Section 10. Definitions of terms we use in this brochure

Accidental injury	An injury resulting from a violent external force.
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.
Assignment	Your authorization for us to pay benefits directly to the provider. We reserve the right to pay you directly for all covered services.
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.
Coinsurance	Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 15.
Copayment	A copayment is a fixed amount of money you pay when you receive covered services. See page 14.
Cost-sharing	Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.
Covered services	Services we provide benefits for, as described in this brochure.
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 special diets Moving the patient Acting as a 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 We determine which services are custodial care. Custodial care that lasts 90 days or more is sometimes known as long term care.
Deductible	A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 14.
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. Determination of experimental/investigational status may require review by a specialty appropriate board-certified health care provider or appropriate government publications such as those of the National Institute of Health, National Cancer Institute, Food and Drug Administration, Agency of Health Care Policy & Research, and the National Library of Medicine.
Group health coverage	Health care 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 health care services or supplies, or that pays a specific amount for each day or period of hospitalization if that specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.
Home health care agency	An agency which meets all of the following: Is primarily engaged in providing, and is duly licensed or certified to provide, skilled nursing care and therapeutic services Has policies established by a professional group associated with the agency or organization. This professional group must include at least one registered nurse (R.N.) to direct the services provided and it must provide for full-time supervision of each service by a physician or registered nurse Maintains a complete medical record on each individual; and Has a full-time administrator
Hospice care program	A coordinated program of home and inpatient palliative and supportive care for the terminally ill patient and the patient's family provided by a medically supervised specialized team under the direction of a duly licensed or certified Hospice Care Program.
Maintenance therapy	Includes but is not limited to physical, occupational, or speech therapy where continued therapy is not expected to result in significant restoration of a bodily function but is utilized to maintain the current status.
Medically necessary	Services, drugs, supplies or equipment provided by a hospital or covered provider of health care 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.
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: For PPO providers, our allowance is based on negotiated rates. PPO providers always accept the Plan's allowance as their charge for covered services. For non-PPO providers, we base the Plan allowance on the lesser of the provider's actual charge or the reasonable and customary charge for the service you received. We determine the reasonable and customary allowance by using health care charges guides which compare charges of other providers for similar services in the same geographical area. For surgery, doctor's services, X-ray, lab and therapies (physical, speech and occupational), we use guides prepared by the Health Insurance Association of America (HIAA) and apply these guides under the High Option at the 70th percentile and under the Consumer Driven Option at the 80th percentile. We update these charges guides at least once each year. If HIAA information is not available, we will use other credible sources including our own data. For more information, see Differences between our allowance and the bill in Section 4.
Rehabilitative care	Treatment that reasonably can be expected to restore and/or substantially restore a bodily function that was impaired as a result of trauma or disease.
Us/We	Us and we refer to APWU Health Plan.
You	You refers to the enrollee and each covered family member.
Consumer Driven Health Plan Definitions
Consumer Driven option	A fee-for-service option under the FEHB that offers you greater control over choices of your health care expenditures. You decide what health care services will be reimbursed under the health plan funded Personal Care Account (PCA). Unused funds from the PCA will roll over at the end of the year. If you spend the entire PCA fund before the end of the year, then you must satisfy a member responsibility before benefits are payable under the traditional type of insurance covered by your Plan. You decide whether to use in-network or out-of-network providers to reach the maximum fund allowed under your PCA.
Member Responsibility	Under the Consumer Driven Option, your Member Responsibility is the amount you must pay, if you have exhausted your Personal Care Account, before your Traditional Health Coverage begins. See page 15.
Personal Care Account	Under the Consumer Driven Option, your Personal Care Account (PCA) is an established benefit amount which is available for you to use first to pay for covered hospital, medical, dental and vision care expenses. You determine how your PCA will be spent and any unused amount at the end of the year may be rolled over to increase your available PCA in the subsequent year(s).
Rollover	Any unused, remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years up to a maximum PCA account of $5,000 per Self Only enrollment or $10,000 per Self and Family enrollment, thereby increasing your PCA in the following year(s). You must use any available PCA benefits, including any amounts rolled over from previous years, before Traditional Health Coverage begins.

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