AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

COBRA
Continuation coverage as required by the Consolidated Omnibus Reconciliation Act of 1985
COINSURANCE
A Covered Individual pays a percentage of his or her expenses after his or her Deductible is met. The
portion that a Covered Individual pays is called Coinsurance. The Plan pays the remaining percentage.
COMPANION
This is the person whose presence as a Companion or caregiver is necessary to enable an NME patient who
receives services in connection with an NME procedure or treatment on an Inpatient or out of patient basis; or
who travels to and from the facility where treatment is given.
CONVALESCENT FACILITY
This is an institution that is licensed to provide, and does provide, the following on an Inpatient basis for
persons convalescing from disease or Injury: professional nursing care by a R.N., or by a L.P.N directed by a
full time R.N.; and physical restoration services to help patients to meet a goal of self-care in daily living
activities. It provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N. and is
supervised full-time by a Physician or R.N. This institution keeps a complete medical record on each patient,
has a utilization review plan and makes charges. It is not mainly a place for rest, for the aged, for drugs
addicts, for alcoholics, for metal retardates, for custodial or educational care, or for care of Mental Disorders.
COPAYMENT (OR COPAY)
A Copayment is a cost-sharing arrangement in which a Covered Individual pays a fixed amount for a
specific service. For example, when a Covered Individual has a Physician’s office visit, the Covered
Individual will pay a flat dollar fee for the visit. The Plan pays the remaining expenses.
COVERED EXPENSE
A Covered Expense is the reasonable fee for a Covered Service. Some Covered Expenses are subject to
certain limitations.
COVERED INDIVIDUAL
An eligible Associate or eligible Dependent who is enrolled in the Plan.
COVERED SERVICES
Services, treatments or supplies identified as payable under the Plan. Covered Services must be
Medically Necessary to be payable, unless otherwise specified.
CUSTODIAL CARE
This means services and supplies furnished to a person mainly to help him or her in the activities of daily life.
This includes room and board and other institutional care. The person does not have to be disabled. Such
services and supplies are Custodial Care without regard to by whom they are prescribed or recommended
and by whom or by which they are performed.
DEDUCTIBLE
A Deductible is the amount a Covered Individual pays each Plan Year before the Plan starts to pay its
portion of the Covered Individual’s expenses. The Plan includes one Deductible for Covered Expenses.
There’s no deductible required for prescription drugs.
The deductible is satisfied on a calendar year basis with expenses from January through December. Any
expense applied toward the deductible during the last three months of the calendar year may be applied
towards the deductible for the following year.
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