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glossary

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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.

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I

Illness or Sickness is a person's illness, disease or pregnancy (including complications). For a newborn child after birth, but before release from a medical facility, sickness also includes a congenital defect, a birth abnormality or a premature birth.

Incurred Date is 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:

1. the date a purchase is contracted; or
2. the date delivery is made; or
3. the actual date a service is rendered.

Injury is an accidental bodily injury.

Inpatient refers to confinement for which room and board is charged by a hospital or approved facility.

Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a hospital solely for the care and treatment of patients who are critically ill. This also includes what is referred to as a "Coronary Care Unit" or an "Acute Care Unit." It has:

1. facilities for special nursing care not available in regular rooms and wards of the hospital;
2. special life-saving equipment which is immediately available at all times;
3. at least two beds for the accommodation of the critically ill; and
4. at least one registered nurse (R.N.) in continuous and constant attendance 24 hours a day.
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L

Licensed Nurse-Midwife specializes in birthing and acts under qualified direction and is affiliated or practicing in conjunction with a facility licensed under Article 28 of the Public Health Law or similar statute.

Lifetime Maximum is the maximum dollar amount payable by the Plan, under the Extended Medical Benefits portion, for covered services. It applies to you, the employee, and each member of your family, separately.
M

Medically Necessary is care which, according to the Plan Administrator(s) is:

1. consistent with the symptoms or diagnosis and treatment of your condition, disease, ailment or injury; and
2. in accordance with standards of good medical practice; and
3. not solely for your convenience, or that of your doctor or other provider; and
4. the most appropriate supply or level of service which can safely be provided to you; and
5. provided for the diagnosis or the direct care and treatment of your condition, illness, disease or injury; and
6. when applied to hospitalization, the participant requires acute care as a bed patient due to the nature of the services rendered, or the participant's condition; and the participant could not have received safe or adequate care as an outpatient.

The determination of Medical Necessity will be made after considering the advice of trained medical professionals. This includes doctors who will use medically recognized standards and criteria.

The Plan administrator(s) will examine all the circumstances surrounding your condition and the care provided, including your doctor's reasons for providing or prescribing the care; and any unusual circumstances. However, the fact that your doctor prescribed the care does not automatically mean that the care qualifies for payments under this Plan.

Medical Care Facility means a hospital; a facility that treats one or more specific ailments; or any type of skilled nursing facility.

Medical Emergency is a life-threatening or disabling condition which requires immediate medical attention and treatment.

Medical Professional for the purpose of this Plan document, shall include a licensed acupunturist; physical therapist; occupational therapist; speech therapist; speech language pathologist or audiologist; chiropractor; optometrist; psychiatrist; certified and registered psychologist; social worker as defined elsewhere in this section; a midwife licensed pursuant to Article 140 of the Education Law; a certified nurse anesthetist; a physician's assistant or nurse practitioner, as defined in the New York Education or Public Health Laws. If you receive care from medical professionals outside of New York State, such Medical Professionals must be licensed or certified under standards, in our sole judgment, similar to those used in New York State by a state agency in the state where the care is provided. All medical professionals must practice only within the scope of their license or certification. A midwife licensed pursuant to Article 140 of the Education Law, a certified nurse anesthetist, a physician's assistant or a nurse practitioner must practice under qualified medical direction, and must be employed by and practice with a doctor as defined above.

Medicare is the Health Insurance For The Aged Disabled program under Title XVIII of the Social Security Act, as amended.

Mental Disorder is neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional diesease or disorder of any kind.

Midwife is a licensed-nurse midwife who specializes in birthing and acts under qualified direction and is affiliated or practicing in conjunction with a facility licensed under Article 28 of the Public Health Law or similar statute.
N

Network/Participating Providers are providers who have agreed to accept payment according to a set schedule of allowances as full payment, or as otherwise defined in the contract.

No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

Non-Participating Providers (Out-of-Network) are providers who have not agreed to accept payments according to a set schedule of allowances as payment in full.
O

Out-of-Network Deductible 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.

Out-of-Network/Non-Participating Providers are providers who have not agreed to accept payments according to a set schedule of allowances as payment in full.

Out of Pocket Costs are those incurred when using out-of-network or non-participating providers. The Plan provides an annual out-of-pocket coinsurance maximum.

Outpatient Care is treatment performed in a hospital on a basis other than as a registered bed patient. Outpatient Care includes:

1. 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; and
2. services rendered in a physician's office, laboratory or x-ray facility, an ambulatory surgical center, or the patient's home.
P
Participating Employer or Covered Employer refers to the employers participating in SWSCHP - for example, your school district.

Participating Providers are providers who have agreed to accept payment according to a set schedule of allowances as full payment, or as otherwise defined in the contract.

Participant is an employee, retiree or dependent who is covered under this Plan.

Plan is the State-Wide Schools Cooperative Health Plan.

Plan Administration means WESCO in conjunction with Systemed, L.L.C., a subsidiary of Merck-Medco Managed Care, L.L.C. and POMCO.

Plan Year is the period of twelve consecutive months beginning January 1 and ending December 31.

Pregnancy is childbirth and conditions associated with pregnancy including complications.

Primary Payer means the plan that will determine the medical benefits that will be be payable to you first.

Private Proprietary Hospital 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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