Accidental injury | A bodily injury sustained solely through violent, external and accidental means such as broken bones, animal bites and poisonings. Note: An injury to teeth while chewing and/or eating is not considered to be an accidental injury. |
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Admission | The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day. |
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Artificial insemination | Artificial Insemination (AI) is an infertility procedure where specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before the procedure. AI is often used to treat mild male factor infertility and couples with unexplained infertility.
Artificial Insemination includes the following procedures: Intrauterine insemination (IUI), Intravaginal insemination (IVI), and Intracervical insemination (ICI). |
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Assignment | An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.
- We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
- Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
- OPM's contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.
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Assisted Reproductive Technology (ART) | Assisted Reproductive Technology (ART) includes all fertility treatments in which either eggs or embryos are handled outside of the body. In general, ART procedures involve surgically removing mature eggs from a woman’s ovaries, combining the eggs with sperm in the laboratory, and returning the embryos to the woman’s body or donating them to another woman. |
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Calendar year | January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year. |
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Certified doula | A professional who has met the necessary education, training and experience requirements of a doula certifying organization to provide non-clinical emotional, physical and informational support before, during and after labor. |
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Clinical Trials Cost Categories | An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.
If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:
- Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition whether the patient is in a clinical trial or is receiving standard therapy
- Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
- Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials. This plan does not cover these costs.
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Coinsurance | See Section 4, page 23. |
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Confinement
| An admission (or series of admissions separated by less than 60 days) to a hospital as an inpatient, for which a full day’s room and board charge is made, for any one illness or injury. |
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Congenital anomaly | A condition existing at or from birth, which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include protruding ear deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes, and other conditions that the Carrier may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intra-oral structures supporting the teeth except for the Dental prosthetic appliances benefit and Orthodontic treatment covered under Section 5(g). Dental Benefits. |
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Convenient care clinic | A small healthcare clinic, usually located in a high-traffic retail outlet with a limited pharmacy, that treats uncomplicated minor illnesses and provides preventative healthcare services on a walk-in basis. Examples of a convenient care clinic include MinuteClinic in CVS pharmacy locations and Take Care Clinicsm in Walgreens pharmacy locations. Convenient care clinics are different from Urgent care centers (see page 113) that primarily provide treatment to patients who have an illness or injury that requires immediate care but is not serious enough to warrant a visit to the emergency room. |
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Copayment | See Section 4, page 22. |
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Cosmetic surgery
| Any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury. |
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Cost-sharing | See Section 4, page 22. |
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Covered services
| Services we provide benefits for, as described in this brochure. |
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Custodial care | Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include but are not limited to:
- personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;
- homemaking, such as preparing meals or specials diets;
- moving the patient;
- acting as companion or sitter;
- supervising medication that can usually be self-administered; or
- treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems.
Custodial care that lasts 90 days or more is sometimes known as long term care. The Plan determines which services are custodial care. |
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Deductible | See Section 4, page 22. |
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Durable medical equipment | Equipment and supplies that:
- Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
- Are medically necessary;
- Are primarily and customarily used only for a medical purpose;
- Are generally useful only to a person with an illness or injury;
- Are designed for prolonged use; and
- Serve a specific therapeutic purpose in the treatment of an illness or injury.
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Experimental or investigational services | A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or 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 the standard means of treatment or diagnosis.
Reliable evidence shall mean 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 or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure. |
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Genetic counseling | Genetic counseling is a process of communication between patients and trained professionals intended to provide patients who have a genetic disease, or risk of such a disease, with information about their condition and its effect on their family. This allows patients and their families to make informed reproductive and other medical decisions. |
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Genetic screening | The diagnosis, prognosis, management, and prevention of genetic disease for those patients who have no current evidence or manifestation of a genetic disease and those who have not been determined to have an inheritable risk of genetic disease. |
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Genetic testing | The diagnosis and management of genetic disease for those patients with current signs and symptoms, and for those who have been determined to have an inheritable risk of genetic disease. |
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Group health coverage | Healthcare coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides payment for hospital, medical, or other healthcare services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of any of these benefits through COBRA. |
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Healthcare professional | A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law. |
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Hospice Care | Hospice is a coordinated program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.
Note: A terminally ill person is a covered family member whose life expectancy is six months or less, as certified by the primary doctor. |
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Inborn Errors of Metabolism | Conditions associated with an inborn error of metabolism interfere with the metabolism of specific nutrients. Examples of an inherited metabolic disorder (inborn errors of metabolism) include, but are not limited to:
- Phenylketonuria (PKU)
- Maple syrup urine disease (MSUD)
- Homocystinuria
- Urea cycle disorders
- Organic acidemias
- Histidinemia
- Tyrosinemia
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Incurred
| An expense is incurred on the date a service or supply is rendered or received unless otherwise noted in this brochure. |
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Infertility | Infertility is defined as not being able to conceive after 1 year (or longer) of egg sperm contact. Because infertility in females (or individuals with female reproductive organs) is known to decline steadily with age, some providers evaluate and treat individuals aged 35 or older after 6 months of egg sperm contact. Infertility may also be established through an evaluation based on medical history and diagnostic testing. |
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Intensive outpatient program
| A comprehensive outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental health and/or substance use disorder conditions. It is an intermediate setting between traditional outpatient therapy and partial hospitalization. Program sessions may occur more than one day per week.
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Medical foods | A medical food, as defined by the Orphan Drug Act (21 U.S.C. 360ee (b) (3)), is a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. In general, to be considered a medical food, a product must, at a minimum, meet the following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements; and the product must be intended to be used under medical supervision.
Modified grocery item foods, even if categorized as medical foods by the manufacturer, are not considered a covered benefit. |
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Medical necessity | Services, drugs, supplies or equipment provided by a hospital or covered provider of healthcare services that we determine:
- are appropriate to diagnose or treat the patient’s condition, illness or injury;
- are consistent with standards of good medical practice in the United States;
- are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
- are not a part of or associated with the scholastic education or vocational training of the patient; and
- in the case of inpatient care, cannot be provided safely on an outpatient basis.
The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary. |
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Mental conditions/substance use disorder | Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychosis, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for use of, or dependence upon, substances such as alcohol, narcotics, or hallucinogens. |
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| Morbid obesity | A diagnosed condition in which the body mass index is 40 or greater or 35 or greater with co-morbidities such as diabetes, coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, pulmonary hypertension, weight related degenerative joint disease, or lower extremity venous or lymphatic obstruction. |
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Observation services | Hospital observation care has a well-defined set of specific, clinically appropriate services that are billed hourly. Although you may stay overnight in a hospital room and receive meals and other hospital services, some services and overnight stays – including “observation services” – are actually outpatient care. Observation care includes care provided to members who require a significant period of treatment or monitoring before a physician can decide whether to admit them to the hospital on an inpatient basis or discharge them to home. The provider may need 6 to 24 hours or more to make that decision.
If you are in the hospital more than a few hours, always ask your physician or the hospital staff if your stay is considered inpatient or outpatient. |
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Orthopedic device
| Any custom fitted external device used to support, align, prevent, or correct deformities or to restore or improve function. |
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Partial hospitalization | A time-limited, ambulatory, active treatment program used to treat mental illness and substance use disorder. The patient continues to reside at home, but commutes to a treatment center that offers intensive clinical services that are coordinated and structured in a stable therapeutic environment. Provides at least 20 hours of scheduled programs extended over a minimum of five days per week in a licensed or JCAHO accredited facility.
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Plan allowance | Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We determine our allowance as follows:
- PPO providers: For services rendered by a covered provider who participates in the Plan's PPO network, our allowance is based on a negotiated rate agreed to under the providers' network agreement.
Note: You will not be responsible for any amount above the providers' negotiated rate; PPO providers accept the Plan's allowance as payment in full.
- Non-PPO providers: When you receive care from a Non-PPO provider, we determine our allowance based on the following rules in order:
When a Non-PPO provider has agreed to discount their charges, our allowance is the amount that the provider has negotiated and agreed to accept for the services or supplies. You are not responsible for the difference between the allowance and the provider’s billed charges.
If the provider has not agreed to discount their charges, we will access Rule Two.
An amount equal to 200% of the current Medicare rate for professional and facility expenses. You may be responsible for the difference between the allowance and the provider’s billed charges.
If there is no Medicare rate for the service(s) billed, we will access Rule Three.
We will utilize outside sources, such as Fair Health, Inc., to determine the allowance for certain services and supplies in a specific geographic area. You may be responsible for the difference between the allowance and the provider’s billed charges
For certain services, exceptions may exist to the use of the out-of-network fee schedule to determine the Plan's Non-PPO allowance. For claims governed by OBRA '90 and '93, the Plan allowance will be based on Medicare allowable amounts as is required by law. For claims where the Plan is the secondary payor to Medicare, the Plan allowance is the Medicare allowable charge.
For covered services rendered by a hospital or by a doctor outside the United States, our allowance is based on the Plan’s allowance established for the Washington, D.C. Metropolitan area.
Note: We will not consider any fee charged above the Plan's allowance. The member is responsible for the difference between the Plan’s allowance and the provider’s charge.
- Other Participating Providers: When you use certain Non-PPO providers that have agreed to discount their charges, our Plan allowance is the amount that the provider has negotiated and agreed to accept for the services and/or supplies. Benefits will be paid at the Non-PPO benefit levels. You are not responsible for the difference between the Plan's allowance/negotiated amount and the provider's billed charges.
For more information, see Differences between our allowance and the bill in Section 4.
You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act. |
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Post-service claims | Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits. |
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Pre-service claims | Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits. |
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Primary care provider | For purposes of the office visit copayment, primary care providers are individual doctors (M.D. or D.O.) whose medical practice is limited to family practice, general practice, internal medicine, pediatrics, adolescent medicine, obstetrics/gynecology, or geriatrics. Also considered primary care providers for the purpose of this benefit are psychiatrists, licensed clinical psychologists, licensed clinical social workers, licensed professional counselors, or licensed marriage and family therapists. Doctors listed in provider directories and/or advertisements under any other medical specialty or sub-specialty area (such as internal medicine doctors also listed under endocrinology, or pediatric sub-specialties such as pediatric cardiology) are considered specialists, not primary care providers. |
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Prosthetic device | An artificial substitute for a missing body part such as an arm, eye, or leg. This device may be used for a functional or cosmetic reason or both. |
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Reimbursement | A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation. |
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Remission
| A remission is a halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred. |
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Routine services
| Services that are not related to any specific illness, injury, set of symptoms, or maternity care. |
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Sound natural tooth
| A sound, natural tooth is a tooth that is whole or properly restored and is without impairment, periodontal or other conditions and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration or treated by endodontics is not considered a sound natural tooth. |
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Subrogation | A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan. |
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Surprise bill | An unexpected bill you receive for:
- emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
- non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
- air ambulance services furnished by nonparticipating providers of air ambulance services.
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Urgent care center | An ambulatory care center, outside of a hospital emergency department, that provides treatment for medical conditions that are not life-threatening, but need quick attention, on a walk-in basis. Urgent care centers are different from convenient care clinics, see page 108. |
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Urgent care claims | A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:
- Waiting could seriously jeopardize your life or health;
- Waiting could seriously jeopardize your ability to regain maximum function; or
- In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Urgent care claims largely involve pre-service claims and not post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.
If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-638-6589 or 301-984-1440 (For TTY, use 301-984-4155). You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care. |
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Us/We
| Us and We refer to SAMBA. |
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You
| You refers to the enrollee and each covered family member. |
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