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  Section 10. Definitions of terms we use in this brochure

Accidental injury A bodily injury sustained solely through violent, external and accidental means such as broken bones, animal bites and poisonings. Note: An injury to teeth while chewing and/or eating is not considered to be an accidental injury.
Admission The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day.
Assignment An authorization by an enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay the member directly for all covered services.
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 13.
Confinement An admission (or series of admissions separated by less than 60 days) to a hospital as an inpatient, for which a full days room and board charge is made, for any one illness or injury.
Congenital anomaly A condition existing at or from birth, which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include protruding ear deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes, and other conditions that the Carrier may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intra-oral structures supporting the teeth except for the Dental prosthetic appliances benefit and Orthodontic treatment covered under Section 5(g); Dental benefits.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.
Cosmetic surgery Any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury.
Cost-sharing Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.
Covered services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include but are not limited to:
  1. personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;


    2.
  2. homemaking, such as preparing meals or specials diets;


    3.
  3. moving the patient;


    4.
  4. acting as companion or sitter;


    5.
  5. supervising medication that can usually be self administered; or


    6.
  6. treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems.

    7.
Custodial care that lasts 90 days or more is sometimes known as long term care. The Plan determines which services are custodial care.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 13.
Durable medical equipment Equipment and supplies that:
  1. Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury);


    2.
  2. Are medically necessary;


    3.
  3. Are primarily and customarily used only for a medical purpose;


    4.
  4. Are generally useful only to a person with an illness or injury;


    5.
  5. Are designed for prolonged use; and


    6.
  6. Serve a specific therapeutic purpose in the treatment of an illness or injury.
Experimental or investigational services A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or 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 the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure.
Group health coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides payment for hospital, medical, or other health care services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.
Hospice care Hospice is a coordinated program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.

Note: A terminally ill person is a covered family member whose life expectancy is six months or less, as certified by the primary doctor.
Incurred An expense is incurred on the date a service or supply is rendered or received unless otherwise noted in this brochure.
Medical necessity Services, drugs, supplies or equipment provided by a hospital or covered provider of health care services that we determine:
  1. are appropriate to diagnose or treat the patients condition, illness or injury;


    2.
  2. are consistent with standards of good medical practice in the United States;


    3.
  3. are not primarily for the personal comfort or convenience of the patient, the family, or the provider;


    4.
  4. are not a part of or associated with the scholastic education or vocational training of the patient; and


    5.
  5. in the case of inpatient care, cannot be provided safely on an outpatient basis.

    6.
The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary.
Mental conditions/ Substance abuse Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychosis, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for abuse of, or dependence upon, substances such as alcohol, narcotics, or hallucinogens.
Morbid obesity A diagnosed condition in which the body mass index is 40 or greater or 35 or greater with co-morbidities such as diabetes, coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, pulmonary hypertension, weight related degenerative joint disease, or lower extremity venous or lymphatic obstruction. Eligible members must be age 18 or over.
Orthopedic device Any custom fitted external device used to support, align, prevent, or correct deformities or to restore or improve function.
Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We determine our allowance as follows:
  • PPO providers: For services rendered by a covered provider who participates in the Plans PPO network, our allowance is based on a negotiated rate agreed to under the providers network agreement.

    Note: You will not be responsible for any amount above the providers negotiated rate; PPO providers accept the Plans allowance as payment in full.


    •
  • Non-PPO/non-participating providers: When you do not use a PPO provider to perform the service or provide the supply, our allowance is based on the 75th percentile factor of claims data and fee information gathered for specific geographic areas by Ingenix.

    Note: We will not consider any fee charged above the Plans allowance. You will be responsible for the difference between our allowance and the bill.


    •
  • For covered services rendered by a hospital or by a doctor outside the United States and Puerto Rico, our allowance is based on the Plans allowance established for the Washington, D.C. Metropolitan area.

    Note: The member is responsible for the difference between the Plans allowance and the providers charge.
For more information, see Differences between our allowance and the bill in Section 4.
Prosthetic device An artificial substitute for a missing body part such as an arm, eye, or leg. This device may be used for a functional or cosmetic reason or both.
Remission A remission is a halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred.
Routine services Services that are not related to any specific illness, injury, set of symptoms, or maternity care.
Sound natural tooth A sound, natural tooth is a tooth that is whole or properly restored and is without impairment, periodontal or other conditions and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration or treated by endodontics is not considered a sound natural tooth.
Us/We Us and We refer to SAMBA
You You refers to the enrollee and each covered family member.



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