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Residential Treatment Facility - a facility established and operated as required by law which provides Mental
Health Care Services or Substance Related and Addictive Disorder Services. It must meet all of the following
requirements:

· Provides a program of treatment under the active participation and direction of a Physician and approved
by the Mental Health/Substance Use Disorder Designee.
· Has or maintains a written, specific and detailed treatment program requiring your full-time residence and
full- time participation.
· Provides at least the following basic services in a 24-hour per day, structured milieu:

· Room and board.
· Evaluation and diagnosis.

· Counseling.
· Referral and orientation to specialized community resources.

A Residential Treatment facility that qualifies as a Hospital is considered a Hospital.
Secondary Plan - the plan which determines its benefits after those of the other Plan. The benefits of the
Secondary Plan may be reduced because of the other Plan's benefits.

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi–private Room is a
Covered Health Care Service, the difference in cost between a Semi–private Room and a private room is a
Benefit only when a private room is Medically Necessary, or when a Semi–private Room is not available.

Shared Savings Program - a program in which we may obtain a discount to an out-of-Network provider's billed
charges. This discount is usually based on a schedule previously agreed to by the out-of-Network provider. When
this happens, you may experience lower out-of-pocket amounts. Co-insurance and any applicable deductible
would still apply to the reduced charge. Policy provisions or administrative practices supersede the scheduled
rate, and a different rate is determined by us. In this case, the out-of-Network provider may bill you for the
difference between the billed amount and the rate determined by us. If this happens, you should call the
telephone number shown on your ID card. Shared Savings Program providers are not Network providers and are
not credentialed by us.
Sickness - disorder, dysfunction, or illness of the body.

Skilled Care – skilled nursing, skilled teaching, skilled habilitation and skilled rehabilitation services when all of
the following are true:
· Must be delivered or supervised by licensed technical or professional medical personnel in order to
obtain the specified medical outcome, and provide for the safety of the patient.
· Ordered by a Physician.

Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law.
Specialist Physician - a Physician who has a majority of his or her practice in areas other than general
pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine.

Spouse - an individual to whom you are legally married or a Domestic Partner as defined in this section.
Subscriber - an Eligible Employee who is properly enrolled under the Plan.

Substance Related and Addictive Disorder Services - Covered Health Care Services for the diagnosis and
treatment of alcoholism and substance-related and addictive disorders that are listed in the current Diagnostic and
Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded. The
fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does
not mean that treatment of the disorder is a Covered HealthCare Service.
Terminally ill - A prognosis, given by a Physician, that a Covered Person has six months or less to live.

Transitional Living - Mental Health Care Services and Substance-Related and Addictive Disorders provided
through facilities, group homes and supervised apartments which provide 24-hour supervision and are either:

· Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. They provide
stable and safe housing, an alcohol/drug-free environment and support for recovery. They may be used

Page 87 Section 15 - Glossary
PPO - 2017