Georgia Health Insurance Definitions

Accidental Injury
Bodily Injury sustained by a Participant as the result of an unforeseen event and which is the direct cause (independent of disease, bodily infirmity or any other cause) for care which the Participant receives. Such care must occur while this Plan is in force. It does not include injuries for which benefits are provided under any Workers' Compensation, Employer's liability or similar law.

Affiliation Period
A period used by the Claims Administrator in lieu of a pre-existing condition exclusion clause, beginning on the enrollment date, which must expire before coverage becomes effective. A Participant is not eligible for health care benefits during this period.

After-Hours Office Visit
Care rendered as a result of a condition that has an onset after the Primary Care Physician's business hours.

Applicant
The corporation, partnership, sole proprietorship, other organization or group which applied for this Plan.

Application for Enrollment
The original and any subsequent forms completed and signed by the Subscriber seeking coverage. Such Application may take the form of an electronic submission.

Brand Name Drugs
A drug item which is under patent by its original innovator or marketer. The patent protects the drug from competition from other drug companies. There are two types of Brand Name Drugs:

• Single Source Brand: those drugs that are produced by only one manufacturer and do not have a generic equivalent available.
• Multi-Source Brand: those drugs that are produced by multiple pharmaceutical manufacturers and do have generic equivalent available on the market.

Chemical Dependency Treatment Facility
An institution established to care for and treat chemical dependency, on either an Inpatient or outpatient basis, under a prescribed treatment program. The institution must have diagnostic and therapeutic facilities for care and treatment provided by or under the supervision of a licensed Physician. The institution must be licensed, registered or approved by the appropriate authority of the State of Georgia or must be accredited by the Joint Commission on Accreditation of Hospitals.

Benefit Period
Twelve months, January 1 - December 31. It does not begin before a Participant's Effective Date. It does not continue after a Participant's coverage ends.

Calendar Year
A period of twelve months commencing on the Effective Date (January 1) and ending at 12:00 midnight on the last day of the year (December 31).

Claims Administrator
The company the Plan Sponsor chose to administer its health benefits. Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. was chosen to administer this Plan.

Coinsurance
If a Participant's coverage is limited to a certain percentage, for example 80%, then the remaining 20% for which the Participant is responsible is the Coinsurance amount. The Coinsurance may be capped by the Out-of-Pocket Limit. Compare to Copayment.

Complications of Pregnancy
Complications of pregnancy result from conditions requiring Hospital confinement when the pregnancy is not terminated. The diagnoses of the complications are distinct from pregnancy but, are adversely affected or caused by pregnancy.

Such conditions include acute nephritis, nephrosis, cardiac decompensation, missed or threatened abortion, preeclampsia, intrauterine fetal growth retardation and similar medical and surgical conditions of comparable severity. An ectopic pregnancy which is terminated is also considered a Complication of Pregnancy. Complications of Pregnancy shall not include false labor, caesarean section, occasional spotting, Physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum and similar conditions associated with the management of a difficult pregnancy which are not diagnosed distinctly as Complications of Pregnancy.

Congenital Anomaly
A condition or conditions that are present at birth regardless of causation. Such conditions may be hereditary or due to some influence during gestation.

Coordination of Benefits
A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claim payment delays by establishing an order in which plans pay their claims and providing an authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision, it does not have to pay its benefits first.

Copayment
A cost-sharing arrangement in which a Participant pays a specified charge for a Covered Service, such as the Copayment indicated in the Summary of Benefits for an office visit. The Participant is usually responsible for payment of the Copayment at the time the health care is rendered. Typical Copayments are fixed or variable flat amounts for Physician office visits, Prescription Drugs or Hospital services. Copayments are distinguished from Coinsurance as flat dollar amounts rather than percentages of the charges for services rendered. Copayments may be collected by the provider of service or the Claims Administrator.

Cosmetic Surgery
Any non-medically necessary surgery or procedure, the primary purpose of which is to improve or change the appearance of any portion of the body, but which does not restore bodily function, correct a disease state, physical appearance or disfigurement caused by an accident, birth defect, or correct or naturally improve a physiological function. Cosmetic surgery includes but is not limited to rhinoplasty, lipectomy, surgery for sagging or extra skin, any augmentation or reduction procedures (e.g., mammoplasty, liposuction, keloids, rhinoplasty and associated surgery) or treatment relating to the consequences or as a result of Cosmetic Surgery.

Covered Dependent
Any Dependent in an Employee's family who meets all the requirements of the Eligibility section of this SPD Booklet, has enrolled in the BlueChoice Healthcare Plan, and is subject to Premium requirements set forth in this Plan.

Covered Services
Medically Necessary health care services and supplies that are (a) defined as Covered Services in the Participant's Plan, (b) not excluded under such Plan, (c) not Experimental or Investigational and (d) provided in accordance with such Plan.

Creditable Coverage
Coverage under another health benefit plan is medical expense coverage with no greater than a 63 day gap in coverage under any of the following: (a) Medicare or Medicaid; (b) an Employer-based accident and sickness insurance or health benefit arrangement; (c) an individual accident and sickness insurance policy; (d) a Spouse's benefits or coverage under Medicare or Medicaid or an Employer-based health insurance benefit arrangement; (e) a conversion policy; or (f) similar coverage as defined in OCGA 33-30-15.

Custodial Care
Any type of care, including room and board, that (a) does not require the skills of professional or technical personnel; (b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-Hospital Skilled Nursing Facility care; (c) is a level such that the Participant has reached the maximum level of physical or mental function and is not likely to make further significant improvement. Custodial Care includes, but is not limited to, any type of care the primary purpose of which is to attend to the Participant's activities of daily living which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples of Custodial Care include, but are not limited to, assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of non-infected, post-operative or chronic conditions, preparation of special diets, supervision of medication that can be self-administered by the Participant, general maintenance care of colostomy or ileostomy, routine services to maintain other service which, in the sole determination of BCBSHP can be safely and adequately self-administered or performed by the average non-medical person without the direct supervision of trained medical and paramedical personnel, regardless of who actually provides the service, residential care and adult day care, protective and supportive care including educational services, rest care and convalescent care.

Deductible
The portion of the bill you must pay before your medical expenses become Eligible Charges. The Deductible is applied on a Calendar Year basis.

Dependent
The Spouse, and all unmarried children until attaining age 19. Children include natural children, legally adopted children and stepchildren. Also included are your children (or children of your Spouse) for whom you have legal responsibility resulting from a valid court decree. Foster children whom you expect to raise to adulthood and who live with you in a regular parent-child relationship are considered children. However, for the purposes of this Plan, a parent-child relationship does not exist between you and a foster child if one or both of the child's natural parents also live with you. In addition, the Plan Administrator does not consider as a Dependent, welfare placement of a foster child under a welfare placement, as long as the welfare agency provides all or part of the child's support.

Children who are students (after high school) in an institution of higher learning at least five months each year (or were prevented from being enrolled due to illness or Injury) remain covered until attaining age 26. Mentally retarded or physically handicapped children remain covered no matter what age. You must give evidence of your child's incapacity within 31 days of attainment of age 19. This proof of incapacity may be required annually by the Claims Administrator. Such children are not eligible under this Plan if they are already 19 or older at the time coverage is effective.

Detoxification
The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient to a minimum.

Developmental Delay
The statistical variation, as defined by standardized, validated developmental screening tests, such as the Denver Developmental Screening Test, in reaching age appropriate verbal/growth/motor skill developmental milestones when there is no apparent medical or psychological problem. It alone does not constitute an illness or an Injury. Services rendered should be to treat or promote recovery of the specific functional deficits identified.

Direct Access
A Participant has the right to receive services from specified providers without a Primary Care Physician Referral. This is called Direct Access. Such providers include a gynecologist for obstetrical or gynecological-related conditions, a dermatologist, an optometrist/ophthalmologist for medical conditions only.

Durable Medical Equipment
Equipment, as determined by the Claims Administrator, which is (a) made to withstand prolonged use; (b) made for and mainly used in the treatment of a disease or Injury; (c) suited for use while not confined as an Inpatient at a Hospital; (d) not normally or use to persons who do not have a disease or Injury; (e) not for exercise or training.