The following terms have the meaning set forth below, unless the defined meaning is plainly inapplicable.
Child, with respect to an Employee,means the Employee's, or the Employee's Spouse's, natural child, stepchild, legally adopted child, foster child, or other child for whom the Employee or the Spouse has been appointed legal guardian or is required to provide dependent coverage pursuant to a QMCSO under Section 5.3; provided, however, that any such individual shall be so treated only through the month in which the individual attains age 26.
Collective Bargaining Agreement means any collective bargaining agreement entered into by Local 6 and SFECA that provides for contributions to the Plan's trust, as it may be amended from time to time. (See Appendix A for a list of the Collective Bargaining Agreements in effect as of the Effective Date.)
Contribution Agreement means an Employer's agreement to contribute to the Plan that is made with either (i) Local 6, under a Collective Bargaining Agreement (including through SFECA) or letter of assent thereto (for example, the Inside Wire Collective Bargaining Agreement), (ii) the Board, under a subscription agreement or substantially similar written agreement, or (iii) the Reciprocal Agreement. (See Appendix A for a list of the Contribution Agreements in effect as of the Effective Date.)
Covered Charge means a charge described in Section 8.8.
Covered Employment means service as an Employee, any Military Service described in Section 6.8, and any Qualified Trustee Service; provided, however, that any service as a responsible management employee (RME) and responsible management official (RMO) shall be excluded.
Custodial Care means treatment, services or confinement that could be rendered safely and reasonably by a person not medically skilled, and which are designed mainly to help the patient with activities of daily life, including personal care, homemaking services, moving the patient, acting as companion or sitter and supervising medication that can ordinarily be self-administered.
Domestic Partner means a Participant's spousal equivalent under the laws of a state, county, city or other municipality, and for whom an official certification of registration of domestic partnership has been submitted to the Plan Office. In order to effectuate enrollment of a Domestic Partner, the Plan Office must receive (i) proof of Domestic Partner status in the form of an official certification of registration of domestic partnership and (ii) either (a) an "affidavit of dependency" for tax purposes or (b) advance remittance of at least six months of taxes that the Plan Office determines are due on any additional imputed federal taxable income to the Participant, including the Employer's portion of such taxes. The Plan shall treat the effective date of a Participant's domestic partnership as if it were the date of marriage. (See, for example the Special Enrollment provisions of Section 6.4, which also applies to Domestic Partners.) The term "divorce" or "dissolution" in this Plan is deemed to include the legal termination of a domestic partnership.
ERISA means the Employee Retirement Income Security Act of 1974, as amended.
Experimental or Not Generally Accepted means, subject to the exceptions described below, and regardless of any claimed therapeutic value, experimental or investigational, limited to research by the FDA, the American Medical Association (Diagnostic and Therapeutic Technology Assessment) or the Office of Medical Application of Research of the National Institute of Health Office of Technology Association, or is not generally accepted by specialists in that particular field of medicine, as determined by the Plan's medical review consultant and/or an independent medical reviewer. If a treatment has not been addressed by one of the organizations listed in the preceding sentence, the Plan may determine if a treatment is Experimental or Not Generally Accepted based on the advice of its medical review department and/or an independent medical reviewer or other medical experts. For this purpose, "Generally Accepted" means treatment or service that (i) has been accepted as the standard of practice according to the prevailing opinion among experts as shown by (or in) articles published in authoritative, peer-reviewed medical and scientific literature, (ii) is in general use in the medical community and (iii) is not under continued scientific testing or research as a therapy for the particular injury or sickness which is the subject of the claim.
Exception 1: Certain FDA Approved Drugs Prescribed for Unapproved Purposes. Coverage is provided for an FDA-approved drug that is used to treat a life threatening condition for which the FDA has not approved the drug's use, if the drug has been recognized for treatment of that condition by the American Medical Association Drug Evaluations, the American Hospital Formulary Service Drug Information or the United States Pharmacopeia Dispensing Information, Volume I, "Drug Information for the Health Care Professional." "Life-threatening," for this purpose, means either (or both) diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted, and diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival.
Exception 2: Certain Suspected Physical Causes of Autistic Symptoms. Coverage is provided for alternative treatment of a condition suspected of playing a role in the expression of symptoms of autism, limited to $3,000 per calendar year. This treatment is considered experimental, and not an essential health benefit within the meaning of the Affordable Care Act of 2010 ("ACA"), and therefore can be subject to an annual benefit maximum. The alternative treatments currently include:
- vitamin supplementation therapy;
- oral secretin therapy;
- hyperbaric oxygen therapy;
- cranio-sacral therapy;
- fibroblast growth factor therapy;
- live cell and stem cell therapy;
- anti-fungal therapy;
- antibiotic therapy; and
- naltexone therapy.
Hour Bank means the system of accounting, as described in Section 3.1, for a Participant's monthly hours of Covered Employment and corresponding Employer contributions received for those work hours for purposes of determining eligibility for Plan coverage.
Injury means physical harm sustained to the body as the direct result of an accident, affected solely through external means, and all related symptoms and recurrent conditions resulting from the same accident.
Medically Necessary means that the treatment must be, and Medical Necessity refers to a treatment that is, ordered by a Physician or Other Accredited Provider to diagnose or treat an Injury or Illness, and be:
Other Accredited Provider means a Physician's assistant, nurse practitioner, midwife or nurse midwife, who provides medical care within the scope of a license or certificate.
Pension Plan means the Northern California Electrical Workers Pension Plan.
Physician means a duly licensed Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) authorized to perform medical or surgical services within the lawful scope of his or her practice, and any other health care provider having substantially equivalent status under state law.
Plan Office means the administrative office of the Plan, which is currently managed by EISB.
Preventive Care means items or services required to be covered without cost-sharing (copayment or coinsurance charges) when delivered by an in-network provider. (See Section 8.8 for examples.) A comprehensive list can be found at: www.HealthCare.gov/center/regulations/prevention.html and additional information regarding the U.S. Preventive Services Task Force recommended services receiving grades A or B is located at www.uspreventiveservicestaskforce.org.
Qualified Trustee Service means those hours of Covered Employment (not to exceed seven per day) under the Employee's typical work schedule that were not performed by the hourly Employee due to service after May 31, 2012, as a Trustee. Such hours shall be treated under this definition as if they were performed.
Reasonable and Customary means falling within the common range of fees billed by a majority of health care providers for a covered procedure in a given geographic region, or which is justified based on the complexity or the severity of treatment for a specific case, as determined from time to time by the Board. For this purpose, "region" means a county or greater area that is necessary to obtain a representative cross-section of the usual charges made. The Plan applies a widely-used claims data base at the 90th percentile to determine Reasonable and Customary (that is, the charge may not exceed the amounts normally charged by 90% of the Physicians in the data base in a particular geographical area).
Reciprocal Agreement means the Electrical Industry Health and Welfare Reciprocal Agreement, effective as of 1996, as it may be amended from time to time by vote of the participating plans throughout the United States. (Check with the Plan Office for any recent changes to the Reciprocal Agreement.)
Retiree means an IBEW member in good standing who formerly, but no longer, performs services in the electrical industry.
Trust Agreement means the trust agreement establishing the trust that is maintained under this Plan, as it may be amended from time to time.
Trustee means any member of the Board.