A bodily injury you didn’t expect to happen, not planned.
A member who is eligible for benefits under Class 1 and is currently receiving Contractor contributions or who is receiving his or her benefits under the Fund based on banked hours and does not meet the eligibility requirements for Class 2, 3, or 4 coverage.
A disease that makes you feel that you can’t live without alcohol. It’s hard to control this feeling. You may feel sick if you go without alcohol.
A state-licensed emergency vehicle which carries injured or sick persons to a Hospital. Services which offer non-emergency, convalescent or invalid care do not meet this definition.
A request for your health insurer or plan to review a decision or a grievance again.
A Covered Service rendered by any provider other than a Network Provider, which has been authorized in advance (except for Emergency Care which may be authorized after the service is rendered) by the Claims Administrator to be paid at the Network level.
When a provider bills you for the difference between the provider’s charge and the allowed amount.
Services that help people make healthy changes in their lifestyles, habits and relationships. Includes services for mental health disorders and Substance Abuse.
The period of time specified in the Schedules of Benefits during which Covered Services are rendered, and benefit maximums, Deductibles, Coinsurance limits, and Out-of-Network Coinsurance limits are accumulated. The first and/or last Benefit Periods may be less than 12 months depending on your initial eligibility date and the date your coverage terminates. Generally, this is one calendar year (January 1 through December 31).
A network of health care facilities selected for specific services based on criteria such as experience, outcomes, efficiency, and effectiveness.
A federal law that requires group health plans to give continued health insurance coverage to certain employees and their dependents whose group coverage has ended.
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of pregnancy.
If a Member’s coverage is limited to a certain percentage, for example 80%, then the remaining 20% for which the Member is responsible is the Coinsurance amount. The Coinsurance may be capped by the Out-of-Pocket Maximum.
A fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
A claim that is reconsidered after it is initially approved (such as recertification of the number of days of a Hospital stay or ongoing course of treatment to be provided over a period of time or number of treatments) and the reconsideration results in reduced benefits or a termination of benefits (other than by Fund amendment or termination).
A condition or conditions that are present at birth regardless of causation. Such conditions may be hereditary or due to some influence during gestation.
Oral, injectable, implantable, or transdermal patches for birth control.
Contractor or Subcontractor means any person, firm or corporation, who or which is a member of the Ohio Contractors Association, Labor Relations Division, and any person, firm or corporation, who as a Contractor becomes signatory to the Labor Agreement and is engaged in either “Highway Construction,” “Heavy Construction,” “Railroad Construction,” “Sewer, Waterworks and Utility Construction,” “Industrial and Building Site,” and 131 “Sewage Plant, Waste Plant, Water Treatment Facilities Construction,” “Hazardous Waste Removal,” and “Lead Abatement Work,” as defined within the jurisdiction.
The gradual recovery of health and strength after illness or injury. It refers to the later stage of an infectious disease or illness when the patient recovers and returns to previous health, but may continue to be a source of infection to others even if feeling better.
A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their claims and providing an authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision, it does not have to pay its benefits first.
Any non-Medically Necessary surgery or procedure, the primary purpose of which is to improve or change the appearance of any portion of the body, but which does not restore bodily function, correct a disease state, physical appearance or disfigurement caused by an accident, birth defect, or correct or naturally improve a physiological function. Cosmetic Surgery includes but is not limited to rhinoplasty, lipectomy, surgery for sagging or extra skin, any augmentation or reduction procedures (e.g., mammoplasty, liposuction, keloids, rhinoplasty and associated surgery) or treatment relating to the consequences or as a result of Cosmetic Surgery.
A Member or Dependent who is covered under the medical, prescription drug, or vision benefits under the Fund and is listed on the Enrollment/Beneficiary Card of the Member on file at the Benefits Office.
Medically Necessary health care services, supplies, and expenses that are: (a) defined as Covered Services in the Member’s Plan, (b) not excluded under such Plan, (c) not Experimental/Investigative (except where costs for these items and services are provided in connection with participation in a clinical trial and federal law requires these items and services be covered) and (d) provided in accordance with such Plan.
Any Medically Necessary human organ and stem cell/bone marrow transplants and transfusions as determined Anthem including necessary acquisition procedures, harvest and storage, and including Medically Necessary preparatory myeloablative therapy.
Any type of care, including room and board, that (a) does not require the skills of professional or technical personnel; (b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-Hospital Skilled Nursing Facility care; (c) is a level such that the Member has reached the maximum level of physical or mental function and is not likely to make further significant improvement. Custodial Care includes, but is not limited to, any type of care the primary purpose of which is to attend to the Member’s activities of daily living which do not entail or require the continuing attention of trained medical or paramedical personnel.
The amount you could owe during a coverage period (usually one year) for health care services your health insurance or plan covers before your health insurance or plan begins to pay.
For example, if your deductible is $800, your plan won’t pay anything until you’ve met your $800 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
An individual that is or can be covered under the Plan based on your familial or legal relationship to the individual.
The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient to a minimum.
The statistical variation, as defined by standardized, validated developmental screening tests, such as the Denver Developmental Screening Test, in reaching age appropriate verbal/growth/motor skill developmental milestones when there is no apparent medical or psychological problem. It alone does not constitute an illness or an injury.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
A condition classified as a mental disorder and described in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or the most recent version, as drug dependence abuse or drug psychosis.
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
The date your insurance plan starts covering you.
Also known as: ER, emergency department, ED, emergency ward, EW, casualty department.
The area of a hospital that gives treatment for people who have an emergency medical condition.
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Enrollment card that must be completed by the eligible Member and accepted by the Fund in order to receive benefits for the eligible Member and his or her eligible Dependents.
An agency of the United States government that reviews food, medications and medical devices for the health, safety and wellness of US citizens.
Also known as: preferred drug list, PDL.
A list of drugs your health insurance or plan covers.
A formulary may include how much you pay for each drug. If the plan uses “tiers,” the formulary may list which drugs are in which tiers. For example, a formulary may include generic drug and brand name drug tiers.
A facility, with a staff of Physicians, at which surgical procedures are performed on an Outpatient basis-no patients stay overnight. The facility offers continuous service by both Physicians and registered nurses (R.N.s). It must be licensed by the appropriate agency. A Physician’s office does not qualify as a Freestanding Ambulatory Facility.
Generic drugs are copies of brand-name drugs that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety, and strength as the original drug. In other words, their pharmacological effects are exactly the same as those of their brand-name counterparts.
A complaint that you communicate to your health insurer or plan.
An employee welfare benefit plan that is established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement or otherwise.
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
An insurance company, insurance service, or insurance organization which is licensed to engage in the business of insurance in a State and subject to regulation by the State.
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of your health information by limiting who can look at and receive it.
This law also protects health insurance coverage for workers and their families if they change or lose their jobs.
Health care services and supplies you get in your home under your doctor’s orders.
Services may be provided by nurses, therapists, social workers or other licensed health care providers. Home health care usually does not include help with non-medical tasks, such as cooking, cleaning or driving.
A provider who renders care through a program for the treatment of a patient in the patient’s home, consisting of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the patient’s attending Physician. It must be licensed by the appropriate agency.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families
A coordinated, interdisciplinary program designed to meet the special physical, psychological, spiritual and social needs of the terminally ill Member and his or her covered family members, by providing palliative and supportive medical, nursing and other services through at-home or Inpatient care. The Hospice must be licensed by the appropriate agency and must be funded as a Hospice as defined by those laws. It must provide a program of treatment for at least two unrelated individuals who have been medically diagnosed as having no reasonable prospect of cure for their illnesses.
An institution licensed by the appropriate agency, which is primarily engaged in providing diagnostic and therapeutic facilities on an Inpatient basis for the surgical and medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff of Physicians duly licensed to practice medicine, and which continuously provides 24-hour-a-day nursing services by registered graduate nurses physically present and on duty.
A charge will be considered Incurred on the date a Covered Individual receives the service or supply for which the charge is made.
A provider which does not meet the minimum requirements to become a contracted provider with the Claims Administrator. Services rendered to a Member by such a provider are not eligible for payment.
The condition of a presumably healthy Member who is unable to conceive or produce conception after a period of one year of frequent, unprotected heterosexual vaginal intercourse. This does not include conditions for men when the cause is a vasectomy or orchiectomy or for women when the cause is tubal ligation or hysterectomy.
The percent you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
A fixed amount you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
A person who stays in a hospital for one or more nights for medical care or treatment.
An individual who is either the natural guardian of a child or who was appointed a guardian of an individual in a legal proceeding by a court having the appropriate jurisdiction.
Obstetrical care received both before and after the delivery of a child or children. It also includes care for miscarriage or abortion. It includes regular nursery care for a newborn infant as long as the mother’s Hospital stay is a covered benefit and the newborn infant is an eligible Member under the Plan.
The maximum amount that the Plan will allow for Covered Services you receive.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
A federal health insurance program for low-income families and children, eligible pregnant women, people with disabilities, and other adults.
The federal government pays for part of Medicaid and sets guidelines for the program. States pay for part of Medicaid and have choices in how they design their program.
Medicaid varies by state and may have a different name in your state.
A federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease.
Eligible individuals can receive coverage for:
- Hospital services (Medicare Part A)
- Medical services (Medicare Part B)
- Prescription drugs (Medicare Part D)
Together, Medicare Parts A and B are known as Original Medicare.
Benefits can also be provided through a Medicare Advantage plan (Medicare Part C).
The status of a provider that is certified by the United States Department of Health and Human Services to receive payment under Medicare.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A Physician, health professional, Hospital, Pharmacy, or other individual, organization and/or facility that has entered into a contract, either directly or indirectly, with the Claims Administrator to provide Covered Services to Members.
A service that is not covered under your health insurance plan.
Transportation for a person who cannot walk on their own in a non-emergency situation. For example, a nursing home patient who is being transported to a doctor’s office.
The status of a physician or other provider that does not have an agreement with a Claims Administrator about payment for Covered Services.
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
A meeting with your health care professional to diagnose, prevent or treat a health care condition.
The percent you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
A fixed amount you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments.
Any provider that has NOT been designated as a “Center of Excellence” for Transplants by Anthem nor has not been selected to participate as a Network Transplant Provider by a designee of Anthem.
The maximum amount of a Member’s Coinsurance payments during a given calendar year. When the Out-of-Pocket Maximum is reached, the level of benefits is increased to 100% of the Maximum Allowed Amount for Covered Services, exclusive of Copayments and other scheduled charges. Also known as Out-of-Pocket Limit.
Someone who receives health services or treatments, but does not stay overnight at a hospital; when the patient does not stay in the hospital.
Drugs you can buy without a prescription. Some OTC medicines relieve aches, pains and itches. Some prevent or cure diseases, like tooth decay and athlete’s foot. Others help manage recurring problems, like migraines. (Examples: Tylenol, Aleve, Claritin, Robitussin, Benadryl, Cortizone, Pepto-Bismol).
A medical device placed inside your chest or abdomen that helps control your heartbeat.
Any form of care designed to relieve pain or side effects of treatment and improve quality of life.
Also known as: PT.
The treatment of pain and weakness through exercise and other therapies.
Exercises may include:
- Using weight and stretch bands
Other therapies may include heat, ice, manipulation, ultrasound and electrical stimulation.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
The person or entity named (Ohio Laborers Benefits) by the Plan Sponsor to manage the Plan and answer questions about Plan details. The Plan Administrator is not the Claims Administrator, with the exception of Death, Accidental Death & Dismemberment, and Short Term Disability Benefits.
The Plan Sponsor is the Board of Trustees of the OLDC-OCA Insurance Fund. It is the legal entity that has adopted the Plan and has authority regarding its operation, amendment and termination. The Plan Sponsor is not the Claims Administrator.
Procedure for reviewing and approving certain health care services prior to the services being rendered. Failure to follow Pre-certification procedures may result in the reduction or denial of benefits.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Any medication, which by federal or state law may not be dispensed without a prescription order.
A claim for Fund benefits where Pre-certification is required before you obtain care.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Procedure for reviewing and approving certain prescription drugs. Failure to follow prior authorization procedures may result in the reduction or denial of benefits. The process applied to certain drugs and/or therapeutic categories to define and/or limit the conditions under which these drugs will be covered. The drugs and criteria for coverage are defined by the Pharmacy and Therapeutics Committee.
A claim for Fund benefits that is not a Pre-Service Claim. When you file a Post-Service Claim, you have already received the services in your claim.
The likely outcome or course of a disease; the chance of recovery or recurrence.
A QMCSO creates or recognizes the right of a child who is recognized under the order as having a right to be enrolled under the health benefit Plan to receive benefits for which the Employee is entitled under the Plan; and includes the name and last known address of the Employee and each such child, a reasonable description of the type of coverage to be provided by the Plan, the period for which coverage must be provided and each Plan to which the order applies. An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that:
- Provides for child support payment related to health benefits with respect to the child of a Group Health Plan Member or requires health benefit coverage of such child in such Plan, and is ordered under state domestic relations law; or
- Enforces a state law relating to medical child support payment with respect to a Group Health Plan.
A major life change that allows you to make changes to your health plan.
Some major changes include marriage, turning 26, divorce, the birth of a child or the loss of a job.
A limit on the amount of a medication you can get at a time.
Certain medications have quantity limits for quality and safety reasons. The quantity limit for each medication is supported by drug studies and doctors.
The use of high-energy rays, such as x-rays, to kill cancer cells and shrink tumors.
The energy comes from a machine (external) and can go into the cancer. Some radiation can come in a small capsule and be placed inside the body near the tumor.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
A facility that provides care on a 24 hour a day, 7 days a week, live-in basis for the evaluation and treatment of residents with psychiatric or Chemical Dependency disorders. The facility provides room and board as well as providing an individual treatment plan for the chemical, psychological, and social needs of each of its residents. The facility meets all regional, state, and federal licensing requirements. The residential care treatment program is supervised by a professional staff of qualified Physician(s), licensed nurses, counselors, and social workers. Residents do not require care in an acute or more intensive medical setting.
Services not considered Medically Necessary.
These services include screenings, checkups and counseling. They help prevent health problems before you have any symptoms. They do not include tests or services to monitor or manage a condition or disease once it has been diagnosed.
A hospital room which contains two or more beds.
An injury or illness that keeps a person from working for a short time.
A Sickness or disease (including pregnancy) that causes loss covered by the Fund, which commences while the Covered Individual is eligible.
Care required, while recovering from an illness or injury, which is received in a Skilled Nursing Facility. This care requires a level of care or services less than that in a Hospital, but more than could be given at the patient’s home or in a nursing home not certified as a Skilled Nursing Facility.
An institution operated alone or with a Hospital which gives care after a Member leaves the Hospital for a condition requiring more care than can be rendered at home. It must be licensed by the appropriate agency and accredited by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or otherwise determined by Anthem to meet the reasonable standards applied by any of the aforesaid authorities.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
A type of prescription drug that, in general, requires special handling or ongoing monitoring and assessment by a health care professional, or is relatively difficult to dispense.
If the plan’s formulary uses “tiers,” and specialty drugs are included as a separate tier, you will likely pay more in cost sharing for drugs in the specialty drug tier.
Any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal.
Therapeutic/Clinically Equivalent drugs are drugs that can be expected to produce similar therapeutic outcomes for a disease or condition.
The inability to perform the substantial and material duties of his or her occupation or employment as a result of injury or Sickness.
A provider that has been designated as a “Center of Excellence” for Transplants by Anthem and/or a provider selected to participate as a Network Transplant Provider by a designee of Anthem.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
A claim for medical care or treatment that would:
- Seriously jeopardize your life, health, or ability to regain maximum function if normal Pre-Service Claim standards were applied; or
- Subject you to severe pain that cannot be adequately managed without the care or treatment for which approval is sought, in the opinion of a Physician with knowledge of your condition.
A function performed by Anthem or by an organization or entity selected by Anthem to review and approve whether the services provided are Medically Necessary, including but not limited to, whether acute hospitalization, length of stay, Outpatient care or diagnostic services are appropriate.
A period of time that must pass before you are covered by insurance.