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STANDARD DEFINITIONS TEAM OF THE CONSUMER INFORMATION (B) SUBGROUP COMPILATION FOR 7-6-10 CONFERENCE CALL

REQUEST FOR PROPOSED DEFINTIONS

I. TERMS WE ARE REQUIRED BY STATUTE TO DEFINE INSURANCE RELATED TERMS Premium –

K.S.A. 40-2209d(t) – Small group statute "Premium" means moneys paid by a small employer or eligible employees or both as a condition of receiving coverage from a small employer carrier, including any fees or other contributions associated with the health benefit plan. K.A.R. 40-1-9 Insurance companies; insurance contracts; premiums defined. (a) (1) The following charges made by insurance companies or their representatives, in connection with the issuance or servicing of policies of their insureds, shall be considered ``premiums'': (A) Membership fees; (B) policy fees; (C) service charges; and (D) charges made by title insurance companies or their agents for the assumption of the risk created by issuance of the title insurance policy. Florida Premium is the consideration for insurance, by whatever name called. Any assessment or any membership, policy, survey, inspection, service of similar fee or charge in consideration for an insurance contract is deemed part of the premium. (s. 627.403, F.S.) Louisiana Any premium or other consideration payable for coverage under a group or individual policy. Idaho "Premium" means all moneys paid by [an employer and eligible employees/an individual and eligible dependents] as a condition of receiving coverage from a carrier, including any fees or other contributions associated with the health benefit plan. North Carolina Premium - periodic payment required to keep a policy in force. Inclusive of a requirement of how the rates are determined i.e. claim experience, age, gender, group size, number of family members being covered. Specify a timeframe for how long the rates are effective as well as when the rates can be readjusted. Define the frequency of readjustment of rates. Require a specified number of days that a notification is sent to the consumer. Utah "Premium" means the monetary consideration for an insurance policy. (b) "Premium" includes, however designated: (i) an assessment; (ii) a membership fee; (iii) a required contribution; or (iv) monetary consideration. (c) (i) "Premium" does not include consideration paid to a third party administrator for the third

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party administrator's services. (ii) "Premium" includes an amount paid by a third party administrator to an insurer for insurance on the risks administered by the third party administrator. Virginia premium – the amount you and/or your employer pays for health insurance coverage. Michael Wroblewski – FTC A flat amount you make to buy and maintain a health plan.

Richard Dropski - Neighborhood Health Plan The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan to purchase health insurance coverage.

Co-insurance -

Florida A sharing of expenses by the insured and the insurer after the deductible is satisfied. The principle under which the company insurers only part of the potential loss with the policyholder paying the other part, up to an annual limit and maximum dollar amount. Louisiana The insured’s or enrollee’s share of covered hospital or medical expenses that is usually in the form of a percentage and that is paid after the insured or enrollee has met their deductible. Idaho "Coinsurance" means a percentage amount a member is responsible to pay out-of-pocket for health care services after satisfaction of any applicable deductibles or copayments, or both. North Carolina Co-insurance - an arrangement by which the insurer and the insured share, in a specific ratio i.e. a percentage of an allowed charge or expense or usual and customary charge for a covered health care service that an enrollee must pay; payment for losses covered by the policy after the deductible has been met. Virginia co-insurance – the percentage of the cost you pay for a covered service. Michael Wroblewski – FTC A percentage of the total cost of a service you must pay for services received. A 20% co-insurance means you pay 20% of the usual, customary, and reasonable fee for the service.

Alan Spielman -URAC The amount you pay as your share for the medical services you receive, such as a doctor’s visit. Coinsurance is a percentage of the plan’s allowance for the service. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

Richard Dropski - Neighborhood Health Plan

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The percentage of the total cost of covered health care services that an insured person must pay out-of-pocket. For example, the insured might have to pay 20% of the cost of a surgery while the insurance company pays the other 80%. This may be in addition to a required Co-Payment.

Deductible

K.S.A. 40-3202(g) – Health Maintenance Organization "Deductible" means an amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment. Florida Amount of expense or loss to be paid by the individual insured before a health insurance policy starts paying benefits. Louisiana The initial amount of covered hospital or medical expenses that the insured or enrollee is liable for under the health insurance policy that is separate from the copayment or coinsurance. Idaho Deductible" means the amount of expense a member must first incur each calendar year before the health benefit plan begins payment for covered services. North Carolina Deductible - specified amount of covered health care expenses that must be incurred and paid by the insured before the insurer will assume any financial liability for all or part of covered health care expenses. Virginia deductible – the amount you pay, generally annually, for covered services before your insurance covers the cost. Michael Wroblewski – FTC An amount you must pay for service you use before the plan begins to pay. The deductible does not include your premium. You must satisfy your deductible before you pay co-payment and co-insurance amounts for services received. Alan Spielman -URAC The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits. There may be separate deductibles for different types of services. For example, a plan can have a prescription drug benefit deductible separate from its calendar year deductible. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009) Richard Dropski - Neighborhood Health Plan The amount that the insured person must pay out-of-pocket for covered health care services before the health insurer pays its share. This is generally expressed as a yearly dollar amount. For example, if the deductible is $1000 per year, the insured must pay $1000 for covered health services before the health plan pays anything.

Co-payment

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K.S.A. 40-3202 (f) – Health Maintenance Organization "Copayment" means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid

Florida A specific dollar amount, except as otherwise provided by statute, that the subscriber must pay upon receipt of covered health care services. Copayments may not be established in an amount that will prevent a person from receiving a covered service or benefit as specified in the subscriber contract approved by the office. (ss.641.19(5), F.S.) Louisiana The insured’s or enrollee’s share of medical care expenses separate from the deductible or coinsurance designated for specific covered health care services and it is a pre-determined amount. Idaho Copayment" means an amount a member must pay to a provider in payment for a specific health care service which is not fully prepaid. North Carolina Co-payment - a fixed or variable dollar amount that the insured must pay each time a covered health service is provided. May or not be a specified amount. Can be the same as co-insurance. Virginia co-payment – the flat fee you pay for a covered service in addition to what is paid by your health insurance coverage. Michael Wroblewski – FTC An amount you pay to the doctor, hospital or pharmacy at the time you receive services.

Alan Spielman -URAC The amount you pay as your share for the medical services you receive, such as a doctor’s visit. A copayment is a fixed dollar amount. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009) Richard Dropski - Neighborhood Health Plan The flat fee the insured person must pay when they receive a covered health care service. For example, the insured person may have to pay $10 each time they visit a doctor.

Out of pocket limit

Florida The amount of cost an insured individual absorbs for the cost of his or her medical expenses. Louisiana The maximum amount an insured or enrollee pays for covered hospital or medical expenses that are not reimbursable under the terms of the policy.

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Idaho “Out-of-Pocket Expense Maximum” means the maximum medical expense that an insured is obligated to pay each calendar year[, including deductibles, copayments and coinsurance]. North Carolina Out of pocket limit - a specified dollar amount of coinsurance incurred and payable by the by the insured for covered services health care services in a specified period. May or may not include deductible amounts, copayment amounts, and charges in excess of allowable amount by the insurer, amounts exceeding the maximum benefits or any other disallowed or not covered expenses under the rules of the insurance contract/health benefit plan. Virginia out of pocket limit – an amount you must pay for covered services including deductibles, co-payments and coinsurance before all covered services will be paid at 100% by your health insurance coverage. Michael Wroblewski – FTC The most you will pay each year for services covered by the health plan. Richard Dropski - Neighborhood Health Plan The maximum amount that an insured person must pay in deductibles and/or coinsurance for covered health care services. This is generally expressed as a yearly dollar amount. For example, if the out-of-pocket limit is $5000, once the insured person paid $5000 in deductibles and/or coinsurance, they would not need to pay any further deductible or coinsurance amounts until the following year.

Preferred provider

K.S.A. 40-4602(f) – Health Maintenance Organization "Participating provider" means a provider who, under a contract with the health insurer or with its contractor or subcontractor, has agreed to provide one or more health care services to insureds with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the health insurer. Florida ‘Preferred provider’ means any licensed health care provider with which the insurer has directly or indirectly contracted for an alternative or a reduced rate of payment, which shall include any health care provider listed in s. 627.419(3) and (4) and shall provide reasonable access to such health care providers. (ss. 627.6471 (1)(b), F.S. Louisiana suggested term, in lieu – “Participating Provider” A provider that has a duly signed and executed agreement with the health insurance issuer or health maintenance organization to participate in its network and who agrees to abide by the terms of the network and who is required to accept reimbursement rate from the health insurance issuer and is prohibited from balance billing the insured or enrollee. North Carolina Preferred provider - a health care provide who has agreed to accept special reimbursement or other terms for health care services from an insurer, employer, third party administrator or other sponsoring group to provide health care services to covered persons.

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Virginia preferred provider – a pre-selected group of medical providers whose charges for covered services will be based on a discounted fee schedule. Michael Wroblewski – FTC Health plans may encourage you to use preferred providers by charging you lower co-payments and/or co-insurance amounts. These providers have negotiated discounts with the health plan.

Richard Dropski - Neighborhood Health Plan A health care provider who has a prior arrangement with the health insurer to accept negotiated payments for health care services. Often, the insured person will have a lower financial obligation (e.g. co-payment) when services are provided by a preferred provider than when provided by a non-preferred provider.

Non preferred provider – the opposite of above Louisiana suggested term, in lieu – “Non-Participating Provider” A provider who renders services to insured or enrollee, patients in the absence of a contractual obligation with a health insurance issuer or health maintenance organization to do so. North Carolina Non - preferred provider - a health care provide who has not agreed to accept special reimbursement or other terms for health care services from an insurer, employer, third party administrator or other sponsoring group to provide health care services to covered persons. Virginia non preferred provider – medical providers whose charges for covered services are not based on a discounted fee schedule. Michael Wroblewski – FTC You may pay more for providers that are not included in the health plan’s network of providers. If you use a non-preferred provider, you pay higher co-insurance and co-payments or you may pay the entire cost of the services received.

Richard Dropski - Neighborhood Health Plan A health care provider who does not have a prior arrangement with the health insurer to accept negotiated payments for health care services. Often, the insured person will have a higher financial obligation (e.g. co-payment) when services are provided by a non-preferred provider than when provided by a preferred provider.

Out of network copayments

Louisiana The amount of co-payments, as expressed under the terms of the policy or agreement, required to be paid by the insured or enrollee, patient when the services rendered were performed by a Non Preferred Provider. Virginia

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out of network co-payments – the co-payments paid for covered services provided by an out-of-network provider/facility. North Carolina Out of network co payments - a fixed dollar amount that the insured must pay each time a covered health service is provided to a non - preferred provider. May or may not include charges in excess of allowable amount by the insurer. Amounts exceeding the maximum benefits or any other disallowed nor not covered expenses under the rules of the insurance contract /health benefit plan. Michael Wroblewski – FTC If you receive services from a non-preferred provider, you may pay a higher co-payment than if you use services from preferred providers. Richard Dropski - Neighborhood Health Plan The flat fee the insured person must pay when they receive a covered health care service from a provider who is not part of the health plan’s network. An out of network copayment may be higher than the copayment the insured person would pay an in-network provider. For example, the insured person may have to pay a $10 copayment for an in-network provider but a $20 copayment for an out-of-network provider.

UCR (usual, customary and reasonable) fees

K.S.A. 40-2202(a)(8) No policy of accident and sickness shall be delivered or issued for delivered to any person in this state unless any provision purporting to base the payments of benefits on “usual, customary and reasonable charges” or a standard of similar import is specifically defined; or the determination of payable benefits is be developed form a statistically valid sample which: (A) equitably recognizes geographic variations, (B) is produced at least every six months, and (C) is collected on the basis of the most current codes and nomenclature developed and maintained by recognized authorities. Florida other health care providers for a procedure; the fee for a procedure charged by the majority of physicians, hospitals, or other health care providers with similar training and experience within the same geographic area. Louisiana Fee that is usual for a particular procedure charged by the majority of physicians with similar training and experience within the same geographic area. Idaho Usual, Customary and Reasonable Charges mean the following: a. “Usual charge” means the most consistent charge by a provider for a given service. b. “Customary charge” means a charge within the range of usual charges for a given service

billed by most providers with similar training and experience taking into consideration the geographic area in which the services are provided and significant regional variations in the costs of services.

c. “Reasonable charge” means a charge that is the usual and customary charge. North Carolina

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UCR fees - charges for health care that are consistent with average rate charged for identical or similar services in a certain geographic locale. Utah UCR (usual, customary and reasonable) fees - "Usual and Customary" shall mean the most common charge for similar services, medicines or supplies within the area in which the charge is incurred.(b) In determining whether a charge is usual and customary, insurers shall consider one or more of the following factors: (i) the level of skill, extent of training, and experience required to perform the procedure or service; (ii) the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; (iii) the severity or nature of the illness or injury being treated; (iv) the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; (v) the cost to the provider of providing the service, medicine or supply; and (vi) other factors determined by the insurer to be appropriate.

Virginia UCR (usual, customary and reasonable) fees - the charge for health care that is consistent with the average rate or charge for identical or similar services in a certain geographical area. Michael Wroblewski – FTC UCR is the total price of the service received. The health plans pays the UCR amount less any co-payment or co-insurance you pay directly to the provider. Richard Dropski - Neighborhood Health Plan A method for paying health care providers in which the amount paid is based on the average rate or charge for identical or similar services in a certain geographical area.

Excluded Services K.S.A. 40-2209f (h) - Group For the purposes of this section, the term "preexisting conditions exclusion" shall mean, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date. Louisiana exclusion of benefits and/or coverage for circumstances in which the terms of the policy have limited such benefits or coverage, either in whole or in part, for particular services. North Carolina Excluded services - specified conditions or circumstances listed in the contract for which the contract will not provide benefits unless otherwise covered in an amendment and/or endorsement. Virginia excluded services – specific condition or circumstance that are not covered by your health insurance coverage.

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Michael Wroblewski – FTC Services not included in your plan and for which you must pay the full price. Richard Dropski - Neighborhood Health Plan Health care services which a health insurer specifically identifies in the Evidence of Coverage as not being covered under the health insurance policy. American Speech-Language Hearing Association Excluded services: Services that are not covered by the health insurance plan. This means that the plan will not pay for these services. Exclusions are not based on a person’s eligibility for other publicly funded programs.

Grievance and appeals

K.S.A. 40-22a09a – Utilization Review Every health insurance plan for which utilization review is performed shall include a description of the health insurance plan's procedures for an insured to obtain an internal appeal or review of an adverse decision. This description shall include all applicable time periods, contact information, rights of the insured and available levels of appeal. If the health insurer uses a utilization review organization, the insured shall be notified of the name of such utilization review organization. The health insurance plan shall provide an insured with written or electronic notification of any adverse decision, and a description of the health insurance plan's internal appeal or review procedure. K.S.A. 40-3202(k) – Health Maintenance Organizations "Grievance" means a written complaint submitted in accordance with the formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization or the medicare provider organization relative to the enrollee. North Carolina Grievance and appeals - a written complaint submitted by a covered person about any of the following: a. An insurer’s decisions, policies, or actions related to the availability, delivery, or quality

of health care services. A written complaint submitted by a covered person about a decision rendered solely on the basis that the health benefit plan contains a benefits exclusion for the health care service in question is not a grievance if the exclusion of the specific service requested is clearly stated in the contract.

b. Claims payment or handling; or reimbursement for services. c. The contractual relationship between a covered person and insurer Inclusive of specified timeframes for submission and completion.

Virginia grievance and appeals (NAIC model, DOL claims reg.) - a written complaint submitted by or on behalf of a covered person regarding the: 1) Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review; 2) Claims payment, handling or reimbursement for health care services; or 3) Matters pertaining to the contractual relationship between a covered person and a health

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carrier. A written or verbal request by a consumer, ordering provider or prescriber to contest an organizational determination (e.g., services have been denied, reduced, etc.) Sharp Health Plans A grievance is an expression of dissatisfaction with the [health plan/insurer] or one of its contracted providers An appeal is a request to change a previous decision made by the [health plan/insurer] or delegated entity. Alan Spielman -URAC An appeal is a written or verbal request by a consumer, ordering provider or prescriber to contest an organizational determination (e.g., services have been denied, reduced, etc.). (URAC Health Accreditation Programs Glossary)

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MEDICAL TERMS Hospitalization

Louisiana Insurance providing for payment of hospital expenses for the insured or enrollee and any such expenses for a covered dependent of the insured or enrollee. North Carolina Hospitalization - the act of placing a person in a hospital as a patient for a condition. Insurance that fully or partially covers a patient’s hospital expenses that may be payable by a fixed dollar amount (daily, weekly, monthly) without regard to actual expense incurred for hospital confinement or specific benefits such as daily hospital room and board and hospital services during hospital confinement. May or not include surgical operations and for in hospital doctor visits. Virginia hospitalization* - overnight stay in a hospital or other such treatment facility. Richard Dropski - Neighborhood Health Plan Health care services that are provided while the patient is confined to a hospital for at least 24 hours

Hospital outpatient care

K.A.R. 40-4-26(a)(3) – Basic hospital expense coverage Hospital outpatient services consisting of: (A) Hospital services on the day surgery is performed;(B) hospital services rendered within 72 hours after accidental injury, in an amount not less than $100; and (C) x-ray and laboratory tests of not less than $200. Florida Those services provided to a member in the outpatient portion of a hospital licensed under part I of chapter 395 (Florida Statutes), that are preventive, diagnostic, therapeutic, or palliative. Louisiana The LDOI will provide a definition at a future date. North Carolina Hospital outpatient care - outpatient hospital services defined as preventative mandated, diagnostic, therapeutic, rehabilitative, or palliative items or services furnished by or under the direction of a physician to a recipient of an institution that is licensed or formally approved as a hospital. All medical services must be medically necessary and not experimental in nature. Virginia hospital outpatient care – medical care or treatment that does not require an overnight stay in a hospital. Richard Dropski - Neighborhood Health Plan Health care services provided on an outpatient basis to those who visit a hospital and depart after treatment on the same day. Also called ambulatory care.

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Sharp Health Plan Services such as surgery, radiology, pathology, hemodialysis and other diagnostic and treatment services provided during a same-day encounter, without an admission to an inpatient facility.

Physician services

Florida Those services delivered by a physician licensed under chapters 458, 459 , 460, 461 and 463 (Florida Statutes) that are medically necessary for the treatment of an injury, illness, or disease. Physician services shall not included those services that are clinically unproven, experimental, or purely for cosmetic. (Para. 408.904(2)(a), F.S.) Louisiana Services rendered by a physician or health care professional legally qualified and licensed to practice medicine and practicing within the scope of his or her license at the time and place service is rendered or other health care practitioner licensed, certified, or registered to perform specified health care services consistent with state law subject to direct supervision by such a licensed physician. North Carolina Physician services - care provided by an individual licensed under state law to practice medicine, which can be comprehensive or limited to surgical expenses and provided in certain setting. Virginia physician services – services legally performed by a person educated, clinically experienced, and licensed to practice medicine. Richard Dropski - Neighborhood Health Plan Physician services include office visits, surgical procedures, and a broad range of other diagnostic and therapeutic services. These services are furnished in all settings, including physicians’ offices, hospitals, ambulatory surgical centers, skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and beneficiaries’ homes. In some cases, non-physician practitioners, such as nurse practitioners, may furnish physician services.

Prescription Drug Coverage

K.S.A. 40-2,105b. Insurance coverage for psychotherapeutic drugs used for treatment of mental illness. On and after January 1, 2002, any group health insurance policy, nonprofit medical and hospital service corporation contract, fraternal benefit society, health maintenance organization, municipal group funded pool and state employee benefit program which provides coverage for prescription drugs, other than prescription drugs administered in a hospital or physician's office shall provide coverage for psychotherapeutic drugs used for the treatment of mental illness under terms and conditions no less favorable than coverage provided for other prescription drugs. 2010 Senate Substitute for HB 2160 – Oral cancer drugs-Kansas Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization, municipal group-funded pool and the state employee health

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care benefits plan which provides coverage for prescription drugs and which is delivered, issued for delivery, amended or renewed on and after July 1, 2011, shall provide coverage for a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits. Louisiana Coverage for medications, which includes specialty drugs, the sale or dispensing of which legally requires the order of a physician or other health care professional and that carry the federally required product legend stipulating that such drugs may not be dispensed without a prescription, and which are currently approved by the Food and Drug Administration for safety and effectiveness, subject to any applicable limitations and exclusions of the policy. North Carolina Prescription drug coverage - insurance that helps people pay for prescription drugs at a participating or non participating pharmacy. May be available via a rider, amendment, or endorsement to an insurance contract. It may pay all or partial payment for prescription drugs. May include co payments, coinsurance, and deductibles. May have restrictions to access to certain drugs and/or pharmacies. Virginia prescription drug coverage* - an essential health benefit provided for in a health plan, policy, or contract describing specific prescription drugs available to be received through a pharmacy, doctor’s office, or hospital and the fixed dollar amount or percentage cost of each drug as it may be eligible for reimbursement either in whole or in part as a covered benefit. Alan Spielman -URAC URAC Definition Benefit (pharmacy): The description of coverage including but not limited to: formulary drugs, participating networks, payment structures, authorization for drug management programs, and drug therapy management programs as selected by the purchaser. The formulary is a subsidiary of the benefits plan. (URAC Pharmacy Quality Management/PQM® Accreditation Programs Glossary) Asian & Pacific Islander American Health Forum (APIAHF) prescription drug coverage* - Any definition of prescription drug coverage should clearly state that prescription drugs include brand name drugs and generic versions of that drug offered at a discounted price.

Durable medical equipment

Louisiana Items and supplies which are used to serve a specific therapeutic purpose in the treatment of an illness or injury, can withstand repeated use, are generally not useful to a person in the absence of illness, injury or disease and are appropriate for use in the insured, enrollee or patient’s home. North Carolina Durable medical equipment - used to describe medical equipment used in the home to aid in a better quality of living. The equipment must be reusable. May require prior approval and be obtained from approved providers. Primarily and customarily used to serve medical purpose; generally not useful to a person in the absence of an illness or injury.

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Virginia durable medical equipment – medical devices or other equipment, prescribed to increase one’s independence in mobility and self care activities, that can stand repeated use and is appropriate for use in your home or work activities for functional living purposes. Richard Dropski - Neighborhood Health Plan Equipment that primarily and customarily services a medical purpose, generally is not useful to a person in the absence of illness or injury, is appropriate for use in the home and can withstand repeated use. The equipment must be order by a physician or other prescriber. Examples include walkers, hospital beds and wheelchairs. American Diabetes Association tie to the definition in Social Security Act, Sec. 1861. [42 U.S.C. 1395x]

(n) The term “durable medical equipment” includes iron lungs, oxygen tents, hospital beds, and wheelchairs (which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a vehicle is determined to be necessary on the basis of the individual's medical and physical condition and the vehicle meets such safety requirements as the Secretary may prescribe) used in the patient's home (including an institution used as his home other than an institution that meets the requirements of subsection (e)(1) of this section or section 1819(a)(1)), whether furnished on a rental basis or purchased, and includes blood-testing strips and blood glucose monitors for individuals with diabetes without regard to whether the individual has Type I or Type II diabetes or to the individual's use of insulin (as determined under standards established by the Secretary in consultation with the appropriate organizations); except that such term does not include such equipment furnished by a supplier who has used, for the demonstration and use of specific equipment, an individual who has not met such minimum training standards as the Secretary may establish with respect to the demonstration and use of such specific equipment. With respect to a seat-lift chair, such term includes only the seat-lift mechanism and does not include the chair.

Home health care Louisiana Services rendered in the insured’s or enrollee ’s place of residence by an organization licensed as a Home Health Care agency by the appropriate state agency which are primarily engaged in providing to people, at the written direction of a licensed physician, in the insured ‘s or enrollee’s place of residence, skilled nursing services by or under the supervision of a registered nurse (R.N.) licensed to practice in the state. Idaho “Home health care” means necessary care and treatment provided at the insured person’s residence by a home health care agency or by others under arrangements made with a home health care agency. The program of treatment shall be prescribed in writing by the insured person’s attending physician, who shall approve the program prior to its start. The physician must certify that hospital confinement would be otherwise required. A “home health care agency” is an agency approved under Medicare, or is licensed to provide home health care under applicable state law, or meets all of the following requirements: (1) It is primarily engaged in providing home health care services; (2)Its policies are established by a group of professional personnel (including at least one physician and one registered nurse);

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(3) A physician or a registered nurse provides supervision of home health care services; (4)It maintains clinical records on all patients; and (5)It has a full time administrator. Home health care includes, but is not limited to:

i. Part-time or intermittent skilled nursing services provided by a registered nurse or a licensed practical nurse;

ii. Part-time or intermittent home health aide services that provide supportive ii. services in the home under the supervision of a registered nurse or a physical,

speech, or hearing occupational therapists; iii. Physical, occupational, or speech and hearing therapy; and iv. Medical supplies, drugs, and medicines prescribed by a physician and related v. pharmaceutical services, and laboratory services to the extent the charges or

costs would have been covered if the insured person had remained in the hospital.

vi. Therapy includes physical, speech, hearing, and occupational therapy; vii. Special equipment including hospital bed, toilette, pulleys, wheelchairs,

aspirator, chux, oxygen, surgical dressings, rubber shields, colostomy, and ileostomy appliances;

viii. Prosthetic devices including wigs and artificial breasts; ix. Nursing home care for non-custodial services; and x. Reconstructive surgery when deemed necessary by the attending physician.

North Carolina Home health care - comprehensive, medically necessary range of health services directly related to medical supplies and appliances provided to an individual in a place of temporary or permanent residence used as individual’s home. Services inclusive of nursing care provided by or under the supervision of a registered nurse, physical, occupational, or speech therapy when provided to an individual who is also is receiving nursing services, or any other these therapies, in a place of temporary or permanent residence used as the individual’s home, medical social services, in - home aide services that involve hands on care to an individual, infusion nursing services, assistance with pulmonary care, pulmonary rehabilitation or ventilation, in home companion, sitter and respite care services provided to an individual, and homemaker services provided in combination with in home companion, sitter, respite, or other home care services provided by a recognized provider or organization to a patient at home. Does not include health promotion, preventative health and community health services provided by public health departments by employees of the Department of Health and Human Services under G.S. 130A - 124, or by developmental evaluation centers under contract with the Department of Health and Human Services to provide services under G.S. 130A - 124; hospitals licensed under Article 5 of Chapter 131E of the General Statutes when providing follow - up care initiated to patients within six months after their discharge from the hospital; facilities and programs operated under the authority of G.S. 122C and providing services within the scope of G.S. 122C; schools, when providing services pursuant to Article 9 of Chapter 115C; the practice of midwifery by a person licensed under Article 10A of Chapter 90 of the General Statutes; hospices licensed under Article 10 of Chapter 131E of the General Statutes when providing care to a hospice patient; an individual who engages solely in providing his own services to other individuals; incidental health care provided by an employee of a physician licensed to practice medicine in North Carolina in the normal course of the physician's practice; or nursing registries if the registry discloses to a client or the client's responsible party, before providing any services, that (i) it is not a licensed home care agency, and (ii) it does not make any representations or guarantees

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concerning the training, supervision, or competence of the personnel provided. The term sitter does not include child care facilities licensed in accordance with Chapter 110 of the General Statutes. The term respite care does not include facilities or services licensed in accordance with Chapter 122C of the General Statutes. The terms in - home companion, sitter, homemaker, and respite care services do not include (i) services certified or otherwise overseen by the Department as not providing personal care or (ii) services administered on a voluntary basis for which there is not reimbursement from the recipient or anyone acting on the recipient's behalf. Utah "Home Health Care" shall mean services provided by a home health agency. Virginia home health care – medical care services rendered in a home setting. Home care includes services such as skilled nursing visits and physical, speech, and occupational therapy for patients confined to their homes. Richard Dropski - Neighborhood Health Plan Skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, and durable medical equipment provided to a patient in their home.

Skilled nursing care

Florida – Skilled care means nursing services or therapeutic services required by law to be delivered by a health care professional who is licensed under part I of chapter 464, part I, part III, or part V of chapter 468, or chapter 486 (Florida Statutes) and who is employed by or under contract with a licensed home health agency or is referred by a licensed nurse registry. (ss.400.62(28), F.S. Louisiana Service that must be provided by a registered nurse, or a licensed practical (vocational) nurse under the supervision of a registered nurse, to be safe and effective. Factors to be considered in the determination of a skilled service include the inherent complexity of the service, the condition of the patient and accepted standards of medical and nursing practice. Some services may be classified as a skilled nursing service on the basis of complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters, and if reasonable and necessary to the treatment of the insured, enrollee’s or patient's illness or injury. North Carolina Skilled nursing care - a service that must be provided by a registered nurse, or a licensed practical (vocational) nurse under the supervision of a registered nurse, to be safe and effective. In determining whether a service requires the skills of a nurse, consider both the inherent complexity of the service, the condition of the patient and accepted standards of medical and nursing practice. Some services may be classified as a skilled nursing service on the basis of complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters, and if reasonable and necessary to the treatment of the patient's illness or injury, would be covered on that basis. However, in some cases the condition of the patient may cause a service that would ordinarily be considered unskilled to be considered a skilled nursing service. This would occur when the patient's condition is such that the service can be safely and effectively provided only by a nurse.

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Utah "Skilled Nursing Care" shall mean nursing services provided by, or under the supervision of, a registered nurse. Such care shall be for the purpose of treating the condition for which the confinement is required and not for the purpose of providing intermediate or custodial care. Virginia skilled nursing care – medical care that is being provided by persons or facilities licensed by the state in which the nursing care or services is perform. Richard Dropski - Neighborhood Health Plan A level of care that includes services that can only be performed safely and correctly by a licensed nurse. Examples of skilled nursing care include complicated wound care, intravenous injections and insertion of catheters. Simple wound care, administration of eye drops and routine care of catheters wound not be considered skilled nursing care.

Rehabilitation services

Louisiana Services which are coordinated with respect to the use of medical, social, educational, or vocational services, beyond the acute care stage of disease or injury, for the purpose of restoring, to the maximum extent practicable, the functioning of an individual disabled by disease or injury.

North Carolina Rehabilitative Services - services which include a process and goal of restoring disabled insured to maximum physical, mental, and vocational independence and productivity commensurate with limitations. Achieved by identifying and developing residual capacities, job modification, or skills retraining. Services may be provided by a physical therapist, occupational therapist, speech and language pathologist, social worker, therapeutic recreation, personal care. Services may be delivered in a variety of settings. Virginia rehabilitation services* - services prescribed to help a patient learn to maximize their abilities following an injury, surgery, or any medical treatment. In addition to physical services that help the body to adjust to changes, rehabilitation services would also include psychosocial services of support groups or counseling and vocational services to assist with job-related or life-style problems.

Richard Dropski - Neighborhood Health Plan Services that are given by or under the direction of nurses and physical, occupational, and speech therapists to help a patient recover from an illness or injury. Examples include working with a physical therapist to help you walk after hip replacement and with a speech therapist to help you speak after having a stroke.

American Speech-Language-Hearing Association (ASHA) Rehabilitation services: Services that help a person regain skills they lost due to illness, disease, or injury. Includes speech-language pathology, physical and occupational therapy, and other services. Suggest also defining habilitation services: Services that help a person gain, keep, or improve skills for daily living. Includes physical and occupational therapy, speech-

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language pathology, and other services that allow a person to develop new skills and increase functioning. Sharp Health Plan Rehabilitative - The processes of treatment and education that result in restoring skills to a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible.

Habilitative - The processes of treatment and education that result in supplying a person with the means to develop maximum self-sufficiency and function in a normal or as near normal manner as possible.

Hospice services Florida Items and services furnished to a patient and family by a hospice, or by others under arrangements with such a program, in a place of temporary or permanent residence used as the patient’s home for the purpose of maintaining the patient at home; or if the patient needs short-term institutionalization, the services shall be furnished in cooperation with those contracted institutions or in the hospice inpatient facility. (ss.400.601(6), F.S. Louisiana Services rendered in an autonomous, centrally administered, medically directed program providing a continuum of home, outpatient, and homelike inpatient care for the terminally ill insured, enrollee, or patient and their family. It employs an interdisciplinary team to assist in providing palliative and supportive care to meet the special needs arising out of the physical, emotional, spiritual, social, and economic stresses which are experienced during the final stages of illness and during dying and bereavement. North Carolina Hospice care - Care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. The goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible. Aggressive methods of pain control may be used. Hospice programs generally are home - based, but they sometimes provide services away from home - - in freestanding facilities, in nursing homes, or within hospitals. Provide support for the patient's emotional, social, and spiritual needs as well as medical symptoms as part of treating the whole person. Programs inclusive of a multidisciplinary team approach, including nurse, doctor, social worker, and clergy providing care. Additional services may include drugs to control pain and manage other symptoms; physical occupational and speech therapy; medical supplies and equipment; medical social service; dietary and other counseling; continuous home care of crisis and bereavement services, and respite care services. Utah "Hospice" shall mean a program of care for the terminally ill and their families which occurs in a home or in a health care facility and which provides medical, palliative, psychological, spiritual, or supportive care and treatment and is licensed and operating within the scope of such license. "Hospice Care" means the care given to the terminally ill and their families which occurs in a home or in a health facility and which includes medical, palliative, psychosocial, spiritual, bereavement and supportive care and treatment. emergency medical transportation.

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Virginia hospice services - care designed to give supportive care to people in the final phase of a terminal illness, focusing on comfort and quality of life, rather than cure, where the goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible. Hospice services are generally home-based, but could include services away from home of a hospice type service administered in freestanding facilities as for example, but not inclusive, within nursing homes or within hospitals. Richard Dropski - Neighborhood Health Plan An array of services for caring for people who are terminally ill. Hospice services are team-oriented and address the medical, physical, social, emotional and spiritual needs of the patient and support the patient’s family or caregiver.

Emergency room care (coverage of “emergency services” in out of network context addressed in PPACA regulation related to patient protections) –

K.S.A. 40-4603(a) – Patient Protection A health benefit plan shall not deny coverage for emergency services if the symptoms presented by an insured and recorded by the attending provider indicate that an emergency medical condition exists, or for emergency services necessary to provide an insured with a medical examination and stabilizing treatment, regardless of whether prior authorization was obtained to provide those services. Florida –‘Emergency services and care’ means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists, and, if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital. (ss. 641.19(7), F.S.) Louisiana The LDOI will provide a definition at a future date. Idaho "Emergency facility" means any hospital or other facility where emergency services are provided to a member including, but not limited to, a physician’s office. Virginia emergency room care (coverage of “emergency services” in out of network context addressed in PPACA regulation related to patient protections) -emergency care services provided in a section of a health care facility intended to provide treatment for victims of sudden illness or trauma. Alan Spielman -URAC NAIC Uniform Health Carrier External Review Model Act (NAIC ER Model Act) provides the following –

“Emergency medical condition” means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical

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attention would result in a serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.

Emergency medical transportation

K.S.A. 40-4602(b) – Patient Protection "Emergency services" means ambulance services and health care items and services furnished or required to evaluate and treat an emergency medical condition, as directed or ordered by a physician.

Louisiana Transportation that is medically necessary, by means of a licensed vehicle or plane, used for transporting the sick and injured. North Carolina Emergency medical transportation - any type of transportation i.e. plane, helicopter, ambulance that get the insured to a specified or non specified medical center outlined in the contract expeditiously. Services must be provided until the extent that is necessary to screen and stabilize the person covered and shall not require prior authorization if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Out of network benefits payable on an in network level. The insured may not be penalized for going out of network. Virginia emergency medical transportation - transportation in or by any vehicle that requires the physical movement of your person to receive emergency medical services. Richard Dropski - Neighborhood Health Plan Transportation, by land or sea, that is needed to transport an individual with an emergency medical condition to a hospital or to transport a critically injured or ill patient requiring care that is beyond the scope of a paramedic from one facility to another.

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II. “OTHER” TERMS THAT WE MAY ALSO WANT TO TACKLE Section 1302(b) Essential Health Benefits: Ambulatory patient services

Louisiana “Ambulatory Insured or enrollee or Patient Services” Services provided or rendered to an insured, enrollee or patient on an outpatient basis and who is not bedridden or required to an inpatient, overnight stay. North Carolina Ambulatory patient services - medical health care services provided on an outpatient basis (non hospitalized). Services may include diagnosis, treatment, surgery and rehabilitation. Virginia ambulatory patient services – medical care delivered, performed, or administered on an outpatient basis that does not require hospital admission or a hospital bed for overnight care.

Emergency services

K.S.A. 40-4602(b) – Patient Protection "Emergency services" means ambulance services and health care items and services furnished or required to evaluate and treat an emergency medical condition, as directed or ordered by a physician. Virginia emergency services – immediate medical attention needed to treat the sudden onset of a health risk or medical condition that manifests itself by symptoms of sufficient severity or severe pain that without immediate medical attention could reasonably be expected by a person with an average knowledge of health and medicine, to result in, serious jeopardy to the mental or physical health of the individual; danger of serious impairment of the individual’s body functions; serious dysfunction of any of the individual’s bodily organs; serious or permanent damage to a body part; or in the case of a pregnant woman, serious jeopardy to the health of the fetus. Louisiana Emergency medical Services - Those medical services necessary to screen, evaluate and stabilize a medical condition of recent onset and severity, including severe pain, that would lead a prudent layperson, acting reasonably and possessing an average knowledge of health and medicine to believe that the absence of immediate medical attention could reasonably be expected to result in: (1)placing the health of the person, or with respect to a pregnant woman the health of her unborn child, in serious jeopardy; (2)serious impairment of bodily function; or (3)serious dysfunction of any bodily organ or part. Idaho "Emergency services" means those health care services that are provided in a hospital or other emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity including, but not limited to, severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent person who possesses an average knowledge of health and medicine, to result in:

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(a) Placing the patient’s health in serious jeopardy; (b) Serious impairment to bodily functions; or (c) Serious dysfunction of any bodily organ or part. North Carolina Emergency services - health care items and services furnished or required to screen for or test an emergency medical condition until the condition is stabilized, including pre - hospital care and ancillary services routinely available to the emergency department. Out of network benefits payable at the in network level until the insured has become stabilized. The insured may not be penalized for going out of network. Utah Emergency services - "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of medicine and health, would reasonably expect the absence of immediate medical attention at a hospital emergency department to result in: (i) placing the insured's health, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part; and (b) "hospital emergency department" means that area of a hospital in which emergency services are provided on a 24-hour-a-day basis. (4) Nothing in this section may be construed as: (a) altering the level or type of benefits that are provided under the terms of a contract or policy; or (b) restricting a policy or contract from providing enhanced benefits for certain emergency medical conditions that are identified in the policy or contract. Alan Spielman - URAC URAC Definition Emergency services: Means health care items and services furnished or required to evaluate and treat an emergency medical condition. (URAC Uniform External Review/UER Accreditation Program Glossary; NAIC ER Model Act Definitions)

Hospitalization

Florida means confined overnight as a registered bed patient in a Hospital or other medical facility where at least one day’s room and board is charged. North Carolina Hospitalization - see previous definition. Virginia hospitalization – you are admitted as bed patient in a hospital or other such treatment facility requiring an overnight admission for care.

Maternity and newborn care

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K.A.R. 40-1-31 Insurance policies; prohibiting certain discriminations An insurance policy, plan or binder, or a rider or endorsement thereto, shall not be delivered or issued for delivery in this state if the amount of benefits payable, or a term, condition, or type of coverage is or may be restricted, modified, excluded, or reduced on the basis of the sex or marital status of the insured or prospective insured. This requirement shall not apply when the amount of benefits, terms, conditions, or type of coverage vary as a result of the application of rate differentials permitted under chapter 40, Kansas Statutes Annotated, or as a result of negotiations between the insurer and insured. Nothing in this regulation shall prohibit an insurer from taking marital status into account for the purpose of defining persons eligible for dependents benefits. K.S.A. 40-2209 (A)(6) A group policy providing hospital, medical or surgical expense benefits may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition K.S.A. 40-2,102 (a) (1) All individual and group policies which provides coverage for a family member of the enrollee, insured or subscriber shall also provide that the health insurance benefits applicable for children shall be payable with respect to a: (A) Newly born child from the moment of birth; (B) newly born child adopted from the moment of birth if a petition for adoption were filed within 31 days of the birth of the child. K.S.A. 40-2,102 (b) (1) All policies which provide coverage for a family member of the enrollee, insured or subscriber, shall also offer an option whereby the health insurance benefits shall include delivery and obstetrical expenses at birth of the birth mother of a child adopted within 90 days of birth of such child the same limitations contained in such policy or contract are applicable. K.S.A. 40-2,160. Coverage for minimum inpatient care following birth of child (b) Any health plan which provides coverage for maternity services, including benefits for childbirth, shall provide coverage for at least 48 hours of inpatient care following a vaginal delivery and at least 96 hours of inpatient care following delivery by caesarean section for a mother and newly born child in a medical care facility. Louisiana Services rendered to (1) a pregnant girl or woman including, but not limited to, accommodations, any health or medical services, and social services provided during the prenatal and postpartal periods related to, in any manner, the preservation, maintenance, overall health, delivery, sustenance and welfare of the unborn child or children, together with health of the mother, and (2) all services rendered to a newly born infant, from the moment of birth or until such time as the infant is well enough to be discharged from a hospital or neonatal special care unit to his or her home, whichever period is longer. North Carolina Maternity and newborn care - an insurer that provides a health benefit plan that contains maternity benefits including benefits for childbirth shall ensure coverage is provided with respect to the mother who is the insured, beneficiary, or policyholder under the plan and her newborn child for a minimum of 48 hours of inpatient length of stay following a normal vaginal deliver and a minimum of 96 hours of inpatient length of stay following a caesarian section, without requiring the attending provide to obtain authorization from the insurer or its representatives. The attending physician may discharge the mother and newborn prior to the aforementioned specified lengths of stay, the health benefit plan provides timely post delivery follow - up care provided by a registered nurse, physician, nurse practitioner, nurse midwife, or physician’s assistant

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experienced in mother and child health in the home, provider’s office, a hospital, a birthing center, an intermediate care facility, a federally qualified health center, a federally rural clinic or a state health department maternity clinic. The insurer is prohibited from denying enrollment, renewal, or continued coverage for the mother and newborn child. The insurer is prohibited from inducing or rebating the mother to encourage the mother to request less than the minimum coverage required. The insurer can not penalize or otherwise reduce or limit reimbursement of the attending provider nor induce the attending provider to provide treatment not consistent with the definition. The mother is not required to deliver the baby in a hospital or stay in the hospital for a fixed period of time following birth of the child. Virginia maternity and newborn care – medical care that begins at the inception of pregnancy for the expectant mother and expected child to include: fetal screenings including tests for the genetic and/or chromosomal status of the fetus which also may include anatomical, biochemical or biophysical tests, and tests; home setting covered with nurse midwives; anesthesia services to provide partial or complete loss of sensation before delivery; hospital services for routine nursery care for the newborn during the mother’s hospital stay; prenatal and postnatal care services for pregnancy and complications of pregnancy for which hospitalization is necessary; initial examination of a newborn and if requested, circumcision of a male child; and services for interruption of pregnancy. These services, to the extent applicable, would also apply to an adopted newborn child under the age of 15 months since the birth of the newborn child.

Mental health and substance abuse disorder services, including behavioral health treatment

K.S.A. 40-2,105. Insurance coverage under individual or small employer group policies for services rendered in treatment of mental illness, alcoholism, drug abuse or substance use disorders; limitations; exceptions.

K.S.A. 40-2,105a. Any group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides medical, surgical or hospital expense coverage shall include, coverage for diagnosis and treatment of mental illnesses and alcoholism, drug abuse or other substance use disorders.

2010 Senate Substitute for HB 2160 – Providing coverage for Autism Spectrum Disorder - Kansas In the coverage for the next health plan coverage year commencing January 1, 2011, the state employee health care commission shall provide for the coverage of services for the diagnosis and treatment of autism spectrum disorder in any covered individual whose age is less than 19 years.

Florida Mental health services’ means inpatient services provided in a hospital licensed under chapter 395 (Florida Statutes) and listed on the hospital license as psychiatric beds for adults; psychiatric beds for children and adolescents; intensive residential treatment beds for children and adolescents; substance abuse beds for adults; or substance abuse beds for children and adolescents. (ss. 408.032(14), F.S.) ‘Substance abuse programs and services’ or “drug control” applies generally to the broad continuum of prevention, intervention, clinical treatment, recovery support initiatives, efforts to limit substance abuse, and initiatives and efforts by law enforcement agencies to limit substance abuse. (Para.397.331(1)(a), F.S.) Louisiana

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see Mental Health Parity and Substance Abuse Act, 2008. North Carolina Mental health and substance abuse disorder services, including behavioral health treatment - mental health services must be treated no less favorable than the benefits for physical illnesses, generally applicable to the same limits. Mental health illness is defined in the state law as diagnosed and defined in the Diagnostic and Statistical Manual of Mental Health disorders by the American Psychological Association. Mental illness means: means: (i) when applied to an adult, an illness which so lessens the capacity of the individual to use self - control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance, or control; and (ii) when applied to a minor, a mental condition, other than mental retardation alone, that so impairs the youth's capacity to exercise age adequate self - control or judgment in the conduct of his activities and social relationships so that he is in need of treatment. The law specifically defines that the insurer may apply durational limits that differ from durational limits physical illnesses. A group health benefit plan shall provide at least the following minimum number of office visits and combined inpatient and outpatient days for all mental illnesses and disorders not listed in subsection (c), as diagnosed and defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM - IV, or a subsequent edition published by the American Psychiatric Association, except those mental disorders coded in the DSM - IV or subsequent edition as substance - related disorders (291.0 through 292.2 and 303.0 through 305.9), those coded as sexual dysfunctions not due to organic disease (302.70 through 302.79), and those coded as "V" codes: (1) Thirty combined inpatient and outpatient days per year. (2) Thirty office visits per year. (c) Durational limits for the following mental illnesses shall be subject to the same limits as benefits for physical illness generally: (1) Bipolar Disorder. (2) Major Depressive Disorder. (3) Obsessive Compulsive Disorder. (4) Paranoid and Other Psychotic Disorder. (5) Schizoaffective Disorder. (6) Schizophrenia. (7) Post - Traumatic Stress Disorder. (8) Anorexia Nervosa. (9) Bulimia. (d) Nothing in this section prevents an insurer from offering a group health benefit plan that provides greater than the minimum required benefits, as set forth in subsection (b). (e) Nothing in this section requires an insurer to cover treatment or studies leading to or in connection with sex changes or modifications and related care. (f) Weighted Average. – If a group health benefit plan contains annual limits, lifetime limits, co - payments, deductibles, or coinsurance only on selected physical illness and injury benefits, and these benefits do not represent substantially all of the physical illness and injury benefits under the group health benefit plan, then the insurer may impose limits on the mental health benefits based on a weighted average of the respective annual, lifetime, co - payment, deductible, or coinsurance limits on the selected physical illness and injury benefits. The weighted average shall be calculated in accordance with rules adopted by the Commissioner. (g) Nothing in this section prevents an insurer from applying utilization review criteria to determine medical necessity as defined in G.S. 58 - 50 - 61 as long as it does so in accordance G.S. 58 - 3 - 220 Page 2 with all requirements for utilization review programs and medical necessity determinations specified in that section, including the offering of an insurer appeal

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process and, where applicable, health benefit plan external review as provided for in Part 4 of Article 50 of Chapter 58 of the General Statutes. (i) Notwithstanding any other provisions of this section, a group health benefit plan that covers both medical and surgical benefits and mental health benefits shall, with respect to the mental health benefits, comply with all applicable standards of Subtitle B of Title V of Public Law 110 - 343, known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Durational limits defined in the state law are dropped for group health benefit plan covering a large employer. Larger employers are required to comply with The Mental Health Parity and Addiction Equity Act of 2008. Chemical dependency is defined in the state law as the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal. Chemical dependency benefits for the necessary care and treatment of chemical dependency that are less favorably than benefits for physical illnesses generally. Every group policy or group contract of insurance that provides benefits for chemical dependency treatment and that provides total annual benefits for all illnesses in excess of eight thousand dollars ($8,000) is subject to the following conditions: (1) The policy or contract shall provide, for each 12 - month period, a minimum benefit of eight thousand dollars ($8,000) for the necessary care and treatment of chemical dependency. (2) The policy or contract shall provide a minimum benefit of sixteen thousand dollars ($16,000) for the necessary care and treatment of chemical dependency for the life of the policy or contract. (d) Provisions for benefits for necessary care and treatment of chemical dependency in group policies or group contracts of insurance shall provide benefit payments for the following providers of necessary care and treatment of chemical dependency: (1) The following units of a general hospital licensed under Article 5 of General Statutes Chapter 131E: a. Chemical dependency units in facilities licensed after October 1, 1984; b. Medical units; c. Psychiatric units; and (2) The following facilities or programs licensed after July 1, 1984, under Article 2 of General Statutes Chapter 122C: a. Chemical dependency units in psychiatric hospitals; b. Chemical dependency hospitals; c. Residential chemical dependency treatment facilities; d. Social setting detoxification facilities or programs; e. Medical detoxification or programs; and (3) Duly licensed physicians and duly licensed practicing psychologists and certified professionals working under the direct supervision of such physicians or psychologists in facilities described in (1) and (2) above and in day/night programs or outpatient treatment facilities licensed after July 1, 1984, under Article 2 of General Statutes Chapter 122C. Provided, however, that nothing in this subsection shall prohibit any policy or contract of insurance from requiring the most cost effective treatment setting to be utilized by the person undergoing necessary care and treatment for chemical dependency. (e) Coverage for chemical dependency treatment as described in this section shall not

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be applicable to any group policy holder or group contract holder who rejects the coverage in writing. Notwithstanding any other provisions of this section, a group health benefit plan that covers both medical and surgical benefits and chemical dependency treatment benefits shall, with respect to the chemical dependency treatment benefits, comply with all applicable standards of Subtitle B of Title V of Public Law 110 - 343, known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Durational limits defined in the state law are dropped for group health benefit plan covering a large employer. Larger employers are required to comply with The Mental Health Parity and Addiction Equity Act of 2008. The insurer is prohibited from refusing to issue or deliver to that individual any policy that affords benefits or coverages for any medical treatment or service for physical illness or injury. Virginia mental health and substance abuse disorder services, including behavioral health treatment – means treatment for mental, emotional, or nervous disorders to include treatment for alcohol or other drug dependence. “Treatment" means services including diagnostic evaluation, medical, psychiatric and psychological care, and psychotherapy for mental, emotional or nervous disorders or alcohol or other drug dependence rendered by a hospital, alcohol or drug rehabilitation facility, intermediate care facility, mental health treatment center, a physician, psychologist, clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed substance abuse treatment practitioner, licensed marriage and family therapist or clinical nurse specialist who renders mental health services. Treatment for physiological or psychological dependence on alcohol or other drugs shall also include the services of counseling and rehabilitation as well as services rendered by a state certified alcoholism, drug, or substance abuse counselor or substance abuse counseling assistant employed by a facility or program licensed by a state or federal jurisdiction to provide such treatment. Laurel Stine, Bazelon Center for Mental Health Law As you know, it is a bit tricky when it comes to defining mental health services since presumably there will not be a laundry list of mental health services to include. The mental health parity law defines mental health benefits as benefits with respect to services for mental health conditions, as defined under the terms of the plan and in accordance with applicable Federal and State laws. It does so similarly for substance use disorder benefits. Because the mental health and substance use parity law would apply under the ACA, I believe it is important to go further and include some of the basic categories within mental health services, including inpatient and outpatient psychiatric services, medications, and emergency services.

Additionally, it is also very important with the rehabilitation term to include psychiatric rehabilitation.

Prescription drugs

K.S.A. 40-2,105b. Insurance coverage for psychotherapeutic drugs used for treatment of mental illness. On and after January 1, 2002, any group health insurance policy, nonprofit medical and hospital service corporation contract, fraternal benefit society, health maintenance organization, municipal group funded pool and state employee benefit program which provides coverage for prescription drugs, other than prescription drugs administered in a hospital or

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physician's office shall provide coverage for psychotherapeutic drugs used for the treatment of mental illness under terms and conditions no less favorable than coverage provided for other prescription drugs.

2010 Senate Substitute for HB 2160 – Oral cancer drugs Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization, municipal group-funded pool and the state employee health care benefits plan which provides coverage for prescription drugs and which is delivered, issued for delivery, amended or renewed on and after July 1, 2011, shall provide coverage for a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications that are covered as medical benefits. Louisiana The LDOI will provide a definition in the future North Carolina Prescription drugs - see previous definition. Virginia prescription drugs - are medicines, including insulin, injections, injectors, or infusion that require a prescription order from your doctor or hospital that are filled or performed or authorized to be filled or performed by a licensed pharmacist. Prescription drugs from your doctor are covered as other medical services or supplies. Prescription drugs from your hospital are be covered as a hospital service. Alan Spielman -URAC URAC Definition Prescription: Medication prescribed to a patient or obtained for treatment and prevention of disease or conditions. This may include OTC drugs and related supplies. (URAC PQM® Accreditation Programs Glossary; Adapted from Academy of Managed Care Pharmacy’s (AMCP) Principles of a Sound Drug Formulary System, 2000) American Diabetes Association definition under EHBP should include notation about fair and affordable cost-sharing for medically necessary prescription drugs

Rehabilitative and habilitative services and devices

Louisiana Rehabilitative Services and Devices” – see “Rehabilitation Services,” Habilitative needs to be defined. The LDOI will provide a definition in the future. North Carolina Rehabilitative and habilitative services and devices - see previous definition Virginia

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rehabilitative services - physical therapy, occupational therapy and speech therapy services designed to restore a function that an individual had, but lost due to disease, injury, or a medical condition. habilitative services & devices - physical therapy, occupational therapy and speech therapy services/devices to enhance a person’s function or ability, without regard to affecting a cure. American Speech-Language-Hearing Association (ASHA) Services and devices that help a person gain, keep, regain, or improve functional skills.

Laboratory services

K.S.A. 40-2,164 – Coverage of prostate cancer screening including a prostate-specific antigen blood test and digital rectal examination K.S.A. 40-2230 –Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this act applies, whenever reimbursement or indemnity for laboratory or x-ray services are covered, reimbursement or indemnification shall not be denied for mammograms or pap smears when performed at the direction of a person licensed to practice medicine and surgery by the board of healing arts within the lawful scope of such person's license, including services performed at a mobile facility certified by the federal health care financing administration and performing mammography testing by American cancer society guidelines. Florida Professional laboratory services ordered by a licensed physician or other licensed practitioner of the healing arts and provided in a laboratory that meets the requirements for Medicare participation and is licensed under chapter 483 (Florida Statutes). Louisiana Any test, specimen collection, or similar service ordered by a physician or other health care provider under the direct supervision of a physician, requiring analytical study, examination, or manipulation, including but not limited to, extraction of blood, genetic material, or any other procedure or service requiring the use, skill or equipment of a licensed healthcare laboratory, as applicable. North Carolina Laboratory Services - services provided in a facility that performs laboratory testing on specimens derived from humans for the purposes of providing information for the diagnosis, prevention or the treatment of impairment of disease, or for the assessment of health. Virginia laboratory services - testing and interpretation of a person’s bodily fluids, tissue, or bodily part to include a biopsy that is conducted in a medical laboratory.

Preventative and wellness services and chronic disease management –

K.S.A. 40-2,102(a)(2) The coverage for newly born children shall consist of: ((B) routine and necessary immunizations for all newly born children of the insured or subscriber. For purposes of this paragraph "routine and necessary immunizations" shall consist of at least five doses of vaccine against diphtheria, pertussis, tetanus; at least four doses of vaccine against polio and Haemophilus B (Hib); and three doses of vaccine against Hepatitis B; two doses of vaccine

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against measles, mumps and rubella; one dose of vaccine against varicella and such other vaccines and dosages as may be prescribed by the secretary of health and environment. The required benefits shall apply to immunizations administered to each newly born child from birth to 72 months of age and shall not be subject to any deductible, copayment or coinsurance requirements. 40-2,163. Coverage for certain expenses relating to care and treatment of diabetes; educational expenses; exceptions. (a) This section shall be known and may be cited as the "diabetes coverage act." (b) Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed on or after January 1, 1999, also, shall provide coverage for equipment, and supplies, limited to hypodermic needles and supplies used exclusively with diabetes management and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes if prescribed by a health care professional legally authorized to prescribe such services and supplies under the law. Such coverage shall include coverage for insulin only if such coverage also includes coverage of prescription drugs. (c) Diabetes outpatient self-management training and education shall be provided by a certified, registered or licensed health care professional with expertise in diabetes. The coverage for outpatient self-management training and education shall be required pursuant to this section only if ordered by a health care professional legally authorized to prescribe such services and the diabetic (1) is treated at a program approved by the American diabetes association; (2) is treated by a person certified by the national certification board for diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional. K.S.A. 40-2,166a. Coverage for osteoporosis. (a) Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization, municipal group-funded pool and the state employee health care benefits plan which provides coverage for hospital, medical and surgical services, other than medicare supplement or accident-only policies which are delivered, issued for delivery, amended or renewed on or after July 1, 2001, shall include coverage for services related to diagnosis, treatment and management of osteoporosis when such services are provided by a person licensed to practice medicine and surgery in this state, for individuals with a condition or medical history for which bone mass measurement is medically necessary for such individual. K.S.A. 40-2,164 – Coverage of prostate cancer screening including a prostate-specific antigen blood test and digital rectal examination K.S.A. 40-2230 –Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this act applies, whenever reimbursement or indemnity for laboratory or x-ray services are covered, reimbursement or indemnification shall not be denied for mammograms or pap smears when performed at the direction of a person licensed to practice medicine and surgery by the board of healing arts within the lawful scope of such person's license, including services performed at a mobile facility certified by the federal health care financing administration and performing mammography testing by American cancer society guidelines.

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Arizona A chronic medical condition is a medical condition that is not curable, but which is under control through active medical treatment. Such chronic conditions may have periodic acute episodes and may require intermittent inpatient hospital care. However, a chronic medical condition can be controlled sufficiently to permit generally continuation of some activities of persons who are not ill (such as work and school). Louisiana Suggest bifurcating these two terms. Preventive and wellness services refer to those services designed to effectively prevent, detect, diagnose, or screen for a disease, condition or illness, genetic anomaly, or any other condition for which there is an effective treatment to cure, reverse, arrest or otherwise alleviate the disease, condition or illness and the onset thereof. Chronic disease management refers to those services or treatment programs of a diagnosed disease or condition that is not acute, but is long-lasting or recurrent, with or without relapses or remissions, that employ a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant designed to improve the quality of life for individuals by preventing or minimizing the effects of such diagnosed disease or condition through integrative care. North Carolina Preventative and wellness services - Employee - centered programs featuring proactive personal fitness programs, including physical examinations, substance abuse and group counseling, and individualized diet and exercise programs. Wellness programs have been very effective in improving employee productivity while reducing absenteeism and health care costs. disease management - a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. Utah Preventative and wellness services and chronic disease management - "Chronic disease" defined. As used in this chapter, "chronic disease" means an impairment or deviation from the normal functioning of the human body having one or more of the following characteristics: (1) It is permanent; (2) It leaves residual disability; (3) It is caused by non reversible pathological alterations; (4) It requires special patient education and instruction for rehabilitation; (5) It may require a long period of supervision, observation and care. Virginia preventive and wellness services - medical care, to include laboratory services, medical examinations and medical procedures, designed to identify and detect disease, even in the absence of physical symptoms. chronic disease management - medical advice or medical care designed to assist individuals who have an ongoing medical condition, regardless of whether the condition is curable.

Alan Spielman - URAC URAC Definitions

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Disease Management (DM): According to the Disease Management Association of America, “Disease management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management: supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. Disease management components include: population identification processes; evidence-based practice guidelines; collaborative practice models to include physician and support-service providers; patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance); process and outcomes measurement, evaluation, and management; routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling.” (URAC Health Accreditation Programs Glossary) Disease Management Program: A program or entity that provides the scope of functions and activities necessary to provide disease management. (URAC Health Accreditation Programs Glossary) Wellness Program: A program that is designed to promote healthy behaviors through a combination of a health risk assessment tool, a series of one or more interventions linked to the assessment process findings, a program evaluation component designed to track individual and program-wide aggregate improvements, supported by a means of program and data integration. (URAC Wellness Accreditation Program Glossary)

Asian & Pacific Islander American Health Forum Preventative and wellness services cover:

• Consultation and education on healthy nutrition, optimal physical activity, and risk avoidance behaviors that address a patient’s cultural background and the associated social and behavioral norms and beliefs.

• Consultation and education on health disparities that persist within a patient’s racial and ethnic group

• Screenings and immunizations as recommended by the United States Preventives Service Task Force

• Creation of wellness plans through shared decision-making with patients Chronic Disease Management:

• All health and mental health services associated with the continued care of chronic disease including coordination of care across primary care and specialty physicians and other health care professionals (e.g. patient navigators) treating the patient for one or multiple chronic conditions.

American Diabetes Association Coverage of primary, secondary and tertiary prevention for prevention and management of chronic disease and its complications: • Screening for those at risk • Prevention and early detection of complications (glucose monitoring; eye and foot

exams) • Prevention of complications from progressing once they are present • Medication and disease management coverage consistent with accepted clinical treatment

guidelines

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• Chronic disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant

Pediatric services including oral and vision care –

K.S.A. 40-2,101 Insurance coverage to include reimbursement or indemnity for services performed by optometrist, dentist or podiatrist. Notwithstanding any provision of any individual, group or blanket policy of accident and sickness, medical or surgical expense insurance coverage or any provision of a policy, contract, plan or agreement for medical service, issued on or after the effective date of this act, whenever such policy, contract, plan or agreement provides for reimbursement or indemnity for any service which is within the lawful scope of practice of any practitioner licensed under the healing arts act of this state, reimbursement or indemnification under such policy contract, plan or agreement shall not be denied when such services are performed by an optometrist, dentist or podiatrist acting within the lawful scope of their license.

K.S.A. 40-2,165. Coverage of general anesthesia in conjunction with dental care for certain individuals. (a) Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed on or after July 1, 1999, also, shall provide coverage for the administration of general anesthesia and medical care facility charges for dental care provided to the following covered persons: (1) A child five years of age and under; or (2) a person who is severely disabled; or

(3) a person has a medical or behavioral condition which requires hospitalization or general anesthesia when dental care is provided.

Louisiana Those services rendered to infants and children, including preventive and wellness services, dental services or procedures (including maxofillial surgical procedures), vision services, and any other medically necessary service as ordered by a physician, health care provider or health care professional and any supplies, devices (whether implantable or durable) or services in connection therewith. North Carolina Pediatric services including oral and vision - services or supplies for the preventative health maintenance for healthy children. Medical care for children who are acutely or chronically ill. Services or supplies that:

• Reduce infant and child mortality • Control infectious disease • Foster healthy lifestyles • Ease the difficulties of children and adolescents with chronic conditions

Treatment and diagnosis for:

• Infections • Injuries • Genetic defects

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• Malignancies • Organic disease and dysfunctions

Services and supplies that involve the prevention, early detection, and management of other problems that affects children and adolescents including

• behavioral difficulties • developmental disorders • functional problems • social stresses

depression or anxiety disorders Virginia pediatric services - medical services, to include oral and vision care, provided by a pediatrician to a patient ranging in age for birth to young adulthood.

Insured/participant/enrollee/member/policyholder

K.S.A. 40-3202j - "Enrollee" means a person who has entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health maintenance organization or the medicare provider organization for health care services. (NOTE: This is from the HMO Statute)

Louisiana Enrollee/Insured: Enrollee or insured means an individual who is enrolled or insured by a health insurance issuer for health insurance coverage. (R.S. 22:1831). Covered person: "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. (R.S. 22:1122). Idaho “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. A covered person includes the authorized representative of the covered person. North Carolina Insured/participant/enrollee/member/policyholder - is a person or an organization that has an insurance policy. The policyholder receives specific types of coverage as stated in the policy subject to payment of premiums. Virginia insured/participant/enrollee/member/policyholder - an individual covered by a health insurance policy issued to a group or to an individual, which provides benefits in accordance with the policy.

Benefit limitations

North Carolina

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Benefit limitations - services or supplies not covered in the insurance contract unless specified in the insurance contract. Virginia benefit limitation - medical services that are provided but subject to treatment limits or a specified dollar amount.

Benefit exclusions

North Carolina Benefit exclusions - specific services and supplies /listed described in the insurance contract (certificate, policy, riders, amendments , or endorsements) that are not covered for a loss caused or contributed by specified services and supplies. Virginia benefit exclusions - medical services that are specifically excluded from coverage as stated in the insurance policy.

Covered service

Louisiana "Covered health care services" means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease that are either covered and payable under the terms of health insurance coverage or required by law to be covered. (R.S. 22:1005). “Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms and conditions of a health benefit plan. North Carolina Covered services - medical, dental vision, or hearing services and supplies shown in the contract. Virginia covered service - medical services that may be covered, if the insurer determines the services are medically necessary and not excluded under the terms of the policy.

Alan Spielman URAC Definition Covered service: A health care service for which reimbursement or other remuneration is provided to a consumer or on behalf of a consumer under the terms of the consumer’s benefits program. (URAC Health Accreditation Programs Glossary)

Discount

North Carolina Discount - In managed care health insurance – the term is typically associated with the negotiated discount off of a health care provider’s usual charge for provision of health care to the insurance company insureds. Seen in health maintenance organization health insurance plans, Preferred Provider Organization health insurance plans, and discounted provider indemnity insurance plans but can also be in certain insurer / provider adhoc arrangements.

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Virginia discount - reimbursement to a participating provider that is less than the provider’s usual charge.

Eligible expense

Idaho “Eligible Expense” (Expense) means the Expense incurred for a covered service or supply. A physician or other licensed facility or Provider must order or prescribe the service or supply. Expense is considered incurred on the date the service or supply is received. Expense does not include any charge:

a. For a service or supply which is not Medically Necessary; or

b. Which is in excess of reasonable and customary charges for a service or supply; or

c. Which is in excess of any contractual arrangements; or

d. For a service or supply for which an Insured would have no legal obligation to pay in the absence of coverage under this policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage.

North Carolina Eligible expense - expenses that can be reimbursed up to the insurance contract’s dollar amount (fixed or percentage) listed in the contract for a calendar year or up to the pro - rated amount if the insured has been enrolled in the plan for the full calendar year. Expenses that are not covered are services not covered in the insurance contract. May apply to coinsurance, deductibles, and copayments. Virginia eligible expense - a charge for medical care that is eligible for payment under the terms of an

insurance policy. Negotiated rate

North Carolina Negotiated rate - the maximum charge a network provider has agreed to make as to any service or supply for the purpose of the benefits under the contract. The negotiated generally does not include or reflect any amount the insurer may receive under a rebate arrangement between the insurer and a drug manufacturer for any prescription drug, including prescription drugs included in the contract. Virginia negotiated rate - the amount an insurance company negotiates with a participating provider to pay for medical services.

Negotiated fee

North Carolina Negotiated fee - Managed care plans and providers mutually agree on a set fee for each service. The negotiated rate usually is based upon a discount from what the provider’s usual charge. Providers can not charge more than the negotiated fee.

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Virginia negotiated fee - the reimbursement amount that a participating provider negotiates with an insurance company.

In-patient benefits

North Carolina In-patient benefits - covered health care services that are received according to the rules of the insurance contract from providers employed by, under contract with, or approved in advance by the insurer; and means an emergency health care service regardless of the status or affiliation of the provider of such services. Virginia in-patient benefits - benefits available to a patient who is admitted and treated as an in-patient in a hospital or other health care facility.

Out-patient benefits

North Carolina Out-patient benefits - non-emergency, medically necessary covered health care services that are not received according to the rules of the insurance contract, including services from affiliated providers that are received without prior approval of the insurer. Virginia out-patient benefits - benefits available to a patient when they are not treated as an in-patient.

In network provider/facility

North Carolina In network provider/facility - a health provider, pharmacy, or dental provide who has contracted to furnish services or supplies for a negotiated charge; but only if the provide is, with the insurer consent, included in the directory of providers as a network provider for:

• The service or supply involved; and • The class of insureds to which the insured belongs.

Enrollees may be required to use only network provider or may have financing liability for using non-network providers for services. Virginia in-network provider/facility - a health care professional/medical treatment facility that participates with an insurance company via a written contract with the insurer.

Alan Spielman -URAC Proposed Definition In Network: You receive treatment from the doctors, clinics, health centers, hospitals, medical practices, and other providers with whom your plan has an agreement to care for its members. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

Out of network provider/facility

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Louisiana Out of network provider/facility: Noncontracted health care provider means a health care provider that has not entered into a contract or agreement with a health insurance issuer or network of providers for the provision of covered health care services. (R.S. 22:1872).

North Carolina Out of network provider/facility - a health care provider, pharmacy or dental provider who has not contracted with the insurer to furnish services or supplies at a negotiated charge. Virginia out-of-network provider/facility - a health care professional/medical treatment facility that does not participate with an insurance company.

Alan Spielman – URAC Proposed Definition Out of Network: You receive treatment from doctors, clinics, health centers, hospitals, and medical practices other than those with whom the plan has an agreement at additional cost. Members who receive services outside the network may pay all charges. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

Pre-authorization/certification

Virginia pre-authorization/precertification - a requirement that you obtain the health carrier’s approval before a medical service is provided or before services by an out-of-network provider are received. Pre-certification/Pre-authorization is not a guarantee of claim payment however; failure to obtain pre-certification/pre-authorization may result in denial of the claim or reduction in payment of the claim. North Carolina Pre-authorization/precertification - a process where the insurer is contacted before certain services are provide such as hospitalization or outpatient surgery or prescription drugs are prescribed to determine whether the service being recommended or the drugs prescribed are considered covered services in the insurance contract. Alan Spielman- URAC URAC Definition Certification: a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness. (URAC UER Accreditation Programs Glossary; NAIC ER Model Act Definitions)

Clinical trials

K.A.R. 40-4-43. Hospital, medical, and surgical expense insurance policies and certificates; prohibiting certain types of discrimination. (a) A hospital, medical, or surgical expense policy or certificate issued by an insurance company, nonprofit health service corporation, nonprofit medical and hospital service corporation, or health maintenance organization shall not be delivered or issued for delivery in this state on an individual, group, blanket, franchise, or association basis if the amount of benefits payable or a term, condition, or type of coverage is or

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could be restricted, modified, excluded, or reduced on the basis of whether both of the following conditions are met: (1) The insured or prospective insured has been diagnosed with cancer and accepted into a phase I, phase II, phase III, or phase IV clinical trial for cancer. (2) The treating physician who is providing covered health care services to the insured recommends participation in the clinical trial after determining that participation in the clinical trial has a meaningful potential to benefit the insured. (b) Each policy or certificate covered by this regulation shall provide coverage for all routine patient care costs associated with the provision of health care services, including drugs, items, devices, treatments, diagnostics, and services that would otherwise be covered under the insurance policy or certificate if those drugs, items, devices, treatments, diagnostics, and services were not provided in connection with an approved clinical trial program, including health care services typically provided to patients not participating in a clinical trial. (c) For purposes of this regulation, "routine patient care costs" shall not include the costs associated with the provision of any of the following: (1) Drugs or devices that have not been approved by the federal food and drug administration and that are associated with the clinical trial; (2) services other than health care services, including travel, housing, companion expenses, and other nonclinical expenses, that an insured could require as a result of the treatment being provided for purposes of the clinical trial; (3) any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the clinical management of the patient; (4) health care services that, except for the fact that they are being provided in a clinical trial, are otherwise specifically excluded from coverage under the insured’s hospital, medical, or surgical expense policy or certificate; or (5) health care services customarily provided by the research sponsors of a trial free of charge for any insured in the trial. (d) This regulation shall not apply if the amount of benefits, the terms, the conditions, or the type of coverage varies as a result of the application of permissible rate differentials or as a result of negotiations between the insurer and insured. (Authorized by K.S.A. 40-103 and K.S.A. 40-2404a; implementing K.S.A. 2009 Supp. 40-2404(7); effective June 4, 2010.) North Carolina Clinical trials - phase II, phase, III, and phase IV patient research studies designed to evaluate new treatments, including prescriptions drugs, and that (I) involve the treatment of life - threatening medical conditions, (ii) are medically indicated and preferable for that patient compared to available noninvestigational treatment alternatives, and, (iii) have clinical and preclinical data that shows that the trial will likely be more effective for that patient than available nonivestigational alternatives. Must involve determinations by treating physicians, relevant scientific data, and opinions of experts in relevant medical specialties. Must be trials approved by centers or cooperative groups that are funded by the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the Agency for Health Care Research and Quality, the Department of Defense, or the Department of Veterans Affairs. The health benefit plan may also cover clinical trials sponsored by other entities. Must be conducted in a setting and by personnel that maintain a high level of expertise because of their training, experience, and volume of patients. Virginia clinical trials - trials to evaluate the effectiveness and safety of medications or medical devices by monitoring their effects on large groups of people.

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Alan Spielman - URAC URAC Definition Randomized clinical trial: a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time. (URAC Health Accreditation Programs Glossary) Asian & Pacific Islander American Health Forum (APIAHF) Clinical trials – In any definition of clinical trials, we ask that the definition include: 1) a statement on the optional nature of participation and 2) a statement clarifying that clinical trials generally represent a deviation from standard care.

Complications of pregnancy vs Complicated pregnancy

Kansas Contractually defined covered conditions of pregnancy that are “in addition to” or “in lieu of” a normal pregnancy. For example, complications of pregnancy usually include Caesarean section, spontaneous miscarriage or abortion and any other condition that is not usually association with a normal pregnancy. Definition of “Complications of Pregnancy” from HIAA Part B Group Life & Health Insurance 1985 Edition Idaho “Involuntary Complications of Pregnancy” includes but is not limited to: i. Conditions, requiring hospital confinement (when the pregnancy is not terminated),

whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologicallly distinct complication of pregnancy; and

ii. Cesarean section delivery, ectopic pregnancy which is terminated, spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible, puerperal infection, eclampsia and toxemia.

North Carolina Complications of pregnancy vs. complicated pregnancy - may not be treated differently from any other illness or sickness under the insurance contract. Covered expenses include charges made in connection with pregnancy complications of a covered female employee only. Pregnancy complications means:

• Hyperemesis gravidarum (pernicious vomiting of pregnancy); toxemia with convulsions; severe bleeding before delivery due to premature separation of the placenta from any cause; bleeding after delivery severe enough to need a transfusion or blood; or

• Amniotic fluid tests, analyses, or intra - uterine fetal transfusion made for Rh incompatibility; or • An emergency medical caesarean section due to pregnancy complications; • Miscarriage if not elective or therapeutic; or • A non - elective caesarean section. A non - elective cesarean section is considered a complication

of pregnancy.

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Terms are interchangeable. Utah Complications of pregnancy vs. Complicated pregnancy - (3) "Complications of Pregnancy" shall mean diseases or conditions the diagnoses of which are distinct from pregnancy but are adversely affected or caused by pregnancy and not associated with a normal pregnancy. (a) "Complications of Pregnancy" include acute nephritis, nephrosis, cardiac decompensation, ectopic pregnancy which is terminated, a spontaneous termination of pregnancy when a viable birth is not possible, puerperal infection, eclampsia, pre-eclampsia and toxemia. (b) This definition does not include false labor, occasional spotting, doctor prescribed rest during the period of pregnancy, morning sickness, and conditions of comparable severity associated with management of a difficult pregnancy. Virginia complications of pregnancy - conditions (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible. complicated pregnancy - pregnancy and childbirth where a Physician has certified that a surgical procedure, or treatment requiring a period of inpatient hospital confinement is required during the pregnancy, and where a normal delivery would endanger the life of the mother and or child(ren).

Cosmetic

K.S.A. 40-2123(c)(9) cosmetic surgery unless provided as the result of an injury or medically necessary surgical procedure; (Note: this is exclusionary language but gives an indication of what cosmetic surgery is – it is from the KHIA Statute) Idaho Cosmetic surgery, except that “cosmetic surgery” shall not include:

i. Reconstructive surgery when the service is incidental to or follows surgery resulting from trauma,

ii. infection or other diseases of the involved part; ii.Reconstructive surgery because of congenital disease or anomaly of a covered dependent child; or

iii. Involuntary conditions or complications related to a cosmetic procedure.

Utah "Cosmetic Surgery" or "Reconstructive Surgery" shall mean any surgical procedure performed primarily to improve physical appearance.(a) This definition does not include surgery, which is necessary: (i) to correct damage caused by injury or sickness; (ii) for reconstructive treatment following medically necessary surgery; (iii) to provide or restore normal bodily function; or

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(iv) to correct a congenital disorder that has resulted in a functional defect. (b) This provision does not require coverage for preexisting conditions otherwise excluded.

Virginia

cosmetic – procedures that change, restore, or enhance your appearance. Services that are not medically necessary for the treatment of an illness or injury.

Investigational/Experimental

K.S.A. 40-2,167. Off-label use of prescription drugs; definitions. As used in K.S.A. 40-2,167 through 40-2,170, and amendments thereto, unless the context clearly indicates otherwise: (a) "Peer-reviewed medical literature" means a published scientific study in a journal or other publication in which original manuscripts have been published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts, and that has been determined by the international committee of medical journal editors to have met the uniform requirements for manuscripts submitted to biomedical journals. Peer-reviewed medical literature does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier. (b) "Off-label use of drugs" means prescribing prescription drugs for treatments other than those stated in the labeling approved by the federal food and drug administration. (c) "Standard reference compendia" means the United States pharmacopeia drug information, the American hospital formulary service drug information or the American Medical Association drug evaluation.

K.S.A. 40-2,168 Coverage for cancer treatment; exclusion from coverage prohibited. An insurance company, nonprofit health service corporation, nonprofit medical and hospital service corporation or health maintenance organization that provides coverage for prescription drugs may not issue, deliver, execute or renew any health insurance policy or health service contract on an individual, group, blanket, franchise or association basis which excludes coverage of a prescription drug for cancer treatment on the grounds the prescription drug has not been approved by the federal food and drug administration for that covered indication if the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature. The prescribing physician shall submit to the insurer documentation supporting the proposed off-label use or uses if requested by the insurer. Idaho "Investigational" means any treatment, procedure, facility, equipment, drug, device or commodity, regardless of its medical necessity, which is experimental, or in the early developmental stage of medical technology, for which there are no randomized clinical trials or, absent such trials, for which there are no cohort studies or case-control studies or, absent such studies, then for which there is no case-series. The determination by the health carrier will be based on objective data and information obtained by the health carrier and reviewed, by competent medical personnel, according to the following: (a) The technology has final approval from the appropriate government regulatory bodies; (b) Medical or scientific evidence regarding the technology is sufficiently comprehensive to permit well substantiated conclusions concerning the safety and effectiveness of the technology;

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(c) The technology's overall beneficial effects on health outweigh the overall harmful effects on health; and (d) The technology is as beneficial as any established alternative. When used under the usual conditions of medical practice, the technology should be reasonably expected to satisfy the criteria of paragraphs (c) and (d) of this definition. Utah Investigational / Experimental - "Experimental Treatment" is defined as medical treatment, services, supplies, medications, drugs, or other methods of therapy or medical practices, which are not accepted as a valid course of treatment by the Utah Medical Association, the U.S. Food and Drug Administration, the American Medical Association, or the Surgeon General. Virginia investigational / experimental – the use of a service, procedure or supply that is not recognized by the Plan as standard medical care for the condition, disease, illness or injury being treated. A service, procedure or supply includes, but is not limited to the diagnostic service, treatment, facility, equipment, drug or device. A service is considered investigational (experimental) if any of the following criteria are met: 1. The services, procedures or supplies requiring Federal or other Governmental body approval, such as drugs and devices, do not have unrestricted market approval from the Food and Drug Administration (FDA) or final approval from any other governmental regulatory body for use in treatment of a specified condition. Any approval that is granted as an interim step in the regulatory process is not a substitute for final or unrestricted market approval. 2. There is insufficient or inconclusive medical and scientific evidence to permit the Plan to evaluate the therapeutic value of the service, procedure or supply. (Adequate evidence is defined as at least two documents of medical and scientific evidence that indicate that the proposed treatment is likely to be beneficial to the member.) 3. There is inconclusive medical and scientific evidence in peer-reviewed medical literature that the service, procedure or supply has a beneficial effect on health outcomes. 4. The service, procedure or supply under consideration is not as beneficial as any established alternatives. 5. There is insufficient information or inconclusive scientific evidence that, when used in a non-investigational setting, the service, procedure or supply has a beneficial effect on health outcomes or is as beneficial as any established alternatives.

Reconstructive surgery or procedure (distinguished from elective surgery or procedures) –

K.S.A. 40-2,102(a)(2) The coverage for newly born children shall consist of: A) Coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

K.S.A. 40-2,166. Coverage of reconstructive breast surgery. (a) Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed on or after July 1, 1999, and which provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or

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beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for: (1) Reconstruction of the breast on which the mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and physical complications in all stages of mastectomy, including lymphedemas. North Carolina Reconstructive surgery or procedures (distinguished from elective surgery or procedures) - reconstruction surgery is a type of plastic surgery performed to reshape abnormal structures of the body to improve function and appearance. It is different from cosmetic surgery, which is performed to reshape normal structures of the body to improve a patient’s appearance or self - esteem. The goals of reconstructive surgery are to reshape abnormal structures of the body, to improve function, and/or to allow a person to have a more normal appearance. Abnormal structures of the body that are corrected during reconstructive surgery may be the result of birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. Virginia reconstructive surgery or procedures (distinguished from elective surgery or procedures) - serving to rebuild, restore, or correct the appearance and function of defective, damaged, or misshaped body structures or parts.

Medical necessity/medically necessary

American Speech-Language-Hearing Association Services needed to diagnose and treat problems related to conditions, illnesses, and injuries. Florida means medical services that are essential for diagnosis, treatment or care of the an injury, accident or sickness for which it is prescribed or performed that meets generally accepted standards of medical practice; and are ordered by a physician and performed under his or her care, supervision or order. Louisiana Medical necessity: "medically necessary treatment or care", shall mean contemplated hospitalization, inpatient or outpatient health care or medical services recommended for appropriate treatment or care in accordance with nationally accepted current medical criteria. (R.S. 22:1821). Idaho "Medically necessary" or "Medical necessity" means health care services and supplies that a physician or other health care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) In accordance with generally accepted standards of medical practice; (b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the covered person’s illness, injury or disease; (c) Not primarily for the convenience of the covered person, physician or other health care provider; and

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(d) Not more costly than an alternative service or sequence of services or supply, and at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the covered person’s illness, injury or disease. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible medical or scientific evidence. "Medical or scientific evidence" means evidence found in the following sources: (a) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (b) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the national institutes of health’s library of medicine for indexing in index medicus (MEDLINE) and elsevier science ltd. for indexing in excerpta medicus (EMBASE); (c) Medical journals recognized by the U.S. secretary of health and human services under section 1861(t)(2) of the federal social security act; (d) The following standard reference compendia: (i) The American hospital formulary service -- drug information; (ii) Drug facts and comparisons; (iii) The United States pharmacopoeia -- drug information; and (iv) The American dental association accepted dental therapeutics. (e) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including: (i) The federal agency for healthcare research and quality; (ii) The national institutes of health; (iii) The national cancer institute; (iv) The national academy of sciences; (v) The centers for medicare and medicaid services; (vi) The federal food and drug administration; and (vii) Any national board recognized by the national institutes of health for the purpose of evaluating the medical value of health care services; or (f) Any other medical or scientific evidence that is comparable to the sources listed in paragraphs (a) through (e) of this definition. North Carolina Medical necessity/medically necessary - covered services or supplies that are:

(1) Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease, and, except as allowed under the clinical trials not for experimental, investigation, or cosmetic purposes.

(2) Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms.

(3) Within generally accepted standards of medical care in the community. (4) Not solely for the convenience of the insured, the insured’s family , or the provider.

The insurer may compare the cost - effectiveness of alternative services or supplies when determining which service or supplies will be covered. If the insurer or its authorized representative determines services and supplies, or other items are covered under the contract, including in the utilization review, the insurer or its authorized representative may not retract payment after the services have been provided, or reduce payments for services, unless based

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upon a material misrepresentation about the insured’s health condition that was knowingly made by the insured or the provider of the service, supply, or other item. The insurer may not penalize the insured or subject the insured to the out of network benefit level offered in the insurance contract unless the contracting health care providers are reasonably available to the insured without a reasonable delay. Utah Medical necessity/medically necessary - "Medical Necessity" means:(a) health care services or products that a prudent health care professional would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (i) in accordance with generally accepted standards of medical practice in the United States; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the convenience of the patient, physician, or other health care provider; and (iv) covered under the contract; and (b) that when a medical question-of-fact exists medical necessity shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective. (i) For interventions not yet in widespread use, the effectiveness shall be based on scientific evidence. (ii) For established interventions, the effectiveness shall be based on: (A) scientific evidence; (B) professional standards; and (C) expert opinion.

Virginia medical necessity/medically necessary – services or supplies provided by a facility or provider that are required to identify or treat a covered person’s illness, injury, bodily dysfunction or complication of pregnancy-related condition. A provider must diagnose or reasonably expect the condition exists. To be considered medically necessary, a service must: • be required to identify or treat an illness, injury, or pregnancy-related condition; • be consistent with the symptoms or diagnosis and treatment of your condition; • be in accordance with standards of generally accepted medical practice; and • be the most suitable supply or level of service that can safely treat the condition and not be for the convenience of the patient, patient’s family, or the provider. American Diabetes Association Service, medication, supply or equipment deemed necessary by a health care provider to treat or prevent a health condition

Ancillary benefits

Florida Health insurance coverage for miscellaneous medical expenses associated with a hospital stay. Benefits provided in ambulance service to and from a hospital, drugs, blood, surgical dressings, operating room, medicines, bandages, X-rays, diagnostic tests and anesthetics. North Carolina

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Ancillary benefits - health care services conducted by providers other than primary care physicians. Benefits for various hospital charges. Virginia ancillary benefits - additional services (other than room and board charges) such as X-rays, anesthesia, lab work, etc.

Designated treatment center

North Carolina Designated treatment center - (also known as centers of excellence) - a hospital or other facility that has contracted with the insurer to furnish services or supplies to a covered insured patient in connection with specific service/procedures identified in the contract at negotiated charge. A facility is a designated treatment center only for those types of services/procedures specified in the contract. i.e. transplants. Virginia designated treatment center – centers that provide treatment for a specific illness such as cancer, epilepsy, etc.

Primary care

North Carolina Primary care - non-specialist care; the level of health care at which a patient is evaluated and treated by a family doctor or nurse, or if necessary, is refereed to as a specialist. Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long - term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate. Primary care provides patient advocacy in the health care system to accomplish cost - effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care. Utah Primary care - provide primary care services, as defined by the health care plan Virginia primary care – health care provided by a medical professional (as a general practitioner, pediatrician, or nurse) with whom a patient has initial contact and by whom the patient may be referred to a specialist.

Residential treatment center

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K.A.R. 40-4-37(c)(3) – this is from the long term care statute``Nursing facility'' means a home, residence or institution, other than a hospital, which is primarily engaged in providing nursing care and related services on an inpatient basis under a license issued by the appropriate licensing agency. It may be a freestanding facility including the following: (A) nursing facility; (B) skilled nursing home; (C) intermediate nursing care home; (D) assisted living facility; or (E) residential health care facility. North Carolina Residential treatment center - a designated/specified facility in the insurance contract that provides medical, psychiatric, nursing, counseling or therapeutic services to treat alcoholism, mental disorders or sever serious biologically - based mental illnesses. The center must meet certain requirements -

• On - site licensed Behavioral Health Provider 24 hours per day/7 days a week. • Provides a comprehensive patient assessment (preferably before admission, but at least upon

admission). • Is admitted by a Physician. • Has access to necessary medical services 24 hours per day/7 days a week. • If the member requires detoxification services, must have the availability of on - site medical

treatment 24 hours per day/7days a week, which must be actively supervised by an attending Physician.

• Provides living arrangements that foster community living and peer interaction that are consistent with developmental needs.

• Offers group therapy sessions with at least an RN or Masters - Level Health Professional. • Has the ability to involve family/support systems in therapy (required for children and

adolescents; encouraged for adults). • Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual

psychotherapy. • Has peer oriented activities. • Services are managed by a licensed Behavioral Health Provider who, while not needing to be

individually contracted, needs to (1) meet the insurer credentialing criteria as an individual practitioner, and (2) function under the direction/supervision of a licensed psychiatrist (Medical Director).

• Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission.

• Provides a level of skilled intervention consistent with patient risk. • Meets any and all applicable licensing standards established by the jurisdiction in which it is

located • Is not a Wilderness Treatment Program or any such related or similar program, school and/or

education service. • Ability to assess and recognize withdrawal complications that threaten life or bodily functions

and to obtain needed services either on site or externally. • 24 - hours per day/7 days a week supervision by a Physician with evidence of close and frequent

observation. • On - site, licensed Behavioral Health Provider, medical or substance abuse professionals 24

hours per day/7 days a week • On - site licensed Behavioral Health Provider 24 hours per day/7 days a week.

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• Provides a comprehensive patient assessment (preferably before admission, but at least upon admission).

• Is admitted by a Physician. • Has access to necessary medical services 24 hours per day/7 days a week. • Provides living arrangements that foster community living and peer interaction that are consistent

with developmental needs. • Offers group therapy sessions with at least an RN or Masters - Level Health Professional. • Has the ability to involve family/support systems in therapy (required for children and

adolescents; encouraged for adults). • Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual

psychotherapy. • Has peer oriented activities. • Services are managed by a licensed Behavioral Health Provider who, while not needing to be

individually contracted, needs to (1) meet the insurer’s credentialing criteria as an individual practitioner, and (2) function under the direction/supervision of a licensed psychiatrist (Medical Director).

• Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission.

• Provides a level of skilled intervention consistent with patient risk. • Meets any and all applicable licensing standards established by the jurisdiction in which it is

located. • Is not a Wilderness Treatment Program or any such related or similar program, school and/or

education service. Virginia residential treatment or care – a specialized program for behavior disorders including substance abuse. It may include therapeutically A planned group living and learning situations including teaching of adaptive skills to help patient functioning in the community.

Specialty care

North Carolina Specialty care - health care services or supplies that require the services of a specialist whom is a physician who practices in any generally accepted medical or surgical subspecialty. Virginia specialty care – care provided by a specialist of specialized healthcare services

Specialty pharmacy

North Carolina Specialty pharmacy - a network of pharmacies designated to fill specialty drug prescriptions. Specialty drugs are drugs designated by the insurer that include, but are not limited, to pharmaceutical products that are: (a) Are very expensive, (b) Typically have no less costly equivalents, (c) Are often biologals, (d) May or may not be infused or injectable, (e) Require a greater amount of pharmaceutical oversight and clinical monitoring, and/or

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Are addressed to serious conditions like cancer, rheumatoid arthritis, and multiple sclerosis. Virginia specialty pharmacy – pharmacy companies that serve patients of chronic with high-cost injectable, infusion or biotech drugs. National Community Pharmacists Association (NCPA) (If defined, suggest this definition) A specialty pharmacy is a pharmacy that dispenses drugs or pharmaceuticals that usually require special handling, administration, unique inventory management and require a high level of patient interaction beyond the initial dispensing process. These pharmacies typically provide care to patients who are undergoing intensive therapies for illnesses that are generally chronic, complex and potentially life threatening. Alan Spielman - URAC URAC Definition Specialty pharmacy: Offers a high touch, comprehensive care system of pharmacological care wherein patients with chronic illnesses and complex disease states receive expert therapy management and support tailored to their individual needs. Medications that health plans and other payers classify as specialty pharmaceuticals may vary and evolve over time. (URAC PQM® Accreditation Programs Glossary)

Urgent care

North Carolina Urgent care - services provided by a physician due to:

• The onset of or change in an illness; or • The diagnosis of an illness; or • An injury • The condition, may or may not be an emergency, may or may not require confinement in a

hospital. Deductibles, coinsurance, and copayments may be applied. An urgent condition means a sudden illness; injury; or condition; that:

• is severe enough to require prompt medical attention to avoid serious deterioration of your health; • includes a condition which would subject you to severe pain that could not be adequately

managed without urgent care or treatment; • does not require the level of care provided in the emergency room of a hospital; • and requires immediate outpatient medical care that cannot be postponed until your physician

becomes reasonably available. Virginia urgent care - medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours. An urgent care condition could be a sprain, sore throat or rising temperature.

Alan Spielman – URAC

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URAC Definition Case Involving Urgent Care: Any request for a utilization management determination with respect to which the application of the time periods for making non-urgent care determinations a) could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function, or b) in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. (Note: This definition is derived from the Department of Labor’s definition of “claim involving urgent care.”)

URAC Interpretive Note for term “Case Involving Urgent Care”: While the URAC standards are silent on the methods by which a claim is determined to be a “case involving urgent care,” the Department of Labor claims regulation (29 C.F.R. § 2560.503-1(m)(1)) specifies that whether a claim is a “claim involving urgent care” is to be determined by an individual acting on behalf of the health benefits plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. Any claim that a physician with knowledge of the claimant's medical condition determines is a “claim involving urgent care” shall be treated as a “claim involving urgent care. (URAC Health Accreditation Programs Glossary)

III. ADDITIONAL SUBMISSIONS TERMS TO DEFINE Arizona

prevailing charge or recognized charge Missouri

coverage period / benefit period Louisiana “Custodial Care” “Pain Management” “Diagnostic Test(s) or Testing” “Experimental or Investigational Services” “Average Wholesale Price”

“balance billing” The LDOI will provide a definition at a future time. Idaho

“Allowable expense” means any health care expense including coinsurance or copayments, and without reduction for any applicable deductible that is covered in full or in part by any plan covering the person. “Allowable expense” means the expense incurred for a covered service or supply as determined by either the contractual allowance for participating providers or the maximum allowance as determined by a carrier’s contracted methodologies for non-participating providers. “Accident,” “accidental injury,” and “accidental” shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization. The definition shall not be more restrictive than the following: “Injury” or “injuries” means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided, independent of disease or bodily infirmity or any other cause, and that occurs while the insurance is in force. (3-30-01) The definition may exclude injuries for which benefits are provided:

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i. Under workers’ compensation, employers’ liability, or similar law; or ii. Under a motor vehicle no-fault plan, unless the motor vehicle no-fault plan provides for coordination of benefits; or iii. For injuries occurring while the insured person is engaged in any activity pertaining to a iv. profession, trade, business, employment or occupation for wage or profit

“Balance billing” means the practice where a provider bills an individual covered under the health benefit plan for the difference between the amount the provider normally charges for a service and the amount the plan recognizes as the allowable charge or negotiated price for the service delivered.

"Facility" means an institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers and rehabilitation and other therapeutic health settings. "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law. "Health care provider" or "provider" means a health care professional or a facility. "Health care services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.

"Restricted network provision" means any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of health care providers that have entered into a contractual arrangement with the carrier to provide health care services to covered individuals.

Michael Wroblewski - FTC:

Some thoughts on terms identified as problematic: The term “benefit” should apply to what the health plan pays for covered services, whereas the term “service” means what a provider provides. Eligible expense, negotiated fees/rates should be defined in terms of the UCR. We should define what happens in case a provider tries to balance bill for fees higher than UCR. We should define “network” as providers that the health plan has negotiated preferred charges and encourages enrollees to use. Pre-authorization: Plans may require you to get permission from your primary care doctor to see a specialist. This permission is called a “referral” or “pre-certification.”

Bill Schiffbauer

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balance billing - A bill from a provider to an insured patient (or the person financially responsible for the patient) for covered medical services or products in an amount that exceeds both what the applicable health insurance plan will cover and what the health plan obligates the patient to pay (e.g., copayments, deductibles, or coinsurance).

Alan Spielman – URAC Recommended Additional Terms for Definition

• generic drug

Proposed Definition Generic Drug: A generic medication is an equivalent of a brand name drug. A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less. A generic drug may have a different color or shape than the brand name, but it must have the same active ingredients, strength, and dosage form (pill, liquid, or injection). (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

• brand name drug

Proposed Definition Brand name drug: A prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer’s brand name. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

• referral • office visit • diagnostic • primary vs secondary benefits • treatment • illness • injury

URAC Definition Injury: Damage or harm caused to the structure or function of the body caused by an outside force, which may be physical or chemical… (URAC PQM® Accreditation Programs Glossary)

• personal care items • step therapy

Proposed Definition Step Therapy – A medication management approach intended to promote utilization of the most appropriate drug. Step therapy usually begins with the recommendation of the least costly and safest drug therapy progressing to more costly and or risky therapy only if necessary. (URAC Staff Recommendation)

• mail service pharmacy

Proposed Definition Mail Service Pharmacy – Pharmacies that dispense medications to patients through mail delivery. (URAC Staff Recommendation)

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• formulary

Alternative Proposed Definitions Formulary: A continually updated list of medications (could include transaction lists and preferred lists) and related information, representing the clinical judgment of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and promotion of health. (URAC PQM® Accreditation Programs Glossary; Adapted from Academy of Managed Care Pharmacy’s Principles of a Sound Drug Formulary System, 2000) Formulary or Prescription Drug List: A list of both generic and brand name drugs often made up of different cost-sharing levels or tiers, that are preferred by your health plan. Health plans choose drugs that are medically safe and cost effective. A team including pharmacists and physicians determines the drugs to include in the formulary. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

• non-covered

• provider

Proposed Definition Provider: A doctor, hospital, health care practitioner, pharmacy, or health care facility. (OPM Guide to Federal Benefits for Federal Civilian Employees; November 2009)

• non-participating provider • Participating provider

URAC Definition Participating provider: A provider that has entered into an agreement with the organization to be part of a provider network. (URAC Health Accreditation Programs Glossary)

Sharp Health Plans

Infertility - Infertility is defined as (1) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual intercourse without contraception, or (2) the presence of a demonstrated condition recognized by a physician as a cause of infertility. A woman without a male partner who is unable to conceive may be considered infertile if she is unable to conceive or produce conception after at least twelve (12) cycles of donor insemination.

Laurel Stine, Bazelon Center for Mental Health Law Psychiatric rehabilitation