Medical plan definitions

Related to emergency medicine, anesthesiology, pathology, radiology, and neonatology;
Provided by assistant surgeons, hospitalists, and intensivists;
Diagnostic services, including radiology and laboratory services, unless such items and services are excluded from the definition of Ancillary Services as determined by the Secretary;
Provided by such other specialty practitioners as determined by the Secretary; and
Provided by an out-of-network physician when no other in-network physician is available.

In vitro fertilization (IVF).
Gamete intrafallopian transfer (GIFT).
Pronuclear stage tubal transfer (PROST).
Tubal embryo transfer (TET).
Zygote intrafallopian transfer (ZIFT).

Federally funded trials. the study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
National Institute of Health (NIH). (Includes National Cancer Institute (NCI)
Centers for Disease Control and Prevention (CDC)
Agency for Healthcare Research and Quality (AHRQ)
Centers for Medicare and Medicaid Services (CMS)
A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA)
A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants, or
The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria:
Comparable to the system of peer review of studies and investigations used by the National Institute of Health, and
Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration
The study or investigation is a drug trial that is exempt from having such an investigational new drug application
The clinical trial must have written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. The Plan may, at any time, request documentation about the trial, or
The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a covered health service and is not otherwise excluded under the Plan.

The applicable copayment.
The eligible expense or the recognized amount when applicable.

Provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, Injury, mental illness, substance-related and addictive disorders, condition, disease or its symptoms
Medically Necessary
Described under "Covered medical expenses"
Provided to a covered person who meets the Plan's eligibility requirements, as described in the SPD
Not otherwise excluded in this SPD under "Expenses not covered"

Are non-health related, such as assistance in activities of daily living including, but not limited to, feeding, dressing, bathing, transferring and ambulating
Are health-related services which do not seek to cure, or which are provided during periods when the medical condition of the patient who requires the service is not changing
Do not require continued administration by trained medical personnel in order to be delivered safely and effectively

Has entered into an agreement with UnitedHealthcare, or with an organization contracting on UnitedHealthcare's behalf, to provide covered health services for the treatment of specific diseases or conditions; or
UnitedHealthcare has identified through UnitedHealthcare's designation programs as a Designated Provider. Such designation may apply to specific treatments, conditions and/or procedures.

Can withstand repeated use
Is not disposable
Is used to serve a medical purpose with respect to treatment of a sickness or injury or their symptoms
Is generally not useful to a person in the absence of a sickness or injury
Is appropriate for use in the home
Is not implantable within the body

As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).
As reported by generally recognized professionals or publications.
As used for Medicare.

Placing the health of the covered person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
Serious impairment to bodily functions.
Serious dysfunction of any bodily organ or part.

An appropriate medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd or as would be required under such section if such section applied to an Independent Freestanding Emergency Department) that is within the capability of the emergency department of a Hospital, or an Independent Freestanding Emergency Department, as applicable, including ancillary services routinely available to the emergency department to evaluate such Emergency.
Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital or an Independent Freestanding Emergency Department, as applicable, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)), or as would be required under such section if such section applied to an Independent Freestanding Emergency Department, to stabilize the patient (regardless of the department of the Hospital in which such further exam or treatment is provided). For the purpose of this definition, "to stabilize" has the meaning as given such term in section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
Emergency Health Services include items and services otherwise covered under the Plan when provided by an out-of-network provider or facility (regardless of the department of the Hospital in which the items are services are provided) after the patient is stabilized and as part of outpatient observation, or as a part of an Inpatient Stay or outpatient stay that is connected to the original Emergency unless the following conditions are met:
The attending Emergency Physician or treating provider determines the patient is able to travel using nonmedical transportation or non-Emergency medical transportation to an available Network provider or facility located within a reasonable distance taking into consideration the patient's medical condition.
The provider furnishing the additional items and services satisfies notice and consent criteria in accordance with applicable law.
The patient is in such a condition, as determined by the Secretary, to receive information as stated in b) above and to provide informed consent in accordance with applicable law.
The provider or facility satisfies any additional requirements or prohibitions as may be imposed by state law.
Any other conditions as specified by the Secretary.

Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not as appropriate for the proposed use in any of the following:
AHFS Drug Information (AHFS DI) under therapeutic uses section;
Elsevier Gold Standard's Clinical Pharmacology under the indications section;
DRUGDEX System by Micromedex under the therapeutic uses section and has a strength recommendation rating of class I, class IIa, or class IIb; or
National Comprehensive Cancer Network (NCCN) drugs and biologics compendium category of evidence 1, 2A, or 2B.

Subject to review and approval by any institutional review board for the proposed use (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be experimental or investigational.)
The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III Clinical Trial as described in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Clinical trials for which benefits are available as described under the definition of "Clinical Trials" above.
If you are not a participant in a qualifying clinical trial as described above, and have a sickness or condition that is likely to cause death within one year of the request for treatment, UnitedHealthcare may, at its discretion, consider an otherwise experimental or investigational service to be a covered health service for that sickness or condition. Prior to such consideration, UnitedHealthcare must determine that, although unproven, the service has significant potential as an effective treatment for that sickness or condition.

Specialized clinical consulting services to covered employees and enrolled dependents to educate on fertility treatment options.
Access to specialized network facilities and physicians for fertility services.

Identifying your potential risks for suspected genetic disorders;
An individualized discussion about the benefits, risks and limitations of Genetic Testing to help you make informed decisions about Genetic Testing; and
Interpretation of the Genetic Testing results in order to guide health decisions.
Certified genetic counselors, medical geneticists and physicians with a professional society's certification that they have completed advanced training in genetics are considered qualified clinicians when covered health services for Genetic Testing require Genetic Counseling.

Is primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment of injured or sick individuals (Care is provided through medical, diagnostic and surgical facilities, by or under the supervision of a staff of physicians.)
Has 24-hour nursing services

Is geographically separate and distinct and licensed separately from a hospital under applicable law; and
Provides emergency health services.

For Mental Health Services, the program may be freestanding or Hospital-based and provides services for at least three hours per day, two or more days per week.
For Substance-Related and Addictive Disorders Services, the program provides nine to nineteen hours per week of structured programming for adults and six to nineteen hours for adolescents, consisting primarily of counseling and education about addiction related and mental health.

In accordance with Generally Accepted Standards of Medical Practice.
Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for your sickness, injury, mental illness, substance-related and addictive disorders disease or its symptoms.
Not mainly for your convenience or that of your doctor or other health care provider.
Not more costly than an alternative drug, service(s), service site or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.

The date it is reviewed.
December 31st of the following calendar year.

Prenatal care
Postnatal care
Childbirth
Any complications associated with pregnancy

Services exceed the scope of Intermittent Care in the home.
The service is provided to covered person by an independent nurse who is hired directly by the covered person or his/her family. This includes nursing services provided on an inpatient or home-care basis, whether the service is skilled or non-skilled independent nursing.
Skilled nursing resources are available in the facility.
The Skilled Care can be provided by a Home Health Agency on a per visit basis for a specific purpose.

Provides for child support with respect to a plan participant's child or directs the participant to provide coverage under a health benefits plan due to a state domestic relations law, or
Enforces a law relating to medical child support described in the Social Security Act, Section 1908, with respect to a group health plan and which satisfies the requirements to be a QMCSO set out in Section 609 of ERISA.

Non-Network Emergency Health Services.
Non-Emergency Covered Health Services received at certain Network facilities by non- Network. Physicians, when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Service Act. For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

Applicable state law
An All Payer Model Agreement if adopted, or
The qualifying payment amount as determined under applicable law.

It is established and operated in accordance with applicable state law for Residential Treatment programs.
It provides a program of treatment under the active participation and direction of a physician.
It offers organized treatment services that feature a planned and structured regimen of care in a 24-hour setting and provides at least the following basic services;
Room and board.
Evaluation and diagnosis.
Counseling.
Referral and orientation to specialized community resources.

Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug-free environment and support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to assist the covered person with recovery.
Supervised living arrangements which are residences such as facilities, group homes and supervised apartments that provide stable and safe housing and the opportunity to learn how to manage activities of daily living. Supervised living arrangements may be utilized as an adjunct to treatment when treatment doesn't offer the intensity and structure needed to assist the covered person with recovery.

Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received).
Well-conducted cohort studies from more than one institution are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.

If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare may, at its discretion, consider an otherwise unproven service to be a covered health service for that sickness or condition. Prior to such a consideration, UnitedHealthcare must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition.