Glossary

Active Status Active status mans performing your job on a regular, full-time basis as defined in the group application. Each day of a regular paid vacation and any regular non-working holiday shall be deemed active status if you were in an active status on your last regular working day.   Acute Illness/Injury Illness or injuries that are of rapid onset witha n expected short-term duration.   Application Form Application form means the form completed by a potential member requesting coverage from MercyCare.   Bodily Injury Bodily injury means an injury resulting from an accident, independent of all other causes.   Certificate Certificate means this Certificate of Coverage wich has been issued to you and which summarizes the terms, conditions, and limitations of your health care coverage.   Change Form Change form means the form that you must complete if you wish to change the information contained on your application form. Change forms are available from MercyCare.   Change of Status Form Change of Status Form means the form you must complete if you wish to add or delete dependents or change the information contained on your enrollment form. Change of Status forms are provided by MercyCare and are available from the Group.   Chronic Illness/Condition Illness or conditions that are of long duration and show little change, or a slow progression, of the symptoms or condition. Treatment is supportive in nature and not curative.   Claim Claim means a demand for payment due in exchange for health care services rendered.   Coinsurance Coinsurance means the member's portion, expressed as a percentage of the fee for covered services that you are required to pay for certain covered services provided under the policy.   Confinement/Confined Confinement or confined means (a) the period of time between admission as an inpatient or outpatient to a hospital, alcohol and other drug abuse (AODA) residential treatment center, skilled nursing facility or licensed ambulatory surgical center, and discharge therefrom; or (b) the time spent receiving emergency care for sickness or bodily injury in a hospital. Hospital swing bed confinement is considered the same as confinement in a skilled nursing facility. If you are transferred to another facility for continued treatment of the same or related condition, it is considered one confinement.   Congenital Congenital means a condition that exists at birth but is not hereditary.   Contract Year Contract year means that 12-month period beginning on the effective date of the Group's policy.   Copayment Copayment means the member's portion, expressed as a fixed dollar amount, that you are required to pay for certain covered services provided under this policy.   Covered Service Covered service means a service or supply specified in this certificate and the Schedule of Benefits for which benefits will be provided.   Custodial Care Custodial care means provision of room and board, nursing care, personal care or other care designed to assist you in the activities of daily living. Custodial care occurs when, in the opinion of a participating provider, you have reached the maximum level of recovery. If you are institutionalized, custodial care also includes room and board, nursing care, or other care when, in the opinion of a participating provider, medical or surgical treatment cannot reasonably be expected to enable you to live outside an institution. Custodial care also includes rest cures, respite care, and home care provided by family members.   Deductible Deductible means a pre-determined amount of money that an individual member may have to pay before benefits are payable by MercyCare. The single deductible applies to each member each contract year, and the family deductible amount is the most that the employee and his or her dependents must pay each contract year.   Dependent Dependent means the following: 1.An employee's lawful spouse; and/or 2.An employee's unmarried and natural blood-related child (ren), stepchild (ren), legally adopted child (ren) or child (ren) placed in the custody of the employee for adoption (as provided for in section 632.896 of the Wisconsin Statutes) whose age is less than the limiting age stated in the Schedule of Benefits; and/or 1.Grandchildren if the parent is a dependent child under the age of 18. If the employee is the father of a child born outside of marriage, the child does not qualify as a dependent unless there is a court order declaring paternity or acknowledgment of paternity is filed with the Wisconsin Department of Health and Family Services or the equivalent agency if the birth was outside of the state of Wisconsin. Upon qualification, coverage for the child will be effective according to the Eligibility and Effective Date of Coverage section. A spouse and stepchild (ren) cease to be dependents on the date in which a divorce decree is granted, and may be terminated subject to Continuation and Conversion privileges. Other child (ren) cease to be dependents at the end of the calendar year in which they reach the limiting age as stated in the Schedule of Benefits or on the date of their marriage, whichever occurs first, except that: 1.A child (ren) over the limiting age who are full-time students, if otherwise eligible, cease to be dependents at the end of the month in which they cease to be full-time students or in which they turn the age specified in the Schedule of Benefits for full-time students, whichever occurs first. Full-time student means the child is in regular full-time attendance at an accredited secondary school; accredited vocational, technical, or adult education school, or an accredited college or university which provides a schedule of courses or classes and whose principal activity is the provision of an education. Proof of attendance is required upon request from MercyCare. Full-time student status is to be defined by the institution in which the student is enrolled. Student status includes any intervening vacation period if the child continues to be a full-time student. 2.A covered dependent child who attains the limiting age while insured under the policy shall remain eligible for benefits if he or she is incapable of self-sustaining employment because of mental retardation or physical handicap which existed before the dependent attained the limiting age. The dependent must continue to be chiefly dependent on the employee for support and maintenance. Written proof of incapacity and dependency must be provided to MercyCare in a form satisfactory to MercyCare within 31 days after the dependent's attainment of the limiting age. MercyCare, at its sole discretion, may require the dependent to be examined from time to time by a participating provider for the purpose of determining the existence of the incapacity prior to granting continued coverage. Such examinations may occur at reasonable intervals during the first two years after continuation under this section is granted and annually thereafter. The employee must notify MercyCare immediately of a cessation of incapacity or dependency. 3.A child who is considered a dependent ceases to be a dependent on the date the child becomes insured as an eligible employee.   Developmental Disability Developmental disability means mental retardation or a related condition such as cerebral palsy, epilepsy or autism, but excluding mental illness and infirmities of aging, which is: a)Manifested before the individual reaches age 22, b)Likely to continue indefinitely, and c)Results in substantial functional limitations in 3 or more of the following areas of major life activity: 1.Self-care. 2.Understanding and use of language. 3.Learning. 4.Mobility. 5.Self-direction. 6.Capacity for independent living. 7.Economic self-sufficiency.   Dual Choice Enrollment Period Dual choice enrollment period means a period each year when the Group and MercyCare agree to allow members who are currently enrolled in any of the Group's other benefit plans to enroll for coverage under MercyCare's Plan.   Elective Hospital Admission An admission to a hospital for a treatment or surgical procedure not requiring immediate attention and therefore planned for the patient's convenience.   Emergency Emergency means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson with an average knowledge of health and medicine reasonably to conclude that, without immediate attention, could likely result in death or serious injury to your body.   Employee Employee means an individual whose employment or other status, except for family dependency, is the basis for eligibility for enrollment under the policy.   Enrollment Form Enrollment form means the form completed by a potential member requesting coverage from MercyCare and listing all dependents to be covered on the effective date of coverage.   Experimental/Investigative Experimental or investigative means the use of any service, treatment, procedure, facility, equipment, drug, devices or supply for a member's bodily injury or sickness that: a)Requires the approval by the appropriate federal or other governmental agency that has not been granted at the time it is used; or b)Is not yet recognized as acceptable medical practice to treat that bodily injury or sickness, as determined by MercyCare for a member's bodily injury or sickness. The criteria that MercyCare's Quality Health Management Department uses for determining whether a service, treatment, procedure, facility, equipment, drug, device or supply is considered to be experimental or investigative include whether: a)It is commonly performed or used on a widespread geographic basis. b)It is generally accepted to treat that bodily injury or sickness by the medical profession in the United States. c)Its failure rate or side effects are unacceptable. d)The member has exhausted more conventional methods of treating the bodily injury or sickness. e)It is recognized for reimbursement by Medicare, Medicaid and other insurers and self-funded plans.   Free-Standing Surgical Facility Free-standing surgical facility means any accredited public or private establishment that has permanent facilities equipped and operated primarily for performing surgery with continuous physician services and registered professional nursing services whenever a patient is in the facility. It does not provide services or accommodations for patients to stay overnight.   Grievance Grievance means any dissatisfaction that you have with MercyCare or with a participating or non-participating provider that has been expressed in writing by you or on your behalf. See the Complaint, Appeal and Grievance Procedures section in this certificate for more information.   Group Group means the employer, union, trust or association to which the policy is issued and through which eligible employees and dependents become entitled to coverage described in this certificate.   Group Application Group application means the form completed by a Group requesting coverage from MercyCare for individuals in their Group.   Hospital Hospital means an institution that: 1. a)Is licensed and run according to Wisconsin laws,or other applicable jurisdictions, that apply to hospitals; b)Maintains at its location all the facilities needed to provide diagnosis of, and medical and surgical care for, bodily injury or sickness; c)Provides this care for fees; d)Provides such care on an inpatient basis; and e)Provides continuous 24-hour nursing services by registered graduate nurses; or 2. a)Qualifies as a psychiatric or tuberculosis hospital. b)Is a Medicare provider; and c)Is accredited as a hospital by the Joint Commission on Accreditation of Healthcare Organizations. Hospital does not mean an institution that is chiefly: a)A place for treatment of chemical dependency; b)A nursing home; or c)A federal hospital.   Identification Card Identification card means the card that MercyCare issues to you that indicates your eligibility to receive covered services from participating providers.   Infertility Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.   Learning Disability Learning Disability means an inability or defect in the ability to learn. It occurs in children and is manifested by difficulty in learning basic skills such as writing, reading and mathematics.   Level 1 Provider A provider listed in the most recently published provider directory.   Level 2 Provider A provider not listed in our most recently published provider directory, but which is included in the Beech Street Provider Network.   Level 3 Provider A provider not listed in our most recently published provider directory and not listed in the Beech Street Provider Network.   Maintenance or Long Term Therapy Maintenance or long term therapy means ongoing therapy delivered after the acute phase of a sickness has passed. It begins when a patient's recovery has reached a plateau or non-measurable improvement if his/her condition has slowed or ceased entirely and only minimal rehabilitative gains can be demonstrated. The determination of what constitutes maintenance or long-term therapy is made by MercyCare after reviewing an individual's case history or treatment plan submitted by a provider.   Maximum Family Deductible Maximum family deductible means the total deductible applied to all members in one family in a contract year. The maximum is stated on the Schedule of Benefits.   Medicaid Medicaid means a program instituted pursuant to Title XIX (Grants to States for Medical Assistance Programs) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or hereafter amended.   Medically Necessary Medically necessary means a service, treatment, procedure, equipment, drug, device, or supply provided by a hospital, physician, or other provider of health care that is required to identify or treat a member's bodily injury or sickness and which is determined by MercyCare to be: 1.Consistent with the symptom(s) or diagnosis and treatment of the member's bodily injury or sickness; 2.Appropriate under the standards of acceptable medical practice to treat that bodily injury or sickness; 3.Not solely for the convenience of the member, physician, hospital or other provider of health care; 4.The most appropriate service, treatment, procedure, equipment, drug, device or supply which can be safely provided to the member; 5.The most economical manner of accomplishing the desired end result.   Medicare Medicare means Title XVIII (Health Insurance Act for the Aged) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or hereafter amended.   Medicare Eligible Medicare eligible means health care services or expenses that are covered by Medicare. Medicare must recognize them as medically necessary and reasonable. The services or expenses may or may not be fully reimbursed by Medicare.   Member Member means the employee and his/her dependents who have been enrolled and are entitled to benefits under the policy.   MercyCare MercyCare means MercyCare Insurance Company.   Network Provider Network provider means any provider in the same provider network as your primary care physician. You can visit any network provider without a referral. In order to determined if a provider is one of your network providers, please review your Provider Directory.   Non-Contracted Provider A Level 3 provider who has not signed a contract with the Plan to provide services at a discounted fee for service.   Non-Elective Hospital Admission An admission though a hospital emergency room for a treatment or surgical procedure requiring immediate attention and therefore unable to be pre-planned for the patient's convenience. See definition of emergency.   Non-Experimental Non-experimental means: a)Any discrete and identifiable technology; regimen or modality regularly and customarily used to diagnose or treat bodily injury or sickness; and b)For which there is conclusive, generally accepted evidence that such technology, regimen or modality is safe, efficient and effective as determined by MercyCare.   Non-Participating Provider Non-participating provider means a provider not listed in the most current provider directory.   Open Enrollment Period Open enrollment period means a period (each year) when the Group and MercyCare agree to allow potential members to enroll for coverage, regardless of whether they are currently enrolled in any of the Group's other medical benefit plans.   Out-of-pocket Expenses Out-of-pocket expenses means the portion of covered charges for which the member is responsible because of applicable coinsurance and/or deductible provisions, or non-covered charges.   Participating Provider Participating provider refers to any provider listed in the most current provider directory.   Physician Change Form Physician change form refers to the form available through MercyCare's Customer Service Department that enables a member to change his or her selection of primary care physician. Refer to the provision entitled Provider Selection in the Obtaining Services section of this certificate for more information.   Plan Plan means the group health Plan offered by MercyCare Insurance Company as described in this certificate.   Policy Policy means the agreement between the Group and MercyCare setting forth the contractual rights and obligations of the parties and wherein MercyCare agrees to provide a health benefit program to eligible employees and their dependents of the Group. The Group Contract, the Certificate of Coverage, the Schedule of Benefits, and any addenda or endorsements thereto, and the applications of the Group and the employee, constitute the entire policy.   Policyholder Policyholder means the Group.   Pre-Existing Condition A disease or physical or mental condition that manifested itself through medical diagnosis or treatment, in the six (6) month period prior to the enrollment date. Pregnancy is not considered a pre-existing condition.   Prescription Drug Prescription drug means any medicinal substance, the label of which, under the Federal Food, Drug and Cosmetic Act, is required to bear the legend: "Caution: Federal Law prohibits dispensing without prescription."   Primary Care Physician Primary care physician means a physician practicing family medicine, internal medicine, or pediatrics that has accepted primary responsibility for the MercyCare member's health care. You must name your primary care physician on your enrollment form or on a later physician change form. Each family member may have a different primary care physician. A member's primary care physician: -Provides entry into MercyCare's health care system. -Evaluates a member's total health care needs. -Provides personal medical care in one or more medical fields. -Is in charge of coordinating other health services and referring the member to other providers of health care when appropriate.   Prior Authorization Prior authorization means obtaining MercyCare's approval before you receive a service or supply. Any prior authorization requirement will be stated in this certificate or in the Schedule of Benefits. To obtain prior authorization, contact MercyCare at the address on the first page of this certificate or at the telephone number printed on your identification card.   Provider Network A provider network is a group of providers contracted with the Plan to provide services for members within a specific geographic location. The primary care physician you select directly determines the provider network with which you will be associated.   Providers of Health Care Providers of health care include: a)Medical or osteopathic physicians, hospitals, and clinics. b)Podiatrists, physical therapists, physician's assistants, psychologists, chiropractors, nurse practitioners, and dentists licensed by the State of Wisconsin, or other applicable jurisdiction to provide covered services. c)Nurses licensed by the State of Wisconsin and certified as a nurse anesthetist to provide covered services. d)Nurse midwives licensed by the State in which they practice to provide covered services.   Qualified Treatment Facility Qualified treatment facility means a facility, institution, or clinic duly licensed to provide mental health or substance abuse treatment; primarily established for that purpose; and operating within the scope of its license.   Referral A referral is the process by which any service that requires prior authorization will be reviewed by MercyCare's Quality Health Management Department. Your doctor will complete a referral form, which will function as a request for authorization for any services that require prior authorization (for example, visits to a non-participating provider). This form is submitted to MercyCare, where the Quality Health Management Department will determine whether or not the requested services will be approved. See page 2 for referral process requirements.   Routine or Preventive Routine or preventive care means any physical exam or evaluation done in accordance with medically appropriate guidelines for age and sex, in consideration of a member's personal and/or family medical history, when an exam is otherwise not indicated for the treatment of an existing or known bodily injury or sickness.   Schedule of Benefits Schedule of Benefits means a summary of coverage and limitations provided under the policy.   Serious Mental Illness Serious mental illness means the following psychiatric illnesses as defined in the most current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association: 1.schizophrenia; 2.paranoid and other psychotic disorders; 3.bipolar disorders (hypomanic, manic, depressive, and mixed); 4.major depressive disorders (single episode or recurrent); 5.schizoaffective disorders (bipolar or depressive); 6.pervasive developmental disorders; 7.obsessive-compulsive disorders; 8.depression in childhood and adolescence; and 9.panic disorder.   Service Area Service area means the geographical area in which MercyCare is authorized to offer a health Plan.   Sickness Sickness means any condition or disease that causes loss of, or affects, normal body function other than those resulting from bodily injury.   Skilled Care Skilled care means medical services that are ordered by a participating provider and given by or under the direct supervision of a registered nurse, licensed practical nurse, licensed physical, occupational or speech therapist. Skilled care is usually necessary for only a limited period of time. It does not include maintenance or long term care. Daily care such as assistance with getting out of bed, bathing, dressing, eating, maintenance of bowel and bladder function, preparing special diets, assisting patients with taking their medicines, or 24 hour supervision for potentially unsafe behavior, do not require skilled care and are considered custodial care.   Skilled Nursing Facility Skilled nursing facility means an institution, which is licensed by the State of Wisconsin, or other applicable jurisdiction.   Sound and Natural Teeth Sound and natural teeth means teeth that would not have required restoration in the absence of a member's traumatic bodily injury, or teeth with restoration limited to composite or amalgam fillings. It does not mean teeth with a crown or root canal therapy.   Substance Abuse Substance Abuse means the uncontrollable or excessive abuse of addictive substances consisting of alcohol, morphine, cocaine, heroin, opium, cannabis, and other barbiturates, amphetamines, tranquilizers and/or hallucinogens, and the resultant physiological and/or psychological dependency which develops with continued use of such addictive substances requiring medical care as determined by a physician or psychologist.   Total Disability or Totally Disabled Total disability or totally disabled means, for an employee or his or her employed covered spouse, that the person is at all times prevented from engaging in any job or occupation for wage or profit for which he or she is reasonably qualified by education, training, or experience. Total disability also means the person cannot engage in any job or occupation for wage or profit. For a covered spouse who is not employed and a covered dependent child, total disability means a disability preventing the person from engaging in substantially all of the usual and customary activities of a person in good health and of the same age and sex. Total disability will be determined based upon the medical opinion of MercyCare's Medical Director and other appropriate sources.   Urgent Care Urgent care is care for an accident or illness that you need sooner than a routine doctor's visit. Examples of urgent care situations are broken bones, sprains, non-severe bleeding, minor cuts and burns, and drug reactions.   Usual and Customary (U&C) The maximum amount payable for covered services under the terms of this Certificate that is the lesser of the fee usually charged for a given service/item by a provider or an amount that doesn't exceed the general level of charges and is reasonable as determined by the Plan, for such a service or item when provided in the same general area under similar or comparable circumstance. The Plan bases U&C fees upon the 80th percentile of our vendor's proprietary U&C payment system. This methodology combines actual charge data and relative value units to determine U&C amounts.   We We means MercyCare Insurance Company.   You/Your You/your means any member enrolled in the Plan   Back to Top