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glossary

A-H

Key words found on this website are defined here. Please click on a letter below for a definition of a term beginning with that letter.

A-H | I-P | Q-Z
 
A  B  C  D  E  F  G  H
 
A
Active Employee refers to the status of you, the employee, prior to your retirement, and other than when you are disabled.

Acupuncture is the technique for treating certain painful conditions by passing long, thin needles through the skin to specific points.

Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a staff of doctors, has continuous doctor and nursing care by registered nurses (R.N.'s) when patients are there and does not provide for overnight stay.

Annual Maximum applies to the Extended Medical Benefits portion of your Medical Expense Benefits. It is based on a calendar year and applies to you, the employee, and each member of your family separately. Certain other benefits may also contain Annual Maximums and are specified in the sections What's Covered and What's Not Covered.

Allowable Expense(s) are expenses incurred by a covered person which are reasonable, for a necessary service or supply, and covered in part by at least one or more plans which insure the covered person. For example, the difference between the cost of a private hospital room and a semi-private hospital room is not considered an allowable expense unless the patient's stay in the private room is medically necessary.
B

Benefit Day is a day of care that is used to count against any benefit limit in your Plan. For example, each day that you are an inpatient in a hospital is counted as one benefit day. Each day that you are a patient in a skilled nursing facility counts as one-half benefit day. Therefore, 20 days in a skilled nursing facility counts as 10 benefit days toward the 365 day limit.

Biofeedback is a training program designed to develop an individual's ability to control his or her autonomic (involuntary) nervous system.

Birthing Center is a free standing facility or a separate area of a hospital which has permanent facilities equipped and operated mainly for childbirth and which provides continuous services by doctors, registered nurses or mid-wife nurse practitioners when a patient is in the center. The center must be licensed by the appropriate agency having jurisdiction in the area in which it is located.
C

Calendar Year means January 1 through December 31 of the same year. The Plan Year begins every twelve-month period starting July 1 and ending June 30.. Click here for more information on the Plan Year.

Chemical Dependence is the condition caused by regular, excessive consumption of alcohol that results in harm to either physical health or personal or social functioning; or, the use or abuse of any illegal, illegally obtained or legal drug, medication, chemical or other substance.

Children, for purposes of the plan, includes natural children, adopted children (including children in a waiting period prior to finalization of adoption), and step-children of the employee. The children must permanently reside in the employee's household. However, a dependent child will continue to be covered after age 19, provided the child is a full-time student at an accredited school, primarily dependent upon his or her parents for support and maintenance, unmarried, and under age 25. Additionally, an unmarried child who has reached the age at which dependent coverage would otherwise terminate, is covered if unable to work or support himself or herself because of reasons of mental illness, developmental disability or mental retardation as defined in New York State Mental Hygiene Law or because of reasons of a physical handicap. (For coverage to be based on these conditions, the condition must have occurred prior to the age at which dependent coverage would otherwise terminate and the child's disability must be certified by a doctor. The Plan Administrators have the right to verify whether such a child continues to be incapacitated. Coverage ceases when such a child is no longer incapacitated.)

COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. This Act permits you to extend your medical benefits by paying the cost required in your Plan for eighteen months after you lose or quit your job or until such time as you obtain different medical coverage.

Coinsurance is the difference between the Reasonable and Customary Charge and the covered percentage under the Extended Medical Expense portion of your Plan. You are responsible for paying the Coinsurance to non-participating providers.

Coordination of Benefits (COB) applies when a covered person is covered under this Plan and one or more other plans. The benefits paid are coordinated between or among the plans.

Continuation of Benefits is the potential ability of certain persons to continue their health care benefits beyond the date that they might otherwise terminate. (See COBRA)

Copayment is a fixed dollar amount that you must pay directly to the doctor or medical services provider each time you or a dependent receive a service requiring a copayment.

Covered Employer or Participating Employer refers to the employers participating in SWSCHP - for example, your school district.

Covered Person is an employee, retiree or dependent who is covered under the SWSCHP Plan.
D

Deductible is a fixed dollar amount which you must pay once each calendar year before payment will be made for covered services that are subject to the deductible. The amount of the deductible is determined by your employer.

Deductible (Out-of-Network) is a fixed dollar amount which you must pay once each calendar year before the Plan administrator(s) will make payment for covered services rendered by out-of-network or non-participating providers. After you have paid the deductible, the Plan administrator(s) will make payment for these services according to the coinsurance terms.

Dependent is any one of the following persons:

1. An employee's spouse.
2. Unmarried children from birth to 19 years of age (and other dependent children as defined under "Children," above).

A divorced spouse of the employee is excluded as a dependent.

Doctor or Physician, for the purposes of the SWSCHP Plan, is a licensed physician, osteopath, dentist or podiatrist.

Drug Abuse is a physical dependence on drugs, including dependence on drugs that are medically prescribed, but not alcohol, tobacco and ordinary caffeine-containing drinks.
E

Employee is an employee or retiree of one of the Participating Employers in the SWSCHP Plan, who is eligible for coverage under the Plan. Click here for information on who is eligible.

Experimental care or treatment is that which is not approved or accepted as essential to the diagnosis and/or treatment of injury or sickness by the American Medical Association, United States Surgeon General, United States Department of Public Health, National Institute of Health, or American Osteopathic Association. Drugs are considered experimental if not commercially available for purchase and/or not approved by the Food and Drug Administration (FDA) for general use. At times, a drug may be approved by the FDA solely for use in connection with the care and treatment of a specific diagnosis. This same drug is still considered to be experimental if prescribed as a remedy or treatment for any diagnosis, illness or injury.
F
Family is the covered employee and his or her family members who are covered as dependents under the Plan.
G
 
H

Home Health Care Agency is an agency that is either:

1. A hospital licensed and/or certified to provide home health services under either the Public Health Law of the State of New York or similar statutory or regulatory authority in the state where home care services are rendered; or
2. A home health service or agency licensed to provide home health services under either the Public Health Laws of the State of New York or similar statutory or regulatory authority in the state where home care services are rendered.

Home Health Care Plan is the plan for home health care services that must meet these specifications:

1. It must be a formal written plan made by the patient's attending physician to be reviewed periodically; and
2. It must certify that the home health care is in place of hospital confinement; and
3. It must specify the type and extent of home health care required for the treatment of the patient.

Home Health Care Services includes:

1. Part-time or intermittent nursing care by or under the supervision of a registered nurse; and
2. Part-time or intermittent home health aide services provided through a Home Health Care Agency. This does not include general housekeeping services; and
3. Physical, occupational or speech therapy when provided by the Home Health Service or Agency; and,
4. Laboratory services by or on behalf of the Home Care Agency or Hospital.

Home Health Care Supplies are medical supplies, including drugs and medication prescribed by a doctor to the home care patient; however, only to the extent such items would be covered for an inpatient confined in a hospital or a skilled nursing facility.

Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Organization, or supervised by a physician.

Hospice Care Services and Supplies are those provided through a Hospice Organization and under a Hospice Care Plan, and include inpatient care in a Hospice Unit or other licensed facility, home care and family counseling during the bereavement period.

Hospice Organization is an organization or agency that has an operating certificate issued by the New York State Department of Health. If the hospice care is provided outside of New York State, the Hospice Organization must have an operating certificate issued, under criteria similar to those used in New York, b a state agency in the state where the hospice care is provided.

Hospice Unit is a free-standing facility or separate hospital unit that provides treatment under a Hospice Care Plan and admits at least two unrelated persons who are expected to die within six months.

Hospital is a short-term, acute care general institution that is primarily engaged in providing, on an inpatient basis, diagnostic and therapeutic facilities for surgical or medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff of doctors and that gives ongoing, 24 hours-a-day nursing service by or under the supervision of registered graduate nurses. A hospital is not a school, college or camp infirmary and is not, other than incidentally, a place of rest; a place for the aged or nursing home; a place for drug addicts; a place for alcoholics; a hemodialysis center; a place for the treatment of tuberculosis or mental disorders or a nursing home or similar institution. This definition shall apply even though the term "Hospital" has a different meaning in other legal contexts.

Hospital, Private Proprietary is an institution, other than a general or public hospital, that:

1. is properly licensed or permitted legally to operate as a facility for the inpatient treatment of mental and nervous conditions and/or chemical dependence; and
2. is approved by the Plan as a legitimate provider of services; and
3. is not a skilled nursing facility; and
4. is not, other than incidentally, a place for the aged or nursing home.

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