AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

A service or supply is not Medically Necessary if made, prescribed, or delivered mainly for the
convenience of the patient or Provider. The fact that a Physician has prescribed a procedure or treatment
does not mean that it is Medically Necessary.
MENTAL DISORDER
This is a disease commonly understood to be a Mental Disorder whether or not it has a physiological or
organic basis and for which treatment is generally provided by or under the direction of a mental health
professional such as a psychiatrist, a psychologist or a psychiatric social worker. A Mental Disorder includes;
but is not limited to: alcoholism and drug abuse, schizophrenia, bipolar disorder, Pervasive Mental
Development Disorder (Autism), panic disorder, major depressive disorder, psychotic depression, obsessive
compulsive disorder. For the purpose of benefits under this Plan, metal disorder will include alcoholism and
drug abuse only if any separate benefit for a particular type of treatment does not apply to alcoholism and
drug abuse.
MORBID OBESITY
This means a Body Mass Index that is; greater than 40 kilograms per meter squared; or equal to or greater
than 35 kilograms per meter squared with a comorbid medical condition, including: hypertension; a
cardiopulmonary condition; sleep apnea; or diabetes.
NEGOTIATED CHARGE
This is the maximum charge a Preferred Care has agreed to make as to any service or supply for the
purpose of the benefits under this Plan.
NETWORK
A Network is a group of Physicians, Hospitals, pharmacies, and other health care Providers that have
agreed to provide health care services subject to negotiated fee arrangements.
ORTHODONTIC TREATMENT
This is any medical service or supply; or dental service or supply; furnished to prevent or to diagnose or to
correct a misalignment of the teeth, bite, jaws or jaw joint relationship; whether or not for the purpose of
relieving pain. It does not include the installation of a space maintainer or a surgical procedure to correct
malocclusion.
OUT-OF-POCKET MAXIMUM
The Out-of-Pocket Maximum is the most a Covered Individual will pay for Covered Expenses during a
Plan Year.
OUTPATIENT
Services are considered Outpatient if they are provided while a Covered Individual receives treatment
either outside a Hospital or other health care Provider or in a Hospital or other health care Provider but
the Covered Individual does not incur room and board charges.
PHYSICIAN
A Physician is a doctor of medicine (M.D.) or osteopathy (D.O.) legally qualified and licensed to practice
medicine or osteopathic medicine and/or perform Surgery at the time and place a service is rendered or
performed. The term Physician may also include categories of limited practice professionals who are
legally qualified and licensed as specified elsewhere in this document.
PLAN
The Plan is the health care coverage under the Medical Program component of Plan 504 of the Trinity
Health Welfare Benefit Plan that is provided through the Aetna Life Insurance Company (“Aetna”)
Preferred Provider Organization (“PPO”) Health Care Plan.
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