2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 83
government, or a foreign country that provides health coverage to individuals who are enrolled in the Medical Plan);
(10) a Peace Corps plan; (11) the State Children’s Health Insurance Program.
Rehabilitation Facility means a facility must meet all of the following requirements: (1) must be for the treatment
of acute Injury or Illness; (2) is licensed as an acute Rehabilitation Facility; (3) the care is under the direct supervision
of a Physician; (4) services are Medically Necessary; (5) services are specific to an active written treatment plan;
(6) the patient's condition requires skilled nursing care and interventions which cannot be achieved or managed at
a lower level of care; (7) nursing services are available 24 hours a day; and (8) the confinement is not for Custodial
Care or maintenance care.
Seasonal Employee means an Employee who is hired into a position that recurs annually at about the same time
each year for which the customary annual employment is 6 months or less.
Special Enrollee is an eligible Dependent that does not elect coverage under this Plan during their original 31-day
eligibility period and who later enrolls in the Medical Plan due to a Special Enrollment Event.
Spouse is defined in the "Eligibility for Participation" section of the Medical Plan.
Substance Use Disorder means any disease or condition that is classified as a Substance Use Disorder in the
current edition of the International Classification of Diseases published by the U.S. Department of Health and
Human Services.
Surgery or Surgical Procedure means any of the following:
(1)
The incision, excision, debridement or cauterization of any organ or part of the body and the suturing of a
wound;
(2)
The manipulative reduction of a fracture or dislocation or the manipulation of a joint including application of
cast or traction;
(3)
The removal by endoscopic means of a stone or other foreign object from any part of the body or the
diagnostic examination by endoscopic means of any part of the body;
(4)
The induction of artificial pneumothorax and the injection of sclerosing solutions;
(5)
Arthrodesis, paracentesis, arthrocentesis and all injections into the joints or bursa;
(6)
Obstetrical delivery and dilation and curettage; or
(7)
Biopsy.
Surprise Bill means an unexpected bill from a provider or facility which usually occurs when a Covered Person
receives medical services from a provider or facility that, usually unknown to the Covered Person, is a NonParticipating Provider or facility with respect to the Health Plan. Surprise Bills can occur for both emergency and
non-emergency care.
Telemedicine means services performed by a Physician in accordance with applicable state and federal law related
to the delivery of clinical medicine via real-time telecommunications such as telephone, the Internet, mobile app, or
other communications networks or device that do not involve direct patient contact, including services for medical
or mental disorders.
Urgent Care Facility means a facility which is engaged primarily in providing minor emergency and episodic
medical care to a Covered Person. A board-certified Physician, a registered nurse and a registered x-ray technician
must be in attendance at all times that the facility is open. The facility must include x-ray and laboratory equipment
and a life support system. For the purpose of this Medical Plan, a facility meeting these requirements will be
considered to be an Urgent Care Facility, by whatever actual name it may be called; however, an after-hours clinic
shall be excluded from the terms of this definition.
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