Act:  Act means the Texas Employees Group Benefits Act (Chapter 1551 of the Texas Insurance Code).

Acquired Brain Injury: A neurological insult to the brain, which is not hereditary, congenital, or degenerative. The injury to the brain has occurred after birth and results in a change in neuronal activity, which results in an impairment of physical functioning, sensory processing, cognition, or psychosocial behavior. Covered services include the
following:

Adverse Determination: The determination by Community First that the health care services furnished or proposed to be furnished to a Member are not Medically Necessary or not appropriate.

After Hours Care:  Health care services provided to a Member for an illness or an injury that occurs after normal provider office hours.

Appeal:  A request, orally or in writing, for reconsideration of a decision reached under the Community First formal Complaint and Appeals process.

Appeals Panel or Panel:  A Panel, composed of equal numbers of Community First Staff, Physicians or other providers, and Members, which advises Community First on the resolution of a dispute.

Associated Company:  Employers that are the Contract Holder's agencies or participating institutions of higher education and are reported in writing to Community First for inclusion under the Group Contract.

Autism Spectrum Disorder. A neurobiological disorder that includes Autism, Asperger's Syndrome, or Pervasive Developmental Disorder (Not otherwise specified).

Balance Billing: The practice of charging an enrollee that uses a provider network the balance of a non-network health care provider’s fee for services received by the enrollee that is not fully reimbursed by the health benefit plan.

Chemical Dependency:  The abuse of, or psychological or physical dependence on, or addiction to alcohol or a controlled substance.

Chemical Dependency Treatment Center:  A facility that provides a program for the treatment of Chemical Dependency pursuant to a written treatment plan approved and monitored by a Physician and meets one of these tests:

Complainant:  A Physician, provider, Member, or other person designated to act on behalf of a Member, who files a complaint.

Complaint:  Any dissatisfaction expressed by a Member or individual acting on behalf of a Member to Community First, orally or in writing, with any aspect of Community First's operation, including but not limited to, dissatisfaction with plan administration; Appeal of an Adverse Determination; the denial, reduction, or termination of a service; the way a service is provided; or disenrollment decisions.  A Complaint is not a misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the Member.

Contract Year:  The twelve (12) month period, commencing with the effective date of the Certificate of Group Health Care Coverage, during which coverage is in effect.

Contributory Coverage, Non-contributory Coverage:  Contributory Coverage is coverage for which the Contract Holder requires Employee contributions. Non-contributory Coverage is coverage for which the Contract Holder does not require Employee contributions.

Controlled Substance:  A toxic inhalant or substance designated as a controlled substance in Chapter 481, Health and Safety Code.

Copayment:  An amount required to be paid by a Member, in addition to premium, in connection with certain Covered Services and Supplies. A Copayment may be a set dollar amount or a percentage of the negotiated cost of the service.

Counseling Services:  Supportive services provided under a Hospice Care Program by members of the Hospice Team in counseling sessions with the Family Unit. These services are to assist the Family Unit in dealing with the death of a Terminally Ill Person.

Court-Ordered Dependent:  Dependent unmarried children whose eligibility for coverage is determined by a court-ordered child support or medical support document.

Covered Services and Supplies:  The services and supplies covered under the Group Health Care Coverage.

Covered Classes:  All Eligible Employees who live, work or reside in the Service Area.  All Eligible Retirees who live or reside in the Service Area.  All eligibility is determined by The Employees Retirement System of Texas.

Crisis Stabilization Unit:  A 24-hour residential program that is usually short term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute psychiatric crisis of moderate to severe proportions.

Custodial Care:  Services which are not intended primarily to treat a specific Injury or Illness (including mental illness or Substance Abuse/chemical Dependency).  These services may include:

Dependent: Your dependent is someone who is:

Diabetic Equipment:  Blood glucose monitors, including noninvasive glucose monitors and glucose monitors designed to by used by blind individuals; insulin pumps and associated appurtenances; insulin devices; and podiatric appliances for the prevention of complications associated with diabetes.

Diabetes Self Mangement Training:  Instruction enabling a member to understand the care and management of diabetes, including nutritional counseling and proper use of diabetes equipment and supplies.

Diabetic Supplies:  Test strips for blood glucose monitors; visual reading and urine test strips; lancets and lancet devices; insulin and insulin analogs;

Durable Medical Equipment:  Equipment prescribed by the attending physician that meets each of the following:

• is medically necessary
• is not primarily or customarily used for non-medical purposes
• is designed to withstand repeated use; and
• serves a specific therapeutic purpose in the treatment of any injury or illness

Eligible Employee:  An Employee as defined under Section 1551.101 of the Texas Insurance Code.

Eligible Retiree:  An eligible Employee or annuitant who has retired as defined in the Act and is eligible for health coverage on the day he or she becomes an annuitant.

Emergency Care:  Health care services provided in a Hospital emergency facility or comparable facility to evaluate and stabilize medical conditions, including a behavioral health condition, of a recent onset and severity including, but not limited to, severe pain that would lead a prudent lay person, possessing an average knowledge of medicine and health to believe that his or her condition, Illness, or Injury is of such a nature that failure to get immediate medical care could result in:

Employee Coverage:  Coverage that applies to an Eligible Employee or Eligible Retiree.

Employer:  Collectively, all Associated Companies.

Employer's Health Benefits Plan:  The health plan(s) of the Employer providing health care expense coverage, other than the Group Health Care Coverage.  This does not include Medicare Part A or Part B.

ERS:  Employees Retirement System of Texas, which is also referred to as the Group Contract Holder in this Certificate of Group Health Care Coverage.

Experimental or Investigational:  Medical, surgical, diagnostic, psychiatric, Substance Abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time Community First makes a determination regarding coverage in a particular case, meet one of the following criteria:

Eye Exam:  Examinations to determine the need for corrective lenses.

Facility Based Physician: A radiologist, anesthesiologist, pathologist, emergency department physician or neonatologist to whom a facility has granted clinical privileges and provides services to patients of the facility.

Family Unit:  Collectively, You and Your Dependents who are Members.

Group:  The Employees Retirement System of Texas.

Group Health Care Coverage:  The services that are included in this Certificate of Group Health Care Coverage.

Health Care Facility:  A hospital, emergency clinic, outpatient clinic, birthing center,  ambulatory surgical center or other facility providing health care services.

Health Status Related Factor:  Any of the following in relation to a Member: health status; medical condition (including both physical and mental Illnesses); claims experience; receipt of health care; medical history; genetic information; evidence of insurability (including conditions arising out of acts of domestic violence, including family violence; or disability).

Heritable Disease:  An inherited disease that may result in mental or psychological retardation or death.

Home Health Care:  A program, prescribed in writing by a Participating Physician and administered by a Home Health Care Agency, that provides for the care and treatment of a person’s Illness or Injury in the person’s home.

Home Health Care Agency:  An organization that has been licensed or certified as a home health agency in the state of Texas, or is a home health agency as defined by Medicare.

Hospice:  An organization that provides short periods of stay for a Terminally-Ill Person in a home-like setting or facility for either direct care or respite.  This organization may be either freestanding or affiliated with a Hospital.  It must operate as an integral part of a Hospice Care Program.  If such an organization is required by a state to be licensed, certified, or registered, it must also meet that requirement to be considered a Hospice.

Hospital:  An acute care institution licensed by the State of Texas as a Hospital, which is primarily engaged, on an inpatient basis, in providing medical care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, under supervision of a staff of Physicians and with 24-hour a day nursing and Physician service; however, it does not include a nursing home or any institution or part thereof which is used principally as a custodial facility.

Hospital Inpatient Stay:  A Hospital stay for which a room and board charge is made by the Hospital.

Illness:  Any disorder of the body or mind of a Member, but not an Injury.

Implant:  A surgically implanted artificial device that functions to correct a significant functional disorder (e.g. hip joints, heart pacemakers, penile implants, and implanted electrical stimulators).

Independent Review Organization:  An organization that is certified by the Texas Department of Insurance to perform independent review of Adverse Determinations, as provided under Chapter 4202 of the Texas Insurance Code.

Individual Conversion Plan:  An individual health care coverage contract.

Individual Treatment Plan:  A plan with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program.

Injury:  Trauma or damage to some part of the body of a Member.

Life-threatening Condition:  A disease or other medical condition with respect to which death is probable unless the course of the disease is interrupted.  A Member or the Member's provider of record shall determine the existence of a Life-Threatening Condition on the basis that a prudent lay person possessing an average knowledge of medicine and health would believe that his or her disease or condition is life-threatening.

Medicaid:  Title XIX (Grants to States for Medical Assistance Programs) of the United States Social Security Act, as amended from time to time.

Medical Director:  A Physician who is retained by Community First to coordinate and supervise the delivery of health care services for Members through Participating Physicians and Participating Providers.

Medical Emergency:  A recent onset of a medical condition requiring Emergency Care.

Medical Necessity or Medically Necessary:  Health care services which are determined by Community First to be medically appropriate, and prevent Illness or deterioration of medical conditions, or provide early screening, interventions and/or treatments for conditions that cause suffering or pain, physical deformity, limitations in function, or endanger life.  Such services are consistent with the diagnosis; provided at appropriate facilities and at the appropriate levels of care; consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies; and are no more intrusive or restrictive than necessary.

Medicare:  Title XVIII (Health Insurance for the Aged and Disabled) of the United States Social Security Act, as amended from time to time.

Member:  An Eligible Employee or Eligible Retiree who is covered under the Group Health Care Coverage described in this Certificate or a Dependent with respect to whom an Eligible Employee or Eligible Retiree is covered for Dependent Coverage described in this Certificate.

Non-Participating Provider:  A Physician, Hospital, or other provider of medical services or supplies that is not a Participating Provider.

Observation Period:  A short-term hospital stay lasting less than 24 hours. 

Ombudsman Program:  Independent medical review program that provides case review for new and emerging technologies/therapies including, but not limited to, issues pertaining to the experimental/investigational status of an intervention, clinical trials and research studies, and other clinical information, for the purpose of assisting Community First in determining Medical Necessity and appropriateness.

Out-of-Area:  Outside the approved Service Area of Community First.

Out-of-Pocket:  The Copayment amounts that are the Member's responsibility each Contract Year. The specific Out-of-Pocket maximum Copayment that applies under this Certificate of Group Health Care Coverage is listed in the attached Schedule of Co-payments.  Community First will assist the Member in determining when he or she has satisfied the Out-of-Pocket maximum Copayment, so it is important to keep all receipts for Copayments actually paid.  Copayments that are paid toward certain Covered Services are not applicable to a Member's Out-of-Pocket as set forth in the attached Schedule of Co-payments.

Outpatient Surgery:  Services provided by a hospital or facility for any procedure rendered that allows for operating room charges to be generated but is not intended to be an inpatient stay.

Participating Physician:  A Physician who is either a Primary Care Physician (PCP) or a Specialty Care Physician and who has contracted with Community First to provide services to Members.

Participating Provider:  A Physician, Hospital, or other provider of medical services or supplies that is licensed or certified in the state in which it is located and which has contracted with Community First to arrange for or provide services and supplies for medical care and treatment of Members.

Phenylketonuria:  An inherited condition that may cause severe mental retardation if not treated.

Physician:  Any individual licensed to practice medicine by the Texas State Board of Medical Examiners.

Practitioner:  A Physician, Hospital or other person or entity licensed to provide medical services under applicable law.

Pre-authorization:  The verbal or written approval by Community First, or its designee, obtained prior to admitting a Member to a Facility or providing certain other Covered Services to a Member when approval is required for such services.  Pre-authorization is not the same as a Referral, and a Member who has been referred to another Physician or Provider by the Member’s PCP may still need to obtain Pre-authorization prior to certain services being rendered by the Referral Physician.

Prescription Medication and/or Supplies:  This means only:

1. a medicinal substance that, by law, can be dispensed only by prescription; or
   
2. other items that require a prescription order to be dispensed.

Primary Care Physician (PCP):  A Participating Physician who is chosen by or for a Member to have the responsibility for:

1. providing initial and primary medical care to the Member;
   
2. maintain the continuity of the Member’s medical care and initiate referrals to Participating or Non-Participating Physicians and/or other Providers.

Prosthesis:  An external or removable artificial device that replaces a limb or body part (e.g. prosthetic arms, legs, and eyes).   See Schedule of Copayments.

Psychiatric Day Treatment:  A mental health facility that provides treatment for individuals suffering from acute, mental, and nervous disorders in a structured psychiatric program using Individual Treatment Plans and that is clinically supervised by a Physician of medicine who is certified in psychiatry by the American Board of Psychiatry and Neurology.

Reasonable Cash Value:  The cash value assigned to a service or supply provided, ordered or authorized by a Participating Provider, as determined by Community First.  Community First will base its determination on the range of usual and customary charges generally made by providers in the area for a like service or supply. Community First will also take into account any unusual circumstances and any medical complications that require additional time or special skill, experience, and/or facilities in connection with a particular service.

Referral:  A recommendation by a Member’s PCP or other treating provider for a patient to be evaluated or treated by another Physician or Provider.

Related Hospital Inpatient Stays:  Separate hospital inpatient stays by a person that occur as a result of the same Illness or Injury.  Hospital Inpatient Stays will be considered unrelated if:

1. for a period of thirty (30) days or more between the stays, the Member fully recovered or no longer presented symptoms from the Illness or Injury that caused the prior stay; or
   
2. the stays result from wholly unrelated causes.

Residential Treatment Center for Children and Adolescents:  A child-care institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is licensed or operated by the appropriate state agency or board.

Retiree:  An Eligible Employee or annuitant who has retired as defined in the Act.

Serious Mental Illness:  The following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM): (A) bipolar disorders (hypomanic, manic, depressive, and mixed; (B) depression in childhood and adolescence; (C) major depressive disorders (single episode or recurrent); (D) obsessive-compulsive disorders; (E) paranoid and other psychotic disorders; (F) schizo-affective disorders (bipolar or depressive; and  (G) schizophrenia. 

Service Area:  The geographic area within which Covered Services and Supplies for medical care and treatment are available and provided, by Participating Providers, under the Group Contract, to Members who live, reside or work within that geographic area.  The Service Area applicable to Members is shown as Attachment A to Your Certificate of Group Health Care Coverage.

Skilled Nursing Facility:  An institution that meets all of these tests:

1. Meets all Texas licensing requirements and is legally operated.
   
2. It mainly provides short-term nursing and rehabilitation services for persons recovering from Illness or Injury.  The services are provided for a fee from its patients, and include both room and board and 24-hour-a-day skilled nursing service.
   
3. It provides the services under the full-time supervision of a Physician or registered nurse (R.N.); or, if full-time supervision by a Physician is not provided, it has the services of a Physician available under a contractual agreement.
   
4. Does not include an institution or part of one that is used mainly as a place for custodial care, rest or for the aged.

Specialty Care Physician:  A Participating Physician who provides certain specialty medical care to Members upon referral by a PCP or other Participating Physician.  Under special circumstances a Specialty Care Physician may function as a PCP if approved by the Medical Director.  Members who are referred to Specialty Care Physicians may still need to obtain Pre-authorization to receive certain services from the Specialty Care Physician and should work with his/her PCP and Specialty Care Physician in order to obtain Pre-authorization when required. 

Summer Enrollment Period:  A period of time each year set by the Contract Holder, during which an Eligible Employee, may:

1. Elect coverage under the Employer’s Health Benefits Plan or the Group Health Care Coverage; or
   
2. Elect to change from the Group Health Care Coverage to coverage under the Employer’s Health Benefit Plan; or
   
3. Elect to change from coverage under the Employer’s Health Benefits Plan to the Group Health Care Coverage.

Supplies:  Medical supplies are non-reusable, disposable, and are not useful in the absence of illness or injury.  Common household items are not considered medical supplies.

Surgical Procedure:  Typically considered an invasive procedure, including, but not limited to: cutting, suturing, treatment of burns, correction of fracture, reduction of dislocation, manipulation of joint under general anesthesia, electrocauterization, tapping (paracentesis), application of plaster casts, administration of pneumothorax, endoscopy, or injection of sclerosing solution.

Telehealth Service:  A health service, other than a telemedicine medical service, delivered by a Provider acting within the scope of his or her license, who does not perform a telemedicine medical service that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including:compressed digital interactive video, audio, or data transmission;clinical data transmission using computer imaging by way of still-image capture and store and forward; and other technology that facilitates access to health care services or medical specialty expertise.

Telemedicine Medical Service: A health care service initiated by a Physician, or another Provider authorized by law to act under Physician delegation and supervision, for purposes of patient assessment by a Provider, diagnosis or consultation by a Physician, treatment, or the transfer of medical data, that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including:compressed digital interactive video, audio, or data transmission;clinical data transmission using computer imaging by way of still-image capture and store and forward; and other technology that facilitates access to health care services or medical specialty expertise.

Terminally ill Person:  A person whose life expectancy is six (6) months or less, as certified by a Participating Physician.

Toxic Inhalant:  A volatile chemical under Chapter 484, Health and Safety Code, or abusable glue or aerosol paint under Section 485.001, Health and Safety Code.

Urgent Care:  Health care services provided in a situation other than an emergency which are typically provided in settings such as a  Physician or provider’s office or Urgent Care center, as a result of an acute Injury or Illness, including an urgent behavioral health situation, that is severe or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, Illness or Injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition of his or her health.

Utilization Review:  A system for prospective or concurrent review of the Medical Necessity and appropriateness of health care services being provided or proposed to be provided to a Member. Utilization Review does not include elective requests for clarification of coverage.

Utilization Review Agent:  Community First, or an entity licensed by the Texas Department of Insurance as a Utilization Review Agent, that conducts Utilization Review for Community First.

You and Your:  An Employee or a Member.