Definitions

Ambulatory Surgical Facility means a facility (other than a Hospital), that:

1. Has the primary function of providing surgical procedures on an ambulatory basis, and
    
2. Is duly licensed by the appropriate state and local authority to provide such services and, if the facility is an in-network facility, it is approved by Blue Cross Blue Shield of Illinois.

Behavioral Health Practitioner means a psychiatrist, mental health counselor, Substance Abuse counselor or social worker with a master’s degree or higher. The Provider must be legally licensed or authorized to practice or provide service, care or treatment for such conditions under state law, and act within the scope of that license.

Beneficiary means a person you designate to receive your life insurance benefits.

Child has the meaning provided in the definition of Eligible Dependent, as defined in the Eligibility section.

Contracted Medical Claim Review Providers mean the third-party reviewers that provide medical review of claims for services that require pre-approval that is arranged through the Fund Office. Such reviewers determine whether services and the proposed duration of services is Medically Necessary.

Covered Employment means work for which a contributing Employer is required to make contributions to the Welfare Fund on behalf of Employees pursuant to the terms of a collective bargaining agreement with Sheet Metal Workers’ Local Union No. 73 or participation agreement with the Fund.

Dental Hygienist means a person who is duly licensed as a Dental Hygienist currently practicing within the scope of his or her license, performing services under the direction of a licensed Dentist, and must not be the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Dental Treatment Plan is a Dentist’s report, on a form satisfactory to the Plan that:
 

1. Itemizes the dental services recommended by the Dentist for the necessary and customary dental care of an eligible person,
    
2. Shows the charge for each dental service, and
    
3. Is accompanied by appropriate diagnostic materials as required by the Plan.

Dentist is a duly licensed Dentist (D.D.S. or D.D.M.) currently practicing within the scope of his or her license and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Dependent has the meaning provided in the definition of Eligible Dependent, and as further described in the Eligibility section.

Diagnostic Services means tests rendered for the diagnosis of symptoms to evaluate or determine the progress of a condition, disease or Injury. Such tests include but are not limited to x-rays, pathology services, clinical laboratory tests, pulmonary function studies, electrocardiograms, electroencephalograms, radioisotope tests and electromyograms.

Durable Medical Equipment means equipment that meets all of the following requirements (see the list in Appendix A):

1. Can withstand repeated use (i.e., could normally be rented and used by successive patients),
    
2. Is primarily and customarily used to serve a medical purpose,
    
3. Generally is not useful to a person in the absence of Sickness or Injury,
    
4. Is appropriate for use in the home, and
    
5. Is used solely for the care and treatment of the patient.

The Trustees have the authority and discretion to determine what constitutes Durable Medical Equipment and covered supplies for items not listed in Appendix A, and when to rent, lease or purchase the equipment.

Eligible Dependent has the meaning provided in the Your Dependents' Eligibility section.

Emergency means the sudden and unexpected onset of a traumatic bodily Injury or Sickness with severe symptoms:

1. That requires immediate diagnosis or treatment to prevent serious physical impairment or death,
    
2. For which you or your Dependent seeks medical care immediately and in no event more than 24 hours after the onset of the symptoms, and
    
3. In the event of a Mental or Nervous Disorder, or Behavioral Health Disorder, the lack of the treatment could reasonably be expected to result in the self-harm or harm to others by the patient.

Employee means an individual, employed by an Employer, on whose behalf the Employer, pursuant to a collective bargaining agreement with the Union or participation agreement with the Fund, is required to make contributions to the Trust Fund.

Employee also means a full-time teacher in the Local 73 Sheet Metal Workers’ Apprenticeship Program and the Eligible Dependents of that teacher, provided the appropriate contributions are made to the Plan on behalf of the Employee.

Sole Proprietors, or partners in a partnership or similar business entity required to make Employer Contributions to the Plan are not considered Employees under the Plan, unless they meet the definition of Employee in the prior two paragraphs.

Employer means an Employer that has or may hereafter have a collective bargaining agreement in effect with the Union requiring periodic payments to the Sheet Metal Workers’ Local 73 Welfare Fund for Active Members for the purpose of providing and maintaining group insurance for the benefit of its Employees.

The term Employer also includes any other Employer that, with the consent of the Trustees, makes payments or contributions to the Welfare Fund and adopts and agrees to be bound by the terms and provisions of the Sheet Metal Workers’ Local 73 Welfare Fund Trust Agreement and any amendments and modifications thereof.

Experimental or Investigative means drugs, services, supplies and procedures that require approval by an agency of the U.S. Government that has not yet been received. Experimental treatments, services and supplies are also those that have been principally confined to laboratory or research settings or have progressed to limited human application but lack wide recognition as proven and effective in clinical medicine. The Trustees have the discretionary authority to determine whether a treatment, service or supply is Experimental or Investigative. The fact that a Physician has prescribed, ordered, recommended or approved the treatment, service or supply does not in itself make it eligible for payment.

Hospital public or private facility or institution, licensed and operating according to law that:
 

1. Provides care and treatment of Physicians and Nurses on a 24-hour basis for Sickness or Injury through the medical, surgical, and diagnostic facilities on its premises;
    
2. May include facilities for treatment of Mental and Nervous Disorders or Behavioral Health Disorders that are licensed and operated according to law;
    
3. May include facilities for acute care, sub-acute care, and specialty Hospitals; and
    
4. May include any portion of a Hospital used as an Ambulatory Surgical Facility, Birth (or Birthing) Center, Hospice, Skilled Nursing Facility, or Subacute Care Facility.

A residential treatment facility or place for rest, custodial care, or place for care of the aged will not be regarded as a Hospital for any purpose related to this Plan.

Injury means a bodily Injury that requires treatment by a Physician, and that results in a loss that is independent of Sickness and other causes.

Inpatient means that you are a registered bed patient and are treated as such in a Hospital or Skilled Nursing Facility.

Medically Necessary means that there is a proven need for treatment intervention to improve or preserve the health of the patient. To be considered Medically Necessary, the service, supply or treatment must:
 

1. Be ordered by a Physician for diagnosis or treatment.
    
2. Be consistent with the diagnosis or treatment.
    
3. Be essential for the diagnosis or treatment of the Injury or Sickness for which it is prescribed or performed.
    
4. Meet generally accepted standards of medical practice.
    
5. Not be of a research, experimental, or educational nature.
    
6. Not involve repeated tests.

 

Mental or Nervous Disorder or Behavioral Health Disorder means a neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind, as defined within the mental disorders section of the current edition of the International Classification of Diseases (ICD) manual or as identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Non-Physician Providers, some of whose services are  excluded from Plan coverage include, but are not limited to, the following: Nurse Assistant, Licensed Vocational Nurse, Psychiatric Mental Health Nurse,  and Registered Surgical Technologist.

Non-Plan Skilled Nursing Facility means a Skilled Nursing Facility that does not have an agreement with Blue Cross Blue Shield of Illinois but has been certified in accordance with guidelines established by Medicare. No benefits under the Plan are provided for services received in a Non-Plan Skilled Nursing Facility.

 

Non-PPO Hospital means a Hospital that is not included in the Blue Cross Blue Shield of Illinois PPO Network at the time services are rendered.

Non-PPO Physician means a Physician who is not included in the Blue Cross Blue Shield of Illinois PPO Network at the time services are rendered.

Outpatient means that you or your Dependent is receiving treatment while not an Inpatient.

Participant means either an Employee or the Employee’s Dependent who has met the eligibility requirements to participate in the Plan and is enrolled in Plan coverage.

Physician and/or Surgeon  means any individual licensed to practice medicine and perform general surgery (MD) in the State where the license is given, and a Doctor of Osteopathy (DO) and Chiropractor (DC) licensed to practice medicine in the State where the license is given, and who acts within the scope of such license, and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

Plan Approved Dialysis Facility means a facility (other than a Hospital) that:
 

1. Has the primary function of treatment and/or provision of maintenance and/or training dialysis on an ambulatory basis for renal-dialysis patients,
    
2. Is duly licensed by the appropriate governmental authority to provide such services, and
    
3. Is approved by Blue Cross Blue Shield MSA.

Plan/PPO Ambulatory Surgical Facility means a Preferred Provider Organization Ambulatory Surgical Facility that has been approved by Blue Cross Blue Shield of Illinois to provide services to the member at the time services are rendered.

Plan/PPO Hospital means a Hospital that has a written agreement with Blue Cross Blue Shield of Illinois to provide services to the member at the time services are rendered.

 

Plan/PPO Skilled Nursing Facility means a Skilled Nursing Facility that has a written agreement with Blue Cross Blue Shield of Illinois to provide services to you or your Dependents at the time services are rendered.

 

Prescription Drugs may be either Brand Name Drugs or Generic Drugs. Both types of drugs may be listed on the OptumRx Formulary.
 

1. A Brand Name Drug is a new drug that has come to market for the first time, for which the drug company that manufactures it has a patent to be the sole manufacturer for a particular number of years.
    
2. A Generic Drug is the equivalent of the Brand Name Drug produced by other manufacturers after the patent has expired. A Generic Drug usually serves the same purpose as the original medication, but generally costs less than the Brand Name Drug.
    
3. A Formulary Drug List is the preferred drug list prepared by OptumRx that lists both Generic and Brand Name Drugs that can be used to treat a condition or symptom. The list is compiled by a team of Pharmacists and Physicians who review the Formulary Drug List and make changes as necessary and as new drugs come to market.

Provider means any healthcare facility such as a Hospital or Skilled Nursing Care Facility, or any person such as a Physician duly licensed to render covered services to you or your Dependents when Medically Necessary. Providers include the following: Ambulatory Surgical Facility, Dental Hygienist, Dentist, Dialysis Facility, Hospital, occupational, speech, or physical therapist, pharmacy, Physician, Registered Nurse or Licensed Practical Nurse or Skilled Nursing Care Facility.

Reasonable and Customary Charge means:
 

1. For a network provider, the Reasonable and Customary Charge is the negotiated fee/rate set forth in the agreement with the participating health network, provider, facility, or organization and the Plan.
    
2. For an out-of-network provider, the Reasonable and Customary Charge means the amount that the Plan will pay for a particular service or supply. The Plan will pay no more than 120% of the Medicare allowable amounts for Physician charges and no more than 150% of the Medicare allowable amounts for facility charges for out-of-network claims. 

Sickness means illness or disease that causes loss covered by the Fund. Losses incurred because of pregnancy, childbirth and related medical conditions are covered under the Fund to the same extent as any other Sickness.

Skilled Nursing Facility means an institution or a distinct part of an institution that:

1. Has a transfer agreement with one or more Hospitals,
    
2. Is primarily engaged in providing comprehensive post-acute Hospital and rehabilitative Inpatient care, and
    
3. Is duly licensed by the appropriate governmental authority to provide such services.

Skilled Nursing Facility does not mean institutions that provide only minimum care, custodial care services, ambulatory or part-time care services or institutions that primarily provide for the care and treatment of Mental or Nervous Disorders, Pulmonary Tuberculosis or Substance Abuse.

Substance Abuse means the uncontrollable or excessive abuse of addictive substances including but not limited to: alcohol, cocaine, morphine, heroin, opium, cannabis and other barbiturates, amphetamines, tranquilizers and/or hallucinogens and the resultant physiological and/or psychological dependency that develops with continued use of such addictive substances requiring medical care as determined by a Physician