2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 82
(2)
“Effective" means the treatments beneficial effects can be expected to outweigh any harmful effects. Effective
care is treatment proven to have a positive effect on your health, while addressing particular problems caused
by disease, Injury, Illness or a clinical condition.
(3)
"Appropriate" means the treatment's timing and setting are proper and cost effective.
Medical treatments which are not proven, effective and appropriate are not covered by the Medical Plan.
All criteria must be satisfied. When a Physician recommends or approves certain care it does not mean that care
is Medically Necessary.
Medical Plan Administrator means RCAA Administrative Services, Inc., which is sponsoring this Medical Plan for
Employees of the Employer. The Medical Plan Administrator may hire persons or firms to process claims and
perform other Medical Plan connected services.
Medical Plan Sponsor means RCAA Administrative Services, Inc.
Medical Plan Year means the period from January 1 - December 31 each year.
Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is classified as
a Mental Disorder in the current edition of the International Classification of Diseases published by the U.S.
Department of Health and Human Services.
Morbid Obesity is defined as a diagnosed condition in which the body weight exceeds the medically recommended
weight by either 100 pounds or is twice the medically recommended weight for a person of the same height, age
and mobility as the Covered Person, has a body mass index (BMI) of 40 or greater. Treatment for Morbid Obesity
is subject to the provisions of the Medical Plan. See Eligible Medical Expenses.
Non-Participating Provider means a health care practitioner or health care facility that has not contracted directly
with the Medical Plan or an entity contracting on behalf of the Medical Plan to provide health care services to
Medical Plan enrollees.
Participating Provider means all participating providers, health professionals, Hospitals, or other organizations
having an agreement with Aetna Choice® POS II the Participating Provider Organization (PPO).
Physician means a legally licensed Physician who is acting within the scope of their license and any other licensed
practitioner required to be recognized for benefit payment purposes under the laws of the state in which they
practice and who is acting within the scope of their license. The definition of Physician includes, but is not limited
to: Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Chiropractor, Licensed Consulting Psychologist,
Licensed Psychologist, Licensed Clinical Social Worker, Occupational Therapist, Optometrist, Ophthalmologist,
Physical Therapist, Podiatrist, Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.), Nurse Practitioner,
Physician’s Assistant, Speech Therapist, Speech Pathologist and Licensed Midwife (if covered by the Medical
Plan). An employee of a Physician who provides services under the direction and supervision of such Physician
will also be deemed to be an eligible provider under the Medical Plan.
Plan means The Roman Catholic Archdiocese of Atlanta Group Medical Plan.
Prescription Drug means any of the following: (a) a Food and Drug Administration-approved drug or medicine,
which, under federal law, is required to bear the legend, “Caution: federal law prohibits dispensing without
prescription,” (b) injectable insulin; or (c) hypodermic needles or syringes, but only when dispensed upon a written
prescription of a licensed Physician. Such drug must be Medically Necessary in the treatment of an Illness or Injury
and be used for approved FDA indications.
Qualified Health Plan The following will be considered Qualified Health Plans: (1) a group health plan; (2) health
insurance coverage; (3) Medicare; (4) Medicaid; (5) TRI-CARE; (6) an Indian Health Service plan or tribal
organization plan; (7) a state risk pool coverage; (8) a federal employees health insurance coverage; (9) a public
health plan (this includes plans established or maintained by a state, the U.S. government, a foreign country, a
state or federal penitentiary, U.S. Veterans Administration, or any political subdivision of a state, the U.S.
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