Customer Service

• Pre-scheduled surgical services
• Emergency Health Services
• Pre-scheduled rehabilitative, laboratory or diagnostic services. An Alternative Facility may also provide Mental Health Services on an outpatient or inpatient/intermediate basis, or Substance Abuse Services on an outpatient or Intermediate Care basis.

Amendment
Any attached written description of additional or alternative provisions to the Policy. Amendments are effective only when signed by us. Amendments are subject to all conditions, limitations and exclusions of the Policy, except for those that are specifically amended.

Basic Health Services
As identified in MCL 500.3501, Basic Health Services are the following:

• Physician services including consultant and referral services by a Physician, but not including psychiatric services
• Ambulatory Services
• Inpatient Hospital services, other than those for the treatment of Mental Illness.
• Emergency Health Services
• Outpatient Mental Health Services
• Diagnostic laboratory and diagnostic and therapeutic radiological services
• Home health services
• Preventive services

Benefits
Your Right to payment for Covered Health Services that are available under the Policy. Your right to Benefits is subject to the terms, conditions, limitations and exclusions of the Policy, including the Certificate of Coverage and any attached Riders and Amendments.

Brand-name
A Prescription Drug Product: (1) which is manufactured and marketed under a trademark or name by a specific drug manufacturer; or (2) that we identify as a Brand-name product. We classify a Prescription Drug Product as a Brand-name based on available data resources, such as First DataBank, that classify drugs as either brand or generic based on a number of factors. You should know that all products identified as a “brand name” by the manufacturer, pharmacy, or your Physician may not be classified as Brand-name by us.

Carrier Replacement
The carrier replacement option provides employees with a health benefit plan provided by a single carrier.

Congenital Anomaly
A physical developmental defect that is present at birth, and is identified within the first twelve months of birth.

Co-payment
The charge you are required to pay for certain Covered Health Services. A Co-payment may be either a set dollar amount or a percentage of Eligible Expenses.

Co-payment Charge
The co-payment charge indicates the amount (or percentage) which a PHPSM member must pay for certain health services offered under the Plan (such as office visits, emergency care services, prescription drugs, or other services).

Cosmetic Procedures
Procedures or services that change or improve appearance without significantly improving physiological function, as determined by us.

Covered Health Service(s)
Those health services provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, Mental Illness, substance abuse, or their symptoms.

A Covered Health Service is a health care service or supply described in Section 1: What’s Covered—Benefits, as a Covered Health Service, which is not excluded under Section 2: What’s Not Covered—Exclusions.

Covered Person
Either the Subscriber or an Enrolled Dependent, but this term applies only while the person is enrolled under the Policy. References to “you” and “your” throughout the Certificate of Coverage are references to a Covered Person.

Custodial Care
Services that:

• Are non-health related services, such as assistance in activities of daily living (including but not limited to feeding, dressing, bathing, transferring and ambulating); or
• Are health-related services which do not seek to cure, or which are provided during periods when the medical condition of the patient who requires the service is not changing; or
• Do not require continued administration by trained medical personnel in order to be delivered safely and effectively.

Dependent
The Subscriber’s legal spouse or an unmarried dependent child of the Subscriber or the Subscriber’s spouse. The term child includes any of the following:

• A natural child
• A stepchild
• A legally adopted child
• A child placed for adoption
• A child for whom legal guardianship has been awarded to the Subscriber or the Subscriber’s spouse

The definition of Dependent is subject to the following conditions and limitations:

• An eligible family dependent, as defined by PHPSM, is a person who is:
• The Subscriber’s legal spouse
• An unmarried child less than 19 years of age
• An unmarried child who is 19 to 25 years of age (or that is designated in the Master Group Policy) who is a full-time student at an accredited educational institution and:
• Not regularly employed on a full-time basis
• Whose principal resident is with the subscriber
• Documentation is furnished to PHPSM as required
• The term shall include any stepchild, legally adopted child, or child under legal guardianship whose principal place of residence is with the subscriber unless other arrangements are approved by Plan. PHPSM may require dependent eligibility verification.
• An unmarried child incapable of self-support because of mental or physical disabilities. Coverage of such child would ordinarily terminate upon attaining the specified age as a family dependent subject to the extended coverage limitation as specific in the Master Group Policy.
• In no event shall the term family dependent include:
• Any spouse covered under this Policy as a subscriber; or
• Any child eligible for coverage under this Policy as a subscriber.

• When Covered Health Services are received from Network providers, Eligible Expenses are our contracted fee(s) with that provider
• When Covered Health Services are received from non-Network providers as a result of an Emergency or as otherwise arranged by your Primary Physician or other Network Physician and approved by us, Eligible Expenses are billed charges unless a lower amount is negotiated.

If you receive services from a non-Network provider that are not a result of an Emergency or are not otherwise arranged by your Primary Physician or other Network Physician and approved by us, those services are not Covered Health Services and any of the costs associated with the services are not Eligible Expenses.

Eligible Person
An employee of the Enrolling Group or other person whose connection with the Enrolling Group meets the eligibility requirements specified in both the application and the policy. An Eligible Person must reside and/or work within the Service Area.

Emergency
The sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual’s health, or to a Pregnancy in the case of a pregnant woman, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Emergency Health Services
Health care services and supplies necessary for the treatment of an Emergency.

Enrolled Dependent
A Dependent who is properly enrolled under the Policy.

Enrolling Group
The employer, or other defined or otherwise legally established group, to whom the Policy is issued.

Experimental Investigational Services
Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time we make a determination regarding coverage in a particular case, are determined to be any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use.
• Subject to review and approval by any institutional review board for the proposed use.
• The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

Full-time Student
A person who is enrolled in and attending, full-time, a recognized course of study or training at one of the following:

• An accredited high school
• An accredited college or university
• A licensed vocational school, technical school, beautician school, automotive school or similar training school.

You continue to be a Full-time Student during periods of regular vacation established by the institution. If you do not continue as a Full-time Student immediately following the period of vacation, the Full-time Student designation will end as described above.

Generic
A Prescription Drug Product: (1) that is chemically equivalent to a Brand-name drug; or (2) that we identify as a Generic product. Classification of a Prescription Drug Product as a generic is determined by us and not by the manufacturer or pharmacy. We classify a Prescription Drug Product as a Generic based on available data resources, such as First DataBank, that classify drugs as either brand or generic based on a number of factors. You should know that all products identified as a “generic” by the manufacturer, pharmacy or your Physician may not be classified as a Generic by us.

Hospital
An institution, operated as required by law, which is both of the following:

• Is primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment of injured or sick individuals. Care is provided through medical, diagnostic and surgical facilities, by or under the supervision of a staff of Physicians.
• Has 24-hour nursing services.

A Hospital is not primarily a place for rest, custodial care or care of the aged and is not a nursing home, convalescent home or similar institution.

Identification Card
A PHPSM Identification Card is sent to each subscriber and spouse (if applicable) with each enrolled dependent listed on the card. This card must be presented at the physician’s office or participating facility when services are received. The card lists:

• Member’s Name
• Identification Number
• Eligible Dependents
• Plan contact numbers

Initial Enrollment Period
The initial period of time, as we agree with the Enrolling Group, during which Eligible Persons may enroll themselves and their Dependents under the Policy.

Injury
Bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Inpatient Rehabilitation Facility
A Hospital (or special unit of a Hospital that is designated as an Inpatient Rehabilitation Facility) that provides rehabilitation health services (physical therapy, occupational therapy, and/or speech therapy) on an inpatient basis, as authorized by law.

Inpatient Stay
An uninterrupted confinement, following formal admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility.

Intermediate Care
The use of any or all of the therapeutic techniques, as identified in a treatment plan for individuals who are physiologically or psychologically dependent upon or abusing alcohol or drugs:

• Chemotherapy
• Counseling
• Other ancillary services, such as medical testing, diagnostic evaluation, and referral to other services identified in a treatment plan.

Medically Necessary
Health care services and supplies which are determined by your Primary Physician or other Network Physician to be medically appropriate, and

• Necessary to meet the basic health needs of the Covered Person
• Consistent with conclusions of prevailing medical research which demonstrate that the health service has a beneficial effect on health outcomes
• Consistent with the diagnosis of the condition
• Demonstrated through prevailing peer-reviewed medical literature to be either
• Safe and effective for treating or diagnosing the condition or Sickness for which their use is proposed, or,
• Safe with promising efficacy:
• For treating a life-threatening Sickness or condition; and
• In a clinically controlled research setting; and
• Using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.

Medicare
Parts A, B, and C of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended. Medicare Part D will be effective 1-1-2006.

Mental Health Services
Covered Health Services for the diagnosis and treatment of Mental Illnesses. The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a Covered health Service.

Mental Health /Substance Abuse Designee
The organization or individual, designated by us, that provides or arranges mental Health Services and Substance Abuse Services for which benefits are available under the Policy.

Mental Illness
Those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded under the Policy.

Network
When used to describe a provider of health care services, this means a provider that has a participation agreement in effect with us or with our affiliate to (either directly or indirectly) to participate in our Network. Our affiliates are those entities affiliated with us through common ownership or control with us or with our ultimate corporate parent, including direct and indirect subsidiaries.

A provider may enter into an agreement to provide only certain Covered Health Services, but not all Covered Health Services, or to be a Network provider for only some of our products. In this case, the provider will be a Network provider for the Health Services and products included in the participation agreement, and a non-Network provider for other Health Services and products. The participation status of providers will change from time to time.

Out-of-Pocket Maximums
The maximum amount of Co-payments you pay every calendar year. Once you reach the Out-of-Pocket Maximum, Benefits for those Covered Health Services that apply to the Out-of-Pocket Maximum are payable at 100% of Eligible Expenses during the rest of that calendar year. Co-payments for some Covered Health Services will never apply to the Out-of-Pocket Maximum, as specified in Section 1 of the Certificate of Coverage: What’s Covered—Benefits, and those Benefits will never been payable at 100% even when the Out-of-Pocket Maximum is reached.

The following costs will never apply to the Out-of-Pocket Maximum:

• Any charges for non-Covered Health Services
• Co-payments for Covered Health Services available by an optional Rider.
• Any Co-payments for Covered Health Services in Section 1 of the Certificate of Coverage: What’s Covered—Benefits, that do not apply to the Out-of-Pocket Maximum. Co-payments that are charged as a flat dollar amount (instead of as a percentage of Eligible Expenses) do not apply to the Out-of-Pocket Maximum

• Any charges for non-Covered Health Services
• Co-payments for Covered Health Services available by an optional Rider
• Co-payments for Covered health Services in Section 1 of the Certificate of Coverage: What’s Covered—Benefits, that are subject to Co-payments that do not apply to the Out-of-Pocket Maximums.

Outpatient Recreational Therapy
Outpatient recreational activities that may be considered to serve a therapeutic purpose including, but not limited to, camp or camping events, sports or sporting events, horseback riding, art therapy services or art instruction, music therapy services or music instruction, boating or other recreational activities.

Participating Hospital, Physicians, Pharmacy
A participating physician, M.D. or D.O., hospital, urgent care facility, or pharmacy that has entered into an agreement with PHPSM to provide medical care services to plan members. Employees who elect to enroll in PHPSM must obtain medical care and/or services from participating hospitals, physicians, urgent care facilities and pharmacies.

There are exceptions for certain emergency situations and authorized referrals to non-participating physicians and facilities. These exceptions are covered in your Master Group Policy with PHPSM.

The Provider Directory is a detailed listing of participating providers.

Physician
Any Doctor of Medicine, "M.D.," or Doctor of Osteopathy, "D.O.," who is properly licensed and qualified by law.

Please Note: Any nurse practitioner, physician assistant, podiatrist, dentist, psychologist, chiropractor, optometrist, or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that we describe a provider as a Physician does not mean that Benefits for services from that provider are available to you under the Policy.

Policy
The entire agreement issued to the Enrolling Group, which includes all of the following:

• The group Policy
• This Certificate of Coverage
• The Enrolling Group’s application
• Amendments
• Riders

Policy Charge
The sum of the Premiums for all Subscribers and Enrolled Dependents enrolled under the Policy.

Pregnancy
Includes all of the following:

• Prenatal care
• Postnatal care
• Childbirth
• Any complications associated with Pregnancy

Premium
The periodic fee required for each Subscriber and each Enrolled Dependent, in accordance with the terms of the Policy.

Prescription Drug Product
A medication, product or device that has been approved by the Food and Drug Administration and that can, under federal or state law, be dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. For the purpose of Benefits under the Policy, this definition includes:

• Inhalers (with spacers)
• Insulin
• The following diabetic supplies:
• Insulin syringes with needles
• Blood testing strips-glucose
• Urine testing strips-glucose
• Ketone testing strips and tablets
• Lancets and lancet devices
• Insulin pump supplies, including infusion sets, reservoirs, glass cartridges, and insertion sets
• Control solutions and combo kits
• Glucose monitors

Prescription Order or Refill
The directive to dispense a Prescription Drug Product issued by a duly licensed health care provider whose scope of practice permits issuing such a directive

Preventive Health Services
Covered Health Services that are designated to keep you in good health and to prevent unnecessary Injury, Sickness or disability in accordance with our current “Preventive Guidelines.” These guidelines include the following as may be appropriate based on your age and/or sex:

• Voluntary family planning
• Well-baby and well-child care
• Routine physical examinations (including related pathology and radiology services)
• Diagnostic screenings (vision screenings do not include refractive examinations to detect vision impairment)
• Immunizations

Primary Physician
A Network Physician that you select to be responsible for providing or coordinating all Covered Health Services. A Primary Physician has entered into an agreement with us to provide primary care health services to Covered Persons. The majority of his or her practice generally includes pediatrics, internal medicine, obstetrics/gynecology, or family or general practice.

Qualifying Event
An event occurring outside the annual open enrollment period which allows members to enroll in the plan. These events include:

• New Hire
• Marriage
• Birth
• Loss of Coverage
• Adoption or placement for adoption

Rate & Premium Classification
The rate code and premium classification in which PHPSM members are assigned determined by the number of eligible family members covered by the employee’s benefit plan.

Rider
Any attached written description of additional Covered Health Services not described in the Certificate of Coverage. Covered Health Services provided by a Rider may be subject to payment of additional Premiums. Riders are effective only when signed by us and are subject to all conditions, limitations and exclusions of the Policy except for those that are specifically amended in the Rider.

Service Area
The geographic area we serve and that has been approved by the appropriate regulatory agency. Contact us to determine the exact geographic area we serve. The Service Area may change from time to time.

It is required that employees reside within the designated service area to be eligible for enrollment in PHPSM. Subscribers who reside outside the service area will be required to sign an Out-of-Area waiver that will be mailed to their home. The subscriber must live within 30 miles of a participating facility in order to be eligible. Subscribers residing outside the designated areas should be aware that non-emergency covered services must be received from participating providers within the PHPSM service area.

Sickness
Physical illness, disease or Pregnancy. The term Sickness as used in the Certificate of Coverage does not include Mental Illness or substance abuse, regardless of the cause or origin of the Mental Illness or substance abuse.

Skilled Nursing Facility
A Hospital or nursing facility that is licensed and operated as required by law.

Subscriber
An Eligible Person who is properly enrolled under the Policy. The Subscriber is the person on whose behalf the Policy is issued to the Enrolling Group. A subscriber is an employee of the Enrolling Group who:

• a. Is eligible on his/her own behalf, and not by virtue of being an eligible family dependent, to participate in the health benefits under the PHPSM Policy, and
• b. Is enrolled for coverage under the PHPSM Policy.

Substance Abuse Services
Covered Health Services for the diagnosis and treatment of alcoholism and substance abuse disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Health Service. Substance Abuse Services include services for the prevention, treatment and rehabilitation for Covered Persons who take alcohol or other drugs at dosages that place the individual’s social, economic, psychological, and physical welfare in potential hazard, or to the extent that an individual loses the power of self-control as a result of the use of alcohol or drugs, or while habitually under the influence of alcohol or drugs, endangers public health, morals, safety, or welfare, or a combination thereof.

Unproven Services
Services that are not consistent with conclusions of prevailing medical research which demonstrate that the health service has a beneficial effect on health outcomes and that are not based on trials that meet either of the following designs.

• Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received.)
• Well-conducted cohort studies. (Patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.)

Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions of prevailing medical research, based on well-conducted randomized trials or cohort studies, as described.

If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment) we may, in our discretion, determine that an Unproven Service meets the definition of a Covered Health Service for that Sickness or condition. For an Unproven Service to take place, we must determine that the procedure or treatment is promising, but unproven, and that the service uses a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.

Usual and Customary Charge
The usual fee that a pharmacy charges individuals for a Prescription Drug Product without reference to reimbursement to the pharmacy by third parties.

Urgent Care Center
A facility, other than a Hospital, that provides Covered Health Services that are required to prevent serious deterioration of your health, and that are required as a result of an unforeseen Sickness, Injury, or the onset of acute or severe symptoms.

If you can’t find what you’re looking for, or need more information, contact theCustomer Service Department.