BIOLOGICALLY BASED MENTAL ILLNESS means a mental, nervous or emotional isorder causedby a biological disorder of the brain which results in a clinically significant, psychological syndrome orpattern that substantially limits the functioning of the person with the illness. Under Timothy’s Law, only the following disorders satisfy the definition of “biologically based mental illness”: schizophrenia/psychotic disorders; major depression; bipolar disorder; delusional disorders; panic disorder; obsessive compulsive disorders; anorexia and bulimia. 

CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCES – as the definition applies to the mandates of Timothy’s Law, means those persons under the age of 18 years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders and one or more of the following: serious suicidal symptoms or other life-threatening self-destructive behaviors; significant psychotic symptoms (hallucinations, delusion, bizarre behaviors); behavior caused by emotional disturbances that place the child at risk of causing personal injury or significant property damage; or behavior caused by emotional disturbances that place the child at substantial risk of removal from the household.

CONFINEMENT – means admission to a Facility as an inpatient due to injury or illness. Successive periods of Confinement for the illness or injury will be considered as one continuous period of Confinement unless separated by a period of 90 days or more during which the Covered Person has not been confined to a Facility. 

COSMETIC SURGERY – means surgery to improve an individual’s appearance, which is not considered Reconstructive Surgery. Cosmetic surgery usually includes procedures like breast enlargement or reduction, liposuction, rhinoplasty, ear pinning and facial lifts, or other surgery not considered Medically Necessary. 

COVERED CHARGE – means the amount of Covered Expenses, after any applicable deductible or copayment that will be paid by the Plan not exceeding the lesser of the Usual and Customary charges, or the Professional Provider’s actual charges, or any discounted rates negotiated with the Professional Provider by the Plan or its representative. (The Covered Person is responsible for any expenses that are not considered Covered Charges.) 

COVERED EXPENSES – means those Covered Charges incurred for Covered Services, treatments, or supplies which are reimbursable under the Plan. The fact that a provider may prescribe, order, recommend or approve a service or supply does not necessarily make it a Covered Expense. Even though it may not specifically be identified as an exclusion, an expense may be non-reimbursable under this Plan. 

COVERED PERSON – means an Employee, Retiree, or Dependent who is covered for benefits under this Plan. 

COVERED SERVICES – means those Medically Necessary services described in this Plan, as well as those services that may not be Medically Necessary but are specifically covered such as mammograms, cervical cytology screening and well child care. 

CUSTODIAL CARE – means any service or supply that is given principally for personal hygiene or assistance in daily activities and can, according to generally accepted medical standards be performed by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over medication that could normally be self administered. The Plan may review medical and progress periodically to determine whether care is or has become Custodial Care. Custodial Care is not covered by the Plan. 

DEPENDENT means an Employee’s (or Retiree’s) spouse or a child who meets the eligibility requirements for coverage in Section 3. 

EMERGENCY CONDITION/EMERGENCY – means a sudden onset of a medical or behavioral condition, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent person, possessing an average knowledge of medicine and health, could reasonably expect to result (in the absence of immediate medical attention) in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; or (b) serious impairment of the person’s bodily functions; or (c) serious dysfunction of any bodily organ or part of the person; or (d) serious disfigurement of such person. 

EMPLOYEE – means, at a minimum, a person who is directly employed in a regular business of an Employer member of this Plan, who receives W-2 compensation from the Employer, and who meets the Employer’s requirements for eligibility for health coverage under the Plan. Eligibility requirements may vary among participating Employers. See Section 3 for additional eligibility information. 

EMPLOYER – means one of the school or BOCES districts participating in the Plan. 

EXPERIMENTAL and/or INVESTIGATIONAL – means those treatments, procedures, drugs, biological products, or medical devices (“Services”), which are not generally covered by this Plan. See Section 11 for additional information and an explanation of Experimental and Investigational exclusions. 

FACILITY – means a Hospital; ambulatory surgery facility; birthing center; dialysis center; rehabilitation facility; Skilled Nursing Facility; hospice; home health agency or home health care services agency certified or licensed under Article 36 of the New York Public Health Law; an institutional provider of mental health or chemical dependence and abuse treatment, operating under Article 31 of the Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services, or any other provider certified under Article 28 of the New York Public Health Law (or other comparable state law, if applicable). 

HOSPITAL – means any short-term acute general hospital facility that

  1.  is primarily engaged in providing, by or under the continuous supervision of physicians, to inpatients, those diagnostic and therapeutic services for diagnosis, treatment and care of injured or sick patients;
  2. has organized departments of medicine and major surgery;
  3. has a requirement that every patient must be under the care of a physician or dentist;
  4. provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.);
  5. if located in New York State, has in effect a hospitalization review plan applicable to all patients which meets at least the standards set forth in section 1861(k) of United States Public Law 89-97, (42 USCA 1395x[k]);
  6. is duly licensed by the agency responsible for licensing such hospitals; and
  7. is not, other than incidentally, a place of rest; a place primarily for the treatment of tuberculosis; a place for the aged; a place primarily dedicated to the treatment of chemical dependence or alcohol abuse; a free-standing ambulatory surgery center; a Skilled Nursing  Facility; a place for convalescent, custodial, educational, or rehabilitative care. 

MAINTENANCE CARE – means continuing care where there is no evidence of improvement of the condition being treated, and the schedule of visits for care is not consistent with an acute pattern of treatment. Unless otherwise stated, the Plan does not pay for Maintenance Care.

MEDICALLY NECESSARY – means those treatments, procedures, drugs or supplies (Services) required to diagnose or treat a Covered Person’s medical condition, as determined in accordance with accepted medical practices and standards. The fact that a provider has furnished, prescribed, ordered, recommended or approved the Service does not make it Medically Necessary or mean that the Plan will provide coverage for it. The Plan will determine whether care was Medically Necessary. We will base our decision in part on a review of your medical records. We will also evaluate medical opinions we receive. This could include the medical opinion of a professional society, peer review committee, or other groups of physicians.

In determining if a Service is Medically Necessary, we will also consider the following:

  • Reports in peer-reviewed medical literature;
  • Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data;
  • Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment;
  • The opinion of the attending Professional Providers (which have credence but do not overrule contrary opinions); and
  •  Any other relevant information brought to our attention.

Services will be deemed Medically Necessary only when:

  • They are appropriate and consistent with the diagnosis and treatment of your medical condition;
  • They are required for the direct care and treatment or management of that condition;
  • If not provided, your condition would be adversely affected;
  • They are provided in accordance with community standards of good medical practice;
  • They are not primarily for the convenience of you, your family, the Professional Provider oranother provider;
  • They are the most appropriate services rendered in the most efficient and economical way and at the most economical level of care which can safely be provided to you; and
  • When you are an inpatient, your medical symptoms or conditions are such that diagnosis and treatment cannot safely be provided to you in any other setting (e.g., outpatient, physician’s office or at home).

Service or care must be approved standard treatment. Except as otherwise required by law, or as provided in the Plan, no service or care rendered to you will be considered Medically Necessary unless we determine that the service or care is consistent with diagnosis and treatment of your medical condition; generally accepted by the medical profession as approved standard treatment for your medical condition; and considered therapeutic or rehabilitative. 

PRE-HOSPITAL EMERGENCY MEDICAL TREATMENT means the prompt evaluation and treatment of an emergency medical condition, and/or non-air-borne transportation of the patient to a hospital; provided however, where the patient utilizes non-air-borne emergency transportation pursuant to this subsection, reimbursement will be based on whether a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (ii) serious impairment to such person’s bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; or (iv) serious disfigurement of such person.

PROFESSIONAL PROVIDER – means a certified and licensed physician, osteopath, dentist, optometrist, chiropractor, registered psychologist, psychiatrist, social worker, clinical social worker, podiatrist, physical therapist, occupational therapist, licensed midwife, speech-language pathologist, audiologist or any other licensed health care provider that the New York State Insurance Law requires to be recognized who charges and bills patients for his or her services. To qualify for reimbursement under this plan, a clinical social worker involved in the diagnosis and treatment of mental, nervous or emotional disorders must be licensed pursuant to Article 154 of the New York State Education law, and have at least six years post-degree experience in psychotherapy under the terms outlined in Section 4303 of the New York State Insurance Law. Any Professional Provider’s services must be rendered within the lawful scope of his practice in order to be covered under this Plan.

RECONSTRUCTIVE SURGERY – means surgery limited to improving or restoring bodily function or correcting a deformity that has resulted in a functional impairment caused by disease or trauma. It may also mean surgery to correct a congenital or developmental abnormality of a covered Dependent child. If a Covered Person is receiving benefits in connection with a mastectomy, reconstruction of the breast on which the mastectomy has been performed, as well as surgery and reconstruction of the other breast to produce a symmetrical appearance, will be considered Reconstructive Surgery and will be a Covered Expense.

RETIREE – means a former Employee of a member school district who qualifies for a retirement benefit from a New York State Retirement System offered by their Employer. 

SKILLED CARE – means a service which we determine is furnished by or under the direct supervision of licensed medical personnel to assure the safety of the patient and achieve the medically desired results as defined by Medicare guidelines. A service is not considered Skilled Care merely because it is performed or supervised by licensed medical personnel. However, it is a service that cannot be safely and adequately self-administered or performed by the average non-medical person without the supervision of such personnel.  

SKILLED NURSING FACILITY – means a Facility accredited as a Skilled Nursing Facility by the Joint Commission on Accreditation of Healthcare Organizations or qualified as a Skilled Nursing Facility under Medicare. We will provide coverage in a Skilled Nursing Facility only if care is determined by us to be Skilled Care (see above). 

SPOUSE – means a person to whom you are legally married under the laws of the State or country in which the marriage took place. Neither a “common law” marriage partner, a “domestic partner,” nor a partner in a “civil union” will be considered a “spouse” for purposes of dependent eligibility under the Plan. Proof of marriage acceptable to the Plan will be required for enrollment of a spouse. 

TIMOTHY’S LAW – means the New York State law that mandates the provision of certain mental health benefits for persons enrolled in this Plan.  

TOTALLY DISABLED – means, when referring to an Employee, that the Employee is unable to perform the substantial and material duties of his occupation or employment or the duties of any other employment for which he is reasonably qualified by training and experience and at comparable wages. During unemployment, a Covered Person will be considered Totally Disabled if he is unable, because of illness or injury, to perform the duties of any employment for which he is reasonably qualified by training and experience. A Dependent Spouse will be considered Totally Disabled if he is completely unable, as a result of injury or illness, to engage in the usual, customary, substantial and material activities engaged in prior to the onset of disability. A Dependent child will be considered Totally Disabled if he is completely unable, as a result of injury or illness, to engage in normal activities of children of similar age. 

USUAL AND CUSTOMARY CHARGES (U&C) – means the normal and necessary charges made for similar services by 90% of the providers of medical service with like experience, education and training, who are practicing in the same geographic area. Determination whether or not a charge is U&C shall be made by the Claims Administrator based on nationally obtained and recognized survey data or on data received from a nationally recognized insurer or consulting service which, as a major portion of its business, is involved in the adjudication of health care claims.