Carpenters Health and Security Plan

Glossary 

Summary

This section is an alphabetical listing of terms and their definitions which help describe 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. Associate employee means a non-bargaining employee covered as an “associate employee” under a written contribution agreement between an Individual Employer and the Trustees.
  3. 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.
  4. 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 by an appropriate state agency.
  5. Congenital or hereditary means existing at or from birth or determined by genetic factors and therefore able to be passed on from parents to their offspring or descendants.
  6. Cosmetic surgery or services (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.
  7. Covered charges or covered expenses means the medically necessary services or supplies covered by this plan and incurred while the patient is eligible under this plan and which have been billed in accordance with generally accepted professional standards and/or medical practice. “Covered charges” and “covered expenses” 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.
  8. 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 self-administered.
    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.
  9. Emergency or emergency medical condition means medical or dental condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to place the health of the individual or unborn child in serious jeopardy, to expose the individual to serious impairment of bodily functions, or result in serious dysfunction of any organ or body part. The plan has the discretion and authority to determine if a service or supply is or should be classified as an Emergency or Emergency Medical Condition.
  10. 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.
  11. Enrollment, enroll or enrolled means the receipt by Carpenters Trusts of the necessary enrollment forms and documents that have been properly completed and signed by the participant or retiree. It also 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.
  12. 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 plan will investigate each claim for benefits which might include experimental or investigational treatment. The plan will consult with medical professionals to determine whether the treatment is excluded as experimental or investigational. The plan may rely on the advice of these medical professionals in deciding all claims and appeals related to experimental or investigational services or supplies.

    Notwithstanding the foregoing, routine patient costs for items and services furnished in connection with an approved clinical trial will not be considered experimental or investigational if the item or service would otherwise be a covered charge for an individual who is not enrolled in the clinical trial. An approved clinical trial is a phase I, II, III, or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition. The individual must be eligible to participate in the approved clinical trial according to the trial protocol.

    The following are not covered for a clinical trial:
    1. The actual clinical trial or the investigational team;
    2. Items and services solely for data collection that are not directly used in the clinical management of the patient; or
    3. Services that are clearly inconsistent with widely accepted and established standards of care for a particular condition.
  13. 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.
  14. 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 licensed as a hospice care agency by an appropriate state agency.
  15. 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.
  16. Illness means a sickness, disorder or disease and all related symptoms and recurrent conditions resulting from the same causes. An illness identified in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered to be a mental health disorder for the purposes of this plan. If there are multiple diagnoses, only the treatment for the illness identified under the DSM code is considered mental health treatment. Only illnesses or injuries that are not employment related are considered for benefits under this plan.
  17. Incurred means the date the service or supply is received or the purchase is made rather than the date the bill is received.
  18. 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.
  19. Intensive outpatient program (IOP) is a kind of treatment service and support program used primarily to treat eating disorders, depression, self-harm, and chemical dependency that does not rely on detoxification. IOP operates on a small scale and does not require the intensive residential or partial day services typically offered by the larger, more comprehensive treatment facilities. The typical IOP offers group and individual services of 10-12 hours per week. IOP allows the individual to participate in his or her daily affairs such as work and then participate in treatment at an appropriate facility in the morning or at the end of the day. The facility must be licensed in the state where it operates and all charges are for items provided within the scope of that license and has accreditation under the Joint Commission on Accreditation of Hospitals (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF).
  20. Maximum allowable fee means the following:
    1. For network providers, it is the contracted rates as agreed to by the Trust through the provider’s direct contract with the Trust’s preferred provider network.
    2. For non-network providers, it is the amount determined by the plan’s network provider based on the charges of similar providers in the geographic region; provided that the methodology may vary from one particular claim to the next based on the facts and circumstance of the claim, the services provided and expected cost savings. The Trust may hire a third-party reviewer to determine the maximum allowable fee for non-network providers consistent with this provision; and irrespective of the Trust’s methodology or determination, the Trustees reserve the right to negotiate an acceptable maximum allowable fee amount directly with a non-network provider.
    3. For network and non-network providers, it is the multiple procedure reductions (100 percent for the first procedure/50 percent for the second procedure/25 percent for the third procedure). Assistant surgeon is limited to a percentage of the maximum allowable fee allowed by the plan for the surgeon.
    In all situations, the plan reserves the right to determine the allowed amount for a given service or supply.
  21. 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.
  22. Partial hospitalization (PHP) is an outpatient program that is provided under the supervision of an attending psychiatrist. Partial hospitalization (PHP) is intended to provide treatment on an outpatient basis, does not include boarding/housing and is intended to provide treatment interventions in a structured setting, with patients returning to their home environments each day. The facility must be licensed in the state where it operates and all charges are for items provided within the scope of that license and has accreditation under the Joint Commission on Accreditation of Hospitals (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF).
  23. Physician refers to a legally qualified physician or surgeon practicing within the scope of the provider’s license as a Medical Doctor (MD) and Osteopath (DO).
  24. Provider means a healthcare provider who is acting within the scope of the provider’s license or certificate under applicable state law. Certain licensed or certified professionals providing services covered by the plan may be required to be under the supervision of an MD, DO, DDS, or DMD as determined by the plan. Covered providers may include:
    1. Acupuncturist
    2. Anesthetist
    3. Certified Nurse Midwife
    4. Chiropodist
    5. Chiropractor
    6. Clinical Psychologist
    7. Denturist
    8. Licensed Practical Nurse
    9. Marriage and Family Therapist
    10. Mental Health Counselor
    11. Nurse Practitioner
    12. Physical Therapist
    13. Physician’s Assistant
    14. Optometrist
    15. Registered Nurse
    Before receiving treatment from any practitioner other than an MD or DO, check with Carpenters Trusts to find out if the expenses will be recognized as covered.
  25. Residential treatment facility means an institution that meets all of the following requirements:
    1. The facility is licensed in the state where it operates and all charges are for items provided within the scope of that license and has accreditation under the Joint Commission on Accreditation of Hospitals (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF).
    2. Provides a comprehensive patient assessment (preferably before admission, but at least upon admission).
    3. Admissions are approved by a physician.
    4. Has access to necessary medical services 24 hours per day/7 days a week and 24-hours per day/7 days a week supervision by a physician with evidence of close and frequent observation.
    5. Provides indoor living arrangements, including room and board, at a physical facility. (Tents, yurts and similar structures with temporary or fabric walls are not considered indoor physical facilities.)
    6. Provides that any group therapy sessions are conducted at least by an RN or masters-level health professional.
    7. For mental health and substance abuse treatment, provides access to psychiatrist or psychologist.
    8. For mental health and substance abuse treatment, services are managed by a licensed behavioral health provider acting within the scope of that license.
    9. For substance abuse admissions, if the patient requires detoxification services, must have the availability of on-site medical treatment 24 hours per day/7days a week, which must be actively supervised by an attending physician.
    10. For substance abuse admissions, ability to assess and recognize withdrawal complications that threaten life or bodily functions and to obtain needed services either on site or externally.
    11. Residential treatment facility does not include adventure, outdoor, or wilderness interventions and camps, that provide outdoor youth or outdoor behavioral programs, or courses or camps that primarily utilize an outdoor or similar non-traditional setting to provide services that are primarily supportive in nature and rendered by individuals who are not providers, including, but not limited to:
      • Building self-esteem or leadership skills;
      • Losing weight;
      • Managing diabetes;
      • Contending with cancer or a terminal diagnosis; or
      • Living with, controlling or overcoming blindness, deafness/hardness of hearing, a mental health condition or substance use disorder.
    Services by physicians or licensed providers in an adventure, outdoor, or wilderness interventions and camps may be covered if they are billed independently and would otherwise be a covered services under the plan.
  26. 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.
  27. Trust means the Carpenters Health and Security Trust of Western Washington, originally created and established on January 1, 1960, as amended.
  28. Trust Agreement means the Trust Agreement establishing the Carpenters Health and Security Trust of Western Washington and any modification, amendment, extension, or renewal thereof.

Last Updated: 11/04/2021