Important Definitions

Important Definitions

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For the purposes of this benefits handbook, the terms below have the following meanings:

ACCIDENTAL INJURY – bodily injury which results from an accident directly and independently of all other causes, and which occurs after the effective date of coverage.

adultBasic HEALTH INSURANCE PROGRAM – the program created by Act 2001-77 that provides basic health care insurance for eligible Pennsylvanians.

BLUECARD® PROGRAM – a program that enables members obtaining health care services while traveling outside Keystone’s service area to receive all the same benefits of their plan and access to BlueCard traditional providers and savings. The program links participating health care providers and the independent Blue Cross and Blue Shield Licensees across the country and also to some international locations through a single electronic network for claims processing and reimbursement.

CARDIAC REHABILITATION THERAPY – a medically supervised rehabilitation program designed to improve a patient’s tolerance for physical activity or exercise.

CHEMOTHERAPY – the treatment of malignant disease by chemical or biological antineoplastic agents.

COGNITIVE THERAPY – is a therapeutic approach designed to improve cognitive functioning after central nervous system injury or trauma. It includes therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning and problem solving. It utilizes tasks designed to reinforce or reestablish previously learned patterns of behavior or to establish new compensatory mechanisms for the impaired neurologic system.

COMPLAINT – a dispute or objection regarding coverage, including exclusions and non-covered services under the plan, participating or non-participating providers’ status or the operations or management policies of Keystone. This definition does not include a grievance (medical necessity appeal). It also does not include disputes or objections that were resolved by Keystone and did not result in the filing of a complaint (written or oral).

COPAYMENT (COPAY) – a specified dollar amount applied to a specific covered service for which the member is responsible per covered service.

COVERED SERVICE – a specified dollar amount applied to a specific covered service for which the member is responsible per covered service.

CUSTODIAL CARE (DOMICILIARY CARE) – care provided primarily for maintenance of the patient or care which is designed essentially to assist the patient in meeting his activities of daily living and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition. Custodial care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets and supervision of self-administration of medications which do not require the technical skills or professional training of medical or nursing personnel in order to be performed safely and effectively.

DESIGNATED PROVIDER – a participating provider with whom Keystone has contracted certain therapy services (other than speech therapy), non-routine podiatry services or diagnostic radiology services for members age five or older. The member’s primary care physician will provide a referral to the participating provider as its sole source for covered rehabilitation therapy services (other than speech therapy), podiatry services or diagnostic laboratory and x-ray services.

DIALYSIS – treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body.

DURABLE MEDICAL EQUIPMENT – equipment which

	A.		can withstand repeated use;
	B.		is primarily and customarily used to serve a medical purpose;
	C.		generally is not useful to a person in the absence of an illness or injury; and
	D.		is appropriate for use in the home.

Durable Medical Equipment includes, but is not limited to, the following: hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, and ostomy supplies.

EFFECTIVE DATE OF COVERAGE – the date adultBasic coverage begins, as shown on the records of Keystone and the Caring Foundation.

ELECTIVE ABORTION – a voluntary termination of pregnancy other than a termination that is necessary to avert the death of the woman, or other than the termination of a pregnancy caused by rape or incest.

ELIGIBLE MEMBER – an adult identified by the Caring Foundation as eligible for the adultBasic program.

EMERGENCY SERVICES (EMERGENCY) – any health care services provided to a member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or 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 result in:

	A.		Placing the health of the member or with respect to a pregnant member, the health of the pregnant member or her unborn child, in serious jeopardy;
	B.		Serious impairment to bodily functions; or
	C.		Serious dysfunction of any bodily organ or part. Emergency transportation and related emergency service provided by a licensed ambulance service shall constitute an emergency service

EXPERIMENTAL or INVESTIGATIVE – services or supplies which Keystone determines are:

	A.		Not of proven benefit for the particular diagnosis or treatment of a member’s particular condition;
	B.		Not generally recognized by the medical community as effective or appropriate for the member’s particular diagnosis or treatment of a particular condition; or
	C.		Provided or performed in special settings for research purposes or under a controlled environment or clinical protocol.

Unless otherwise required by law with respect to drugs which have been prescribed for the treatment of a type of cancer for which the drug has not been approved by the United States Food and Drug Administration (FDA), Keystone will not cover any services or supplies, including treatment, procedures, prescription drugs, biological products or medical devices or any hospitalizations in connection with experimental or investigational services or supplies.

Keystone will also not cover any technology or any hospitalization primarily to receive such technology if such technology is obsolete or ineffective and is not used generally by the medical community for the particular diagnosis or treatment of a member’s particular condition.

Governmental approval of technology is not necessarily sufficient to render it if proven beneficial, appropriate or effective for a particular diagnosis or treatment of a particular condition, as explained below.

Keystone will apply the following six criteria in determining whether services or supplies are experimental or investigational:

	A.		Any medical device, drug, or biological product must have received final approval to market by the FDA for the particular diagnosis or condition. Any other approval granted as an interim step in the FDA regulatory process, e.g., an Investigational Device Exemption or Investigational New Drug Exemption, is not sufficient. Once FDA approval has been granted for a particular diagnosis or condition, use of the medical device, drug or biological product for another diagnosis or condition will require that one or more of the following established reference compendia: The American Medical Association Drug Evaluations; The American Hospital Formulary Service Drug Information; or The United States Pharmacopeia Drug Information In any event, any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed will be considered experimental or investigational.
	B.		Conclusive evidence from the published peer-reviewed medical literature must exist that the technology has a definite positive effect on health outcomes; such evidence must include well-designed investigations that have been reproduced by non-affiliated authoritative sources, with measurable results, backed up by the positive endorsements of national medical bodies or panels regarding scientific efficacy and rationale.
	C.		Demonstrated evidence as reflected in the published peer-reviewed medical literature must exist that over time the technology leads to improvement in health outcomes, i.e., the beneficial effects outweigh any harmful effects.
	D.		Proof as reflected in the published peer-reviewed medical literature must exist that the technology is at least as effective in improving health outcomes as established technology, or is usable in appropriate clinical contexts in which established technology is not employable.
	E.		Provided or performed in special settings for research purposes or under a controlled environment or clinical protocol.
	F.		Reliable evidence showing 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.

FOLLOW-UP CARE – care scheduled for medically necessary follow-up visits that occur while the member is away from home. Follow-up care is provided only for urgent ongoing treatment of an illness or injury that originates while the member is still at home. An example is dialysis. Follow-up care must be preapproved by the member’s primary care physician prior to traveling. This service is available through the BlueCard Program for temporary absences (less than 90 consecutive days) from Keystone’s service area.

GENERIC DRUG – pharmacological agents approved by the FDA as a bioequivalent substitute and manufactured by a number of different companies as a result of the expiration of the original patent.

GRIEVANCE – a request by a member or a health care provider, with the written consent of the member, to have Keystone reconsider a decision solely concerning the medical necessity or appropriateness of a health care service. This definition does not include a complaint. It also does not include disputes or objections regarding medical necessity that were resolved by Keystone and did not result in the filing of a grievance (written or oral).

GUEST – a member who has a pre-authorized guest registration in a host HMO service area other than the Keystone service area for a defined period of time. After that period of time has expired, the member must again meet the eligibility requirements of the guest program and re-enroll as a guest to be covered for guest services.

GUEST PASS – the member identification card that is provided to the guest once enrolled in the host HMO service area. The guest pass is generated and distributed by the host HMO.

GUEST PROGRAM – temporary registration (not less than ninety (90) consecutive days nor more than one hundred-eighty (180) consecutive days) at a contracting HMO available to any qualifying member, entitling the member to benefits for all health care covered services.

HOME HEALTH CARE PROVIDER – a licensed provider that has entered into an agreement with Keystone to provide home health care covered services to members on an intermittent basis in the member’s home in accordance with an approved home health care plan of treatment.

HOSPICE PROVIDER – a licensed provider that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people whose estimated survival is six months or less. Covered services to be provided by the hospice provider include home hospice and/or inpatient hospice services that have been referred by your primary care physician and preapproved by Keystone.

HOSPITAL – any institution duly licensed, certified and operated as a hospital. In no event shall the term hospital include a convalescent facility, nursing home, or any institution or part thereof which is used as a convalescent facility, rest facility, nursing facility or facility for the aged.

HOSPITAL SERVICES – except as limited or excluded herein, acute-care covered services furnished by a hospital which are referred by your primary care physician, preapproved by Keystone, and set forth in the Summary of Benefits.

HOST HMO – (also referred to as the “HOST HMO or HOST PLAN”) – the contracting HMO through which a member can receive away from home care covered services when traveling in that HMO’s service area.

HOST HMO SERVICE AREA – the geographic service area(s) designated by a contracting HMO as the portion of its approved service area in which away from home care covered services are available.

IDENTIFICATION CARDS (ID CARD) – the currently effective card issued to an enrolled adultBasic member by Keystone Health Plan East which must be presented when a covered service is requested.

IMMUNIZATIONS – Medically necessary adult immunizations (except those required for work or travel). Coverage will be provided for those immunizations, including the immunizing agents, which, as determined by the Department of Health, conform with the standards of the Advisory Committee on Immunization Practices of the Center for Disease Control, U.S. Department of Health and Human Services.

INPATIENT CARE – treatment received as a bed patient in a hospital, a rehabilitation hospital, a skilled nursing facility or a substance abuse treatment facility.

KEYSTONE HEALTH PLAN EAST, INC. (KEYSTONE) – a health maintenance organization providing access to comprehensive health care to members.

LIMITATIONS – the maximum number of covered services, measured in number of visits or days, or the maximum dollar amount of covered services that are eligible for coverage. Limitations may vary depending on the type of program and covered services provided. Limitations, if any, are identified in this handbook.

MEDICAID – the program of Medical Assistance established by Title XIX of the Social Security Act of 1965, as amended, and Pennsylvania Statue, 62 P.S. Section 441.1 et seq., as amended.

MEDICAL DIRECTOR – a physician designated by Keystone to design and implement quality assurance programs and continuing education requirements, and to monitor utilization of health services by members.

MEDICAL SCREENING EVALUATION – an examination and evaluation within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, performed by qualified personnel.

MEDICALLY NECESSARY or MEDICAL NECESSITY – the requirement that covered services or medical supplies are needed, in the opinion of: (a) your primary care physician; (b) the referred specialist; and/or (c) Keystone and:

	A.		Are consistent with Keystone policies, coverage requirements and utilization guidelines;
	B.		Are necessary in order to diagnose and/or treat a member’s illness or injury;
	C.		Are provided in accordance with accepted standards of American medical practice;
	D.		Are essential to improve the member’s net health outcome and may be as beneficial as any established alternatives;
	E.		Are as cost-effective as any established alternative; and
	F.		Are not solely for the member’s convenience, or the convenience of the member’s family or health care provider.

MEDICARE – hospital or medical insurance benefits provided by the United States Government under Title XVIII of the Social Security Act of 1965, as amended.

OCCUPATIONAL THERAPY – medically prescribed treatment concerned with improving or restoring neuromusculoskeletal functions which have been impaired by illness or injury, congenital anomaly or prior therapeutic intervention. Occupational therapy also includes medically prescribed treatment concerned with improving the member’s ability to perform those tasks required for independent functioning where such function has been permanently lost or reduced by illness or injury, congenital anomaly or prior therapeutic intervention. This does not include services specifically directed towards the improvement of vocational skills and social functioning.

OFFICE VISITS – covered services provided in the physician’s office and performed by or under the direction of your primary care physician or a referred specialist.

OUT-OF-AREA SERVICES – services provided outside Keystone’s service area. Covered services are limited to:

	A.		emergency services and services that are arranged or referred by a Keystone primary care physician in Keystone’s service area, and preapproved by Keystone; and
	B.		Are necessary in order to diagnose and/or treat a member’s illness or injury;

OUTPATIENT CARE – medical, nursing, counseling or therapeutic treatment provided to a member who does not require an overnight stay in a hospital or other inpatient facility.

PARTICIPATING PROVIDER – a provider with whom Keystone has contracted to render covered services.

	A.		Primary Care Physician (PCP) – a participating provider selected by a member who is responsible for providing all primary care covered services and for authorizing and coordinating all covered medical care, including referrals for specialist services.
	B.		Referred Specialist – a provider who provides covered specialist services upon referral from a primary care physician. In the event there is no participating provider to provide the specialty or subspecialty services, referral to a non-participating provider will be arranged by your primary care physician with preapproval by Keystone. The benefits under the plan will be the same terms and conditions as for participating providers. A referred specialist also includes a participating obstetrician or gynecologist who provides to female members, routine maternity care, routine gynecological care, or specialty gynecological care in the provider’s office other than reproductive endocrinology/infertility care and gynecological oncology care. For the following services, the referred specialist is your primary care physician’s designated provider: certain rehabilitation therapy services (other than speech therapy); non-routine podiatry services; and diagnostic radiology services. Your primary care physician will provide a referral to the designated provider for these services.
	C.		Participating Hospital – a hospital that has contracted with Keystone to provide covered services to members.

PHARMACIST – an individual, duly licensed as a pharmacist by the State Board of Pharmacy or other governing body having jurisdiction, who is employed by or associated with a pharmacy.

PHYSICAL THERAPY – medically prescribed treatment of physical disabilities or impairments resulting from disease, injury, congenital anomaly, or prior therapeutic intervention by the use of therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and the functional activities of daily living.

PLAN OF TREATMENT – a plan of care which is developed or approved by your primary care physician for the treatment of an injury or illness. The plan of treatment should be limited in scope and extent to that care which is medically necessary for the member’s diagnosis and condition.

PREAPPROVED or PREAPPROVAL – the approval which your primary care physician or referred specialist must obtain from Keystone to confirm Keystone coverage for certain covered services. Such approval must be obtained prior to providing you with covered services or referrals. Approval will be given by the appropriate Keystone staff, under the supervision of the medical director. If your primary care physician or referred specialist is required to obtain a preapproval, and provides covered services or referrals without obtaining such preapproval, you will not be responsible for payment. Preapproval is not a guarantee of coverage if the member is subsequently found to be ineligible.

PRESCRIBE or PRESCRIBED – to write or give a prescription order.

PRESCRIPTION DRUG – A legend drug or controlled substance, which has been approved by the Food and Drug Administration for a specific use and which can, under federal or state law, be dispensed only pursuant to a prescription order.

PRESCRIPTION ORDER or REFILL – The authorization for a prescription drug issued by a primary care physician or referred specialist who is duly licensed to make such an authorization in the ordinary course of his or her professional practice.

PRIMARY CARE PHYSICIAN – a participating provider selected by a member who is responsible for providing all primary care, covered services and for authorizing and coordinating all covered medical care, including referrals to participating specialists.

PRIVATE DUTY NURSING – medically necessary continuous skilled nursing services provided to a member by a registered nurse or a licensed practical nurse.

PROVIDER – any health care institution or practitioner that is licensed to render health care services including, but not limited to, a physician, allied health professional, certified nurse, midwife, hospital, skilled nursing facility, rehabilitation hospital, birthing facility or home health care provider.

PULMONARY REHABILITATION – multi-disciplinary treatment that combines physical therapy with an educational process directed at stabilizing pulmonary diseases and improving functional status.

RADIATION THERAPY – the treatment of disease by x-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes, or other radioactive substances regardless of the method of delivery.

REFERRED (REFERRAL) – written documentation from the member’s primary care physician that authorizes covered services to be rendered by a Keystone participating provider or provider specifically named on the referral. Referred care includes all services provided by a referred specialist. Referrals to non-participating providers must be preapproved by Keystone. A referral must be issued to the member prior to receiving covered services and is valid for 90 days from the date of issue for an enrolled member.

REHABILITATION HOSPITAL – a facility licensed by the Department of Health that is primarily engaged in providing rehabilitation care on an inpatient basis. Rehabilitation care consists of the combined use of medical, educational, and vocational services to enable patients disabled by disease or injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of physicians. Continuous nursing services are provided under the supervision of a registered nurse.

RELIABLE EVIDENCE – only published reports and articles in the 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.

RENEWAL – the outcome of a review of eligibility that results in an eligible adult continuing to receive adultBasic coverage.

RESPIRATORY THERAPY – medically prescribed treatment of diseases or disorders of the respiratory system with therapeutic gases and vaporized medications delivered by inhalation.

SERVICE AREA – the geographical area within which Keystone is approved to provide access to covered services.

SKILLED NURSING FACILITY – an institution that is licensed as a skilled nursing facility and has contracted with Keystone to provide covered services to members.

SPECIALIST SERVICES – all physician services providing medical care in any generally accepted medical or surgical specialty or subspecialty.

SPEECH THERAPY – medically prescribed treatment of speech and language disorders due to disease, surgery, injury, congenital and developmental anomalies, or previous therapeutic processes that result in communication disabilities and/or swallowing disorders.

STANDING REFERRAL or STANDING REFERRED – written documentation from Keystone that authorizes covered services for a life-threatening, degenerative or disabling disease or condition. The covered services will be rendered by the referred specialist named on the standing referral form. The referred specialist will have clinical expertise in treating the disease or condition. A standing referral must be issued to the member prior to receiving covered services. The member, the primary care physician and the referred specialist will be notified in writing of the length of time that the standing referral is valid. Standing referred care includes all primary and specialist services provided by that referred specialist.

URGENT CARE – medically necessary covered services provided in order to treat an unexpected illness or accidental injury that is not life- or limb-threatening. Such covered services must be required in order to prevent a serious deterioration in the member’s health if treatment were delayed.