Glossary of Terms

Summary

This glossary is an alphabetical listing of terms and their definitions which help describe Employee Health Plan benefits and provisions.

The following definitions apply to the plan:

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 a patient is in the facility.
   6. Maintains a medical record for each patient.
   7. Has a written agreement with a local acute care hospital for the immediate transfer of patients 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 patients to stay overnight.

2. American Dental Association (ADA) specialist means a specialist as approved by the ADA including practices limited to public health, endodontics, oral pathology, oral and maxillofacial surgery, orthodontics, pedodontics, periodontics, and prosthodontics. The specialists must also meet the general standard requirements set forth by the ADA as to education and licensing.

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 person with the benefits available under this 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 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 plan 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 non-supervisory capacity in work of the type covered by a collective bargaining agreement requiring contributions to this 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.

   The Trustees have discretion to adopt rules and regulations for participation in the plan by Associate Employees.

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. Building and construction industry means the various trades and related positions associated with the building and construction industry including, but not limited to, the specific trades represented by the collective bargaining agreements and written contribution agreements recognized by the Board of Trustees.

8. Calendar year means a period that starts on January 1 at 12:01 a.m. and ends on December 31 at midnight of each year.

9. 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.

10. 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.

11. 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.

12. 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 the equivalent department of another state.

13. Children mean:
    1. Natural children and legally adopted children.
    2. Children placed with you (the participant) for adoption before the adoption is finalized.
    3. Stepchildren who live with you (the participant).
    4. Children of domestic partners who live with you (the participant).
    5. Legally placed children meaning any child who is placed with you (the participant) by an authorized placement agency, or by judgment, decree, or other court order specifying you have legal custody.

    Your paternity (if a male participant) must be established for natural children born out of wedlock. The effective date of coverage for a child born out of wedlock is the earliest of the following:

    1. The date of birth, if paternity is acknowledged jointly with the consent of the mother immediately after birth in connection with the application for the original birth certificate.
    2. The date a written acknowledgment is submitted to the Department of Vital Statistics officially acknowledging paternity to establish yourself as the natural father on the original or a substitute birth certificate, provided you are named as the child's father on the child's birth certificate.
    3. If you did not acknowledge paternity, the date of entry of a decree or judgment issued by a court with jurisdiction finding that you are, as a matter of law, the natural father of the child.

14. Coinsurance means the percentage of covered expenses each patient 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.

15. 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.

16. Consecutive month or year means the exact date a specified number of months or years from the date of service.

17. Copayment means a specified dollar amount each patient 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.

18. Cosmetic surgery or treatment (including any complications direct or indirect) means any operative procedure, any portion of an operative procedure or any other treatment performed primarily for the purpose of improving or reshaping structures of the body in order to enhance a patient's appearance and self-esteem, and is not needed to correct or improve a bodily function. Cosmetic procedures can have psychological benefits by improving a patient's body image and self-esteem and may also have some medical benefit, even if this is not the main reason for the treatment.

19. 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 the patient 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.

20. 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 Dental Hygienists (under the supervision of a DDS or DMD)
    5. Licensed Denturists
    6. Licensed Home Health Care, Hospice and Home Care Agencies
    7. Licensed Midwives (LM)
    8. Licensed Mental Health Counselors (LMHC)
    9. Certified Nurse Midwife (CNM)
    10. Licensed Marriage and Family Therapist (LMFT)
    11. Licensed Social Worker (MSW)
    12. Licensed Nurses (RN, LPN, ARNP, or NP)
    13. Licensed Occupational Therapists (OTA)
    14. Licensed Ocularists
    15. Licensed Opticians (dispensing)
    16. Licensed Optometrists (OD)
    17. Licensed Osteopathic Physicians (DO)
    18. Licensed Osteopathic Physician Assistants (OPA) (under the supervision of a DO)
    19. Licensed Pharmacists (RPh)
    20. Licensed Physical Therapists (LPT, RPT)
    21. Licensed Physicians (MD)
    22. Licensed Physician's Assistants (under the supervision of an MD)
    23. Licensed Podiatric Physicians (DPM)
    24. Licensed Clinical Psychologists
    25. Certified Radiologic Technologists (CRT, CRTT, CRDT, CNMT)
    26. Certified Registered Nurse Anesthetists (CRNA)
    27. Certified Respiratory Care Practitioners

    Additional covered categories of providers, when furnishing services consistent with state law and the conditions of coverage described elsewhere in this plan are met, including 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."

21. Custodial care means care that consists of services and supplies that are given mainly to help a patient meet the activities of daily living, whether or not the patient 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 selfadministered.
    4. Care not requiring constant attention of trained medical personnel.
    5. Personal care such as helping a patient 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.

22. Deductible means the amount of covered charges the patient is responsible for each calendar year before the plan's medical benefits are considered.

23. Dental fee schedule means the description of dental procedures and the amount paid for each as approved by the plan and amended from time to time.

24. Dependent means, at a minimum, the participant's lawful spouse, domestic partner and unmarried dependent children who qualify for coverage under the provisions of this plan as defined on pages 5-7. Please refer to page 119 for the definition of "dependent" that applies to the health reimbursement accounts.

25. 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.

26. Employment status (current) means the person is an employee, is the employer, or is associated with the employer in a business relationship by virtue of current employment status. An individual is considered to have coverage through current employment status if he or she (or his or her family member such as a spouse or parent) is (1) actively working or (2) not actively working but meets all of the following conditions:

    1. Retains employment rights in the industry;
    2. Has not had his or her employment terminated by the employer, if the employer provides the coverage, or has not had his or her membership in the employee organizations terminated, if the employee organization provides the coverage;
    3. Is not receiving disability payment from an employer for more than six months;
    4. Is not receiving Social Security disability benefits; and
    5. Has employment-based group health plan coverage that is not COBRA Continuation Coverage.

27. 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.

28. Enrollment, enroll or enrolled means the receipt by the Trust Office of the necessary enrollment forms which have been properly completed and signed by the participant.

29. 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 patient 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.

30. Extension of benefits means certain benefits are extended beyond the date eligibility terminates under this plan.

31. Full-time student means the dependent child is attending an educational organization which normally maintains a regular faculty and curriculum and normally has a regularly enrolled body of pupils or students in attendance at the place where its educational activities are regularly carried on. "Full-time" means 12 or more quarter, trimester, or semester hours. Students are also eligible during the summer months as long as they attend school full time before the summer and did not graduate. Proof of student status is required each quarter, trimester, or semester. The student must also primarily depend on you for support and maintenance.

    If a full-time student is required to reduce his or her class schedule below 12 hours because of a medically necessary leave of absence, the plan can extend coverage through the end of that quarter, trimester or semester. Similarly, if a student who was full-time during the spring but was required to reduce his or her class schedule below 12 hours in the fall, the plan can extend coverage through the summer. A leave of absence is deemed "medically necessary" only if the plan receives written certification from the student's treating physician stating that the student is suffering from a serious illness or injury and that the leave of absence or change of enrollment is medically necessary. The participant must be covered under the plan during the leave of absence for a student to qualify for the leave.

    Attendance at the following programs do not qualify the child as a full-time student:

    1. On-the-job training courses.
    2. Apprenticeship programs.
    3. Correspondence schools including web-based programs.
    4. Night schools.
    5. Job corp.
    6. General educational development (GED).

32. 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.

33. 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 Advantage Plan and Medicare Supplemental Insurance (Medigap).

34. 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.

35. 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.

36. 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.

37. Hospital means an institution which fully meets every one 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 persons.
    2. Maintains clinical records on all patients.
    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 patients with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient patients, or as a nursing home, hotel, or similar institution.

38. Illness means a sickness, disorder or disease and all related symptoms and recurrent conditions resulting from the same causes. Only injuries that are not employment related are considered for benefits under this plan.

39. Incurred means the date the service or supply is received or the purchase is made rather than the date the bill is received.

40. 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, except as provided for under "Life Insurance and Accidental Death and Dismemberment Benefits."

41. Inpatient refers either to the setting in which medical care is given or to a person who is receiving care in that setting. Inpatient means that the care is furnished to a patient while the patient is confined in a facility as a registered bed patient.

42. Intensive or coronary care unit means only 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.

43. Medically necessary means those covered services and supplies which are, in the judgment 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 patient, the patient's family, 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.

44. 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.

45. Medicare entitlement means receiving coverage from Medicare. Normally this is accomplished when a person who is age 65 signs up for Social Security benefits, which automatically enrolls the person in the Medicare program. Medicare coverage also is possible with end-stage renal disease, generally beginning three months after treatment begins, or for a person younger than age 65 who Social Security deems disabled, effective on the first day of the 25th month after the date the person's Social Security disability began.Social Security disability benefits do not begin until the sixth full month of disability.

46. 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.

47. 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 patients 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 patients 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 patient based on a diagnostic assessment of the patient's medical, psychological and social needs with documentation that the plan 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. Has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals.

48. Myofascial pain dysfunction syndrome (MPDS) means a disorder involving muscles of the temporomandibular joint (TMJ) area which is generally characterized by:

    1. Preauricular, temporal, occiput, and/ or jaw pain.
    2. Spasm and/or tenderness of the masticatory muscles.
    3. Limited jaw movement.
    4. The occasional sound of a click in the joint (TMJ).

49. 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" charges.
    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. Expenses which exceed vision and dental scheduled amounts.

50. Outpatient refers either to the setting in which medical care is given or to a patient who is receiving care in that setting. Outpatient means that the care is furnished to a patient while the patient is not so confined.

51. Placed or placement in connection with any placement for adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child.

52. Plan means this document outlining benefits provided by the Carpenters Health and Security Plan of Western Washington. This plan booklet describes the benefits available to participants and their dependents.

    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.

53. Post-retirement service shall be determined in accordance with Department of Labor Regulation 2530.203-3.

54. 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 which evaluates 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 patient is undergoing treatment in the hospital.
    3. Discharge planning. Discharge planning is designed to identify patients 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 patient and physician decide on the treatment actually performed.

55. 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 and/or the Commission on Accreditation of Rehabilitation Facilities and fully meets every one 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 patients with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient patients, or as a nursing home, hotel, or similar institution.

56. Residential treatment center means a facility which provides full-day and partday 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.

57. Retired carpenter or retiree means any person who meets the eligibility requirements for retired carpenters as established by the Carpenters Health and Security Plan of Western Washington and the Carpenters Retirement Plan of Western Washington, and as amended from time to time. Please refer to page 119 for the definition of "employee" that applies to the health reimbursement accounts.

58. Self contribution means the monthly contribution amount required, under the terms of the plan, in order to maintain continued eligibility.

59. Skilled nursing facility means an institution, or distinct part thereof, recognized as such by Medicare and approved by Medicare for payment which also fully meets every one of the following criteria:

    1. It is licensed to provide, and is engaged in providing, on an inpatient basis, for patients 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 patients 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. 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. 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 patients with mental, nervous or emotional disorders or conditions, for the care of senile or mentally deficient patients, or as a nursing home, hotel, or similar institution.

60. Temporomandibular joint dysfunction or disease (TMJ) means a disorder of the temporomandibular joint (the joint which connects the mandible or jawbone to the temporal bone) which is generally characterized by:

    1. Pain or muscle spasms in one or more of the following areas: face, jaw, neck, head, ears, throat, or shoulders.
    2. Popping or clicking of the jaw.
    3. Limited jaw movement or locking.
    4. Malocclusion, overbite or underbite.
    5. Mastication (chewing) difficulties.

61. Total disability or permanently and totally disabled means:

    1. In the case of a participant, the complete inability to work or engage in any occupation for compensation or profit or, in the case of a dependent, the complete inability to substantially engage in all the normal activities of a person of like age and gender in good health.
    2. In the case of a child, the complete inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months; entitled to Social Security benefits on the date eligibility for benefits under this plan would otherwise end because the child attained the limiting age; and covered under this plan immediately prior to attainment of the limiting age.

62. 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.

63. Trust means the Carpenters Health and Security Trust of Western Washington, originally created and established on January 1, 1960, as amended.

64. Trust Agreement means the Trust Agreement establishing the Carpenters Health and Security Trust of Western Washington and any modification, amendment, extension, or renewal thereof.

65. Usual, customary and reasonable (UCR) means a charge, as determined by the plan, that meets every one of the following criteria and is:

    1. The usual fee which the provider of service most frequently charges to the majority of his or her patients for a similar service or medical procedure (usual).
    2. 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 (customary).
    3. Unusual circumstances or medical complications requiring additional time, skill and experience in connection with a particular service or medical procedure (reasonable). 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.

    The plan makes the final determination as to whether or not the fee is "usual, customary and reasonable." If you become obligated to a physician for a charge in excess of the usual, customary and reasonable charge as determined by the plan, the excess amount is your responsibility.

66. Waiting period means, with respect to a group health plan and a person who is a potential participant or dependent in the plan, the period that must pass with respect to the person before the person is eligible to be covered for specific benefits under the terms of the plan.