EOC - Erlanger Health System

You are required to pay directly to a
Provider for certain Covered Services. You
must pay such Copayments at the time You
receive those Services.
15. Cosmetic Surgery – Any treatment intended
to improve Your appearance. Our Medical
Policy establishes the criteria for what is
cosmetic, and what is Medically Necessary
and Appropriate.
16. Covered Dependent – A Subscriber’s
family member who: (1) meets the eligibility
requirements of this EOC; (2) has been
enrolled for Coverage; and (3) for whom the
Plan has received the applicable Payment for
Coverage.
17. Covered Family Members – A Subscriber
and his or her Covered Dependents.
18. Covered Services, Coverage or Covered –
Those Medically Necessary and Appropriate
services and supplies that are set forth in
Attachment A of this EOC, (which is
incorporated by reference). Covered
Services are subject to all the terms,
conditions, exclusions and limitations of the
Plan and this EOC.
19. Creditable Coverage – Credit for Your
individual or group health coverage prior to
Your Enrollment Date that may be applied to
reduce Your Pre-existing Condition Waiting
Period, if any, stated in this EOC. Creditable
Coverage also includes coverage under: (1)
a group health plan; (2) health insurance
coverage; (3) health maintenance
organization (HMO); (4) Medicare; (5)
Medicaid (including TennCare SM and
TennCare Select SM ); (6) COBRA
continuation and state continuation; (7) the
Federal Employee Health Benefit Plan; (8) a
public, government, military or Indian
Health Service health benefit program;
and/or (9) State Children’s Health Insurance
Program (S-CHIP).
Up to 18 months of Creditable Coverage may
be applied to reduce Your applicable Preexisting
Condition Waiting Period.
However, a period of coverage will not be
counted for purposes of reducing Your Preexisting
Condition Waiting Period if there is
a break in such coverage of 63 days or more
during which You were not Covered under
any Creditable Coverage.
20. Custodial Care – Any services or supplies
provided to assist an individual in the
activities of daily living as determined by the
Plan including but not limited to eating,
bathing, dressing or other self-care activities.
21. Deductible – The dollar amount, specified in
Attachment C, Schedule of Benefits, that
You must incur and pay for Covered
Services during a Calendar Year before the
Plan provides benefits for services. There
are 2 separate Deductible amounts – one for
Network Providers and one for Out-of-
Network Providers. Satisfying the
Deductible under the Network Provider
benefits does not satisfy the Deductible for
the Out-of-Network Provider benefits, and
vice versa; the two Deductibles are not
combined. Dollar amounts incurred during
the last 3 months of a Calendar Year that are
applied to the Deductible during that
Calendar Year will also apply to the
Deductible but not the Out-of-Pocket
Maximum for the next Calendar Year. The
Deductible will apply to the Individual Outof-Pocket
and Family Out-of-Pocket
Maximum(s).
Copayments and any balance of charges (the
difference between Billed Charges and the
Maximum Allowable Charge) are not
considered when determining if You have
satisfied a Deductible.
22. Emergency – A sudden and unexpected
medical condition that manifests itself by
symptoms of sufficient severity, including
severe pain, that a prudent layperson, who
possesses an average knowledge of health
and medicine could reasonably expect to
result in:
a. serious impairment of bodily functions;
or
b. serious dysfunction of any bodily organ
or part; or
c. placing a prudent layperson’s health in
serious jeopardy.
Examples of Emergency conditions include:
(1) severe chest pain; (2) uncontrollable
bleeding; or (3) unconsciousness.
23. Emergency Care Services – Those services
and supplies that are Medically Necessary
and Appropriate in the treatment of an
Emergency.
28 Erlanger Health System 2009