Common use of Benefits Booklet Clause in Contracts

Benefits Booklet. The Benefits Booklet is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between KFHPWA and the Group. Convalescent Care Care furnished for the purpose of meeting non-medically necessary personal needs which could be provided by persons without professional skills or training, such as assistance in walking, dressing, bathing, eating, preparation of special diets, and taking medication. Copayment The specific dollar amount a Member is required to pay at the time of service for certain Covered Services. Cost Share The portion of the cost of Covered Services for which the Member is liable. Cost Share includes Copayments, coinsurances and Deductibles. Covered Services The services for which a Member is entitled to coverage in the Benefits Booklet. Creditable Coverage Coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare prescription drug coverage, as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS actuarial guidelines. In general, the actuarial determination measures whether the expected amount of paid claims under KFHPWA’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. Deductible A specific amount a Member is required to pay for certain Covered Services before benefits are payable. Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements, is enrolled hereunder and for whom the premium has been paid. Emergency The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Member’s health, or if the Member is pregnant, the health of her unborn child, in serious jeopardy, or any other situations which would be considered an emergency under applicable federal or state law. Essential Health Benefits Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including the categories of ambulatory patient services, Emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Family Unit A Subscriber and all his/her Dependents. Group An employer, union, welfare trust or bona-fide association which has entered into a Group medical coverage agreement with KFHPWA. Hospital Care Those Medically Necessary services generally provided by acute general hospitals for admitted patients. KFHPWA-designated Specialist A specialist specifically identified by KFHPWA. Medical Condition A disease, illness or injury. Medically Necessary Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Members will be notified in writing when a determination has been made. Appropriate and clinically necessary services, as determined by KFHPWA’s medical director according to generally accepted principles of good medical practice, which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under KFHPWA’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Member’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the Member’s condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by KFHPWA’s medical director. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service and not excluded from coverage. Medicare The federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Member Any enrolled Subscriber or Dependent. Network Facility A facility (hospital, medical center or health care center) owned, operated or otherwise designated by KFHPWA, or with whom KFHPWA has contracted to provide health care services to Members.

Benefits Booklet. The Benefits Booklet is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between KFHPWA Group Health and the Group. Convalescent Care Care furnished for the purpose of meeting non-medically necessary personal needs which could be provided by persons without professional skills or training, such as assistance in walking, dressing, bathing, eating, preparation of special diets, and taking medication. Copayment The specific dollar amount a Member is required to pay at the time of service for certain Covered Services. Cost Share The portion of the cost of Covered Services for which the Member is liable. Cost Share includes Copayments, coinsurances and Deductibles. Covered Services The services for which a Member is entitled to coverage in the Benefits Booklet. Creditable Coverage Coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare prescription drug coverage, as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS actuarial guidelines. In general, the actuarial determination measures whether the expected amount of paid claims under KFHPWAGroup Health’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. Deductible A specific amount a Member is required to pay for certain Covered Services before benefits are payable. Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements, is enrolled hereunder and for whom the premium has been paid. Emergency The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Member’s health, or if the Member is pregnant, the health of her unborn child, in serious jeopardy, or any other situations which would be considered an emergency under applicable federal or state law. Essential Health Benefits Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including the categories of ambulatory patient services, Emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Family Unit A Subscriber and all his/her Dependents. Group An employer, union, welfare trust or bona-fide association which has entered into a Group medical coverage agreement with KFHPWA. Hospital Care Those Medically Necessary services generally provided by acute general hospitals for admitted patients. KFHPWA-designated Specialist A specialist specifically identified by KFHPWA. Medical Condition A disease, illness or injury. Medically Necessary Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Members will be notified in writing when a determination has been made. Appropriate and clinically necessary services, as determined by KFHPWA’s medical director according to generally accepted principles of good medical practice, which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under KFHPWA’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Member’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the Member’s condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by KFHPWA’s medical director. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service and not excluded from coverage. Medicare The federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Member Any enrolled Subscriber or Dependent. Network Facility A facility (hospital, medical center or health care center) owned, operated or otherwise designated by KFHPWA, or with whom KFHPWA has contracted to provide health care services to Members.

Benefits Booklet. The Benefits Booklet is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between KFHPWA Group Health and the Group. Community Provider Physicians licensed under 18.71 or 18.57 RCW, registered nurses licensed under 18.79 RCW, midwives licensed under 18.79 RCW, naturopaths licensed under 18.36A RCW, acupuncturists licensed under 18.06 RCW, podiatrists licensed under 18.22 RCW or, in the case of non-Washington State providers or out-of-country providers, those providers meeting equivalent licensing and certification requirements established in the territories where the provider's practice is located. For purposes of the Benefits Booklet, Community Providers do not include individuals employed by or under contract with Group Health’s Network or who provide a service or treat Members outside the scope of their licenses. Convalescent Care Care furnished for the purpose of meeting non-medically necessary personal needs which could be provided by persons without professional skills or training, such as assistance in walking, dressing, bathing, eating, preparation of special diets, and taking medication. Copayment The specific dollar amount a Member is required to pay at the time of service for certain Covered Services. Cost Share The portion of the cost of Covered Services for which the Member is liable. Cost Share includes Copayments, coinsurances and Deductibles. Covered Services The services for which a Member is entitled to coverage in the Benefits Booklet. Creditable Coverage Coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare prescription drug coverage, as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS actuarial guidelines. In general, the actuarial determination measures whether the expected amount of paid claims under KFHPWAGroup Health’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. Deductible A specific amount a Member is required to pay for certain Covered Services before benefits are payable. Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements, is enrolled hereunder and for whom the premium has been paid. Emergency The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Member’s health, or if the Member is pregnant, the health of her unborn child, in serious jeopardy, or any other situations which would be considered an emergency under applicable federal or state law. Essential Health Benefits Benefits set forth under the Patient Protection and Affordable Care Act of 2010, including the categories of ambulatory patient services, Emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Family Unit A Subscriber and all his/her Dependents. Group An employer, union, welfare trust or bona-fide association which has entered into a Group medical coverage agreement with KFHPWAGroup Health. Group Health-designated Specialist A specialist specifically identified by Group Health. Health Savings Account (HSA) A tax-exempt savings account established exclusively for the purpose of paying qualified medical expenses and meeting other requirements under federal law. Health Savings Account (HSA) Qualified Health Plan A high deductible health plan that meets regulatory requirements for use in conjunction with a Health Savings Account. Hospital Care Those Medically Necessary services generally provided by acute general hospitals for admitted patients. KFHPWA-designated Specialist A specialist specifically identified by KFHPWA. Medical Condition A disease, illness or injury. Medically Necessary Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Members will be notified in writing when a determination has been made. Appropriate and clinically necessary services, as determined by KFHPWAGroup Health’s medical director according to generally accepted principles of good medical practice, which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Member, his/her family or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Member; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under KFHPWAGroup Health’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Member’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the Member’s condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by KFHPWAGroup Health’s medical director. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service and not excluded from coverage. Medicare The federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Member Any enrolled Subscriber or Dependent. Network Facility A facility (hospital, medical center or health care center) owned, operated or otherwise designated by KFHPWA, or with whom KFHPWA has contracted to provide health care services to MembersGroup Health’s Network.