Glossary of Terms

Ambulatory Surgical Facility - a facility (other than a Hospital) whose primary function is the provision of surgical procedures on an ambulatory basis and which is duly licensed by the appropriate state and local authority to provide such services.

Behavioral Health Care Practitioner – a practitioner who evaluates and treats psychological and/or substance abuse disorders.

Certified Clinical Nurse Specialist - a nurse specialist who
- is licensed under the Nursing and Advanced Practice Nursing Act;
- has an arrangement or agreement with a Physician for obtaining medical consultation, collaboration and hospital referral and
- meets the following qualifications:
- is a graduate of an approved school of nursing and holds a current license as a registered nurse; and
- is a graduate of an advanced practice nursing program.

Certified Nurse Midwife - a nurse-midwife who
- practices according to the standards of the American College of Nurse-Midwives;
- has an arrangement or agreement with a Physician for obtaining medical consultation, collaboration and hospital referral and
- meets the following qualifications:
- is a graduate of an approved school of nursing and holds a current license as a registered nurse; and
- is a graduate of a program of nurse-midwives accredited by the American College of Nurse Midwives or its predecessor.

Certified Nurse Practitioner - a nurse practitioner who
- is licensed under the Nursing and Advanced Practice Nursing Act;
- has an arrangement or agreement with a Physician for obtaining medical consultation, collaboration and hospital referral and
- meets the following qualifications:
- is a graduate of an approved school of nursing and holds a current license as a registered nurse; and
- is a graduate of an advanced practice nursing program.

Certified Registered Nurse Anesthetist (CRNA) - a person who
- is a graduate of an approved school of nursing and is duly licensed as a registered nurse;
- is a graduate of an approved program of nurse anesthesia accredited by the Council of Accreditation of Nurse Anesthesia Education Programs/Schools or its predecessors;
- has been certified by the Council of Certification of Nurse Anesthetists or its predecessors; and
- is recertified every two years by the Council on Recertification of Nurse Anesthetists.

Chemical Dependency - the uncontrollable or excessive abuse of addictive substances and the resultant physiological or psychological dependency which develops with continued use, requiring Medical Care as determined by a Physician or Psychologist. Addictive substances include, but are not limited to, alcohol, morphine, cocaine, heroin, opium, cannabis and other barbiturates, tranquilizers, amphetamines and/or hallucinogens.

Chemical Dependency Treatment - an organized, intensive, structured, rehabilitative treatment program of either a Hospital or Chemical Dependency Treatment Facility. It does not include programs consisting primarily of counseling by individuals other than a Physician or Psychologist, court-ordered evaluations, programs which are primarily for diagnostic evaluations, mental retardation or learning disabilities, care in lieu of detention or correctional placement or family retreats.

Chemical Dependency Treatment Facility - a facility (other than a Hospital) whose primary function is the treatment of Chemical Dependency and which is licensed by the appropriate state and local authority to provide such service. It does not include half-way houses, boarding houses or other facilities that provide primarily a supportive environment, even if counseling is provided in such facilities.

Chemotherapy - the treatment of malignant conditions by pharmaceutical and/or biological anti-neoplastic drugs.

Chiropractor - a duly licensed chiropractor.

Claim - notification in a form acceptable to the Plan that a service has been rendered or furnished to you. This notification must include full details of the service received, including your name, age, sex, identification number, the name and address of the Provider, an itemized statement of the service rendered or furnished, the date of service, the diagnosis, the Claim Charge, and any other information which the Plan may request in connection with services rendered to you.

Claim Payment - the benefit payment calculated by the Plan, after submission of a Claim, in accordance with the benefits described in this Certificate. All Claim Payments will be calculated on the basis of the Provider’s Charge for Covered Services rendered to you, regardless of any separate financial arrangement between the Plan and a particular Provider. (See provisions of this Certificate regarding ‘‘Plan’s Separate Financial Arrangements with Providers.’’)

COBRA – those sections of the Consolidated Omnibus Budget Reconciliation Act (P.L. 99-272) which allow the temporary extension of group coverage to persons who would otherwise lose their group insurance.

Consulting Physician - any physician who practices in one of the specialized areas of medicine and to who a Primary Care Physician may refer members for diagnosis and/ or treatment.

Coordinated Home Care Program - an organized skilled patient care program in which care is provided in the home. Care may be provided by a Hospital’s licensed home health department or by other licensed home health agencies. You must be homebound (that is, unable to leave home without assistance and requiring supportive devices or special transportation) and you must require Skilled Nursing Service on an intermittent basis under the direction of your Physician. This program includes Skilled Nursing Service by a registered professional nurse, the services of physical, occupational and speech therapists, Hospital laboratories and necessary medical supplies. The program does not include and is not intended to provide benefits for Private Duty Nursing Service. It also does not cover services for activities of daily living (personal hygiene, cleaning, cooking, etc.)

Coordination of Benefits - action taken by IPA and/ or Payor, jointly or separately, to seek recovery of costs of an incident of sickness or accident involving a Covered Person; to the extent such incident is covered by another insurer, service plan, government, third party payor, or other organization.

Copayment - A fixed payment the patient pays (varies by the plan selected by your employer) each time he or she visits a physician or provider or receives a covered service.

Covered charges – the fees for services or supplies provided to the Member which are approved by a Primary Care Physician or a Women’s Principal Health Care Provider and are within the HMO health care benefit program.

Covered Person - an individual who is entitled to benefits under a Plan.

Covered services – those services or supplies which are approved for a Member by a Primary Care Physician or a Woman’s Health Care Provider and are within the HMO health care benefit program.

Credentialing - A process of review to approve a provider who applies to participate in a health plan. Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.

Deductible - More typical in traditional health insurance, a fixed amount the patient must pay each year before the insurer will begin covering the cost of care.

Dependent – all eligible Members of a Subscriber’s family who are covered under the Subscriber’s HMO Certificate of Health Care Benefits. This may include: the legal spouse; newborn children, children of the Subscriber and/or spouse who are under the age of 26; dependents who are discharged from the military until age 30; legally adopted children; children under the subscriber’s legal guardianship or who are in his/her custody pursuant to an interim court order of adoption or placement of adoption, whichever comes first; children of the subscriber not residing with the subscriber when he/she is required by a court of law to provide health insurance benefits for such children. Such children must reside within the service area of the HMO; children who are dependent upon the subscriber for support and maintenance because of mental retardation or physical handicap regardless of age, as long as they were covered prior to reaching the limiting age; and adult dependents as contracted between the HMO and Employer Groups. And such other individuals who may be defined as dependent under any applicable laws or regulations.

Diagnostic Service - tests performed to diagnose your condition because of your symptoms or to determine the progress of your illness or injury. Examples of these types of tests are x-rays, pathology services, clinical laboratory tests, pulmonary function studies, electrocardiograms, electroencephalograms, radioisotope tests and electromyograms.

Emergency Condition - an accidental bodily injury or a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- 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;
- serious impairment to bodily functions; or
- serious dysfunction of any bodily organ or part.

Examples of symptoms that may indicate the presence of an emergency medical condition include, but are not limited to, difficulty breathing, severe chest pains, convulsions or persistent severe abdominal pains.

Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a Prudent Layperson could reasonably expect the absence of immediate medical attention to result in:
- 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;
- serious impairment to bodily functions; or
- serious dysfunction of any bodily organ or part.

Employer Group - an employer, association or trust that has entered into an agreement with the HMO to provide the HMO health care benefit program.

Enrollment Date - the first day of coverage under your Group’s health plan or, if your Group has a waiting period prior to the effective date of your coverage, the first day of the waiting period (typically, the date employment begins).

Exclusions - Specific conditions or circumstances listed in the contract or employee benefit plan for which the policy or plan will not provide benefit payments.

Family Coverage - that your application for coverage was for yourself and other eligible members of your family.

Formulary Drug - a brand name prescription drug that has been designated as a preferred drug by the Plan. The listing of drugs designated as being Formulary Drugs may be amended from time to time by the Plan.

Freestanding Ambulatory Surgical Facility (Surgi-center) - a facility other than a Hospital:
- whose primary function is the provision of surgical procedures on an ambulatory basis; and
- that is duly licensed by the appropriate state and local authorities to provide such services, and has received accreditation by an appropriate accrediting body.

Freestanding Chemical Dependency Treatment Facility - a facility other than a Hospital; whose primary function is the treatment of chemical dependency; and that is duly licensed by the appropriate state and local authority to provide such services. This term does not include half-way houses, boarding houses or other such facilities that provide primarily a supportive environment whether or not individual and/or group counseling is provided in such facility.

Group-Approved Service - a Covered Service provided or ordered by the IPA Physician or otherwise approved by appropriate IPA staff.

Health Professionals - physicians, dentists, nurses, optometrists, physician assistants, clinical psychologists, social workers, nutritionists, occupational therapists, physical therapists, and other professionals engaged in the delivery of health services that are licensed where required by laws of the State of Illinois, registered with and credentialed with Fox Valley Medicine.

HMO (health maintenance organization) - A public or private organization that provides healthcare in return for pre-set monthly payments. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that their members must use to be covered for that care.

Home Health Care (HHC) - a program of care provided by an agency which: is primarily engaged in providing skilled nursing service and other skilled therapeutic services in the patient’s home or place of residence; is certified by the Social Security Administration as eligible for participation under Medicare; has received accreditation by an appropriate accrediting body; and is licensed as a Home Health Care Agency by the Department of Public Health, State of Illinois.

Hospice Care Program - a centrally administered program designed to provide physical, psychological, social and spiritual care for terminally ill persons and their families. The goal of hospice care is to allow the dying process to proceed with a minimum of patient discomfort while maintaining dignity and a quality of life. Hospice Care Program service is available in the home, or in Inpatient Hospital or Skilled Nursing Facility special hospice care unit.

Hospice Care Program Provider - an organization duly licensed to provide Hospice Care Program service.

Hospital - a facility which is a duly licensed institution for the care of the sick which provides services under the care of a Physician including the regular provision of bedside nursing by registered nurses and which is either accredited by the Joint Commission on Accreditation of Hospitals or certified by the Social Security Administration as eligible for participation under Title XVIII, Health Insurance for the Aged and Disabled. It does not include health resorts, rest homes, nursing homes, custodial homes for the aged or similar institutions.

Hospital Based Out-Patient Surgical Facility - a duly licensed institution that meets the definition of “Hospital” above and which also dedicates part of the facility to providing surgical procedures on an ambulatory basis.

In-Area - those medical services and supplies provided within a 30-mile radius of the IPA or IPA Affiliated Hospital site in which the Member is enrolled.

Individual Benefits Management Program (IBMP) - an alternative treatment plan providing alternative benefits for services in which the Member’s condition would otherwise require continued care in a Hospital or other health care facility. These services must be requested by the Primary Care Physician or Woman’s Principal Health Care Provider and agreed to in writing by the requesting physician, the Member and all other required parties.

Individual Coverage - your application for coverage was only for yourself.

Inpatient - you are a registered bed patient and are treated as such in a health care facility.

Investigational - procedures, drugs, devices, services and/or supplies which (a) are provided or performed in special settings for research purposes or under a controlled environment and which are being studied for safety, efficiency and effectiveness, and/or (b) are awaiting endorsement by the appropriate National Medical Specialty College or federal government agency for general use by the medical community at the time they are rendered to a covered person, and (c) specifically with respect to drugs, combination of drugs and/or devices, are not finally approved by the Food and Drug Administration at the time used or administered to the covered person.

IPA (Independent Physicians Association) - IPAs generally include large numbers of individual private practice physicians who are paid either a fee or a fixed amount per patient to care for the IPA's members.

Long Term Acute Care (LTAC) - Facility means a duly licensed long term acute care hospital that provides extended, intensive medical care to patients who are clinically complex and suffering from multiple acute or chronic conditions.

Long Term Care Services - those social services, personal care services and/or Custodial Care Services needed by you when you have lost some capacity for self-care because of a chronic illness, injury or condition.

Maintenance Care - those services administered to you to maintain a level of function at which no demonstrable and/or measurable improvement of a condition will occur.

Maintenance Occupational Therapy, Maintenance Physical Therapy, and/or Maintenance Speech Therapy - therapy administered to you to maintain a level of function at which no demonstrable and/or measurable improvement of a condition will occur.

Managed Care - A healthcare delivery system that uses a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care. The goal is a system that delivers value by giving people access to quality, cost-effective healthcare.

Medical Care - the ordinary and usual professional services rendered by a Physician, or other specified Provider during a professional visit, for the treatment of an illness or injury.

Medical Emergency - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in
- 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,
- serious impairment of bodily functions, or
- serious dysfunction of any bodily organ or part.

Medical Management Programs - the customer satisfaction plans, quality management programs, utilization management programs, credentialing, rules and regulations and other similar programs, procedures and protocols conducted by or on behalf of Payors and/ or IPA pursuant to the Agreement.

Medicare - the program established by Title XVIII of the Social Security Act (42 U.S.C. _1395 et seq.).

Medicare Secondary Payer or MSP - those provisions of the Social Security Act set forth in 42 U.S.C. _1395 y (b), and the implementing regulations set forth in 42 C.F.R. Part 411, as amended, which regulate the manner in which certain employers may offer group health care coverage to Medicare-eligible employees, their spouses and, in some cases, dependent children.

Member(s) - the Subscribing Member and eligible dependents.

Mental Illness - those illnesses classified as mental disorders in the edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association which is current as of the date services are rendered to a patient.

Network - The doctors, clinics, ancillary providers, medical group practices, hospitals, and other providers that an HMO, PPO, or other managed care network plan has selected and contracted with to care for its members.

Non-Contracting Provider - a Hospital facility, health care facility, laboratory, person or other entity that does not meet the definition of Contracting Provider.

Non-Participating Prescription Drug Provider - a Prescription Drug Provider which does not meet the definition of a Participating Prescription Drug Provider.

Non-Urgent Symptomatic - a medical condition where symptoms exist however immediate services are not required.

Not Group-Approved Service - services or supplies not provided, ordered or approved by the IPA Physician or appropriate IPA staff.

Occupational Therapy - a constructive therapeutic activity designed and adapted to promote the restoration of useful physical function.

Office Based Surgery - is a surgery that is often provided in a Hospital Based Outpatient Surgical Facility or Free Standing Ambulatory Surgical Facility, but that can also be provided in a physician office which has been properly accredited to perform office based surgery.

Ongoing Course of Treatment - the treatment of a condition or disease that requires repeated health care services pursuant to a plan of treatment by a Physician because of the potential for changes in the therapeutic regimen.

Open enrolment period - A time during which members in a health benefit program have an opportunity to re-enroll or select an alternate health plan being offered to them.

Out-of-Area - those medical services and supplies provided more than 30-miles away from the IPA or IPA-Affiliated Hospital in which the Member is enrolled.

Out-of-network - Not in the HMO's network of selected and approved doctors and hospitals. HMO members who get care out-of-network (sometimes called out-of-area) without getting permission from the HMO to do so may have to pay for all or most of that care themselves.

Outpatient Procedures - are those procedures B that are commonly done in a physician’s office or outpatient setting, but that are not customarily performed in a Freestanding Ambulatory Surgical Facility or Hospital Based Out-Patient Surgical Facility.

Partial Hospitalization Psychiatric Treatment Program - a Hospital’s planned therapeutic treatment program, which has been approved by your Participating IPA, in which patients with Mental Illness spend days or nights.

Participating Allied Health Practitioner - any non-physician healthcare practitioner, facility, program or agency who/that has entered into, or otherwise become bound by, an agreement to provide Covered Services under a Plan.

Participating Hospital - a hospital that has entered into, or otherwise become bound by, an agreement to provide Covered Services under a Plan. Not all services are available at all hospitals.

Participating IPA - any duly organized Individual Practice Association of Physicians which has a contract or agreement with the Plan to provide professional and ancillary services to persons enrolled under this benefit program.

Participating Medical Group - any duly organized group of Physicians which has a contract or agreement with the Plan to provide professional and ancillary services to persons enrolled under this benefit program.

Participating Physician - a physician who has entered into, an agreement to provide Covered Services under a Plan or Plans.

Participating Prescription Drug Provider - a Prescription Drug Provider which has entered into a written agreement with this Plan, or any entity designated by the Plan to administer its prescription drug program, to provide services to you at the time services are rendered to you and, for Pharmacies located in the state of Illinois, which has direct on-line computer access to the Plan or such administrative entity.

Participating Provider - a Participating Hospital, Participating Physician or Participating Allied Health Practitioner.

Pharmacy - any licensed establishment in which the profession of pharmacy is practiced.

Physical Therapy - the treatment by physical means by or under the supervision of a qualified physical therapist.

Physician - a physician duly licensed to practice medicine in all of its branches.

Physician Assistant - a duly licensed physician assistant performing under the direct supervision of a Physician.

Plan(s) - HMO Health Plans, regardless of payment methodology.

Policy - the agreement between the Plan and the Group, including the Certificate, any addenda or riders that apply, the Benefit Program Application of the Group and the individual applications, if any, of the persons covered under the Policy.

Practice guidelines - Carefully developed information on diagnosing and treating specific medical conditions. Practice guidelines --- usually based on clinical literature and expert consensus --- are designed to help physicians and patients make decisions, and to help a health plan evaluate appropriateness and medical necessity of care.

Prescription Drug Provider - any Pharmacy which regularly dispenses drugs.

Preventive care - Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include immunization and regular screenings (such as Mammograms, Pap smears Colorectal cancer screening or Cholesterol screening).

Primary Care Physician - a physician licensed and registered to practice medicine in the State of Illinois, who:
- is a Participating Physician,
- provides Covered Services in the fields of internal medicine, family practice, or pediatrics; and
- to the extent required by the applicable Plan, is responsible for the general supervision, treatment and coordinating all aspects of the medical care of Enrollees assigned to him or her.

Prior authorization - The process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

Provider - any health care facility (for example, a Hospital or Skilled Nursing Facility) or person (for example, a Physician or Dentist) duly licensed to render Covered Services to you.

Psychiatric Care - Medical Care rendered for the treatment of a Mental Illness. This type of care is limited to psychotherapy, group therapy, psychological testing and family therapy (joint sessions with family members and the patient).

Psychologist:
- a Clinical Psychologist who is registered with the Illinois Department of Professional Regulation pursuant to the Illinois ‘‘Psychologist Registration Act’’ (111 Ill. Rev. Stat. _5301 et seq., as amended or substituted); or
- in a state where statutory licensure exists, a Clinical Psychologist who holds a valid credential for such practice; or
- if practicing in a state where statutory licensure does not exist, a psychologist who specializes in the evaluation and treatment of Mental Illness and Chemical Dependency and who meets the following qualifications:
- has a doctoral degree from a regionally accredited University, College or Professional School and has two years of supervised experience in health services of which at least one year is postdoctoral and one year in an organized health services program; or
- is a Registered Clinical Psychologist with a graduate degree from a regionally accredited University or College and has not less than six years experience as a psychologist with at least two years of supervised experience in health services.

Referral - A formal process that authorizes an HMO member to get care from a specialist or hospital. To assure coverage, an HMO patient generally must get a referral from his or her primary care doctor before seeing a specialist.

Routine Care - maintenance or follow-up services for an ongoing condition or illness.

Self-Injectable Medication - prescription drugs or medicines that the patient can be trained to safely self-administer and which are so classified by HMO.

Skilled Nursing Facility - an institution or a distinct part of an institution which is primarily engaged in providing comprehensive skilled services and rehabilitative Inpatient care and is duly licensed by the appropriate governmental authority to provide such services.

Skilled Nursing Service - those services provided by a registered nurse (R.N.) or licensed practical nurse (L.P.N.) which require the clinical skills and professional training of an R.N. or L.P.N. and which cannot reasonably be taught to a person who does not have specialized skill and professional training. Benefits for Skilled Nursing Service will not be provided due to the lack of willing or available non-professional personnel. Skilled Nursing Service does not include Custodial Care Service.

Specialist - A Physician or other health professional who is trained and expertise are in a specific area of medicine, like cardiology or dermatology. Most HMOs require members to get a referral from their primary care physician before seeing a specialist.

Specialized Medical Services - those services rendered by any physician practicing one of the specialized areas of medicine and to whom a primary care physician may refer members for a diagnosis and/ or treatment.

Subscriber - an employee who meets eligibility requirements and elects HMO coverage.

Subscribing Group - each organization or firm contracting with Plan(s) to arrange health care services for its employees.

Subscribing Member - the individual who has made application, requested enrollment, and has paid the necessary dues or whose dues have been paid for him/her, for the services and benefits stated in the various Service Agreement(s).

Surgery - the performance of any medically recognized, non-Investigational surgical procedure including specialized instrumentation and the correction of fractures or complete dislocations and any other procedures as reasonably approved by the Plan.

Urgent Care - services which:
- result from an unforeseen illness or injury when the Member is temporarily absent from the Participating IPA’s geographic area and receipt of the health care services cannot be delayed until the Member’s return to the geographic area; and
- are required in order to prevent serious deterioration of a Member’s health.

Utilization review (UR) - Health care services and treatment plans are formally assessed according to the medical necessity, efficiency, or appropriateness on a prospective, concurrent, or retrospective basis.

Utilization Review – is overseen by the Assistant Medical Director(s) and a staff of nurses and clerical staff. All referrals are reviewed by Utilization Review for:
- Eligibility of the member
- Participation of the physician referred to
- Covered benefits
- Medical appropriateness
- Case management and discharge planning

Woman’s Principal Health Care Provider (WPHCP) - any IPA Physician who specializes in obstetrics and gynecology or family practice and who has been selected by a female Member to be directly accessible for treating and coordinating that Member’s health care needs and that has a referral arrangement with the female Member’s PCP.