Section 8
Glossary

The definitions in this section apply whether or not the defined words are bolded when used in this handbook.

ACUPUNCTURE:
The stimulation of a point or points on or near the surface of the body by the insertion of needles. The purpose of acupuncture treatment is to prevent or modify the patient's perception of pain or to control pain.

ADMISSION:
Being checked in to a hospital or outpatient facility. If, after you're discharged, you're re-admitted within 30 days for the same injury or illness, that admittance is considered part of the initial admission.

AMBULATORY SURGERY CENTER:
A freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It must also be Medicare-approved or meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.

ANNUAL BENEFIT MAXIMUM:
The maximum amount the plan pays each plan year for an eligible expense.

ASSIGNMENT OF BENEFITS:
Refers to giving a provider permission to submit claims (evidence of loss) for medical services to the appropriate Claims Administrator for processing. Benefits may be assigned automatically to network providers based on their agreement with the plan's network. Benefits may also be assigned to a non-network provider if he/she allows it.

BRAND-NAME DRUG:
A prescription drug that's patented and subject to an exclusivity agreement, which allows the patent owner to be the sole manufacturer of the drug for a certain number of years.

CALENDAR-YEAR DEDUCTIBLE:
The portion of eligible expenses you're responsible for paying each calendar year before the Fund begins to pay certain benefits.

CASE MANAGEMENT:
A program offered by the Fund which provides participants assistance, coordination and management of medical care and treatment.

CERTIFIED RETIREE:
A participant who satisfies certain requirements is designated as a Certified Retiree. (See "Certified Retirees" for eligibility requirements.)

CHIROPRACTIC CARE:
Care that may be provided by chiropractors acting within the licensed scope of practice, except for:

• On-site calls; and
• Exercise at a gym or similar facility.

COBRA:
The acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985 which allows for the purchase of coverage after loss of eligibility due to certain qualifying events.

COINSURANCE:
The percentage of eligible expenses you're responsible for paying.

COMPLICATIONS OF PREGNANCY:
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. Examples are acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity.

The following are not considered complications of pregnancy: false labor; occasional spotting; physician-prescribed rest during pregnancy; morning sickness; hyperemesis gravidarum; pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; an elective Caesarean section; an ectopic pregnancy that is terminated; or a spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.

Complications of pregnancy as defined above are covered under the plan to the same extent as any other sickness.

COMPREHENSIVE MEDICAL REHABILITATION HOSPITAL:
Hospitals that are licensed and certified facilities that provide special rehabilitative health care services rather than general medical and surgical service. Rehabilitative therapy focuses on restoring physical function and abilities lost due to an acute debilitating condition. At the onset of therapy, it is assumed that there is a reasonable expectation of complete or partial restoration of function. In order to clarify the standards governing such coverage, the plan was amended as of April 1, 2002 to provide that coverage for an admission must meet the following requirements:

• The patient has a condition that has resulted in a significant decrease in functional ability;
• There is a reasonable expectation that the patient will improve in a reasonable and generally predictable period of time and that such recovery will be aided by the inpatient rehabilitation care;
• The intensity of service required cannot be provided in the outpatient setting;
• The patient requires and will receive multidisciplinary team care, defined as at least two therapies (e.g., speech, occupational, physical, and/or respiratory therapies) provided on a daily basis (at least three hours per day, five days per week); and
• The patient's medical condition and treatment require physician supervision at least three times per week.

CONTRACTED RATE:
The fee that is negotiated between the plans and their network providers. Contracted rate applies to network services only.

COORDINATION OF BENEFITS (COB):
The payment of health care benefits when a member is covered by two or more benefit plans. One of the health plans will be primary and the other secondary. The primary plan pays first following its rules and schedule of benefits; then the payments under the secondary plan are coordinated so that combined plan payments don't exceed 100% of eligible expenses.

COPAY:
A fixed dollar amount you pay for an eligible expense at the time the service is provided.

COSMETIC SURGERY:
Procedures performed primarily to make an improvement in a person's appearance. Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance or self-esteem. Reconstructive surgery, unlike cosmetic surgery, is covered. Reconstructive surgery is performed on abnormal structures of the body, resulting from congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Reconstructive surgery is generally performed to improve function, but may also be done to approximate a normal appearance.

COVERED EARNINGS:
Income for writing services covered by the Minimum Basic Agreement (MBA) that employers report to the Fund.

CUSTODIAL CARE:
Care designed to help a person in the activities of daily living. Continuous attention by trained medical or paramedical personnel is not necessary. Such care may involve:

• Preparation of special diets;
• Supervision of medication that can be self-administered; and
• Helping the person get in or out of bed, walk, bathe, dress, eat or use the toilet.

DEDUCTIBLE:
The amount you must pay for covered services in a plan year before the plan begins to pay benefits.

DEDUCTIBLE CARRYOVER:
A special provision that applies to every covered family member. It allows you, under certain circumstances, to carry over from one year to the next eligible expenses that were applied to your deductible.

DENTIST:
A doctor of dentistry who is licensed to practice dentistry at the time and place involved where the particular dental procedure was rendered.

DURABLE MEDICAL EQUIPMENT:
Equipment that is:

• Ordered by your physician;
• Used primarily for medical purposes;
• Able to withstand repeated use;
• Generally not of use in the absence of sickness or injury; and
• Appropriate for use in the home.

ELIGIBLE DEPENDENT:
Any dependent of a participant who meets the criteria for eligibility established by the Fund.

ELIGIBLE EXPENSE:
Any reasonable and customary charge for medically necessary services or supplies which is cove red in full or in part by the plan.

EMPLOYER CONTRIBUTIONS:
Contributions employers pay to the Fund that are based on a percentage of a writer's earnings.

FULL-TIME STUDENT:
Your unmarried child between age 19 and age 23, provided the child is attending an accredited school of higher learning on a full-time basis and is dependent on you for full support and maintenance. Coverage will be granted for the semester enrolled plus 90 days. If the dependent child does not return to school on a full-time basis immediately following the 90-day extension period, coverage will end on the last day of the 90-day period or, if earlier, the last day of the month in which the child turns age 23.

A student verification form, including a school seal or stamp, must be completed by the Registrar's Office of the accredited school of higher learning. This verification form must be submitted for each semester the child is enrolled as a full-time student. The school must indicate that the student is enrolled as a full-time student and give the start and end dates of the school term.

FUND:
The Writers' Guild-Industry Health Fund.

GENERIC DRUG:
A prescription drug that has the same active ingredients as a brand-name drug and is subject to the same FDA standards for quality, strength and purity as its brand-name counterpart, but is marketed with its chemical name and typically costs less. Not all brand-name drugs have generic equivalents.

HOME HEALTH CARE:
A program for care and treatment of a sick or injured person in that person's home by a home health care agency. The program must be ordered by the sick or injured person's attending physician and approved by case management intervention.

HOME HEALTH CARE AGENCY:
A hospital, service or agency which holds a valid certificate of approval or license, authorizing it to provide home health care services; or any establishment approved as a home health agency by Medicare.

HOSPICE:
An agency that provides health care services for palliative treatment and supportive care of terminally ill individuals. Services may include medical social services, skilled RN visits, intermittent visits by a nursing assistant, all equipment needed for the comfort and care of the patient, pain management, therapy needed to maintain function and pastoral counseling. The agency that provides this service must:

• Provide on-call coverage 24 hours a day, 7 days a week;
• Provide a program of services under direct supervision of a physician or licensed R.N.;
• Maintain full and complete records of all services provided to all covered persons; and
• Be established and operated in accordance with the applicable laws or regulations of the jurisdiction in which it is located.

HOSPITAL:
A facility that provides diagnosis, treatment and care of persons who need acute inpatient care under the supervision of physicians. It must be licensed as a general acute care hospital according to state and local laws. It must also be registered as a general hospital by the American Hospital Association and meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations.

A hospital also includes:

• A psychiatric health facility as defined in Section 1250.2 of the California Health and Safety Code, when service is rendered there for psychiatric or mental conditions; and
• An outpatient center as defined on page 102.

ILLNESS:
A sickness or disease that causes loss covered by the plan. Pregnancy is considered a sickness with respect to a covered female participant, the same-sex domestic partner of a female covered participant and the spouse of a male covered participant only. Pregnancy for dependent children isn't covered, except for complications of pregnancy.

INJURY:
Bodily harm caused by an accident. The injury must also result, for the purposes of accidental death and dismemberment coverage, directly and independently of all other causes, in a loss covered by the plan.

INTENSIVE CARE UNIT:
A section within a hospital which operates exclusively for the care of critically ill patients and which provides special supplies, equipment and constant observation and care by registered nurses or other highly trained hospital personnel. It is not a hospital facility maintained for the purpose of providing normal postoperative recovery treatment.

INVESTIGATIONAL/EXPERIMENTAL TREATMENT:
A treatment that fails to meet specific criteria and, except in certain situations involving organ or tissue transplants, is not covered.

A procedure will be considered non-investigational or non-experimental (and thus eligible for coverage) if it meets all of the following criteria:

• The technology has final approval from the appropriate government regulatory bodies;
• The scientific evidence permits conclusions concerning the effect of the technology on health outcomes. The evidence must include appropriate studies in peer-reviewed journals;
• The technology improves the net health outcome. Its beneficial effects should outweigh any harmful effects;
• The technology is as beneficial and cost-efficient as any established alternatives; and
• The improvement is attainable outside the investigational setting (i.e., it is being performed in additional hospitals/facilities other than the hospitals/facilities doing the investigation). When used in the usual conditions of practice, the technology must satisfy the criteria of this bullet and the one above. When the application of a technology is limited to a tertiary care environment, that technology must be in regular use in tertiary care facilities and not restricted to a single center.

LIFETIME MAXIMUM BENEFIT:
The maximum medical benefit payable by the Fund for a covered person throughout his/her lifetime. Once the lifetime benefit maximum is reached, no additional plan benefits will be paid.

MAINTENANCE MEDICATIONS:
Prescription drugs that are used on an ongoing basis (e.g., thyroid replacement, diabetes or cardiac medications).

MEDICAL EMERGENCY:
A sudden and, at that time, unexpected change in a person's physical or mental condition which, if not treated immediately, could result in a loss of life or limb, significant impairment of a bodily function or permanent dysfunction of a body part. Examples include heart attack, stroke, severe bleeding, serious burns and poisoning.

MEDICALLY NECESSARY:
Medical treatment that satisfies the definition of "necessary treatment."

MENTALLY RETARDED:
Having a condition of arrested or incomplete development of mind, present from birth or early infancy, which is especially characterized by a deficiency of intelligence.

MORBID OBESITY:
A body mass index in excess of 40 or a body mass index in excess of 35 with significant co-morbid conditions. Body mass index is calculated as the weight in kilograms divided by the square of height in meters.

NECESSARY TREATMENT:
Provision of services or supplies that the Fund determines to be:

• Appropriate and necessary for the diagnosis or treatment of the medical or dental condition;
• Provided for the diagnosis or direct care and treatment of the medical or dental condition;
• Within standards of good medical or dental practice within the organized medical or dental community;
• Not primarily for the patient's convenience, or for the convenience of the physician or another provider; and
• The most appropriate supply or level of service that can safely be provided. For hospital stays, this means that acute care as an inpatient is needed due to the kind of services the patient is receiving or the severity of the patient's condition, and safe and adequate care cannot be received as an outpatient or in a less intense medical setting.

OCCUPATIONAL THERAPY:
The provision, by a person acting within the licensed scope of practice or state certification, of evaluation and training in self-care, work, and play activities to increase independent function, enhance development, and prevent disability. Services may include evaluation, individualized modifications, and training of patients to use adaptive equipment for activities of daily living. Occupational therapy services may include evaluation or work in coordination with a physical therapy provider and/or speech therapy/pathology provider. Occupational therapy services may also include environmental assessment at home, work, or school, and in other community settings to identify how multiple settings may need modification to better match a patient's abilities.

OUT-OF-POCKET MAXIMUM:
The maximum amount you pay each plan year for eligible medical expenses.

OUTPATIENT CENTER:
A freestanding center or entity within a hospital which is approved and licensed by the state as a place where outpatient diagnostic services or surgical treatment of an illness or injury are performed.

PARTICIPANT:
An individual or that individual's dependent(s) or same-sex domestic partner who meet(s) the eligibility requirements established by the Fund.

PCP:
The acronym for primary care physician.

PHYSICAL THERAPY:
The provision, by a person acting within the licensed scope of practice, of evaluation and training in muscle strengthening, neuromuscular reeducation, and ambulation training. Services may include ambulation aids, such as walkers, wheelchairs and devices to assist with transferring a patient, such as lifts. Services may also include therapeutic interventions related to strength and mobility; teaching of in-home exercises; use of modalities such as ultrasound, hot packs/cold packs, galvanic stimulation, and TENS units; and assessment of equipment needs.

PHYSICALLY HANDICAPPED:
Having a bodily defect, disability or characteristic that restricts, limits or prevents an individual's participation in normal physical activities or interferes with standard achievements, and/or limits or prohibits an individual's capacity to work or be gainfully employed and requires dependency on parents or other care providers for lifetime care and supervision.

PHYSICIAN:

• A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is licensed to practice medicine or osteopathy where the care is provided; or
• One of the following providers, but only when the provider is licensed to practice where the care is provided, is rendering a service within the scope of that license, and is providing a service for which benefits are specified in this booklet; and when benefits would be payable if the services were provided by a physician, as defined above:
  • Acupuncturist (A.C.)
  • Audiologist*
  • Chiropractor (D.C.)
  • Clinical social worker (L.C.S.W.)
  • Dispensing optician
  • Marriage, family and child counselor (M.F.C.C.)
  • Nurse midwife*
  • Occupational therapist (O.T.R.)*
  • Optometrist (O.D.)
  • Oriental medicine doctors (O.M.D.)*
  • Physical therapist (P.T. or R.P.T.)*
  • Podiatrist or chiropodist (D.P.M, D.S.P. or D.S.C.)
  • Psychiatric mental health nurse (R.N.)*
  • Psychologist
  • Respiratory care practitioner (R.C.P.)*
  • Speech pathologist*

* The providers indicated by an asterisk (*) are covered only by referral of a physician as defined above.

The physician may not be you, a member of your immediate family, your same-sex domestic partner or a person residing in your home. "Immediate family" means your spouse, children, brothers, sisters or parents.

PLAN:
The group of benefits provided by the Fund. The plan is subject to change by the Board of Trustees of the Fund at any time.

PPO:
An acronym for Preferred Provider Organization.

PREDETERMINATION OF BENEFITS:
The process of obtaining certification or authorization from a plan for a procedure before it's performed.

PREEXISTING CONDITION:
An injury or illness for which you or your eligible dependent has received treatment, incurred expenses or received a diagnosis within 90 days before the enrollment date.

PREFERRED PROVIDER ORGANIZATION:
A medical plan with a network of doctors, hospitals and other health care providers who have agreed to provide their services at contracted rates. Each time you need medical care, you may go to an in-network or out-of-network provider.

PRIMARY CARE PHYSICIAN:
A physician within your plan's network who you've selected to coordinate all of your medical care. This includes providing routine medical services and referring you to a specialist, if necessary.

REASONABLE AND CUSTOMARY (R&C) CHARGE:
The fee regularly charged and received for a given service by the health care provider which doesn't exceed the general level of charges, as determined by the Fund, being made by providers of similar training and experience for treatment of a similar sickness, condition or injury in a similar geographic area. To determine an R&C charge, physicians are surveyed by region to determine what they will accept as payment for each procedure. That data is organized in percentile groups - the Fund uses the 80th percentile to determine R&C charges.

SAME-SEX DOMESTIC PARTNER:
An individual who has submitted to the Fund an Affidavit of Domestic Partnership on a form provided by the Fund, along with supporting documentation, and who meets the criteria set forth in such Affidavit. Generally, for a partner to qualify, both the participant and his/her same-sex partner must acknowledge being in a committed relationship which has been in existence for at least six months. For more information, contact the Administrative Office.

SKILLED NURSING FACILITY:
A facility that is certified by Medicare to provide 24-hour nursing care and rehabilitation services in addition to other medical services.

SPEECH THERAPY/SPEECH PATHOLOGY:
The evaluation and treatment of communication and swallowing disorders by a person acting within the scope of licensed practice. Services provided may involve measurement, testing, identification, prognosis, counseling or instruction related to the development and disorders of speech, voice or language for the purpose of identifying, preventing and rehabilitating such disorders. Services may include evaluation of patients for augmentative/alternative communication systems, evaluation of verbal and written language reception and expression and evaluation of cognitive processing of language.

TOTAL DISABILITY:
"Total disability," as used in Section 2: Medical Benefits, means:

• For an active participant, the inability to perform the substantial and material duties of his/her occupation or employment. The inability must be as a result of injury or illness;
• For a Certified Retiree and for a dependent spouse/same-sex domestic partner, the inability to engage in the substantial and material activities engaged in before the start of the disability. The inability must be a result of injury or illness; or
• For a child, confinement to the house or a hospital. The confinement must be as a result of injury or illness.

"Total disability," as used in Section 5: Protection Benefits, means the inability to engage in any occupation for wage or profit for which you are reasonably qualified by reason of education, training or experience. The inability must be as a result of injury or sickness and must be verified by an attending physician's statement.

URGENT CONDITION:
A condition that's not as serious as an emergency medical condition but that still requires immediate medical treatment, such as an ear infection, a sprain, a urinary tract infection, a simple bone break (e.g., toe, finger), a minor burn, or back pain.