Definitions

This chapter defines some of the more commonly used terms. To help you better understand the benefits and provisions of your Plan, it is important to review these definitions.

ADMINISTRATOR (CLAIMS*)

AETNA, Inc.
P. O. Box 981109
El Paso, TX 79998-1109 1-877- 223-1685

* See section titled HOW TO USE YOUR BENEFITS for prescription drug claims.

ADMINISTRATOR (PLAN)

Joint Governance Board
Putnam/Northern Westchester Health Benefits Consortium
200 BOCES Drive
Yorktown Heights, NY 10598

ALLOWABLE CHARGES
The Plan may limit the amount of a provider’s charges that will be considered for reimbursement or payment. Charges may be limited to amounts contracted by the Plan or its claims administrator or to amounts that do not exceed Usual, Reasonable or Customary charges. Please refer to the definition of Usual, Reasonable or
Customary charges.

AMBULANCE/LOCAL AMBULANCE
Professional ambulance service to the closest hospital or place of service.

AMBULATORY CARE CENTER
Any public or private establishment with:

a. an organized medical staff of Physicians;

b. permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures;

c. continuous Physician services and registered professional nursing services whenever a patient is in the facility; and

d. which does not provide services or other accommodations for patients to stay overnight.

BIRTH(ING) CENTER

A facility, duly licensed by the political subdivision of appropriate jurisdiction where located and operating pursuant to that license, which:

a. is operating primarily as a facility for the delivery of children following a normal, uncomplicated pregnancy;

b. is operating under the direct, full-time supervision of a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or a Registered Nurse (R.N.);

c. is equipped to perform routine diagnostic laboratory tests, and to handle medical emergencies;

d. maintains adequate, written medical records for each patient; and

e. has a written agreement with at least one local hospital for immediate acceptance of patients who develop complications or require hospital confinement.

CALENDAR YEAR

A period of one year beginning with January 1 and ending December 31.

CHEMICAL DEPENDENCE
Chemical dependence/alcohol abuse; drug addiction/abuse; the use/abuse of any illegal or illegally obtained drug, medication, chemical or other substance; and/or the abuse of any legally obtained drug, medication, chemical or other substance.

CHEMICAL DEPENDENCE TREATMENT FACILITY
A facility in New York State which is certified by the state division of alcoholism and alcohol abuse or by the state division of substance abuse services as a medically supervised ambulatory chemical dependence program; and in other states, a facility accredited by the Joint Commission on Accreditation of Hospital as an
alcoholism or chemical dependence treatment program.

COMPANION
This is a person whose presence as a Companion or caregiver is necessary to enable a National Medical Excellence Program (NME) Patient:

• to receive services in connection with an NME procedure or treatment on an in-patient or
• out-patient basis; or to travel to and from the facility where treatment is given.

CONVALESCENT NURSING HOME/ EXTENDED CARE FACILITY/ SKILLED NURSING FACILITY
Only an institution, other than a hospital, which meets all of the following requirements:

a. maintains permanent and full-time facilities for bed care of 10 or more resident patients;

b. has available at all times the services of a Physician;

c. has a Registered Nurse (R.N.) or Physician on full-time duty in charge of patient care and one or more Registered Nurses (R.N.s), Licensed Vocational Nurses (L.V.N.s) or Licensed Practical Nurses (L.P.N.s) on duty at all times;

d. maintains a daily medical record for each patient;

e. is primarily engaged in providing continuous skilled nursing care for sick or injured persons during the convalescent stage of their illness or injuries, and is not, other than incidentally, a rest home or a home for custodial care for the aged; and

f. is operating lawfully as a nursing home or extended care facility in the jurisdiction where it is located; in no event, however, shall such term include an institution primarily engaged in the care and treatment of chemical dependence.

COINSURANCE/CO-PAYMENT
The percentage or amount of charges payable by the member.

COVERED EXPENSE/COVERED CHARGE
Usual, reasonable and customary (URC) charges made for MEDICALLY NECESSARY services, treatments or supplies rendered in the treatment of illness or injury as of the date of the service, treatment or purchase of the supply giving rise to the charge, except that the expenses incurred for supplies purchased while confined in a
hospital for use in part or in whole outside of the hospital will be considered to be incurred after discharge from the hospital.

COVERED PERSON
An individual enrolled and eligible for benefits under this Plan.

CUSTODIAL CARE
This means help in transferring, eating, dressing, bathing, toileting, and other such related activities.

DEPENDENT
a. The covered spouse of an Employee and covered children between the ages of birth and 19 years provided such children are unmarried and dependent upon their parent(s) for support and maintenance. The term “children” shall include: natural children; legally adopted children; step-children. The term “children” shall also include any other children if the Employee provides support and maintenance and claims them as dependents in accordance with section 152 of the Internal Revenue Code. Proof of
dependency may be required.

b. A covered dependent child after his 19th birthday provided the child is a full-time student (as determined by the educational institution) at an accredited secondary or preparatory school, college or university, or other accredited educational institution, dependent on his prent(s) for at least 50%
support and maintenance and is under the age of 25. A covered dependent child whose 19th birthday occurs during school vacation period shall continue to be considered a covered Dependent under the Plan, provided the child is enrolled in an accredited educational institution as specified above and it is
anticipated that the child will resume full-time student status at the end of the vacation period.

c. A covered dependent child is also an unmarried child who is incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation as defined in the mental hygiene law, or physical handicap, and chiefly dependent upon the employee for support and maintenance, and who became so incapable prior to attainment of the age at which dependent coverage would otherwise terminate. Proof of such incapacity and dependency must be furnished to the Plan by the Covered Person within 31 days of the termination age. If a dependent child is 19 or
older at the time of initial enrollment, and that child was incapable of self-sustaining enrollment by reason of mental illness, developmental disability, mental retardation as defined in the mental hygiene law, or physical handicap before the age at which coverage would otherwise terminate, such proof as
required by the Plan must be submitted within 31 days of the initial effective date of coverage. The Administrator may require, at reasonable intervals, subsequent proof of the child's disability and dependency.

Excluded as a Dependent under a., b. and c. above is:

1. a spouse divorced from the Employee;

2. any person(s) while on active duty in any military service of any country. Refer to "Eligibility", and “Continuation Of Coverage COBRA) and Extended Benefits” sections for additional information.

DISABILITY/PERIOD OF DISABILITY
Any period of illness or injury, or multiple illnesses or injuries arising from the same cause, including any and all complications therefrom, which are not separated by complete recovery as certified by the attending Physician and return to active full-time employment in the case of the Employee; or in the case of a Dependent, return to the resumption of the normal activities of a person of the same age and sex in good
health. For the purpose of renewing in-patient hospital and/or convalescent nursing home/extended care facility/skilled nursing facility benefits, a new period of disability shall begin when the Covered Person has not been confined in such a facility for at least 90 days.

DURABLE MEDICAL EQUIPMENT
Appliances and/or supplies which are: medically necessary; recommended by a Physician for therapeutic use; considered to be appropriate by standards of professional medical practice to treat an illness or injury; and are approved by the Plan.

EMERGENCY ADMISSION
One where the physician admits the person to the hospital or treatment facility for an "emergency condition" as defined later in this section..

EMERGENCY CARE
This means the treatment given in a hospital's emergency room to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

• placing the person's health in serious jeopardy; or
• serious impairment to bodily function; or
• serious dysfunction of a body part or organ; or
• in the case of a pregnant woman, serious jeopardy to the health of the fetus.

EMERGENCY CONDITION
This means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (A) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or (B) serious impairment to such person’s bodily functions; (C) serious dysfunction of any bodily organ or part of such person; or (D) serious disfigurement of such person.

EMPLOYER/PARTICIPATING EMPLOYER
The Employer is, individually or collectively, the various school districts and BOCES which elect to become Participating Employers in the Putnam/Northern Westchester Health Benefits Consortium.

EXPERIMENTAL/INVESTIGATIVE AND/OR NON-CONVENTIONAL DRUGS, DEVICES, PROCEDURE, SURGERY, THERAPY OR TREATMENTS
A drug, device or medical/surgical therapy, treatment or procedure which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration (FDA) and which has not received the approval of the FDA, even when such drug, device or medical/surgical therapy, treatment or procedure is recommended by a medical professional: or a drug, device or medical/surgical therapy, treatment or procedure which has not been approved for payment by the U.S. Health Care Financing Administration (HCFA) in its directives to its claims payers for their administration of the Federal Medicare Program, even when such drug, device or medical/surgical therapy, treatment or procedure is recommended by a medical professional.

FORMULARY
A formulary is a listing of prescription medications identifying applicable co-payments for preferred and nonpreferred drugs. Preferred drugs are selected based upon approval of the Federal Food and Drug Administration (FDA) and cost effectiveness. Non-preferred drugs must also be approved by the FDA but are more costly. The co-payment is highest for non-preferred drugs.

GENDER PRONOUNS
Whenever the masculine pronoun is used in this document it shall include the feminine gender unless the context clearly indicates otherwise.

GENERIC DRUG
A drug, available only upon the written prescription of a Physician, used for the treatment of an illness or injury and supplied in the form of its generic or chemical name rather than in the form of a proprietary, trade or brand name product.

HOME HEALTH AIDE
A person, other than a Physician or a nurse, who provides care of a medical or therapeutic nature and reports to and is under the direct supervision of a Home Health Care Agency.

HOME HEALTH CARE AGENCY
A Hospital or a home health care agency which primarily provides skilled nursing service or other therapeutic service under the supervision of a Physician or Registered Nurse, is run according to rules established by a Physician, maintains clinical records on all patients and does not primarily provide custodial care or care and treatment of the mentally ill. In those jurisdictions where licensure or certification by statute exists, the Home Health Care Agency must be licensed or certified and operated according to the laws that pertain to agencies which provide home health care.

HOME HEALTH CARE PLAN
A plan for medical care and treatment of a person in his home. To qualify, the plan must be established and approved in writing by a Physician who certifies that the person would require confinement in a Hospital or Convalescent Nursing Home/Extended Care Facility/Skilled Nursing Facility if he did not have the care and treatment stated in the plan, and is approved by the Plan's Managed Benefits Program Coordinator.

HOSPICE
An organization, licensed by the state of residence, which provides a coordinated set of services rendered at home or in out-patient or institutional settings for individuals suffering from a disease or condition with a terminal (within six months) prognosis.

HOSPICE CARE/PROGRAM
A program of care which offers 24-hour services to terminally ill patients in the home, on an outpatient basis and/or on a short-term in-patient basis, and included such services and items as nursing care, physical therapy, medical social services, home health aid, medical supplies, Physician services, short-term in-patient care and counseling for the patient and his family.

HOSPITAL
This means a short-term, acute, general hospital, which:

(1) is primarily engaged in providing, by or under the continuous supervision of physicians, to inpatients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons;

(2) Has organized departments of medicine and major surgery;

(3) Has a requirement that every patient must be under the care of a physician or dentist;

(4) Provides 24-hour nursing service by or under the supervision of a registered professional nurse (RN);

(5) If located in New York State, has in effect a hospitalization review plan applicable to all patients which meets at least the standards set forth in section 1861(k) of United States Public Laws 89-97(42 USCA 1395x(k));

(6) Is duly licensed by the agency responsible for licensing such hospitals; and

(7) Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational or rehabilitory care.

HOSPITAL (OR CONVALESCENT NURSING HOME/ EXTENDED CARE FACILITY/SKILLED NURSING FACILITY) MISCELLANEOUS CHARGES
The usual, reasonable and customary amounts charged by the hospital or convalescent nursing home/extended care facility/skilled nursing facility for necessary services, medicines, supplies or services for diagnosis or treatment of an illness or injury (except services of a Physician and drugs or supplies not consumed or used in the hospital or
convalescent nursing home/extended care facility/skilled nursing facility) while the Covered Person is hospital confined and a charge is made for room and board.

ILLNESS/ACTIVE ILLNESS
Any sickness or disease which manifests treatable symptoms and which requires treatment by a Physician.

INCURRED DATE
The date a charge for a covered expense shall be deemed to be incurred. The Incurred Date shall be the latest of the following to occur the date a purchase is contracted; the date delivery is made; or the actual date a service is rendered.

INJURY
Any accidental bodily injury sustained while the individual is covered under the Plan and which requires treatment by a Physician.

IN-PATIENT/IN-PATIENT CARE
The period of time during which a Covered Person is treated at a hospital or a convalescent nursing home/extended care facility/skilled nursing facility as a registered bed patient. In-patent care includes charges for room and board and (hospital or convalescent nursing home/extended care facility/skilled nursing facility) miscellaneous charges.

INTENSIVE/CORONARY/ACUTE CARE CHARGE
A service prescribed by the attending Physician, as a medical necessity, which is normally reserved for critically and seriously ill patients requiring constant audio-visual surveillance, which provides room and board, care by registered graduate nurses or other highly trained hospital personnel, and special equipment and supplies immediately available on a standby basis, and is rendered at a location segregated from the rest of the hospital's facilities. This term does not include care in a surgical recovery or post-operative room.

MANAGED BENEFITS PROGRAM
A managed benefits program which requires a pre-admission review of proposed hospitalization, or notice of an emergency admission, in order to establish and inform the Covered Person of the number of days of hospitalization for which the Plan will provide benefits.

MANAGED BENEFITS PROGRAM COORDINATOR

AETNA, Inc.
1-877-223-1685

MEDICALLY NECESSARY/ MEDICALLY NECESSARY CARE
Care which is:

a. consistent with the symptoms or diagnosis and treatment of a condition, disease, ailment or injury; and

b. in accordance with generally accepted medical practices; and

c. not solely for convenience of the Covered Person, Physician or other service provider, and

d. the most appropriate supply or level of service which can be safely provided.

When it is questionable that an expense incurred is for medically necessary care, the Managed Benefits Program Coordinator shall have the appropriate medical authority to establish the medical necessity of such expense. Just because a physician orders or suggests a service does not make such expense medically necessary.

MEDICARE
Title XVIII (Health Insurance for the Aged) of the United States Social Security Act as amended by the Social Security Amendment of 1965 or as later amended.

OUT-PATIENT/OUT-PATIENT CARE
A Covered Person shall be considered to be an "Out Patient' if treated in a hospital on a basis other than as a registered bed patient. Out-patient care includes services, supplies and medicines provided and used at a hospital under the direction of a Physician to a person not admitted as a registered bed patient. Out-patient care shall also include covered services rendered in the Physician's office, laboratory or X-ray facility, ambulatory care center or free-standing surgical facility, or the patient’s home.

PHYSICIAN
To the extent performing services covered by the Plan, a person acting within the scope of his license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatric Medicine (D.P.M.), Doctor of Chiropractic (D.C.) and Doctor of Optometry (O.D.). The term Physician shall also be extended to include a Doctor of Psychology (Ph.D.), Registered Physical Therapist (R.P.T.), Licensed Speech Language Pathologist and Audiologist, Registered Nurse Practitioner (R.N. Practitioner) and Registered Occupational Therapist (O.R.T.). The term Physician shall also include a social worker who is certified pursuant to article one hundred fifty-four of the New York State Education Law; and who, in addition, has either six or more years of post-degree experience in psychotherapy, satisfactory to the (New York) state board for social work, or six or more years of post-degree experience in psychotherapy under the supervision, satisfactory to the (New York) state board for social work, of a psychiatrist, a certified and registered psychologist or another social worker who is qualified as a social worker as defined above, or has a combination of the (New York) state required experience specified above which totals an aggregate of six or more years, satisfactory to the (New York) state board for social work; and who in addition is listed by the (New York) state board for social work as qualified for reimbursement. A qualified social worker shall also
include a certified social worker providing services outside the State of New York, provided such social worker is, by the resident state statutes, qualified to provide such services, and required by the resident state statutes to be covered under a group health plan or service.

PLAN NAME
The name of the Plan is the PUTNAM/NORTHERN WESTCHESTER HEALTH BENEFITS CONSORTIUM HEALTH PLAN. The Plan currently utilizes AETNA’s Choice POS II option.

PREFERRED PHYSICIAN/PROVIDER
A Physician or hospital who/which has a contractual agreement with the Plan to provide medical services to Covered Persons at pre-agreed upon rates.

PRE-HOSPITAL EMERGENCY MEDICAL SERVICES
The prompt evaluation and treatment of an emergency medical condition, and/or non-airborne transportation of the patient to a hospital; provided however, where the patient utilizes non-airborne emergency transportation pursuant to this subsection, reimbursement will be based on whether a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (ii) serious impairment to such person’s bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; or (iv) serious disfigurement of such person.

PSYCHIATRIC SERVICES/TREATMENT
Treatment of mental and nervous disorders, including services provided by a Doctor of Medicine, and services provided by a Doctor of Psychology. Psychiatric Services/Treatment shall not include services and treatment related to chemical dependence.

REHABILITATION FACILITY
A legally operating institution or distinct part of an institution which:

a. has a transfer agreement with one or more hospitals;

b. is primarily engaged in providing comprehensive, multi-disciplinary physical restorative services, post-acute hospital and rehabilitative in-patient care; and

c. is duly licensed by the appropriate government agency to provide such services.

A rehabilitation facility shall not include an institution which provides only minimal care, custodial care, ambulatory or part-time care services, or an institution which primarily provides treatment of mental disorders, chemical dependency or tuberculosis, unless such facility is licensed, certified or approved as a rehabilitation facility for the treatment of medical conditions or chemical dependence in the jurisdiction where it is located, or
is accredited as such a facility by the Joint Commission for the Accreditation of Health Care Organizations or the Commission for Accreditation of Rehabilitation Facilities.
For determination of benefits under the Plan, a rehabilitation facility shall be considered on the same basis as a convalescent nursing home/extended care facility/skilled nursing facility.

ROOM AND BOARD CHARGES
These are charges made by an institution for room and board and other necessary services and supplies. They must be regularly made at a daily or weekly rate.

SEMI-PRIVATE CHARGE
The charge made by a hospital for a room containing two or more beds but does not include the charge made by the Hospital for Intensive Care/Coronary Care/Acute Care.

USUAL, REASONABLE AND CUSTOMARY CHARGES (URC)
The normal and necessary charges made for similar services by the providers of medical services who are practicing in the same geographic area or the actual charge, whichever is less. Determination of whether or not a charge is URC shall be made by the Claims Administrator based on nationally obtained and recognized survey data or on data received from an insurance company which, as a major portion of its business, is involved in the adjudication of health care claims. URC shall also mean, and is interchangeable with, Reasonable charge, Customary charge, Usual Customary and Reasonable (UCR) charges, and references of a similar nature used to describe Covered Expenses, charges or allowable amounts.

WAITING PERIOD
That period of time between the Employee's date of eligibility and/or hire and the date the Employee becomes covered under this Plan.

The Waiting Period for Employees of each respective Participating Employer shall be determined by the Participating Employer.