Performing your job on a regular, full-time basis as defined in the group application. Each day of a regular paid vacation and any regular non-working holiday shall be deemed as active status if you were in an active status on your last regular working day.
Acute illness or injury
Illness or injuries that are of rapid onset with an expected, short-term duration.
The form completed by a potential member requesting coverage from MercyCare Health Plans.
An injury resulting from an accident, independent of all other causes.
Certificate refers to a member’s certificate of coverage, which summarizes the terms, conditions and limitations of your health care coverage.
The form you must complete if you wish to change the information contained on your application form. Change forms are available from MercyCare’s customer service department.
Change of status form
Complete this if you wish to add or delete dependents or change the information contained on your enrollment form. Change of status forms are provided by MercyCare.
Chronic illness or condition
Illnesses or conditions that are of long duration and show little change or a slow progression of symptoms or condition. Treatment is supportive in nature and not curative.
A demand for payment due in exchange for health care services rendered.
The member’s payment portion, expressed as a percentage of the fee, required for certain covered services provided under the policy.
Confinement or confined
The period of time between admission as an inpatient or outpatient to a hospital, alcohol and other drug abuse (AODA) residential treatment center, skilled nursing facility or licensed ambulatory surgical center, and discharge from; or the time spent receiving emergency care for sickness or bodily injury in a hospital. Hospital swing-bed confinement is considered the same as confinement in a skilled nursing facility. If you are transferred to another facility for continued treatment of the same or related condition, it is considered one confinement.
A condition that exists at birth but is not hereditary.
The 12-month period beginning on the effective date of the Group’s policy.
The member’s portion, expressed as a fixed dollar amount, required for certain covered services provided under this policy.
A service or supply specified in the certificate of coverage and the schedule of benefits for which benefits will be provided.
Provision of room and board, nursing care, personal care or other care designed to assist you in the activities of daily living. Custodial care occurs when, in the opinion of a participating provider, you have reached the maximum level of recovery. If you are institutionalized, custodial care also includes room and board, nursing care or other care when, in the opinion of a participating provider, medical or surgical treatment cannot reasonably be expected to enable you to live outside an institution. Custodial care also includes rest cures, respite care and home care provided by family members.
A predetermined amount of money an individual member may have to pay before benefits are payable by MercyCare. The single deductible applies to each member each contract year, and the family deductible amount is the most that the employee and his or her dependents must pay each contract year.
1. a covered employee’s lawful spouse; or
2. a covered employee’s married and natural blood-related child, child placed for adoption with the covered employee, stepchild or legal ward who is both:
a. under the age of 26, and
b. not eligible for coverage under a group health benefit plan offered by the child’s employer.
3. a covered employee’s unmarried and natural blood-related child, child placed for adoption with the covered employee, stepchild or legal ward who is both:
a. under the age of 27, and
b. not eligible for coverage under a group health benefit plan offered by the child’s employer for which the amount of the child’s premium is no greater than the premium amount for his or her coverage as a dependent under this plan.
4. a covered employee’s unmarried, natural child, adopted child, child placed for adoption with the covered employee, stepchild or legal ward who is both:
a. not eligible for coverage under a group health benefit plan offered by the child’s employer for which the amount of the child’s premium is no greater than the premium amount for his or her coverage as a dependent under this plan, and
b. a full-time student as defined in this Certificate, if the child was called to federal active duty in the National Guard or in a reserve component of the U.S. armed forces while the child was under 27 years of age when attending, on a full-time basis, an institution of higher learning; To qualify under this paragraph b, the child must apply to an institution of higher education as a full-time student within 12 months from the date the child fulfilled his or her active duty obligation. In addition, when a child is called to active duty more than once within a 4-year period of time, we will use the adult child’s age when first called to active duty for determining eligibility under this paragraph; or
5. an unmarried, natural child of a dependent child (as described above) until the dependent child is 18 years of age.
In the case of a child placed for adoption with the covered employee, “placed for adoption” is defined in section 632.896, Wisconsin Statutes.
If the employee is the father of a child born outside of marriage, the child does not qualify as a dependent unless there is a court order declaring paternity or acknowledgment of paternity is filed with the Wisconsin Department of Health Services or the equivalent agency if the birth was outside of the state of Wisconsin. Upon qualification, coverage for the child will be effective according to the section about eligibility and effective date of coverage.
A spouse and stepchild cease to be a dependent on the date in which a divorce decree is granted, and may be terminated subject to Continuation and Conversion privileges.
A child, who is a full-time student, if otherwise eligible, ceases to be a dependent when the child ceases to be full-time student. Full-time student means the child is in regular full-time attendance at an accredited secondary school; accredited vocational, technical or adult education school, or an accredited college or university which provides a schedule of courses or classes and whose principal activity is the provision of an education. Proof of attendance is required upon request from MercyCare. Full-time student status is to be defined by the institution in which the student is enrolled. Full-time student status includes any intervening vacation period if the child continues to be a full-time student. Full-time student status also includes a medically necessary leave of absence during which the child ceases to be a full-time student. MercyCare may require the child to submit documentation and certification of the medical necessity of the leave of absence from the child’s attending physician. Full-time student status due to a medically necessary leave of absence ends when any of the following occurs:
a. The child advises MercyCare that he or she does not intend to return to school full time.
b. The child becomes employed full time.
c. The child obtains other health care coverage.
d. The child marries and is eligible for coverage under his or her spouse’s health care coverage.
e. Coverage of the employee is discontinued or not renewed.
f. One year has elapsed since the child ceased to be a full-time student due to the medically necessary leave of absence, and the child has not returned to school full time.
A covered dependent child who attains the limiting age while insured under the policy shall remain eligible for benefits if he or she is incapable of self-sustaining employment because of mental retardation or physical handicap which existed before the dependent attained the limiting age. The dependent must continue to be chiefly dependent on the employee for support and maintenance. Written proof of incapacity and dependency must be provided to MercyCare in a form satisfactory to MercyCare within 31 days after the dependent’s attainment of the limiting age. MercyCare, at its sole discretion, may require the dependent to be examined from time to time by a participating provider for the purpose of determining the existence of the incapacity prior to granting continued coverage. Such examinations may occur at reasonable intervals during the first two years after continuation under this section is granted and annually thereafter. The employee must notify MercyCare immediately of a cessation of incapacity or dependency.
A child who is considered a dependent ceases to be a dependent on the date the child becomes insured as an eligible employee.
Intellectual disability or a related condition such as cerebral palsy, epilepsy or autism, but excluding mental illness and infirmities of aging, which is: a) manifested before the individual reaches age 22, b) likely to continue indefinitely, and c) resulting in substantial functional limitations in three or more of the following areas of major life activity: 1. self-care, 2. understanding and use of language, 3. learning, 4. mobility, 5. self-direction, 6. capacity for independent living. 7. economic self-sufficiency.
Dual-choice enrollment period
A period each year when the Group and MercyCare agree to allow members who are currently enrolled in any of the Group’s other benefit plans to enroll for coverage under MercyCare’s plan.
Elective hospital admission
An admission to a hospital for a treatment or surgical procedure not requiring immediate attention and therefore planned for the patient’s convenience.
A medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that leads a prudent layperson with an average knowledge of health and medicine reasonably to conclude that, without immediate attention, will likely result in death or serious injury to your body.
An individual whose employment or other status, except for family dependency, is the basis for eligibility for enrollment under the policy.
The form completed by a potential member requesting coverage from MercyCare and listing all dependents to be covered on the effective date of coverage.
Experimental or investigative
The use of any service, treatment, procedure, facility, equipment, drug, devices or supply for a member’s bodily injury or sickness that a) requires the approval by the appropriate federal or other governmental agency that has not been granted at the time it is used; or b) is not yet recognized as acceptable medical practice to treat that bodily injury or sickness, as determined by MercyCare for a member’s bodily injury or sickness. The criteria that MercyCare’s quality health management department uses for determining whether a service, treatment, procedure, facility, equipment, drug, device or supply is considered to be experimental or investigative include whether: a) it is commonly performed or used on a widespread geographic basis, b) it is generally accepted to treat that bodily injury or sickness by the medical profession in the United States, c) its failure rate or side effects are unacceptable, d) the member has exhausted more conventional methods of treating the bodily injury or sickness, e) it is recognized for reimbursement by Medicare, Medicaid and other insurers and self-funded plans.
Free-standing surgical facility
Any accredited public or private establishment that has permanent facilities equipped and operated primarily for performing surgery with continuous physician services and registered professional nursing services whenever a patient is in the facility. It does not provide services or accommodations for patients to stay overnight.
Any dissatisfaction that you have with MercyCare or with a participating or non-participating provider that has been expressed in writing by you or on your behalf.
The employer, union, trust or association to which a policy is issued and through which eligible employees and dependents become entitled to coverage.
The form completed by a Group requesting coverage from MercyCare for individuals in their Group.
An institution that: a) is licensed and run according to Wisconsin laws, or other applicable jurisdictions, that apply to hospitals, b) maintains at its location all the facilities needed to provide diagnosis of, and medical and surgical care for, bodily injury or sickness, c) provides this care for fees, d) provides such care on an inpatient basis, and e) provides continuous, 24-hour nursing services by registered graduate nurses; or a) qualifies as a psychiatric or tuberculosis hospital, b) is a Medicare provider, and c) is accredited as a hospital by the Joint Commission on Accreditation of Healthcare Organizations. Hospital does not mean an institution that is chiefly: a) a place for treatment of chemical dependency, b) a nursing home or c) a federal hospital.
The card that MercyCare issues to a member indicating eligibility to receive covered services from participating providers.
The inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy.
An inability or defect in the ability to learn. It occurs in children and is manifested by difficulty in learning basic skills such as writing, reading and mathematics.
Level 1 provider
A provider listed in the most recently published provider directory.
Level 2 provider
A provider not listed in our most recently published provider directory, but is included in the Beech Street Provider Network.
Level 3 provider
A provider not listed in our most recently published provider directory and not listed in the Beech Street Provider Network.
Maintenance or long-term therapy
Ongoing therapy delivered after the acute phase of a sickness has passed. It begins when a patient’s recovery has reached a plateau or non-measurable improvement if his/her condition has slowed or ceased entirely and only minimal rehabilitative gains can be demonstrated. The determination of what constitutes maintenance or long-term therapy is made by MercyCare after reviewing an individual’s case history or treatment plan submitted by a provider.
Maximum family deductible
The total deductible applied to all members in one family in a contract year. The maximum is stated on the schedule of benefits.
A program instituted pursuant to Title XIX (Grants to States for Medical Assistance Programs) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or hereafter amended.
Medically necessary means a service, treatment, procedure, equipment, drug, device, or supply provided by a hospital, physician, or other provider of health care that is required to identify or treat a member’s bodily injury or sickness and which is determined by MercyCare to be a) consistent with the symptom(s) or diagnosis and treatment of the member’s bodily injury or sickness, b) appropriate under the standards of acceptable medical practice to treat that bodily injury or sickness, c) not solely for the convenience of the member, physician, hospital or other provider of health care, d) the most appropriate service, treatment, procedure, equipment, drug, device or supply which can be safely provided to the member, e) the most economical manner of accomplishing the desired end result.
Title XVIII (Health Insurance Act for the Aged) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or hereafter amended.
Health care services or expenses covered by Medicare. Medicare must recognize them as medically necessary and reasonable. The services or expenses may or may not be fully reimbursed by Medicare.
The employee and his/her dependents who have been enrolled and are entitled to benefits under the policy.
MercyCare or MCHP
MercyCare represents MercyCare Health Plans (MCHP), a MercyCare Insurance Company.
Any provider in the same network as your primary care physician (PCP). You can visit any network provider without a referral. In order to determined if a provider is one of your network providers, please review your our online provider directory.
A Level 3 provider who has not signed a contract with the plan to provide services at a discounted fee for service.
Non-elective hospital admission
An admission though a hospital emergency room for a treatment or surgical procedure requiring immediate attention and therefore unable to be preplanned for the patient’s convenience. See definition of emergency.
Any discrete and identifiable technology; regimen or modality regularly and customarily used to diagnose or treat bodily injury or sickness for which there is conclusive, generally accepted evidence that such technology, regimen or modality is safe, efficient and effective as determined by MercyCare.
A provider not listed in the most current provider directory.
Open enrollment period
A period (each year) when the Group and MercyCare agree to allow potential members to enroll for coverage, regardless of whether they are currently enrolled in any of the Group’s other medical benefit plans.
The portion of covered charges for which the member is responsible because of applicable coinsurance and/or deductible provisions or non-covered charges.
Any provider listed in the most current provider directory.
Physician change form
The form available through MercyCare’s customer service department that enables a members to change their primary care physician (PCP) selection. Refer to the provider selection in obtaining services section of your certificate of coverage for more information.
The group health plan offered by MercyCare as described in your certificate of coverage.
The agreement between the Group and MercyCare setting forth the contractual rights and obligations of the parties and wherein MercyCare agrees to provide a health benefit program to eligible employees and their dependents of the Group. The Group Contract, the Certificate of Coverage, the Schedule of Benefits, and any addenda or endorsements thereto, and the applications of the Group and the employee, constitute the entire policy.
Policy holder means the Group.
A disease or physical or mental condition that manifested itself through medical diagnosis or treatment, in the six (6) month period prior to the enrollment date. Pregnancy is not considered a preexisting condition.
Prescription drug means any medicinal substance, the label of which, under the Federal Food, Drug and Cosmetic Act, is required to bear the legend: “Caution: Federal law prohibits dispensing without prescription.”
Primary care physician (PCP)
A physician practicing family medicine, internal medicine or pediatrics who has accepted primary responsibility for a MercyCare member’s health care. You must name your PCP on your enrollment form or on a later physician change form. Each family member may have a different primary care physician. A member’s primary care physician provides entry into MercyCare’s health care system, evaluates a member’s total health care needs, provides personal medical care in one or more medical fields and is in charge of coordinating other health services and referring the member to other providers of health care when appropriate.
Obtaining MercyCare’s approval before you receive a service or supply. To obtain prior authorization, contact MercyCare at (800) 895-2421.
A group of providers contracted with the plan to provide services for members within a specific geographic location. The primary care physician you select directly determines the provider network with which you will be associated.
Providers of health care
Providers of health care include a) medical or osteopathic physicians, hospitals, and clinics, b) podiatrists, physical therapists, physician’s assistants, psychologists, chiropractors, nurse practitioners, and dentists licensed by the State of Wisconsin, or other applicable jurisdiction to provide covered services, c) nurses licensed by the state of Wisconsin and certified as a nurse anesthetist to provide covered services, d) nurse midwives licensed by the state in which they practice to provide covered services.
Qualified treatment facility
A facility, institution or clinic duly licensed to provide mental health or substance abuse treatment, primarily established for that purpose, and operating within the scope of its license.
The process by which any service that requires prior authorization will be reviewed by MercyCare’s quality health management department. Your doctor will complete a referral form, which will function as a request for authorization for any services that require prior authorization (for example, visits to a non-participating provider). This form is submitted to MercyCare, where the quality health management department will determine whether or not the requested services will be approved.
Routine or preventive
Routine or preventive care means any physical exam or evaluation done in accordance with medically appropriate guidelines for age and sex, in consideration of a member’s personal and/or family medical history, when an exam is otherwise not indicated for the treatment of an existing or known bodily injury or sickness.
Schedule of benefits
A summary of coverage and limitations provided under the policy.
Serious mental illness
The following psychiatric illnesses as defined in the most current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association: 1. schizophrenia, 2. paranoid and other psychotic disorders, 3. bipolar disorders (hypomanic, manic, depressive, and mixed), 4. major depressive disorders (single episode or recurrent), 5. schizoaffective disorders (bipolar or depressive), 6. pervasive developmental disorders, 7. obsessive-compulsive disorders, 8. depression in childhood and adolescence, and 9.panic disorder.
The geographical area in which MercyCare is authorized to offer a health plan.
Any condition or disease that causes loss of, or affects, normal body function other than those resulting from bodily injury.
Medical services ordered by a participating provider and given by, or under the direct supervision of, a registered nurse, licensed practical nurse, licensed physical, occupational or speech therapist. Skilled care is usually necessary for only a limited period of time. It does not include maintenance or long term care. Daily care such as assistance with getting out of bed, bathing, dressing, eating, maintenance of bowel and bladder function, preparing special diets, assisting patients with taking their medicines, or 24-hour supervision for potentially unsafe behavior, do not require skilled care and are considered custodial care.
Skilled nursing facility
A SNF is an institution licensed by the state of Wisconsin or other applicable jurisdiction.
Sound and natural teeth
Teeth that would not have required restoration in the absence of a member’s traumatic bodily injury or teeth with restoration limited to composite or amalgam fillings. It does not mean teeth with a crown or root canal therapy.
The uncontrollable or excessive abuse of addictive substances consisting of alcohol, morphine, cocaine, heroin, opium, cannabis and other barbiturates, amphetamines, tranquilizers and/or hallucinogens, and the resultant physiological and/or psychological dependency which develops with continued use of such addictive substances requiring medical care as determined by a physician or psychologist.
Total disability or totally disabled
An employee, or his or her employed covered spouse, who is at all times prevented from engaging in any job or occupation for wage or profit for which he or she is reasonably qualified by education, training or experience. Total disability also means the person cannot engage in any job or occupation for wage or profit. For a covered spouse who is not employed and a covered dependent child, total disability means a disability preventing the person from engaging in substantially all of the usual and customary activities of a person in good health and of the same age and sex. Total disability will be determined based upon the medical opinion of MercyCare’s medical director and other appropriate sources.
Care for an accident or illness that you need sooner than a routine doctor’s visit. Examples of urgent care situations are broken bones, sprains, non-severe bleeding, minor cuts and burns, and drug reactions.
Usual and customary
The maximum amount payable for covered services under the terms of your certificate of coverage that is the lesser fee charged for a given service/item by a provider, or an amount that doesn’t exceed the general level of charges and is reasonable as determined by the plan when provided under similar or comparable circumstance. The plan bases usual and customary fees upon the 80th percentile of our vendor’s proprietary payment system. This methodology combines actual charge data and relative value units to determine usual and customary amounts.
We refers to MercyCare Health Plans, where referenced in your certificate of coverage.
You/your means any member enrolled in the plan, where referenced in your certificate of coverage.