagnosis and treatment of such condition.
Year or Calendar Year is a 12 month period starting January 1 at 12:01 a.m. Pacific Standard Time.