22 CSR 10-3.010 - Definitions
(1)
Accident. An unforeseen and unavoidable event resulting in an injury.
(2) Active employee. A benefit-eligible
person employed by a public entity who meets the plan eligibility
requirements.
(3) Activities of
daily living. Bathing, dressing, toileting, and associated personal hygiene;
transferring (being moved in and out of a bed, chair, wheelchair, tub, or
shower); mobility, eating (getting nourishment into the body by any means other
than intravenous), and continence (voluntarily maintaining control of bowel
and/or bladder function; in the event of incontinence, maintaining a reasonable
level of personal hygiene).
(4)
Administrative appeal. A written request submitted by or on behalf of a member
involving plan-related administrative issues such as eligibility, effective
dates of coverage, and plan changes.
(5) Adverse benefit determination. An adverse
benefit determination means any of the following:
(A) A denial, reduction, or termination of,
or a failure to provide or make payment (in whole or in part) for a benefit
based on a determination of an individual's eligibility to participate in the
plan;
(B) A denial, reduction, or
termination of, or a failure to provide or make payment (in whole or in part)
for a benefit resulting from the application of any utilization review, or
failure to cover an item or service for which benefits are otherwise provided
because it is determined to be experimental, investigational, or not medically
necessary or appropriate; or
(C)
Rescission of coverage after an individual has been covered under the
plan.
(6) Allowed amount.
Maximum amount on which payment is based for covered health care services. This
may be called eligible expense, payment allowance, or negotiated rate. If the
provider charges more than the allowed amount, the member may be balance-billed
(see balance billing, section (8)).
(7) Applied behavior analysis. The design,
implementation, and evaluation of environmental modifications, using behavior
stimuli and consequences, to produce socially-significant improvement in human
behavior, including the use of observation, measurement, and functional
analysis of the relationship between environment and behavior.
(8) Balance billing. When a provider bills
for the difference between the provider's charge and the allowed amount. For
example, if the provider's charge is one hundred dollars ($100) and the allowed
amount is seventy dollars ($70), the provider may bill the member for the
remaining thirty dollars ($30). A network provider may not balance
bill.
(9) Benefits. Health care
services covered by the plan.
(10)
Board. The board of trustees of the Missouri Consolidated Health Care Plan
(MCHCP).
(11) Cancellation of
coverage. The ending of medical, dental, or vision coverage per a subscriber's
voluntary request.
(12) Claims
administrator. An organization or group responsible for processing claims and
associated services for a health plan.
(13) Coinsurance. The member's share of the
costs of a covered health care service, calculated as a percent (for example,
twenty percent (20%)) of the allowed amount for the service. The member pays
coinsurance plus any deductibles owed. For example, if the health insurance or
plan's allowed amount for an office visit is one hundred dollars ($100) and the
member has met his/her deductible, the member's coinsurance payment of twenty
percent (20%) would be twenty dollars ($20). The health insurance or plan pays
the rest of the allowed amount.
(14) Congenital defect. Existing or dating
from birth. Acquired through development while in the uterus.
(15) Copayment. A fixed amount, for example,
fifteen dollars ($15), the member pays for a covered health care service,
usually when the member receives the service. The amount can vary by the type
of covered health care service.
(16) Date of service. Date medical services
are received.
(17) Deductible. The
amount the member owes for health care services that the health plan covers
before the member's health plan begins to pay. For example, if the deductible
is one thousand dollars ($1,000), the member's plan will not pay anything until
s/he meets his/her one thousand dollar ($1,000) deductible for covered health
care services subject to the deductible. The deductible may not apply to all
services.
(18) Dependent. Spouse or
child(ren) enrolled in the plan by a subscriber.
(19) Diabetes Self-Management Education. A
program prescribed by a provider and facilitated by health care professionals
with the appropriate credentials, training, and experience to educate and
support members with diabetes.
(20)
Doctor/physician. A licensed practitioner of the healing arts, as approved by
the plan administrator, including:
(A) Doctor
of medicine;
(B) Doctor of
osteopathy;
(C)
Podiatrist;
(D)
Optometrist;
(E)
Chiropractor;
(F)
Psychologist;
(G) Doctor of dental
medicine, including dental surgery;
(H) Doctor of dentistry; or
(I) Qualified practitioner of spiritual
healing whose organization is generally recognized for health insurance
reimbursement purposes and whose principles and practices of spiritual healing
are well established and recognized.
(21) Effective date. The date on which
coverage takes effect.
(22)
Eligibility date. The first day a member is qualified to enroll for
coverage.
(23) Eligibility period.
The time allowed to enroll in accordance with the rules in this
chapter.
(24) Emergency medical
condition. The sudden and, at the time, unexpected onset of a health condition
that manifests itself by symptoms of sufficient severity that would lead a
prudent layperson, possessing an average knowledge of medicine and health, to
believe that immediate medical care is required, which may include, but shall
not be limited to:
(A) Placing a person's
health in significant jeopardy;
(B)
Serious impairment to a bodily function;
(C) Serious dysfunction of any bodily organ
or part;
(D) Inadequately
controlled pain; or
(E) With
respect to a pregnant woman who is having contractions-
1. That there is inadequate time to effect a
safe transfer to another hospital before delivery; or
2. That transfer to another hospital may pose
a threat to the health or safety of the woman or unborn child.
(25) Emergency services.
With respect to an emergency medical condition-
(A) A medical screening examination that is
within the capability of the emergency department of a hospital, including
ancillary service routinely available to the emergency department to evaluate
such emergency medical condition; and
(B) Such further medical examination and
treatment, to the extent they are within the capabilities of the staff and
facilities available at the hospital, as are required to stabilize the patient.
The term "to stabilize" means to provide such medical treatment of the
condition as may be necessary to ensure, within reasonable medical probability,
that no material deterioration of the condition is likely to result from, or
occur during, the transfer of the individual from a facility.
(26) Employee. A benefit-eligible
person employed by a participating public entity, including present and future
retirees from the participating public entity, who meet the plan eligibility
requirements.
(27) Employer. The
public entity that employs the eligible employee.
(28) Essential benefits. The plan covers
essential benefits as required by the Patient Protection and Affordable Care
Act. Essential benefits include:
(A)
Ambulatory patient services-office visits, urgent care, outpatient diagnostic
procedures, outpatient surgery, and outpatient hospice;
(B) Emergency services-ambulance services and
emergency room services;
(C)
Hospitalization-inpatient hospital benefits, inpatient surgery, transplants,
and inpatient hospice;
(D)
Maternity and newborn care-maternity coverage and newborn screenings;
(E) Mental health and substance use disorder
services, including behavioral health treatment-inpatient and outpatient and
mental health/substance use disorder office visits;
(F) Prescription drugs;
(G) Rehabilitative and habilitative services
and devices-durable medical equipment; cardiac and pulmonary rehabilitation;
outpatient physical, speech, and occupational therapy; and home health
care;
(H) Laboratory services-lab
and X-ray;
(I) Preventive and
wellness services and chronic disease management; and
(J) Pediatric services, including oral and
vision care-routine vision exam, dental care/accidental injury, vaccinations,
preventive services, and newborn screenings.
(29) Excluded drug. A drug the pharmacy
benefit manager (PBM) does not pay for or cover unless an exception is approved
by the PBM.
(30) Excluded services.
Health care services that the member's health plan does not pay for or
cover.
(31)
Experimental/investigational/unproven. A treatment, procedure, device, or drug
that meets any of the criteria listed below and that the plan administrator
determines, in the exercise of its discretion, is considered
experimental/investigational/unproven and is not eligible for coverage under
the plan-
(A) Has not received the approval
of the U.S. Food and Drug Administration for marketing the drug or device at
the time it is furnished, if such approval is required by law;
(B) Is shown by reliable evidence that the
consensus of opinion among experts regarding the treatment, procedure, device,
or drug is that further studies or clinical trials are necessary to determine
its maximum tolerated dose, its toxicity, its safety, its efficacy, or its
efficiency as compared with the standard means of treatment or diagnosis;
or
(C) Reliable evidence includes
anything determined to be such by the plan administrator, in the exercise of
its discretion, and may include published reports and articles in the medical
and scientific literature generally considered to be authoritative by the
national medical professional community.
(32) Formulary. A list of U.S. Food and Drug
Administration approved drugs and supplies developed by the pharmacy benefit
manager (PBM) and covered by the plan administrator. The PBM categorizes each
formulary drug and formulary supply as preferred or non-preferred.
(33) Generic drug. The chemical equivalent of
a brand-name drug with an expired patent. The color or shape may be different,
but the active ingredients must be the same for both.
(34) Health savings account (HSA). A
tax-advantaged savings account that may be used to pay for current or future
qualified medical expenses. Enrollment in the plan's qualified High Deductible
Health Plan is required for participation in an HSA.
(35) High deductible health plan. A health
plan with a higher deductible than a traditional health plan that, when
combined with an Health Savings Account (HSA), provides a tax-advantaged way to
help save for future medical expenses.
(36) Illness. Any bodily sickness, disease,
or mental/nervous disorder. For purposes of this plan, pregnancy is considered
an illness.
(37) Incident. A
definite and separate occurrence of a condition.
(38) Injury. A condition that results
independently of an illness and all other causes and is a result of an external
force or accident.
(39) Lifetime
maximum. The amount payable by a medical plan during a covered member's life
for specific non-essential benefits.
(40) Long-term disability subscriber. A
subscriber eligible for long-term disability coverage through a public entity's
retirement system.
(41) MCHCPid. An
individual MCHCP subscriber identifier used for member verification and
validation.
(42) myMCHCP. A secure
MCHCP member website that allows members to review coverage selections, verify
covered dependents, make coverage changes, add/change email address, retrieve
and send secure messages, upload documents, and access health plan
websites.
(43) Medically necessary.
The fact that a provider has performed, prescribed, recommended, ordered, or
approved a treatment, procedure, service, or supply; or that it is the only
available treatment, procedure, service, or supply for a condition, does not,
in itself, determine medical necessity. Medically necessary treatments,
procedures, services, or supplies that the plan administrator or its designee
determines, in the exercise of its discretion are-
(A) Expected to be of clear clinical benefit
to the member;
(B) Clinically
appropriate, in terms of type, frequency, extent, site and duration, and
considered effective for a member's illness, injury, mental illness, substance
use disorder, disease, or its symptoms;
(C) In accordance with generally accepted
standards of medical practice that are based on credible scientific evidence
published in peer-reviewed medical literature generally recognized by the
relevant medical community;
(D) Not
primarily for member or provider convenience; and
(E) Not more costly than an alternative
service(s) or supply that is at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or treatment of member's
illness, injury, disease, or symptoms.
(44) Medicare-allowed amount. The fee
Medicare sets as reasonable for a covered medical service. This is the amount a
provider is paid by the member and Medicare for a service or supply. It may be
less than the actual amount charged by a health care provider.
(45) Member. Any person covered as either a
subscriber or a dependent in accordance with the terms and conditions of the
plan.
(46) Network. The providers
the health insurer or plan has contracted with to provide health care services
to members.
(47) Non-network. The
providers the health insurer or plan does not contract with to provide health
care services to members. Some providers may be a part of secondary provider
networks recognized by the vendor for non-network benefits.
(48) Out-of-pocket maximum. The most the
member will pay during a plan year before the plan begins to pay one hundred
percent (100%) of the allowed amount. This limit never includes the member's
premium, balance-billed charges, or health care services the plan does not
cover.
(49) Participant. Shall have
the same meaning as the term member defined herein (see member, section
(45)).
(50) Plan. The program of
health care benefits established by the board of trustees of the Missouri
Consolidated Health Care Plan as authorized by state law.
(51) Plan administrator. The board of
trustees of the Missouri Consolidated Health Care Plan, which is the sole
fiduciary of the plan. The board has all discretionary authority to interpret
its provisions and to control the operation and administration of the plan and
whose decisions are final and binding on all parties.
(52) Plan year. The period of January 1
through December 31.
(53) Preferred
provider organization (PPO). An arrangement with providers whereby discounted
rates are given to plan members. Benefits are paid at a higher level when
network providers are used.
(54)
Premium. The monthly amount that must be paid for health insurance.
(55) Primary care provider (PCP). An
internist, family/general practitioner, pediatrician, or physician assistant or
nurse practitioner in any of the practice areas listed in this
definition.
(56) Preauthorization.
A decision by the plan that a health care service, treatment plan, prescription
drug, or durable medical equipment is medically necessary. Sometimes called
prior authorization, prior approval, or precertification. The plan may require
preauthorization for certain services before the member receives them, except
in an emergency. Preauthorization is not a promise the plan will cover the
cost. The provider must contact the appropriate plan administrator to request
preauthorization.
(57) Provider. A
physician, hospital, medical agency, specialist, or other duly licensed health
care facility or practitioner certified or otherwise authorized to furnish
health care services pursuant to the law of the jurisdiction in which care or
treatment is received. A doctor/physician as defined in
22 CSR
10-3.010(21). Other providers
include, but are not limited to:
(A)
Audiologist (AUD or PhD);
(B)
Certified Addiction Counselor for Substance Abuse (CAC);
(C) Certified Nurse Midwife (CNM)-when acting
within the scope of his/her license in the state in which s/he practices and
performing a service which would be payable under this plan when performed by a
physician;
(D) Certified Social
Worker or Masters in Social Work (MSW);
(E) Chiropractor;
(F) Licensed Clinical Social Worker
(LCSW);
(G) Licensed Professional
Counselor (LPC);
(H) Licensed
Psychologist (LP);
(I) Nurse
Practitioner (NP);
(J) Physician
Assistant (PA);
(K) Occupational
Therapist;
(L) Physical
Therapist;
(M) Speech
Therapist;
(N) Registered Nurse
Anesthetist (CRNA);
(O) Registered
Nurse Practitioner (ARNP); or
(P)
Therapist with a PhD or Master's Degree in Psychology or Counseling.
(58) Prudent layperson. An
individual possessing an average knowledge of health and medicine.
(59) Public entity. A political subdivision
or governmental entity or instrumentality that has elected to join the plan and
has been accepted by the board.
(60) Qualified Medical Child Support Order
(QMCSO). A child support order from a court of competent jurisdiction or state
child care agency, which requires the plan to provide coverage for a dependent
child or member if the plan normally provides coverage for dependent
children.
(61) Retiree.
Notwithstanding any provision of law to the contrary, for the purposes of these
regulations, a "retiree" is defined as a former employee who, at the time of
retirement, is receiving an annuity benefit from an entity-sponsored retirement
system.
(62) Sound, natural teeth.
Teeth and/or tissue that is viable, functional, and free of disease. A sound,
natural tooth has no decay, fillings on no more than two (2) surfaces, no gum
disease associated with bone loss, no history of root canal therapy, is not a
dental implant, and functions normally in chewing and speech.
(63) Specialty care physician/specialist. A
physician who is not a primary care physician and provides medical services to
members concentrated in a specific medical area of expertise.
(64) Specialty medications. High-cost drugs,
as determined by the pharmacy benefit manager and/or third party administrator
which treat chronic or complex conditions such as hepatitis C, multiple
sclerosis, and rheumatoid arthritis.
(65) State. Missouri.
(66) Step therapy. Therapy designed to
encourage use of therapeutically equivalent, lower-cost alternatives before
using more expensive therapy. It is especially for people who take prescription
drugs regularly to treat ongoing medical conditions and is developed under the
guidance and direction of independent, licensed doctors, pharmacists, and other
medical experts.
(67) Subrogation.
The substitution of one (1) "party" for another. Subrogation entitles the
insurer to the rights and remedies that would otherwise belong to the insured
(the subscriber) for a loss covered by the insurance policy. Subrogation allows
the plan to stand in the place of the member and recover the money directly
from the other insurer.
(68)
Subscriber. The person who elects coverage under the plan.
(69) Survivor. A dependent of a deceased
vested active employee, terminated vested subscriber, vested long-term
disability subscriber, or retiree of a public entity with a retirement
system.
(70) Termination of
coverage. The termination of medical, dental, or vision coverage initiated by
the employer or required by MCHCP eligibility policies.
(71) Usual, customary, and reasonable. The
amount paid for a medical service in a geographic area based on what providers
in the area usually charge for the same or similar medical service.
(72) Vendor. The current applicable
third-party administrators of MCHCP benefits or other services.
(73) Vested subscriber. An active employee
eligible for coverage under the plan and eligible for future benefits through a
public entity's retirement system.
(74) Waiting/probationary periods. The length
of time the employer requires an employee to be employed before he or she is
eligible for health insurance coverage. Public entities may set different
waiting/probationary periods for different employee classifications (full-time
vs. part-time).
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.