Adverse Determination: A determination by FHLAC or our designated medical management agent, based upon a review of information to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the coverage requirements for medical necessity, appropriateness of health care setting, level of care or effectiveness.

Allowed Charge: The amount that is used to calculate payment of your covered benefits, based on the fee schedule we have negotiated with that FCHP Direct Care network provider.

Anniversary date: The date each year when most major changes to your health plan take effect. Group health plans usually allow subscribers to switch health plans during a designated “open enrollment” period prior to the anniversary date.

Coverage period: The 12-month span of plan coverage, and the time during which the deductible, out-of-pocket maximum and specific benefit maximums accumulate.

COBRA: The Consolidated Omnibus Reconciliation Act of 1985. Provides for continuation of benefits under certain circumstances when benefits are lost.

Coinsurance: Your share of the allowed charges for certain covered benefits, expressed as a percentage. For example, if your coinsurance is 20%, you pay 20% of the allowed charges for the services you received, and the plan pays the remaining 80%.

Copayment: The amount you are responsible to pay for covered services. The copayment amounts for services are listed in the accompanying Schedule of Benefits.

Cosmetic services: A surgery, procedure or treatment that is performed primarily to reshape or improve the patient’s appearance. Cosmetic services are not medically necessary, and are not covered, whether intended to improve an individual’s emotional well being or to treat a mental health condition.

Covered services: Health care services or supplies that are covered by the plan, as described in this Member Handbook.

Custodial care: A level of care which: (1) is chiefly designed to assist a person with the activities of daily life; and (2) cannot reasonably be expected to improve a medical condition. Custodial care is not covered by the plan.

Deductible: The amount of allowed charges you pay before payment is made by the plan for certain covered services.

Deductible carryover: Any deductible amount that is incurred by the member for services rendered during the last three months of the calendar year. This may be applied toward the deductible for the next calendar year. Deductible amounts are incurred as of the date of the service.

Diagnostic care: Services and tests that are intended to diagnose, check the status of or treat a disease or condition.

Durable medical equipment: Medical care-related items that: 1) can withstand repeated use (e.g., could normally be rented), 2) are used in a private residence (not a hospital or skilled nursing facility), and 3) are primarily and customarily for a medical purpose and generally not useful to a person in the absence of illness or injury

Effective date: The date, as shown on our records, on which your coverage begins under this contract or under an amendment to it. Your effective date is determined by your employer group in accordance with the group agreement for waiting periods, open enrollment periods and special qualifying events.

Emergency medical condition: A medical condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.

Emergency services: Inpatient and outpatient services, whether inside or outside the FCHP service area, that are: (1) furnished by a qualified provider and (2) needed to evaluate or stabilize an emergency medical condition.

ERISA: The Employee Retirement Income Security Act of 1974, and regulations thereunder, as may be amended from time to time.

Experimental/investigational: In cases where a drug, device, treatment or procedure does not meet one or more of FCHP’s technology assessment criteria, the drug, device, treatment or procedure will be considered experimental or investigational. No coverage is provided for drugs, devices, treatments or procedures that FCHP’s Technology Assessment Committee considers experimental or investigational. If the committee determines that a technology is experimental or investigational, FCHP will not pay for any services, including but not limited to, drugs, devices, treatments, procedures, or facility and professional charges related to that technology.

Facility: A licensed institution providing health care services or a health care setting, including, but not limited to, hospitals and other inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers and rehabilitation and other therapeutic health settings.

FCHP: Fallon Community Health Plan, Inc.

FCHP Direct Care network: A group of plan providers who have contracted with FCHP, either directly or through our agent, to provide services to members covered by this contract.

FCHP Direct Care network service area: The geographical area served by FCHP Direct Care. The counties in the FCHP Direct Care service area are included in this Member Handbook.

FHLAC: Fallon Health & Life Assurance Company, Inc.

Formulary: A list of prescription medications that are approved for coverage.

Group: Any partnership, association or corporation that has an agreement with us to pay the plan or its agent the premium charge for a group of subscribers.

Homebound: A member who has an injury/illness that restricts his or her ability to leave home without the aid of supportive devices or the assistance of another person, or if leaving home is medically contraindicated

Housekeeping services: Those routine and necessary tasks carried out within the home to maintain the functioning of the household. This may include routine housecleaning and related chores; laundry; food preparation and dishwashing.

Inpatient: A registered bed patient in a licensed hospital or other facility.

Medical and surgical supplies: Special products, such as materials used to repair a wound or instruments used for your care.

Medically necessary (service): A service or supply that is consistent with generally accepted principles of professional medical practice, as determined by whether or not: (1) the service is the most appropriate available supply or level of service for the member in question, considering potential benefits and harms to the individual; (2) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; (3) for services and interventions not in widespread use, is based on scientific evidence.

Medicare: Benefits under Title XVIII of the Social Security Act of 1965, as amended from time to time.

Member: Any person who has the right to services under this contract, which includes the subscriber and any family members covered under the subscriber’s contract (also referred to as “you”).

Network pharmacy: A licensed pharmacy in the FCHP Direct Care network, with whom we contract to provide covered prescription drugs to members.

Nurse practitioner: A registered nurse who holds authorization in advanced nursing practice as a nurse practitioner under M.G.L. C112, § 80B.

Off-label: The prescribing of a medication in a different dose, for a different duration of time, or for a different medical indication than recommended in the prescribing information.

Open enrollment: A designated period, just prior to a group’s anniversary date, when group members may change to another health plan or make changes to their existing health care contract. Any changes made become effective on the group anniversary date.

Out-of-pocket maximum: The total amount of deductible, coinsurance and copayments you are responsible for in a calendar year. The out-of-pocket maximum does not include your premium charge or any amounts you pay for services that are not covered by the plan. It may also not include certain copayment for prescription drugs, chiropractic, mental and behavioral health services.

Outpatient: A patient who is not a registered bed patient in a hospital or other medical facility.

Peace of Mind Program™: A medical management program, which provides access to certain specialty care services at specified Boston medical centers, in a specific set of circumstances described in this Member Handbook.

Personal comfort items: Products which do not directly contribute to the treatment of an illness or injury or to the functioning of an injured body part. These include, but are not limited to: air conditioners, recliners, televisions, radios and telephones.

Physical functional impairment: A condition in which the normal or proper action of a body part is damaged. This may include, but is not limited to, problems with ambulation, communication, respiration, swallowing, vision, or skin integrity. A physical functional impairment affects the ability to participate in activities of daily living. A physical functional impairment does not include an individual’s emotional well-being or mental health.

Plan: The Teamsters Local 170 Health and Welfare Benefit Plan (also referred to as “the plan,” “us,” “we,” and “our”).

Plan Administrator: The person or persons who have the authority to control and manage operation and administration of the plan.

Plan facility: Any inpatient hospital or other medical facility in the FCHP Direct Care network, with which FCHP contracts to provide health care services to members.

Plan physician: A licensed physician in the FCHP Direct Care network, with whom FCHP contracts to provide health care services to members.

Plan provider: A licensed physician, plan facility or other health care professional in the FCHP Direct Care network, with whom FCHP contracts to provide health care services to members. This includes, but is not limited to: doctors of medicine, osteopathy and podiatry; registered nurse anesthetists; nurse practitioners; ambulance companies; and home health care providers.

Plan specialist: A licensed specialty physician or other specialty health care professional in the FCHP Direct Care network, with whom FCHP contracts with to provide health care services to members. A specialist typically has a practice concentrated in a specific field of medicine in which a primary care physician may not have specialized training.

Plan sponsor: Teamsters Local 170 Health and Welfare Fund Board of Trustees

Preventive care: Services, tests and immunizations that are intended to screen for diseases or conditions and to improve early detection of disease when there is no diagnosis or symptoms present. This includes immunizations; health maintenance visits (routine physical exams) for adults and children, as well as those mammograms, Pap tests and other tests associated with the health maintenance visit; prenatal maternity care; well child care, including vision and auditory screening; voluntary family planning; nutrition counseling; and health education. For more information about the services that are part of a health maintenance visit, please see the FCHP preventive care guidelines on our Web site or call Customer Service for a copy.

Primary care provider (PCP): A plan provider, specializing in internal medicine, family practice pediatrics, geriatric medicine or adolescent medicine, whom you choose to work with to manage your medical care.

Prior authorization: An assurance by the plan to pay for medically necessary covered benefits provided by a plan physician for an eligible plan member.

Provider: A doctor, hospital, health care professional or health care facility licensed by the state to deliver or furnish health care services.

Reconstructive surgery: A procedure performed to improve or correct a physical functional impairment resulting from a congenital defect or birth abnormality, accidental injury, prior surgical procedure or disease.

Referral: A recommendation by which a physician sends a member to another physician or provider for services that are typically outside the referring doctor’s scope of practice. Since plan physicians are freely able to recommend treatment options without restraint from the plan, a referral in and of itself does not guarantee that a recommended treatment is a covered benefit or that the accepting provider is contracted with the plan, and does not obligate the plan to pay for the service. Please note that referrals are not required for behavioral health services. See Obtaining specialty care and services for a complete explanation of the referral and prior authorization process.

Reliant Medical Group (formerly Fallon Clinic) PCP: A primary care physician (PCP) who is employed by the Reliant Medical Group and who practices within the Reliant Medical Group practice.

Reliant Medical Group (formerly Fallon Clinic) specialist: A specialist, including physicians, physician assistants, nurse midwives, and nurse practitioners, who is employed by the Reliant Medical Group and who practices within the Reliant Medical Group practice.

Restorative surgery: The initial procedure to repair or restore appearance that was damaged by an accidental injury. For example, the repair of a facial deformity following a serious automobile accident.

Room and board: Your room, meals and general nursing services while you are an inpatient.

Self-referral: The process by which you make an appointment directly with a plan provider without needing a referral from your PCP or prior authorization from the plan. See Obtaining specialty care and services for information on the services for which you can self refer.

Skilled home health care services: Services and/or equipment provided in the member’s home, such as intermittent skilled nursing care, home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Subscriber: The person who is responsible for the premium charge. On group plans, the subscriber is typically a member of Teamsters Local 170 Health and Welfare Fund.

Technology Assessment Criteria: Fallon Community Health Plan (FCHP) maintains a formal mechanism for evaluating medical technologies through our Technology Assessment Committee. The committee includes physician administrators, practicing physicians from the plan’s service area, and plan staff. When necessary, the committee seeks the input of specialists or professionals who have expertise in the proposed technology. In all cases, the technology is reviewed against the following technology assessment criteria:

  1. The technology must have final approval from the appropriate government regulatory body. This applies to drugs, devices, biologics, and treatments or procedures that must have final approval to market from the U.S. Food and Drug Administration or any other federal governmental body with authority to regulate the technology. Devices must have final FDA approval for the specific indications under evaluation by FCHP.
  2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes. The evidence should consist of well-designed and well-conducted investigations published in peer-reviewed journals. The quality of the study as well as the results are considered in evaluating the evidence. Opinions by national medical associations, consensus panels, or other technology evaluation bodies are evaluated according to the scientific quality of the supporting evidence.
  3. The evidence must show that the technology improves health outcomes. Specifically, the technology’s beneficial effects on health outcomes should outweigh any harmful effects on health outcomes.
  4. The technology must be at least as effective as the established technology. In addition, the technology must be as cost-effective as any established alternatives that achieve a similar health outcome.
  5. The outcome must be attainable outside investigational settings.

Terminal illness: An illness as a result of which a member has a life expectancy of less than six months.

Urgent care: Medical care that is needed right away for minor emergencies, such as cuts that require stitches, a sprained ankle or abdominal pain.

Usual, customary and reasonable charge: an amount that is consistent with the normal range of charges for the same or similar services in the geographical area where the service was provided, as determined by the plan.