COBRA - Consolidated Omnibus Budget Reconciliation Act

The COBRA Act of 1985 requires employers of 20 or more employees must continue health care coverage for terminated employees and for the widows, ex-spouses and dependents of employees, effective for plan years beginning after June 30, 1986.

COINSURANCE

The percentage of an Eligible Expense that must be paid by the Covered Person. Coinsurance does not include Deductibles, Copayments or non-covered expenses during that Plan Year.

CONTRACT

This agreement, any Supplemental Benefit Riders, the Premium Schedule and the application signed by the Member.

COPAYMENT

A specified amount the Covered Person must pay at the time services are rendered for certain Covered Services, which may not be used as part of the Deductible. All services received during a Provider office visit are covered by the payment of a single Copayment.

COVERAGE DENIAL

An insurer's determination that a service, treatment, drug or device is specifically limited or excluded under the covered person's Health Benefit Plan.

COVERED PERSON

The Member and Dependents covered under this Health Benefit Plan Coverage Document.

COVERED SERVICE

A service or supply that is available under this Plan, when Medically Necessary and obtained in full compliance with all Plan rules. Please refer to the Plan's Health Care Delivery Rules. A charge for a Covered Service shall be considered to have been incurred on the date the service or supply was provided.

CREDITABLE COVERAGE

Prior coverage by a Covered Person under any of the following:

1. A group health plan, including church and governmental plans;
2. Health insurance coverage;
3. Part A or Part B of Title XVIII of the Social Security Act (Medicare);
4. Medicaid, other than coverage consisting solely of benefits under section 1928;
5. The health plan for active military personnel, including CHAMPUS);
6. The Indian Health Service or other tribal organization program;
7. A state health benefits risk pool;
8. The Federal Employees Health Benefits Program;
9. A public health plan as defined in federal regulations; and
10. A Health Benefit Plan under section 5(e) of the Peace Corps Act; and
11. Any other plan which provides comprehensive hospital, medical, and surgical services.

Creditable Coverage does not include any of the following:

1. Accident-only coverage, disability income insurance or any combination thereof;
2. Supplemental coverage to liability insurance;
3. Liability insurance, including general liability insurance and automobile liability insurance;
4. Workers' compensation or similar insurance;
5. Automobile medical payment insurance; v F. Credit-only insurance;
6. Coverage for on-site medical clinics;
7. Benefits if offered separately:
8. 1. Limited scope dental and vision;
   2. Long-term care, nursing home care, home health care, community based care, or any combination thereof;
   3. Other similar limited benefits.
9. Benefits if offered as independent non-coordinated benefits:
   1. Specified disease or illness coverage; and
   2. Hospital indemnity or other fixed indemnity insurance.
10. Benefits if offered as a separate policy:
    1. Medicare Supplement insurance;
    2. Supplemental coverage to the health plan for active military personnel, including CHAMPUS; and
    3. Similar supplemental coverage provided to group health plan coverage.

DEDUCTIBLE

A specified dollar amount of Covered Services that must be incurred by the Covered Person before the Plan will provide benefits for all or part of the remaining Covered Services during the Plan Year. Please review the Schedule of Benefits for the method by which the Deductible is calculated.

DEPENDENT

A person other than the Member, more specifically defined as:

1. The Member's spouse under a legally valid existing marriage;
2. Any unmarried children from birth to age 19;
3. Any unmarried children 19 to 25 years of age who are full-time students enrolled in and attending an accredited educational institution and who are primarily dependent on the Member for maintenance and support. Semester or quarter breaks do not jeopardize the children's dependent status. Children who enroll full-time and actually attend an accredited educational institution shall be covered through the entire semester or quarter in which they actually attend classes and any regularly scheduled break following the semester or quarter. Coverage will terminate at the end of the month in which the next succeeding semester or quarter begins. The Plan may require proof of such Dependent's student status at its discretion, but not more than twice a year.;
4. For the purpose of determining eligibility for Dependent coverage, the term child or children includes
   1. natural children, including newborn children,
   2. stepchildren by a legal marriage,
   3. children legally placed for adoption, and legally adopted children of the Member,
   4. children for whom legal guardianship has been awarded, and
   5. children eligible to be claimed as Dependents on the Member's federal income tax return. Also classified as a Dependent child is a child whom the Member or the Member's spouse has a legal obligation under a divorce decree or other court order to provide for the health care expenses of the child;
5. Eligibility may continue past the age limit for an unmarried child, who has been continuously covered under this Health Benefit Plan (or another health plan) since prior to the child reaching the age limit, who is totally disabled and unable to work to support himself due to mental illness or retardation or physical handicap that started before the age limit, and where disability is medically certified by a Physician. The Plan may require proof of such Dependent's disability from time to time. A total disability is defined as the condition that results when any medically determinable physical or mental condition prevents a Dependent from engaging in substantial gainful activity and can be expected to result in death or to be of continuous or indefinite duration and is approved by the Plan.

EFFECTIVE DATE

The date on which coverage for a Covered Person begins.

ELIGIBLE INDIVIDUAL

An applicant for an individual coverage who has eighteen months prior Creditable Coverage, with no break in coverage of more than 63 days, the most recent of which was an employment related group plan sponsored by an employer, church or governmental plan. Certain children are Eligible Individuals, even if they do not have a full 18 months of Creditable Coverage, provided that they were covered under Creditable Coverage within 30 days of birth, adoption, or placement for adoption and have not had a 63-day break in coverage.

ENROLLMENT DATE

The date of enrollment of the individual in the plan.

FAMILY COVERAGE

Coverage for the Member and eligible covered Dependents.

GENERIC DRUGS

Prescribed therapeutic equivalents (approved by a government agency) of a brand name drug that is usually available at a lower cost.

HMO

Health Maintenance Organization provides rich benefits - preventive care coverage and low out-of-pocket expenses. There is typically no coverage for care from doctors or hospitals outside your HMO plan. Unless you have a Point of Service option or except in an emergency. HMO plans usually offer comprehensive benefits, affordable premiums with no deductibles and minimal cost- sharing. PCP or Primary Care Physician that you select from within the network oversees all your care. Unless you have a direct access feature in your plan - your Primary Care Physician will coordinate referrals to specialists when necessary.

INPATIENT

A Covered Person who is treated as a registered bed patient in a Hospital or other institutional Provider and for whom a room and board charge is made.

MEDICALLY NECESSARY (or MEDICAL NECESSITY)

The services or supplies furnished by a Provider that are required to identify or treat a Covered Person's illness or injury and which, as determined by the Plan, are:

1. Consistent with the symptom or diagnosis and treatment of the Covered Person's condition, disease, ailment, or injury;
2. Appropriate with regard to standards of good medical practice;
3. Not solely for the convenience of a Covered Person or Provider; and
4. The most appropriate supply or level of service which can be safely provided to the Covered Person. When applied to the care of an Inpatient, it further means that the Covered Person's medical symptoms or condition require that the services cannot be safely provided as an Outpatient.

MEMBER

An individual eligible for coverage who meets all eligibility requirements. The term "Member" includes any such individual whether referred to as a "Member", "Insured", "Subscriber", "Participant" or otherwise.

NON-PARTICIPATING PROVIDER

Any Provider other than a Participating Provider.

OPEN ACCESS

A provision that specifies that plan members may self-refer to a specialist, either in-network or out-of-network, at full benefit or at a reduced benefit, without first obtaining a referral from a primary care provider.

OPEN-ENROLLMENT

When an employee receives health insurance, you often have an open-enrollment period. Open enrollment is generally a once-a-year period that lets you modify your insurance coverage. If you give birth to a child or have a change in your marital status, you are allowed another opportunity to modify your health insurance coverage.

OUT-OF-POCKET LIMIT

A specified amount of expense incurred by a Covered Person for Covered Services in a Plan Year that exceeds the maximum amount of Out-of-Pocket expenditures as specified on the Schedule of Benefits. When the Out-of-Pocket Limit is reached, Coinsurance and Copayments decrease as specified in the Schedule of Benefits. It does not include any Deductible amounts, any amounts not paid because a maximum benefit limit has been reached, any coinsurance or copayment for prescription drugs or any amount above an Eligible Expense.

OUTPATIENT

A Covered Person who receives services or supplies while not an Inpatient.

PARTICIPATING PROVIDER

Any Provider which has an agreement with Anthem or Anthem's associated medical groups for the Option 2000 Advantage Plan to provide Covered Services.

PLAN DELIVERY SYSTEM RULES

A section of this Health Benefit Plan Coverage Document which describes the Plan's specific procedures that must be followed to obtain maximum benefits for Covered Services.

PLAN YEAR

Each successive twelve-month period starting on January 1 and ending on December 31.

PPO

Preferred Provider Organization is a network of physicians and hospitals that have agreed, by contract, to discount their rates to members. The networks are typically very large, and the members are free to seek care from any physician or provider within that network, including specialists, without a referral. Members may also access non-contracted providers, but at a higher out-of-pocket cost, this is called out of network benefit. PPO plans consumers usually have deductibles, co-pays, prescription benefits, and co-insurance.

PREMIUM

The periodic charges due which the Covered Person or the Covered Person's group must pay to maintain coverage.

PREMIUM DUE DATE

The date on which a Premium is due under this Health Benefit Plan.

PRE-EXISTING CONDITION

A condition, (mental or physical), which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on the Enrollment Date. Pregnancy is considered a Pre-existing Condition. Domestic violence is not considered a Pre-existing Condition. Genetic information may not be used as a condition in the absence of a diagnosis. Pre-existing Conditions do not apply to Eligible Individuals.

SINGLE COVERAGE

Coverage for the Member only.

SUPPLEMENTAL HEALTH BENEFIT RIDERS

Approved riders which may be offered to enhance benefits under the approved standard plan. These riders may not duplicate benefits paid under this Plan.

URGENT CARE

Medical care which is appropriate to the treatment of an illness or injury that is not a life-threatening emergency, but requires prompt medical attention. Urgent care includes the treatment of minor injuries as a result of accidents, the relief or elimination of severe pain or the moderation of an acute illness.