§ 135-45.1. General definitions. - North Carolina Statutes

§ 135‑45.1.  Generaldefinitions.

As used in this Article unlessthe context clearly requires otherwise, the following definitions apply:

(1)        Allowed amount. – Thecharge that the Plan or its claims proessors determines is reasonable forcovered services provided to a Plan member. This amount may be established inaccordance with an agreement between the provider and the Plan or its claimsprocessor. In the case of providers that have not entered into an agreementwith the Plan or its claims processor, the allowed amount will be the lesser ofthe provider's actual charge or a reasonable charge established by the Plan orits claims processor using a methodology that is applied to comparableproviders for similar services under a similar health benefit plan.

(2)        Benefit period. – Theperiod of time during which charges for covered services provided to a Planmember must be incurred in order to be eligible for payment by the Plan.

(3)        Chemical dependency.– The pathological use or abuse of alcohol or other drugs in a manner or to adegree that produces an impairment in personal, social, or occupationalfunctioning and which may, but need not, include a pattern of tolerance andwithdrawal.

(4)        Claims Processor. – Oneor more administrators, third‑party administrators, or other partiescontracting with the Plan to administer Plan benefits.

(5)        Clinical trials. – Patientresearch studies designed to evaluate new treatments, including prescriptiondrugs. Coverage for clinical trials shall be as provided in G.S. 135‑45.8.

(6)        Comprehensive healthbenefit plan. – Health care coverage that consists of inpatient and outpatienthospital and medical benefits, as well as other outpatient medical services,prescription drugs, medical supplies, and equipment that are generally availablein the health insurance market.

(7)        Covered service;benefit; allowable expense. – Any medically necessary, reasonable, andcustomary items of service, including prescription drugs, and medical suppliesincluded in the Plan.

(8)        Deductible. – Thedollar amount that must be incurred for certain covered services in a benefitperiod before benefits are payable by the Plan.

Thedeductible applies separately to each covered individual in each fiscal year,subject to an aggregate maximum per employee and child, employee and spouse, oremployee and family coverage contract in any fiscal year.

Iftwo or more family members are injured in the same accident, only onedeductible is required for charges related to that accident during the benefitperiod.

(9)        Dependent. – Aneligible Plan member other than the subscriber.

(10)      Dependent child. – Anatural, legally adopted, or foster child or children of the employee and orspouse, unmarried, up to the first of the month following his or her 19thbirthday, whether or not the child is living with the employee, as long as theemployee is legally responsible for such child's maintenance and support.Dependent child also includes a stepchild of the member who is married to thestepchild's natural parent. To be eligible, the stepchild must have his or herprimary residence with the member. Dependent child shall also include any childunder age 19 who has reached his or her 18th birthday, provided the employeewas legally responsible for such child's maintenance and support on his or her18th birthday. Dependent children of firefighters, rescue squad workers, andmembers of the National Guard are subject to the same terms and conditions asare other dependent children covered by this subdivision. Eligibility ofdependent children is subject to the requirements of G.S. 135‑45.2(d).The Plan may require documentation from the member confirming a child'seligibility to be covered as the member's dependent.

(11)      Employee or Stateemployee. – Any permanent full‑time or permanent part‑time regularemployee (designated as half‑time or more) of an employing unit.

(12)      Employing Unit. – ANorth Carolina School System; Community College; State Department, Agency, orInstitution; Administrative Office of the Courts; or Association or ExaminingBoard whose employees are eligible for membership in a State‑SupportedRetirement System. An employing unit also shall mean a charter school inaccordance with Part 6A of Chapter 115C of the General Statutes whose board ofdirectors elects to become a participating employer in the Plan under G.S. 135‑45.5.Bona fide fire departments, rescue or emergency medical service squads, andNational Guard units are deemed to be employing units for the purpose ofproviding benefits under this Article.

(13)      Experimental/Investigational.– Experimental/Investigational Medical Procedures. – The use of a service,supply, drug, or device not recognized as standard medical care for thecondition, disease, illness, or injury being treated as determined by theExecutive Administrator and Board of Trustees upon the advice of the ClaimsProcessor.

(14)      Firefighter. – Eligiblefirefighters as defined by G.S. 58‑86‑25 who belong to a bona fidefire department as defined by G.S. 58‑86‑25 and who are noteligible for any type of comprehensive group health insurance or othercomprehensive group health benefit coverage and who have been without any formof group health insurance or other comprehensive group health benefit coveragefor at least six months. Firefighter shall also include members of the NorthCarolina Firemen and Rescue Squad Workers' Pension Fund who are in receipt of amonthly pension, who are not eligible for any type of comprehensive grouphealth insurance or other comprehensive group health benefit coverage, and whohave been without any form of group health insurance or other comprehensivegroup health benefit coverage for at least six months. Comprehensive grouphealth insurance and other benefit coverage consists of inpatient andoutpatient hospital and medical benefits, as well as other outpatient medicalservices, prescription drugs, medical supplies, and equipment that aregenerally available in the health insurance market. For purposes of thissubdivision, comprehensive group health insurance and other benefit coverageincludes Medicare benefits, CHAMPUS benefits, and other Uniformed Servicesbenefits. North Carolina fire departments or their respective governing bodiesshall certify the eligibility of their firefighters to the Plan for theirparticipation in its benefits prior to enrollment.

(15)      Health BenefitsRepresentative. – The employee designated by the employing unit to administerthe Plan for the unit and its employees. The HBR is responsible for enrollingnew employees, reporting changes, explaining benefits, reconciling groupstatements, and remitting group fees. The State Retirement System is the HealthBenefits Representative for retired State employees.

(16)      Medical necessity ormedically necessary. – Covered services or supplies that are:

a.         Provided for thediagnosis, treatment, cure, or relief of a health condition, illness, injury,or disease; and, except for clinical trials covered under the Plan, not forexperimental, investigational, or cosmetic purposes.

b.         Necessary for andappropriate to the diagnosis, treatment, cure, or relief of a health condition,illness, injury, disease, or its symptoms.

c.         Within generallyaccepted standards of medical care in the community.

d.         Not solely for theconvenience of the Plan member, the Plan member's family, or the provider.

Formedically necessary services, the Plan or its representative may compare thecost‑effectiveness of alternative services or supplies when determiningwhich of the services or supplies will be covered and in what setting medicallynecessary services are eligible for coverage.

(17)      National Guardmembers. – Members of the North Carolina Army and Air National Guard who arenot eligible for any type of comprehensive group health insurance or othercomprehensive group health benefit coverage and who have been without any formof group health insurance or other comprehensive group health benefit coveragefor at least six months. Members of the North Carolina Army and Air NationalGuard include those who are actively serving in the National Guard as well asformer members of the National Guard who have completed 20 or more years ofservice in the National Guard but have not attained the minimum age to beginreceipt of a uniformed service military retirement benefit. Comprehensive grouphealth insurance and other benefit coverage consists of inpatient andoutpatient hospital and medical benefits, as well as other outpatient medicalservices, prescription drugs, medical supplies, and equipment that aregenerally available in the health insurance market. Comprehensive group healthinsurance and other benefit coverage includes Medicare benefits, CivilianHealth and Medical Program of the Uniformed Services (CHAMPUS) benefits, andother Uniformed Services benefits. North Carolina National Guard units shallcertify the eligibility of their members to the Plan for their participation inits benefits prior to enrollment.

(18)      Optional alternativecomprehensive benefit plans. – Comprehensive benefit plans administered by thePlan that differ in coverage, deductibles, coinsurance from the Standard Planproviding for 80/20 coinsurance, and that are alternative choices for coverageat the option of the Plan member.

(19)      Plan or State HealthPlan. – The North Carolina State Health Plan for Teachers and State Employees.Unless otherwise expressly provided, "Plan" includes allcomprehensive health benefit plans offered under the Plan.

(20)      Plan member. – Asubscriber or dependent who is eligible and currently enrolled in the Plan andfor whom a premium is paid.

(21)      Plan year. – Theperiod beginning July 1 and ending on June 30 of the succeeding calendar year.

(22)      Predecessor plan. – TheHospital and Medical Benefits for the Teachers' and State Employees' RetirementSystem of the State of North Carolina and the North Carolina Teachers' andState Employees' Comprehensive Major Medical Plan.

(23)      Rescue squad workers.– Eligible rescue squad workers as defined by the provisions of G.S. 58‑86‑30who belong to a rescue or emergency medical services squad as defined by thesame statute and who are not eligible for any type of comprehensive grouphealth insurance or other comprehensive group health benefit coverage and whohave been without any form of group health insurance or other comprehensivegroup health benefit coverage for at least six months. Rescue squad workersshall also include members of the North Carolina Firemen and Rescue SquadWorkers' Pension Fund who are in receipt of a monthly pension, who are noteligible for any type of comprehensive group health insurance or othercomprehensive group health benefit coverage, and who have been without any formof group health insurance or other comprehensive group health benefit coveragefor at least six months. Comprehensive group health insurance and other benefitcoverage consists of inpatient and outpatient hospital and medical benefits, aswell as other outpatient medical services, prescription drugs, medicalsupplies, and equipment that are generally available in the health insurancemarket. For purposes of this subdivision, comprehensive group health insuranceand other benefit coverage includes Medicare benefits, CHAMPUS benefits, andother Uniformed Services benefits. North Carolina rescue or emergency medicalservices squads or their respective governing bodies shall certify theeligibility of their rescue squad workers to the Plan for their participationin its benefits prior to enrollment.

(24)      Retired employee(retiree). – Retired teachers, State employees, and members of the GeneralAssembly who are receiving monthly retirement benefits from any retirementsystem supported in whole or in part by contributions of the State of NorthCarolina, so long as the retiree is enrolled.

(25)      Subscriber. – A Planmember who is not a dependent.

(26)      Surviving spouse. – Thespouse of a deceased Plan member who is eligible for Plan enrollment.  (2008‑168, s. 3(e);2009‑16, s. 3(a); 2009‑281, s. 1.)