Definitions
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Ambulatory Medical-Surgical Facility - A freestanding ambulatory surgical center or a facility offering ambulatory medical services 24 hours a day, seven days a week, provided such facilities:
- Are not part of a Hospital; and
- Have been reviewed an approved by the Missouri Board of Health, or other appropriate licensing body, to provide medical treatment.
Association - The Builder's Association of Missouri.
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Behavioral Health Disorder - Any Illness that is defined within the mental disorders section of the current edition of the International Classification of Diseases (ICD) manual (http://www.cdc.gov/nchs/icd9.htm) or is identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (DSM-IV - Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition), including a psychological and\or physiological dependence on, or addiction to, alcohol or psychiatric drugs or medications regardless of any underlying physical or organic cause. Behavioral Health Disorder includes autism, depression, schizophrenia and substance abuse and treatment that primarily uses psychotherapy or other psychotherapist methods, and is provided by a Behavioral Health Practitioner.
Behavioral Health Practitioner - A psychiatrist, psychologist or a mental health or substance abuse counselor or social worker who has a Master's degree and who:
- Is legally licensed and/or legally authorized to practice or provide service, care or treatment of Behavioral Health Disorders under the laws of the state or jurisdiction where the services are rendered;
- Acts 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.
Brand Name Drug or Brand Name Medication - A prescription drug that is, or was at one time, under patent protection.
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Collective Bargaining Agreement - An agreement between the United Brotherhood of Carpenters and Joiners of America, or a subordinate body, and an Employer or Association of Employers that requires contributions to the Carpenters' District Council of Kansas City and Vicinity Health Fund.
Contributing Employer or Employer - An Employer who, pursuant to the terms of a Collective Bargaining Agreement or other written agreement that is approved by the Board of Trustees, agrees to contribute to the Carpenters' District Council of Kansas City and Vicinity Health & Welfare Fund on behalf of individuals employed by the Employer.
Cosmetic or Reconstructive Surgery - Any surgical procedure performed primarily to:
- Improve physical appearance or to change or restore bodily form without materially correcting a bodily malfunction; or
- Prevent or treat a mental or nervous disorder through a change in bodily form.
Covered Expense - An expense for which benefits are payable under the Plan.
Covered Person - Any participant (or Dependent) while the participant or Dependent meets the eligibility requirements under this Plan.
Custodial Care - Any care intended primarily to help a disabled person meet basic personal needs when there is no plan of active medical treatment to reduce the disability.
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Dependent - Under the Plan, eligible Dependents include your:
- Legal spouse;
- Unmarried children under the age of 19;
- Unmarried children between the ages of 19 and 22 who are primarily dependent on you for full support and maintenance and who are full-time students. To be eligible for coverage, your Dependent must provide proof of full-time student status to the Fund Office;
- Your unmarried children for whom you are required to provide medical coverage for under a Qualified Medical Child Support Order (QMCSO) and who fulfill the requirements of a Dependent under the Plan; and
- Unmarried children
over age 19 who are incapable of self-sustaining employment because
of mental or physical handicap provided:
- The children depend on you primarily for support and maintenance; and
- You provide proof of incapability to the Fund Office within 31 days after the Dependent reaches age 19, or within 31 days of the date your eligibility is established, whichever is later. Proof of continuing incapability may also be required from time to time, but not more often than once a year.
In addition to your natural born child, children covered under the Plan include your stepchildren living in your home, adopted children, children placed for adoption and Foster Children, provided the children are dependent on you for support and maintenance and fulfill the requirements of a Dependent under the Plan.
Doctor, Physician or Surgeon - A legally qualified doctor, physician or surgeon, provided he or she is a Doctor of Medicine (MD, or Doctor of Osteopath (DO) (that is licensed to practice medicine in all of its branches), Doctor of Dental Surgery (DDS), Doctor of Podiatry (DPM), Doctor of Chiropody (DPM, DSC), Doctor of Medical Dentistry (CMC). The term also includes clinical psychologist, clinical social worker (provided the individual is licensed in the state where the treatment or services are provided and is practicing within the scope of his or her license), clinical professional counselor, certified mental health counselor, certified registered nurse anesthetist (CRNA), speech therapist, occupational therapist, physical therapist, optometrist, orthoptic technician and licensed nurse-practitioners working under the supervision of a licensed Physician. Benefits will be payable for services performed within the scope of each individual's specialty and only within the provisions and limitations of the Plan.
Durable Medical Equipment - Equipment that:
- Can withstand repeated use and is not a consumable or disposable item;
- Is exclusively and customarily used to serve a medical purpose;
- Is not useful to a person in the absence of an Injury or Illness; and
- Is appropriate for use in the home.
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Emergency - A situation in which the sudden onset of a severe medical condition requires immediate medical attention to prevent the individual from:
- Putting their health in permanent jeopardy;
- Incurring other serious medical consequences;
- Having a serious impairment of bodily functions; or
- Incurring serious permanent dysfunction of any bodily organ.
Employee - Any person who is employed by an Employer for whom the Employer is required to make contributions to the Fund, and for whom the Employer has paid contributions to the Fund.
Experimental or Investigative - A service or treatment on which the consensus of expert medical opinions (based on reliable evidence such as published reports and/or articles) indicates that further trials or studies are needed to determine the safety, efficacy and outcomes of such treatment or service compared to standard treatment. Experimental or Investigative also means those services or treatments that are:
- Not yet recognized as having proven beneficial outcomes;
- Still primarily confined to a research setting; and
- Not appropriate based on medical circumstances and/or given the advanced stage of a person's Sickness; or the likelihood that the service or treatment will measurably improve the person's Sickness or medical condition.
Extended Care Facility - An institution that is licensed as an extended Care Facility or long-term nursing facility and that is qualified to participate in and is eligible to receive payments under the United States Medicare Program, but that is not, other than incidentally, a home of the aged or a domiciliary care home.
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Foster Child - A child you are raising as your own; who lives in your home; who is chiefly dependent on you for support and for whom you have taken full parental responsibility and control. A Foster Child is not a child:
- temporarily living in your home;
- placed with you in your home by a social service agency that retains control of the child; or
- whose natural parent is in a position to exercise or share parental responsibility of the child.
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Generic Drug or Medication - Drug products that are approved by the FDA to be manufactured and distributed after the patent of the brand-name drug has expired. The generic drug must have the same active ingredient, strength and dosage form as its brand-name counterpart.
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Home Health Care - A program of care provided by a public agency or private organization, or subdivision of such an agency or organization, that:
- Is primarily engaged in providing skilled nursing services and other therapeutic services in the home or places of residence of its patients.;
- Has policies established by a group of professional personnel associated with the agency or organization, including one or more Physicians and one or more graduate Registered Nurses (RN) or Licensed Practical Nurses (LPN) to govern the services that it provides, and provides for the supervision of such services by a Physician, an RN or an LPN;
- Maintains clerical records of all patients; and
- Is licensed according to the applicable laws of the state and of the locality in which it is located or provides services.
Hospital - Any institution that:
- Maintains permanent and full-time facilities for bed care of five or more resident patients;
- Has a Doctor in regular attendance;
- Continually provides 24-hour-a-day nursing service by registered nurses;
- Is primarily engaged in providing diagnostic and therapeutic facilities for medical and surgical care of Injured and Sick persons on a basis other than as a rest home, nursing home, convalescent home, a place for the aged or a place for drug addicts or for long-term residential care; and
- Is operating lawfully in the jurisdiction where it is located.
Hospital does not include psychiatric Hospitals and general Hospitals where more than 15% of the beds are for psychiatric patients, unless the average length of stay for the Hospital or all units within the Hospital is less than 60 days.
Hospice Care Agency - A licensed agency or organization that keeps a medical record of each patient that:
- Has hospice care available 24 hours a day, seven days a week;
- Provides skilled nursing services, medical social services and psychological and dietary counseling primarily in a home setting using a hospice team;
- Has a full-time administrator and at least one Physician, one registered nurse (RN), one licensed or certified social worker employed by the agency and one counselor; and
- Has established policies governing the provision of hospice care.
Hospice Care Program - A written plan of hospice care that:
- Is established and periodically reviewed by a Physician attending the Terminally Ill Person or family member and appropriate personnel of a Hospice Care Agency;
- Is designed to provide palliative and supportive care to Terminally Ill Persons and supportive care to their families; and
- Includes an assessment of the Terminally Ill Person's or family member's medical and social needs and a description of the care to be rendered to meet those needs.
The Hospice Care Program may provide care and or services in the Terminally Ill person's or family member's residence, licensed medical facility or inpatient care in a hospice facility or Hospital.
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Illness or Sickness - A disease, mental, emotional or nervous disorder or covered pregnancy. A recurrent Sickness is considered as one Sickness. All related Sicknesses are considered as one Sickness. Concurrent Sicknesses are considered to be one Sickness unless such Sicknesses are totally unrelated.
Injury - Under the Plan, Injury refers only to an accidental bodily Injury. All Injuries sustained by a Covered Person in connection with any one accident are considered one Injury.
Intensive Care Unit - A room with permanently established facilities for two or more patients in which critically ill or Injured patients requiring continuous nursing services are temporarily confined. In no event will Intensive Care Unit be construed to include the post-operative recovery room of a Hospital.
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Maintenance Rehabilitation - Therapy in which a patient actively participates after a patient has met the functional goals of active rehabilitation so that no continued significant and measurable improvement is reasonably and medically anticipated, but where additional therapy of a less intense nature and decreased frequency may reasonably be prescribed to maintain, support and/or preserve the patient's functional level. Active rehabilitation is therapy in which a patient who has the ability to learn and remember, actively participates in the rehabilitation that is intended to provide significant and measurable improvement of an individual who is restricted and cannot perform normal bodily function.
Medical Food - Modified low protein foods and metabolic formulas. Medical Foods are not natural foods low in protein and/or galactose, spices, flavorings or foods or formulas required by persons who do not have inherited metabolic disorders.
Modified low protein foods that are formulated to be consumed or administered through the gastrointestinal tract and are processed or formulated to contain less than one gram of protein per unit of serving and are administered for the medical and nutritional management of a person who has limited ability to properly metabolize food or nutrients and such medical food is essential to the person's growth, health and metabolic homeostasis and are administered under the direction of a Physician for a person who has an inherited metabolic disorder.
Metabolic formulas are solutions consumed or administered through the gastrointestinal tract and are processed or formulated to be deficient in one or more nutrients present in typical food products and are administered because a person has limited ability to properly metabolize food or nutrients and such Medical Food is essential to the person's growth, health and metabolic homeostasis and are administered under the direction of a Physician for a person who has an inherited metabolic disorder.
Medically Necessary or Medical Necessity - A service or supply that is ordered by a Physician and that the Fund or a party or entity selected by the Fund determines is:
- Provided for the diagnosis or direct treatment of an Injury or Illness;
- Appropriate and consistent with the symptoms and findings or diagnosis and treatment of the person's Injury or Illness;
- Provided in accord with generally accepted medical practices on a national basis; and
- The appropriate supply or level of service that can be provided on a cost-efficient basis (including, but not limited to, inpatient versus outpatient care, electric vs. manual wheelchair, surgical vs. medical and other types of care).
The fact that the person's Physician prescribes services or supplies does not automatically mean such services or supplies are Medically Necessary and covered by the Plan.
Medicare - The programs established by Title 1 of Public Law 89-98 (79 Statutes 291) as amended entitled Health Insurance for the Aged Act, and that includes Parts A, B and C and Title XVIII of the Social Security Act (as amended by Public Law 89-98, 79), as such programs are amended from time to time.
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Name Fiduciary - The entity or persons who have the authority to control and manage the operation and administration of this Plan. The Named Fiduciary for this Plan is the Board of Trustees of the Carpenters' District of Kansas City and Vicinity Health & Welfare Fund.
Non-Occupational Disease - A disease that does not arise from, is not caused or contributed to, by, or as a consequence of, any course of any employment or occupation for compensation or profit. If evidence satisfactory to the Trustees is furnished that the individual concerned is covered as an Employee under any Workers' Compensation law, occupational disease law, any other legislation or similar purpose or under maritime doctrine of maintenance, wages and cure, but that the disease involved is one not covered under the applicable laws or doctrine, then the disease will, for the purposes of this Plan, be regarded as a Non-Occupational Disease.
Non-Occupational Injury - An accidental bodily Injury that does not arise from and is not caused or contributed to by, or as a consequence of, any Injury that arises out of or in the course of any employment or occupation for compensation or profit.
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Pension Credits - Credits used to determine your eligibility for pension benefits. Generally, if you are a participant in the Carpenters' District of Kansas City Pension Fund, you earn one pension credit for each Plan year in which you work at least 400 hours in covered employment or occupation for compensation or profit.
Plan - The Carpenters' District Council of Kansas City and Vicinity Health Plan, as it may be amended from time to time.
Plan Administrator - The persons responsible for the day-to-day functions and management of the Plan. The Plan Administrator is the Board of Trustees of the Carpenters' District Council of Kansas City and Vicinity Health Plan.
Plan Year - A 12-month period ending December 31.
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Reasonable and Customary Charges - The Plan pays benefits only to the extent that they are "Reasonable and Customary." In general, this is the amount providers most frequently charge for the same service or procedure in a geographic area. Reasonable and Customary Charges are determined by the Trustees who may rely on advice of medical professionals.
The discounted rates charged by PPO providers are considered Reasonable and Customary by the Plan. For charges incurred by a non-PPO provider, the Fund's claim payor determines Reasonable and Customary Charges.
Retiree - A person who is receiving pension benefits from the Carpenters' District Council of Kansas City and Vicinity Pension Fund.
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Terminally Ill Person - A person whose medical records indicate a life expectancy of six months or less.
Totally Disabled or Total Disability - You are considered Totally Disabled for purposes of this Plan if you are wholly and continuously disabled by a sickness or accidental bodily Injury that prevents you from being gainfully employed in your own occupation.
All disability absences will be considered as having occurred during a single period of Total Disability unless acceptable evidence is furnished that:
- The causes of the latest Total Disability cannot be connected with the causes of any prior Total Disability and the latest Total Disability occurs after return to active work full-time for at least one day; or
- A connection with prior Total Disability can be established, but between the last of the previous Total Disabilities that are connected and the latest one there was a return to active work on a full-time basis for at least two consecutive weeks.
Trust Agreement - The Carpenters' District Council of Kansas City and Vicinity Health & Welfare Fund Agreement and Declaration of Trust, as amended. The Trust agreement and any amendments will form a part of this Plan as if all terms and provisions were incorporated in the Plan.
Trust Fund or Fund - The Carpenters' District Council of Kansas City and Vicinity Health & Welfare Fund and the entire assets, including all funds received by the Trustees in the form of Employer contributions, together with all contracts (including dividends, interest, refunds and other sums payable to the trust Fund on account of the contracts), all investments made and held by the Trustees, all income, increments, earnings and profits and any and all other property or funds received and held by the Trustees under the amended Agreement and Declaration of Trust.
Trustees or Board of Trustees - The Trustees of the Carpenters' District Council of Kansas City and Health & Welfare Fund.
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Union - The Carpenters' District Council of Kansas City & Vicinity of the United Brotherhood of Carpenters and Joiners of America and any other Union that may become party to the established Agreement and Declaration of Trust.
Work Hardening - A program designed to help an injured employee return to work that incorporates physical conditioning, work simulation and education to build strength and endurance and improve function while helping to prevent re-injury.
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