SPD Table of Contents

Definitions

Allowable Charge

The maximum covered charge for a service rendered or supply furnished by a health care provider that will be considered for payment.

For in-network facilities and professional providers, the allowable charge is the contracted fee.
For out-of-network facility charges, the allowable charge is the reasonable and customary amount, as defined on page 77. For out-of-network professional fees, the allowable charge is 120% of Medicare’s allowable charge.
If this Plan is secondary to Medicare, the allowable charge means only that amount which is an allowable charge under Medicare’s benefit rules.

Contributing Employer

An employer who, according to the terms of a collective bargaining agreement or participation agreement, agrees to contribute to the IBEW Local 701 Welfare Fund on an employee’s behalf.

Cosmetic

A treatment or procedure for the primary purpose of changing the person’s appearance. The fact that the patient may suffer psychological or behavioral consequences absent the treatment or procedure does not make it noncosmetic or covered by the Plan.

Custodial Care

Care designed mainly to help a person with daily living activities. It is not care primarily intended to help a person recover from an injury or illness.

Dependent

The following categories of individuals:

Your spouse;
Your natural or adopted children who are less than 26 years of age;
Your unmarried stepchildren who are less than 26 years of age, and
Your unmarried child older than age 26 who is deemed totally and permanently disabled by a federal or state authority due to a disability that began prior to age 26. For purposes of this paragraph, “permanently disabled” means that the child is unable to engage in any gainful activity by reason of a medically determinable physical or mental impairment that is expected to result in death or last for a continuous period of twelve (12) months or more. The Plan may require you to furnish proof of the child’s continued disability from time to time, but not more often than once in a 12-month period. Coverage will terminate if the Plan determines, based upon medical evidence, that the child is no longer disabled or if the child does not undergo an examination or furnish proof required by the Plan.

“Children” means children who are naturally born to you, or are legally adopted by you (“legally adopted” means from the time the child is placed in your home for purposes of adoption). “Children” also include other children for whom you have legal guardianship, or children listed as alternate recipients in Qualified Medical Child Support Orders (QMCSOs). The Trustees, in consultation with the Fund legal counsel, have adopted procedures for determining whether a particular court order qualifies as a QMCSO. If you would like a copy of the Plan’s QMCSO procedures, please call or write the Fund Office. If you are a responsible party in a court action involving a child, you should request a copy of the Plan’s procedures BEFORE the final order is entered.

“Stepchildren” are children who were born to your current legal spouse or who were legally adopted by your spouse before your marriage.

Dependent coverage terminates at the end of the month during which the person no longer meets the definition of a dependent.

Durable Medical Equipment

Equipment that meets all the following criteria: 1) It is related to the patient’s physical disorder; 2) It is appropriate for in-home use; 3) It can stand repeated use; 4) It is manufactured solely to serve a medical purpose; 5) It is not merely for comfort or convenience; and 6) It is normally not useful to a person not ill or injured.

Eligible Dependent

A dependent who is eligible to receive benefits under this Plan in accordance with the dependent eligibility rules beginning on page 23 (actives) and page 32 (retirees).

Eligible Participant

An actively employed individual who is eligible to receive participant benefits under this Plan in accordance with the eligibility rules beginning on page 16.

Eligible Retiree

An individual who is eligible to receive post-retirement benefits from this Welfare Fund in accordance with the eligibility rules beginning on page 30.

Emergency

An “emergency” is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part.

Experimental, Investigative or Inappropriate

A service or treatment on which the consensus of expert medical opinion, based on reliable evidence (i.e., published reports and/or articles) indicates that further trials or studies are needed to determine the safety, efficiency and outcomes compared to standard treatment. Experimental, investigative or inappropriate also means services or treatments that are:

Not yet recognized as having proven beneficial outcomes;
Primarily confined to a research setting;
Not appropriate based on medical circumstances and/or given the advanced stage of the individual’s illness or the likelihood that the service or treatment will measurably improve the individual’s illness or medical condition; or
Not calculated to yield a favorable result.

Fund

The Electrical Workers’ General Welfare Fund, usually referred to as the IBEW Local 701 Welfare Fund.

Home Health Agency

A public or private agency that specializes in giving nursing or therapeutic services in the home; is licensed as a home health agency; and operates within the scope of its license.

Hospice

An agency, or a facility or part of one that provides inpatient, outpatient or home care for terminally ill persons who have been diagnosed by a physician as having a life expectancy of six months or less; is licensed as a hospice or hospice agency and operating within the scope of such license; meets the minimum standards for certification under the Medicare program; has full-time supervision by at least one physician; and provides 24hour nursing service by registered nurses.

Hospital

A licensed institution that is in the Plan’s PPO network or accredited by an accrediting agency approved by the Centers for Medicare and Medicare (CMS) that provides inpatient and/or outpatient medical care and treatment for sick and injured persons. Services provided by a hospital must also include all of the following:

Facilities for diagnosis of injury and illness on its premises;
care of patients who are convalescing from injury or illness.

An institution that is used primarily as a rest home, nursing home, convalescent home, or a place for the aged shall be excluded from this definition of hospital.

Medically Necessary

A service, supply or treatment that:

Is essential for the diagnosis or treatment of the injury or illness for which it is prescribed or performed;
Is within the medical standard of care (it meets generally accepted standards of medical practice);
Is ordered by a physician; and
Is not experimental, investigative or inappropriate.

The fact that a physician may prescribe, order, recommend or approve a service or supply does not, by itself, make it medically necessary or make the expense a covered charge.

Mental or Nervous Disorder; Mental/Nervous Disorder

Illnesses in which psychological, intellectual, emotional, or behavioral disturbances are the dominating feature as manifested in maladaptive behavior or impaired functioning, whether caused by genetic, physical, chemical, biological, environmental, psychological, social, or cultural factors, meeting the criteria further described in the current edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, but excluding V codes, and developmental and learning disorders.

Participant

A person who is covered by a collective bargaining agreement, or performs work that is covered under a collective bargaining agreement, between the Union and a contributing employer, or any individual on whose behalf an employer is obligated to make contributions to the Fund, including non-bargained persons employed by the Union or the Fund. A person who met this definition and then retired and qualified for post-retirement Plan coverage is also a “participant.”

Physician

A legally qualified doctor or surgeon who is a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.).

Additional Covered Providers - Although not included in the definition of “physician,” benefits are payable for services provided by the following types of licensed providers when the services are within the Plan’s normal covered expense provisions and are rendered within the scope of each such individual’s license and specialty: a chiropractor (DC), a dentist (D.D.S. or D.M.D.), a podiatrist (D.P.M.), an optometrist (O.D.), a physical therapist (P.T.), a physical therapy assistant (P.T.A.) working under the supervision of a P.T., an occupational therapist (O.T.), an occupational therapy assistant (O.T.A) working under the supervision of an O.T., a speech therapist (S.T.), a nurse (L.P.N., R.N.), a nurse practitioner (N.P.) if payment would have been made under this Plan to a doctor for the same services, a physician assistant (P.A.) working under the direct supervision of a physician, and a licensed nutritionist. The Plan also covers a certified surgical assistant (C.S.A.) or nurse anesthetist (C.R.N.A.) if payment would have been made under this Plan to a doctor for the same services. With respect to covered mental/nervous or substance abuse treatment, the following will also be considered covered practitioners: clinical psychologist (Ph.D. or Psy.D.), licensed Masters-level clinical social worker or therapist (such as L.SW., L.C.S.W, M.S.W., L.P.C. or L.C.P.C.).

Plan

The health care benefit plan provided by the Electrical Workers General Welfare Plan Fund. The Plan is usually referred to as the IBEW Local 701 Welfare Plan.

Reasonable and Customary Charges

The amount charged for medical services or supplies made by a majority of medical service providers in the community. In determining the reasonable and customary charge, the Plan uses standard tables commercially available for such purpose, and it is the current practice of the Fund to allow up to the 90th percentile reported in these tables.

Note that maximum amount allowable by the plan for out-of-network professional medical fees is 120% of Medicare’s allowable amount for the same service in the same location. This amount is not intended to represent a “reasonable and customary” fee.

Residential Treatment Facility

A state-licensed facility other than a hospital providing non-acute inpatient treatment of substance abuse or mental/nervous disorders is considered a skilled nursing facility if it satisfies the requirements for a “skilled nursing facility” below.

Skilled Nursing Facility

A licensed institution, other than a hospital, which:

Provides inpatient medical care and treatment to convalescing patients;
Provides full-time supervision by at least one physician or registered nurse;
Provides 24-hour nursing service by licensed professional nurses; and
Is in the Plan’s medical PPO network or accredited as an inpatient facility by a CMS-approved accreditation agency. (“CMS” is the Centers for Medicare and Medicaid, a federal agency.)

Substance Abuse

Alcoholism, alcohol abuse, drug addiction, drug abuse, or any other type of addiction to, abuse of, or dependency on any type of drug, narcotic, or chemical, except nicotine.

Surgical Center

A free-standing facility which is wholly owned and operated by a hospital on the same basis as the outpatient department of its main facility, or a legally constituted and licensed institution that is established, equipped and operated primarily for the purpose of performing surgical procedures. The Plan does not cover services by outof-network surgical centers except when Medicare is primary and covers that facility.

Trustees

The Trustees of the Electrical Workers General Welfare Fund.

Union

The International Brotherhood of Electrical Workers, Local No. 701 and any other Unions which may become parties to the established Agreements and Declarations of Trust.

IBEW 701 Fringe Benefit Office