Common Definitions Used by Lumenos Health Insurance of Georgia

Definitions included here will help you understand your Lumenos plan benefits.

Bridge

If you use your annual company allocation to your HRA and you need additional services from the Traditional Health Coverage, you will have to pay a specified out-of-pocket amount before the Traditional Health Coverage begins. This is called your Bridge.

Your Bridge is:

• $500 -single coverage
• $1,000 - family coverage

If you have been in the Lumenos plan for more than a Plan year, you may have money saved up in your HRA from previous Plan years. If so, you may have enough to cover your Bridge - and not pay anything out of your pocket before the Traditional Health Coverage begins.

Change in Status

An event that permits changing insurance coverage.

Claims Administrator

Organization contracted by Company who provides administrative services for specific Company benefit plans offered to Company employees and their dependents.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

A federal law that enables you or your enrolled dependents to continue medical and dental coverage in the event that you or they lose coverage as the result of certain qualifying events.

Covered Providers

Medical benefits extend to covered services provided by licensed providers as follows:

• Medical doctors
• Osteopaths
• Podiatrists
• Physical and occupational therapists
• Midwives
• Speech therapists
• Licensed clinical psychologists

Provided they practice:

• Within the scope of their license
• Within the scope of generally accepted medical practices
• Who are recognized by the state in which they practice
• Licensed clinical social workers and licensed marriage, family and/or child counselors are also covered.

They must either:

• Be licensed or certified by the appropriate governmental authority having jurisdiction over such licensure or certification in the jurisdiction where the provider renders service to a retiree or spouse, or
• Be a member or fellow of the American Psychological Association if there is no licensure or certification in the jurisdiction where that provider renders service to a retiree and their spouse.

Providers who are professionally registered in their state, but do not meet these criteria will not be covered.

Custodial Care

Care which consists of services and supplies used to assist an individual in the activities of daily living, whether or not the person is disabled. These services and supplies are considered custodial care, regardless of who prescribes, recommends or performs them. However, when room and board and skilled nursing services must be combined with other therapeutic methods to establish a program of medical treatment, they are not considered custodial if:

• they are provided in an institution covered by the Lumenos plan
• this care can be reasonably expected to substantially improve the patient's medical condition

Deductible

Your annual deductible is the combination of your annual allocation and your Bridge. You meet your deductible by spending your HRA on covered services and paying your Bridge either out of your pocket or with HRA savings. Once this occurs, Traditional Health Coverage begins.

Domiciliary Care

Care that is provided or taking place in the home.

Durable Medical Equipment (DME)

Coverage is provided for rental or, at the discretion of the Plan, purchase of durable medical equipment, which is prescribed by a professional provider and required for therapeutic use.

If purchased, charges for repair or Medically Necessary replacement of durable medical equipment will be considered a covered expense.

Covered items include, but are not limited to: crutches, commodes, hospital beds, nebulizers, monitoring equipment, wheelchairs.

Emergency Services

The Lumenos plan covers medical, surgical, hospital, and related health care services and testing including ambulance service, required for serious accidents, sudden illness, or any condition that, if not treated immediately, may result in serious long-term medical complications, loss of life, or permanent impairment to bodily functions.

Family Medical Leave Act (FMLA)

Provides unpaid leaves of absence with job protection for as long as 12 workweeks, for birth of a child, newborn care, adoption or foster care placement, or the serious health condition of an employee, or an employee's spouse, child, or parent.

Free-Standing Surgical Facility

An institution that meets all of the following requirements:

• Medical staff of physicians, nurses, and licensed anesthesiologists
• Maintains at least two operating rooms and one recovery room
• Has immediate access to diagnostic laboratory and X-ray facilities
• Has equipment for emergency care
• Has a blood supply
• Maintains medical records
• Has agreements with hospitals for immediate acceptance of patients who need hospital confinement on an inpatient basis
• Is licensed in accordance with the laws of the appropriate legally authorized agency

Full-Time Student

An eligible dependent child who regularly attends an accredited school on a full-time basis as defined by the school (usually 12 hours for undergraduate or nine hours for graduate work on a semester system) and who normally resides with you in a parent-child relationship except while away at school.