Applied Behavior Analysis (ABA) | Outpatient treatment involving behavioral modification techniques in which reinforcement, either positive or negative, is used to encourage or reduce certain behaviors. The treatment is delivered in a highly structured and intensive program with one-to-one instruction by a certified therapist. Prior authorization is required. |
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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. Plan normally pays provider for all covered services.
- 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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Autism Spectrum Disorder | A developmental disorder of brain function which is classified as one of the pervasive developmental disorders. For purposes of this Plan, Autism Spectrum Disorder is treatment coverage for diagnosis of Autistic Disorder, Unspecified Pervasive Developmental Disorder, and Other Pervasive Developmental Disorders (Asperger’s Disorder, Rhett’s Disorder). |
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Brochure | The legal document that describes the rights and responsibilities of both you and Priority Health according to our contract (CS 2944) with the United States Office of Personnel Management, as authorized by the Federal Employee Health Benefits law. It includes this document and any amendments and attachments to this document. |
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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; or is a drug trial that is exempt from the requirement of an investigational new drug application. - 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 26. |
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Complications of a pregnancy | Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Examples of such conditions include acute nephritis, nephrosis, cardiac decompensation, missed abortion, hyperemesis gravidarum, pre-eclampsia, and similar medical and surgical conditions of comparable severity. It also includes conditions such as termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible. It does not include medically/clinically necessary or emergency cesarean section, false labor, occasional spotting, physician-prescribed rest during a pregnancy, morning sickness and similar conditions associated with the management of a difficult pregnancy not constituting a distinct complication of pregnancy. |
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Contract year | The period of time that starts on the day you first enroll in coverage under this Plan and ends on December 31 of the same year. |
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Copayments | See Section 4, page 26. |
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Cost-sharing | See Section 4, page 26. |
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Covered or eligible dependent | An individual eligible to enroll in this plan because he or she is the enrollee’s legally married spouse or dependent child under age 26. |
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Covered services, coverage, cover or covered | Services and supplies for which this plan will pay all or part of the costs, as listed in this brochure, so long as you are an eligible member. The services or supplies must be preventive or medically/clinically necessary and not otherwise excluded by this Plan. When we say we will “cover” a service or supply, that means we will treat the service or supply as a covered service. |
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Custodial care | Care you receive if, in our opinion, you have reached the maximum level of mental and/or physical function and you will not improve significantly more. This type of care includes room and board, therapies, nursing care, home health aides and personal care designed to help you in the activities of daily living and home care and adult day care that you receive, or could receive, from a member of your family. |
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Deductible | See Section 4, page 26. |
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Disputed claims process | The process you may follow if you do not agree with our decision regarding a claim or prior approval decision. A more detailed explanation of the disputed claims process is available in Section 8 of this brochure. |
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Durable medical equipment (DME) | Information about DME is available in Section 5(a) of this brochure. |
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Enrollee | A Federal employee or retiree eligible to enroll in this plan. |
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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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Home health care | Information about home health care is available in Section 5(a) of this brochure. |
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Hospice care | Services for the terminally ill and their families including pain management and other supportive services. |
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Hospital | An appropriately licensed acute care institution (including a long-term acute care facility) that provides inpatient and outpatient medical care and treatment for ill and injured persons through medical, diagnostic, and major surgical facilities. All services must be provided on its premises under the supervision of a staff of physicians and with 24 hour-a-day nursing and physician service. |
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Hospital inpatient care | Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for hospital observation care may be considered outpatient care. |
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Hospital observation care | Short term treatment and monitoring that is provided on an outpatient basis. This type of care is commonly provided after you visit an emergency room to allow health professionals to determine if you can be discharged or if you need to be admitted as an inpatient for additional treatment. Hospital observation care is typically limited to 24-48 hours. Even when you are required to stay at the hospital overnight, if you are receiving observation care, you have not been admitted as an inpatient. See Section 5(a) of this brochure for information about your hospital outpatient care benefit. |
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Hospital outpatient care | Care in a hospital that usually doesn't require an overnight stay. |
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Ill or illness | A sickness or a disease, including congenital defects or birth abnormalities. |
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Infertility | The inability to conceive a successful pregnancy after 12 months of egg-sperm contact if the individual is under the age of 35 or after 6 months if the individual is age 35 and older. Infertility may also be justified based on the individual having a medical or other recognized condition as a cause of infertility. |
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Injury or injured | Accidental bodily harm. |
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Intellectual disabilities | Disabilities characterized by significant limitations both in intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills originating before the age of 18. |
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Medicaid | Title XIX of the Social Security Act, as amended. |
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Medical Director | A Michigan-licensed physician, employed by Priority Health, who oversees the plan’s medical delivery system. |
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Medical emergency | The sudden onset of an illness or injury, symptom or condition serious enough that not seeking immediate medical attention could reasonably be expected to result in serious harm to your health, serious jeopardy to a pregnancy, or death. |
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Medically/clinically necessary | The services or supplies needed to diagnose or treat your physical or mental condition. Whether services or supplies are medically/clinically necessary is determined in accordance with Priority Health’s medical and behavioral health policies or adopted criteria that have been approved by community physicians and other providers. The determination is made by Priority Health’s medical director, or anyone acting at the medical director’s direction, in consultation with other physicians. medical/clinical necessity of mental health and substance use services is determined by our Behavioral Health Department. In order to be considered medically/clinically Necessary, the services or supplies must: (a) be widely accepted as effective; (b) be appropriate for the condition or diagnosis; (c) be essential, based upon nationally accepted evidence-based standards; and (d) cost no more than a treatment that is likely to yield a comparable health outcome.
The determination of whether proposed care is a Covered Service is independent of, and should not be confused with, the determination of whether proposed care is Medically/Clinically Necessary. |
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Medicare | Title XVIII of the Social Security Act, as amended. |
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Member | A person enrolled with us as an enrollee or as a covered/eligible dependent. |
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Mental Health | Acute Inpatient Hospitalization. This is the most intensive level of care. Prior approval from our Behavioral Health department is required for inpatient services except in a medical emergency. Upon discharge, you will be referred to a less intensive level of care.
Residential Treatment. This is 24-hour confinement in a subacute residential setting (as defined above) licensed by the state with structured, licensed health care professionals accessible 24 hours a day and 7 days a week. A licensed foster-care facility serving as your residence is not covered and does not meet the definition of “Residential Treatment”. Prior approval from our Behavioral Health department is required for residential treatment services.
Partial Hospitalization. This is a non-residential level of service that is similar in intensity to acute inpatient hospitalization. You are generally in treatment for more than four hours but less than eight hours daily. Prior approval from our Behavioral Health department is required for partial hospitalization services.
Intensive Outpatient Treatment. This is outpatient treatment that is provided with more frequency and intensity than routine outpatient treatment. You are generally in treatment for up to four hours per day, and up to five days per week. You may be treated individually, as a family or in a group.
Outpatient Treatment. This is the least intensive, and most common, type of service. It is provided in an office setting, generally from 45-50 minutes (for individuals) to 90 minutes (for group therapies) per day by a licensed behavioral health professional |
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Newborn | A child 30 days old or younger. |
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Non-covered or excluded services | Health care services that this plan does not pay for or cover. |
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Non-participating or non-Plan provider | The physicians, health professionals, hospitals and other providers and facilities that have not contracted with Priority Health to provide covered services to members. Non-participating or non-Plan providers are not listed in the Priority Health Provider Directory. covered services and supplies you seek from a non-Plan provider are not covered except as otherwise stated in this brochure. |
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Open season | An annual period during which you and your eligible dependents may enroll in this Plan or, if you are already enrolled, during which you may change your coverage elections. |
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Out-of-area services | Those services and supplies provided outside our service area. |
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Out-of-pocket limit or maximum | The maximum amount of deductibles, copayments and coinsurance you will pay for covered services in a contract year. Once you reach this overall maximum, covered services will be covered at 100% with no cost to you unless we tell you otherwise in this brochure. This protects you against catastrophic costs. Some costs do not count toward this protection. |
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Physician | A licensed medical doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) or surgeon. |
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Plan Allowance | Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways.
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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Plan or participating provider | The physicians, health professionals, hospitals and other facilities that have contracted with Priority Health to provide covered services. The Providers that make up our network are considered Plan or participating providers and are listed in our Provider Directory. Most Plan or participating providers offer services within Priority Health's service area. However, if you are a covered dependent child residing outside the service area, covered services received outside the service area but within the United States are also available from Cigna, a Priority Health leased network provider. |
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Post-service claim | 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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Premium | The total amount paid to us for coverage under this plan, including contributions from your employer and you. |
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Prescription drug coverage | Prescription drug coverage you are entitled to receive under this Plan. More information about drugs covered under your Priority Health plan is available in Section 5(f). |
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Pre-service claim | Those claims (1) that require prior approval or a referral and (2) where failure to obtain prior approval or a referral results in a reduction of benefits. |
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Preventive Health Care Guidelines | A list of immunizations, screenings, lab tests and other services that we cover to help you maintain optimum health and prevent unnecessary injury, illness or disability. Our guidelines are developed by health professionals who are Plan providers or employed by us, and are based on federal requirements for coverage of preventive health care services contained in Section 1001 of the Patient Protection and Affordable Care Act (PPACA), available at www.healthcare.gov. |
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Primary Care Provider (“PCP”) | The Plan provider you select as explained in Section 3. Your PCP provides, arranges and coordinates all aspects of your health care to help you receive the right care, in the right place, at the right time. |
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Prior approval | A decision made by Priority Health as to whether a service or supply is covered or not covered under the plan. It may also include a decision to partially cover a service. See Section 3 for more information about when and how to obtain prior approval. |
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Provider | A licensed health professional or facility that provides health care services.
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Provider Directory | The names and locations of Plan providers who comprise our network. Also included, among other things, are whether the provider is accepting new members and quality and performance information. You may call our Customer Service department to obtain a list of providers in your area, or you can go to the Member Center on our website at www.priorityhealth.com. |
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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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Residential treatment | Treatment provided in a state-licensed subacute facility with structured, licensed health professionals. This treatment must be medically-monitored and must include access to the following: (i) medical services twenty-four (24) hours per day, seven (7) days per week; (ii) nursing services twenty-four (24) hours per day, seven (7) days per week; and (iii) physician on call availability for emergency twenty-four (24) hours per day, seven (7) days per week. Services provided in a licensed foster-care facility serving as an individual’s residence are not covered and do not meet the definition of “Residential Treatment.” |
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Retail Health Clinic | A category of walk in clinic located in retail stores, supermarkets and pharmacies within the United States that treat uncomplicated minor illnesses and provide some preventive health care services. |
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Service area | A geographical area, made up of counties or parts of counties, where we have been authorized by the State of Michigan to sell and market our health plans and where the majority of our participating providers are located. We publish precise service area boundaries that you can find on our website www.priorityhealth.com or receive from our Customer Service Department. |
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Skilled nursing services | Information about skilled nursing services is available in Section 5(c) of this brochure. |
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Specialist or specialist provider | A physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. |
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Specialty drug | Drugs listed on our approved drug list that meet certain criteria, such as drugs or drug classes whose cost on a per-month or per-dose basis exceed a threshold established by the Centers for Medicare and Medicaid Services; drugs that require special handling or administration; drugs that have limited distribution; or drugs in selected therapeutic categories. |
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Specialty pharmacy | A pharmacy that specializes in the handling, distribution, and patient management of specialty drugs. |
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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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Subscriber | An FEHB Employee or FEHB Annuitant. |
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Substance Use | Inpatient Detoxification. These are detoxification services that are provided while you are an inpatient in a hospital or subacute unit. When provided in a medical setting, services are managed jointly by our Behavioral Health and Health Management Departments.
Medically Monitored Intensive Inpatient Treatment. Following full or partial recovery from acute detoxification symptoms, this type of care is provided at an inpatient facility or subacute unit.
Residential Treatment. This is 24-hour confinement in a subacute residential setting (as defined above) licensed by the state with structured, licensed health care professionals accessible 24 hours a day and 7 days a week. A licensed foster-care facility serving as your residence is not covered and does not meet the definition of “residential treatment”. Prior approval from our Behavioral Health department is required for residential treatment services.
Partial Hospitalization. This is an intensive, non-residential level of service provided in a structured setting, similar in intensity to inpatient treatment. You are generally in treatment for more than four hours but generally less than eight hours daily.
Intensive Outpatient Programs. These are outpatient services provided by a variety of health professionals at a frequency of up to four hours daily, and up to five days per week.
Outpatient Treatment. This is the least intensive level of service. It is provided in an office setting generally from 45-50 minutes (for individuals) to 90 minutes (for group therapies) per day.
Outpatient/Ambulatory Detoxification. These detoxification services may be provided on an outpatient basis within a structured program when the consequences of withdrawal are non-life-threatening. These services are covered under your medical benefits. |
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Surprise bill | 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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Treatment Plan | A method of using objectives and measurable goals to monitor progress and improvement in an individual’s care for Autism Spectrum Disorder. The plan is developed under the supervision of a Board Certified Behavior Analyst (BCBA). |
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Urgent care or urgent care center | Care provided at an urgent care center, instead of a hospital emergency room, when you need immediate care to treat a non-life threatening illness or injury to limit severity and prevent complications.
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 usually involve Pre-serve 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 800 446-5674. 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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We, us or our | Priority Health. |
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You, your or yourself | The member, whether enrolled with Priority Health as an enrollee or covered/eligible dependent. |
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