Glossary Of Terms

Summary

This glossary is an alphabetical listing of terms and their definitions which apply to this plan.

For the purpose of this plan, the definitions as written here apply:

1. Ambulatory surgical center means any public or private establishment which fully meets all of the following criteria:
   1. Is licensed as such by the state.
   2. Is Medicare certified.
   3. Has an organized medical staff of physicians.
   4. Has permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures.
   5. Provides continuous physician and registered professional nursing services whenever an individual is in the facility.
   6. Maintains a medical record for each individual.
   7. Has a written agreement with a local acute care hospital for the immediate transfer of individuals who require greater care than can be furnished at the facility.
   8. Complies with all licensing and other legal requirements.
   9. Is not the office or clinic of one or more physicians.
   10. Is the most appropriate supply or level of service needed to provide safe and adequate care as determined by the plan.
       
       Ambulatory surgical center does not include (1) physician’s or dentist’s offices, (2) any facilities whose primary purpose is the termination of pregnancy, or (3) a facility which provides services or other accommodations for individuals to stay overnight.
2. Approved treatment facility means an institution providing treatment for chronic chemical dependency abuse and operating under the direction and control of the Washington State Department of Social and Health Services or the equivalent department of another state. If the facility does not operate under the direction and control of the Department, then it must provide effective treatment for chemical dependency through a contract with the Department, be included in the Department’s current list of approved public and private treatment facilities, and meet all applicable government standards.
3. Associate employee means:
   1. Officers, agents, representatives, and employees of the union and any apprentice or training coordinator or instructor or any organization whose purpose is to enforce prevailing wage rates, and for whom contributions to this Trust are made, pursuant to a written contribution agreement, by the union or other employer thereof for the purpose of providing such persons with the benefits available under the Employed Plan.
   2. Persons otherwise within the definition of the preceding subsection who have accepted or do hereafter accept supervisory or administrative employment with the national or international union and for whom contributions to this Trust are made, pursuant to a written contribution agreement, by such national or international union as employer.
   3. “Shareholder-Officer-Employee” – those employees of an incorporated individual employer which is actively engaged in bargaining unit work; provided, such employees have previously been employed in a nonsupervisory capacity in work of the type covered by a collective bargaining agreement requiring contributions to this Trust, and who are either corporate officers, spouses of corporate officers or are allied with the management of the employer because of a material financial interest therein,  either direct or indirect, and for whose benefit the employer makes contributions to this Trust pursuant to a written contribution agreement acceptable to the Trustees.
   4. Supervisory employees for whom contributions to this Trust are made by an individual employer; provided, such supervisory employees have previously been employed in a nonsupervisory capacity in work of the type covered by a collective bargaining agreement requiring contributions to the Trust, and that such supervisory employees are actively engaged in the affairs of the business of the individual employer, and that the individual employer has entered into a written contribution agreement acceptable to the Trustees.
      
      If the Trustees in their discretion allow participation in the plan by Associate Employees, then specific rules and regulations for eligibility of Associate Employees shall be set forth as part of the plan.
4. Benefit maximum means a maximum amount of benefits that will be paid by the plan for a specified type of covered charge incurred during a given period of time.
5. Birthing center means a freestanding or hospital-based birthing center which operates under the direction and control of the Washington State Department of Social and Health Services or the equivalent department of another state.
6. Board of Trustees or Board means the Board of Trustees established by the Trust Agreement.
7. Calendar year means a period that starts on January 1 at 12:01 AM and ends on December 31 at midnight of each year.
8. Carpenter, employee or participant means any individual for whom an employer (as defined by the Trust Agreement) makes contributions or has previously made contributions who qualifies for plan benefits in accordance with the eligibility provisions (as amended from time to time) and is still eligible for or is receiving benefits under the plan. It also includes retirees who qualify for benefits in accordance with the eligibility rules established by the Board of Trustees.
9. Carryover means covered charges incurred in the last three months of a calendar year which were applied toward the annual deductible and will be applied toward the annual deductible for the following year.
10. Certificate of prior coverage means under HIPAA, in certain circumstances, group health plans and health insurance issuers are required to furnish certificates to plan participants that note the amount of previous qualified health coverage.
11. Certified Nurse Midwife (CNM) means a registered nurse who has gained the special knowledge and skills of midwifery in an educational program accredited by the American College of Nurse-Midwives and who is licensed in the State of Washington by the Board of Registered Nursing as a nurse-midwife or an equivalent body in another state.
12. Coinsurance means the percentage of covered expenses each individual pays each calendar year. The coinsurance amount varies depending on the type of service or supply received and the type of health care provider used.
13. Congenital anomaly or hereditary complication means a condition existing at or from birth that creates a functional problem and is a significant deviation from the common form or norm.
14. Copayment means a specified dollar amount each individual pays each time certain covered charges are incurred. Copayments do not apply toward the annual deductible and do not accumulate toward the annual coinsurance maximum.
15. Covered charges or expenses as determined by this plan, means the medically necessary and “usual, customary and reasonable” charge for services or supplies covered by this plan and incurred while an individual is eligible under this plan. “Covered charges” do not include services or supplies that fall within the exclusionary provisions of this plan, exceed benefit maximums or are not covered as a result of a benefit reduction under the medical review program, even if that service or supply is recognized as a “covered charge” under any of the other plans involved or Medicare.
16. Covered provider means a person who is in a category of persons regulated under Title 18 or Chapter 70.127 RCW of the State of Washington to practice health care or health care related services consistent with state law. Also included is an employee or agent of a person described herein, acting in the course and scope of his or her employment. Provider also includes certain health care facilities regulated under Chapter 70 and 71 RCW or 90.96A RCW, and other providers of health care services and supplies, as specifically indicated in the provider category listing below and recognized by the plan as a covered provider. Health care facilities which are owned and operated by a political subdivision or instrumentality of the State of Washington and other such facilities are included as required by state and federal law. Covered licensed, registered or certified categories of providers regulated under Title 18 and Chapter 70.127 RCW, when the condition of coverage described elsewhere in this plan are met, include:
    1. Licensed Chiropractors (DC)
    2. Licensed Dentists (DDS, DMD)
    3. Certified Dietitians/Nutritionists (D, CD, CN)
    4. Licensed Home Health Care, Hospice and Home Care Agencies
    5. Licensed Midwives (LM)
    6. Certified Nurse Midwives (CNM)
    7. Licensed Nurses (RN, LPN, ARNP, or NP)
    8. Licensed Occupational Therapists (OTA)
    9. Licensed Ocularists
    10. Licensed Opticians (dispensing)
    11. Licensed Optometrists (OD)
    12. Licensed Osteopathic Physicians (DO)
    13. Licensed Osteopathic Physician Assistants (OPA) (under the supervision of a DO)
    14. Licensed Pharmacists (RPh)
    15. Licensed Physical Therapists (LPT, RPT)
    16. Licensed Physicians (MD)
    17. Licensed Physician’s Assistants (under the supervision of an MD)
    18. Licensed Podiatric Physicians (DPM)
    19. Licensed Clinical Psychologists
    20. Certified Radiologic Technologists (CRT, CRTT, CRDT, CNMT)
    21. Certified Registered Nurse Anesthetists (CRNA)
    5. Certified Respiratory Care Practitioners
    23. Licensed Social Workers (MSW)
        
    Additional covered categories of providers, when furnishing services consistent with state law and the conditions of coverage described elsewhere in this plan are met, include the following health care facilities and other providers of health care services and supplies:
    1. Licensed Ambulance Companies
    2. Licensed Ambulatory Diagnostic, Treatment and Surgical Facilities
    3. Audiologists (CCC-A, CCC-MSPA)
    4. Licensed Birthing Centers
    5. Blood Banks
    6. Licensed Drug and Alcohol Treatment Facilities
    7. Licensed Home Medical and Respiratory Equipment Suppliers
    8. Licensed Hospitals
    9. Licensed Kidney Disease Treatment Centers
    10. Licensed Psychiatric Hospitals
    11. Speech Therapists (Certified by the American Speech, Language and Hearing Association)
    Benefits for some types of services furnished by the provider categories listed above may be limited or excluded under this plan. Benefits available under this plan are subject to the provisions stated under this plan, including “Glossary of Terms” and “General Limitations and Exclusions.”
    
17. Custodial care means care that consists of services and supplies that are given mainly to help an individual meet the activities of daily living, whether or not the individual is disabled, and that are not rendered mainly for their therapeutic value in the treatment of an illness or injury. Custodial care includes, but is not limited to, care such as:
    1. Care mainly to provide room and board.
    2. Preparation of special diets.
    3. Supervision of the administration of medications that can usually be self-administered.
    4. Care not requiring constant attention of trained medical personnel.
    5. Personal care such as helping the individual to walk, get in and out of bed, bathe, dress, eat, or use the toilet.
    Such services and supplies are custodial care without regard to the practitioner or provider by whom or by which they are prescribed, recommended or performed.
18. Deductible means the amount of covered charges the individual is responsible for each calendar year before the plan’s medical benefits are considered.
19. Dependent means, at a minimum, the retiree’s lawful spouse and unmarried dependent children who qualify for coverage under the provisions of this plan as defined on pages 3-6.
20. Employer contributions means the contributions that an individual employer is required to make to the Carpenters Health and Security Plan of Western Washington under the terms of a collective bargaining agreement recognized by the Board of Trustees or a written contribution agreement recognized by the Board of Trustees.
21. Enroll means to become covered for benefits under a group health or other plan (that is, when coverage becomes effective) without regard to when the individual may have completed or filed any forms that are required in order to enroll in the plan.
22. Experimental or investigative means:
    1. The drug or device cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and approval for marketing has not been given for regular nonexperimental or noninvestigational purposes at the time the drug or device is furnished; or
    2. The drug, device, medical treatment, or procedure has been determined to be an experimental or investigational procedure by the treating facility’s institutional review board, treating practitioner, or other body serving a similar function, and the individual has signed an informed consent document acknowledging such experimental status; or
    3. Federal law classifies the drug, device, or medical treatment under an investigative program; or
    4. Reliable evidence shows the drug, device, medical treatment, or procedure is the subject of on-going phase I, II or III clinical trials or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis; or
    5. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis.
    For the purpose of this definition, “reliable evidence” means only published reports and articles in peer reviewed authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment, or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure.
    
    The Board of Trustees will investigate each claim for benefits which might include experimental or investigational treatment. The Trustees will consult with medical professionals to determine whether the treatment is excluded as experimental or investigational. The Board of Trustees may rely on the advice of these medical professionals in deciding all claims and appeals related to experimental or investigational services or supplies.
23. Group health plan as defined by ERISA means an employee welfare benefit plan to the extent that the plan provides medical care (including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement or otherwise.
24. Health insurance coverage as defined by ERISA means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or HMO contract offered by a health insurance issuer. For purposes of this plan, health insurance coverage also includes a Medicare Managed Care Plan and Individual Medicare Supplemental Insurance (Medigap).
25. Home health care agency means a public or private agency or organization (or subdivision of such an agency or organization) that administers and provides home health care and is either a Medicare-certified home health care agency or certified as a home health care agency by the Washington State Department of Social and Health Services or the equivalent department of another state.
26. Home health care plan means a program of home care that is required as a result of an illness or injury; is established in writing and periodically reviewed by the attending physician; and is certified by the physician as a replacement for hospital or skilled nursing care confinement that would otherwise be necessary.
27. Hospice agency means a public or private agency or organization that administers and provides hospice care and is either a Medicare-certified hospice agency or certified as a hospice care agency by the Washington State Department of Social and Health Services or the equivalent department of another state.
28. Hospital means an institution which fully meets all of the following criteria:
    1. Is primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic, surgical and therapeutic services for the diagnosis, treatment and rehabilitation of injured, disabled or sick individuals.
    2. Maintains clinical records on all individuals.
    3. Has bylaws in effect with respect to its staff of physicians.
    4. Has a requirement that every patient be under the care of a physician.
    5. Provides 24-hour nursing service rendered or supervised by a registered, professional nurse.
    6. Has in effect a hospital utilization review plan.
    7. Is licensed pursuant to any state or agency of the state responsible for licensing hospitals.
    8. Has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.
    Unless specifically provided, the term “hospital” does not include any institution or part thereof which is used principally as a place for rest, for custodial care, as a home for the aged, for drug addicts, for alcoholics, for the care of individuals with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient individuals, or as a nursing home, hotel, or similar institution.
29. Illness means a sickness, disorder or disease and all related symptoms and recurrent conditions resulting from the same causes that is not employment related.
30. Incurred refers to the date the service was rendered or the supply was ordered rather than the date the bill was submitted or received.
31. Injury means physical damage to the body caused by purely accidental means, such as external force, independent of all other causes requiring immediate medical attention. Only injuries that are not employment related are considered for benefits under this plan.
32. Inpatient and outpatient refers either to the setting in which medical care is given or to an individual who is receiving care in that setting:
    1. “Inpatient” means that the care is furnished to an individual while the individual is confined in a facility as a registered bed patient.
    2. “Outpatient” means that the care is furnished to an individual while the individual is not so confined.
33. Intensive or coronary care unit means a separate, clearly designated service section that is part of an acute care hospital and fully meets all of the tests listed below:
    1. It is solely for treatment of patients who are in a critical condition.
    2. It provides constant special nursing care and observation not available in the other sections of the hospital.
    3. It contains special life-saving equipment that is ready for immediate use.
    4. It contains at least two beds for critically ill patients.
    5. It has, at all times, at least one registered nurse who is in constant attendance.
    6. It meets the standards set for an intensive care unit by the Joint Commission on Accreditation of Hospitals.
    “Intensive care unit” shall include a burn unit or a cardiac care unit that meets all of the above tests. The term shall not include a unit for post-operative recovery, intensive alcoholism or psychiatric treatment.
34. Medically necessary means those covered services and supplies which are, in the judgement of the plan, determined to meet all of the following requirements. They must be:
    1. Essential to the diagnosis or the treatment of an illness, injury or condition and could not have been diagnosed or treated without it.
    2. Consistent with the symptom or diagnosis and treatment of the condition.
    3. Generally recognized by the medical profession as tested and accepted medical practice in accordance with authoritative medical or scientific literature.
    4. The most appropriate supply or level of service that is vital to the patient’s needs.
    5. Not primarily for research or data accumulation.
    6. Not primarily for the convenience of the retiree, the retiree’s family, the patient, the patient’s provider, or another provider.
    7. Neither experimental or investigative and not in conflict with accepted medical standards.
    The fact that a physician or other provider has prescribed, ordered, suggested, or approved a service, supply or setting, does not alone make it medically necessary or make the charge covered even though it is not specifically listed as an exclusion. A service or supply may be medically necessary in part only.
35. Medicare means the program established under Title XVII of the Social Security Act (Federal Health Insurance for the Aged) as it is presently constituted or may hereafter be amended.
36. Medicare entitlement means receiving coverage from Medicare. Normally this is accomplished when an individual who is age 65 signs up for Social Security benefits, which automatically enrolls the individual in the Medicare program. Medicare coverage also is possible with kidney (end-stage renal) disease, generally beginning three months after treatment begins, or for individuals younger than age 65 who Social Security deems disabled, effective on the first day of the 25th month after the date the individual’s Social Security disability began. Social Security disability benefits do not begin until the sixth full month of disability.
37. Mental health conditions means any nervous or mental disease or disorder whether the cause is organic, physical, mental, or environmental including, but not limited to, conditions which fall within the range of diagnostic codes 290.0 through 319.9 as listed in the current edition of the International Classification of Diseases Manual. The term includes eating disorders but does not include problems that relate to alcohol or drug use or abuse, or specific delays in the development of thinking, motor, speech, or language skills.
38. Mental health facility as it applies to the treatment of a nervous or mental condition means a hospital or an institution, or a distinct part of a hospital, that admits individuals for 24-hour skilled care of mental conditions. It is also able to provide full-day or part-day acute treatment of the condition for individuals who do not require full-time hospitalization, but who need broader programs than are possible from outpatient visits in a hospital-based or hospital-affiliated facility. A mental health facility also meets all of the following requirements:
    1. It is primarily engaged in providing for compensation from its patients a program for diagnosis, evaluation and treatment of mental or nervous disorders. It is not primarily a school or custodial, recreational or training institution.
    2. It provides, or has an agreement with a hospital in the area to provide, medical services for the treatment of any physical disease or injury manifested during the treatment period.
    3. It is under the continuous supervision of a psychiatrist who has the overall responsibility for coordinating patient care and who is at the facility on a regularly scheduled basis.
    4. It is staffed by psychiatrists who are directly involved in the treatment program, at least one of whom is present at all times during the treatment program, and continuously provides the service of psychiatric registered nurses and licensed psychiatric social workers.
    5. It prepares and maintains a written treatment plan for each individual based on a diagnostic assessment of the individual’s medical, psychological and social needs with documentation that the plan of treatment is under the supervision of a psychiatrist.
    6. It meets any applicable licensing standards established by the jurisdiction in which it is located.
    7. It continuously provides skilled nursing services under the direction of a full-time registered nurse, with licensed nursing personnel on duty at all times.
    8. It has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.
39. Monthly contribution means the contribution amount required, under the terms of the plan, to maintain continued eligibility.
40. Out-of-pocket expense means expenses such as the annual deductible, copayment, coinsurance, and any or all of the following:
    1. Expenses that exceed the “usual, customary and reasonable” charge.
    2. Expenses for services or supplies not medically necessary.
    3. Expenses for services or supplies not covered under this plan.
    4. Expenses that exceed benefit maximums.
    5. Expenses not covered as a result of a benefit reduction under the medical review program.
    6. Charges for services or supplies received from a non-Medicare eligible provider that exceed the amount that would be provided if such services or supplies were received from a Medicare eligible provide
41. Outpatient and inpatient refers either to the setting in which medical care is given or to an individual who is receiving care in that setting:
    1. “Inpatient” means that the care is furnished to an individual while the individual is confined in a facility as a registered bed patient.
    2. “Outpatient” means that the care is furnished to an individual while the individual is not so confined.
42. Placed or placement is a term used to describe the event that makes a child who is being adopted eligible to be covered under this plan. A child is “placed” for the purposes of legal adoption on the date the retiree takes on the legal duty to support that child as part of the process of adopting the child.
43. Plan means this document outlining benefits provided by the Carpenters Health and Security Plan of Western Washington – For Retired Carpenters. “Plan” does not mean benefits provided under the Prescription Drug Supplement.
    
    For the purpose of coordination of benefits under this plan, the term “plan” also means all of the following, even if they do not have their own coordination of benefits provision: group, individual, or blanket disability insurance policies and health care service contractor and health maintenance organization agreements issued by insurers, health care service contractors and health maintenance organizations; labor-management trustee plans, labor organization plans, employer organization plans or employee benefit organization plans; government programs which provide benefits for their own civilian employees or their dependents; and group coverage required or provided by any law including Medicare. This does not include workers’ compensation.
44. Post-retirement service shall be determined in accordance with Department of Labor Regulations 2530.203-3.
45. Preadmission certification involves utilization management which includes the evaluation of medical necessity, appropriateness, and efficiency of the use of health care procedures and facilities under the auspices of this plan. This includes the evaluation of medical necessity by medical professionals from the medical review agency. The review programs include prospective review, concurrent review, discharge planning, and retrospective review of hospital admissions as described below:
    1. Prospective review. The process begins during precertification review by medical professionals from the medical review agency who evaluate the medical necessity of the hospital admission. If the admission is considered medically necessary, the medical review agency initially certifies the number of inpatient hospital days for the admission. Follow-up reviews are conducted with the hospital if an extension is necessary.
    2. Concurrent review. Ongoing review while the individual is undergoing treatment in the hospital.
    3. Discharge planning. Discharge planning is designed to identify individuals who could be discharged with appropriate arrangements made for covered alternative care.
    4. Retrospective review. Retrospective review includes all the steps of precertification review, but after services are rendered. Retrospective review occurs when the medical review program is not contacted before treatment.
    The role of the medical review program is to advise on medical appropriateness. The individual and physician decide on the treatment actually performed.
46. Rehabilitative hospital means a licensed institution which is accredited as a medical inpatient rehabilitation hospital by the Joint Commission on Accreditation of the American Hospital Association or the Commission on Accreditation of Rehabilitation Facilities and meets all of the following criteria:
    1. It provides facilities for the diagnosis and inpatient rehabilitative treatment of an illness or injury with the objective of improving or restoring physical function to the fullest extent possible.
    2. It has facilities or a contractual agreement with another hospital in the area for emergency treatment, surgery and any other diagnostic or therapeutic services that might be required during a confinement.
    3. It provides all normal infirmary level medical services required for the treatment of any illness or injury occurring during confinement.
    4. It has a staff of physicians specializing in physical medicine and rehabilitation directly involved in the treatment program, one of whom is present at all times during the treatment day.
    Unless specifically provided, the term “rehabilitative hospital” does not include any institution or part thereof which is used principally for vocational counseling, job training or social adjustment services, as a place for rest, for custodial care, as a home for the aged, for drug addicts, for alcoholics, for the care of individuals with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient individuals, or as a nursing home, hotel, or similar institution.
47. Residential treatment center means a facility which provides full-day and part-day programs to treat alcohol and drug dependence or mental conditions, but that is not licensed to provide inpatient care. The center must be licensed or otherwise approved to provide this care by the state in which it is located.
48. Retired carpenter or retiree means any individual who meets the eligibility requirements for retired carpenters as determined by the Carpenters Health and Security Plan of Western Washington, as amended,  and the Carpenters Retirement Plan of Western Washington, as amended.
49. Retirement effective date means the date a carpenter retires as determined by the Carpenters Retirement Plan of Western Washington.
50. Skilled nursing facility means an institution (or distinct part thereof) recognized as such by Medicare and approved by Medicare for payment which also meets all of the following criteria:
    1. It is licensed to provide, and is engaged in providing, on an inpatient basis, for individuals convalescing from an illness or injury, professional nursing services rendered by a registered nurse (RN) or by a licensed practical nurse (LPN) under the direction of a registered nurse; and physical restoration services to assist individuals to reach a degree of body functioning to permit self-care in essential daily living activities.
    2. Its services are provided for compensation from its patients and under the full-time supervision of a physician or registered nurse.
    3. It provides 24-hour-per-day skilled nursing services by licensed nurses, under the direction of a full-time registered nurse.
    4. It has a contract for the services of a physician, maintains daily records on each patient and is equipped to dispense and administer drugs.
    5. It complies with all licensing and other legal requirements, and is recognized as an “extended care facility” by the Secretary of Health, Education and Welfare of the United States pursuant to Title XVIII of the Social Security Administration of 1965.
    6. It has transfer arrangements with one or more hospitals, a utilization review plan, and operating policies developed and monitored by a professional group that includes at least one physician.
    Unless specifically provided, the term “skilled nursing facility” does not include any institution or part thereof which is used principally as a place for rest, for custodial care, as a home for the aged, for drug addicts, for alcoholics, for the care of individuals with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient individuals, or as a nursing home, hotel, or similar institution.
51. Special enrollment date means enrollment allowed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as described under Special Enrollment Rights.
52. Trust means the Carpenters Health and Security Trust of Western Washington, originally created and established on January 1, 1960, as amended.
53. Trust Agreement means the Trust Agreement establishing the Carpenters Health and Security Trust of Western Washington and any modification, amendment, extension, or renewal thereof.
54. Usual, customary and reasonable (UCR) means a charge, as determined by this plan, that meets all of the following criteria and is:
    1. Usual. The usual fee which the provider of the service most frequently charges to the majority of his or her patients for a similar service or medical procedure.
    2. Customary. The fees which fall within the customary range of fees charged in a locality by most providers of a similar training and experience for the performance of a similar service or medical procedure.
    3. Reasonable. Unusual circumstances or medical complications requiring additional time, skill and experience in connection with a particular service or medical procedure. When an unusual or complicated service or supply is provided, the usual and customary charge is determined by taking into consideration charges for treatment of comparable nature and complexity.
    This plan makes the final determination as to whether or not the fee is “usual, customary and reasonable.” If an individual becomes obligated to a physician for a charge in excess of the usual, customary and reasonable charge as determined by this plan, the excess amount is the individual’s responsibility.
55. Waiting period means, with respect to a group health plan and an individual who is a potential retiree, spouse or dependent child in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for specific benefits under the terms of the plan.