Page 113 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Section 9: Defined Terms

Addendum - any attached written description of additional or revised provisions to the Plan. The Benefits
and exclusions of this SPD and any amendments thereto shall apply to the Addendum except that in the
case of any conflict between the Addendum and SPD and/or Amendments to the SPD, the Addendum
shall be controlling.
Allowed Amounts - for Covered Health Care Services, incurred while the Plan is in effect, Allowed
Amounts are determined by the Claims Administrator as shown in the Schedule of Benefits.
Allowed Amounts are determined solely in accordance with the Claims Administrator reimbursement
policy guidelines. The Claims Administrator develops these guidelines, as the Claims Administrator
determines, after review of all provider billings in accordance with one or more of the following
methodologies:

• As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of
the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).

• As reported by generally recognized professionals or publications.

• As used for Medicare.
• As determined by medical staff and outside medical consultants pursuant to other appropriate
source or determination that the Claims Administrator accepts.
Alternate Facility - a health care facility that is not a Hospital. It provides one or more of the following
services on an outpatient basis, as permitted by law:

• Surgical services.
• Emergency Health Care Services.

• Rehabilitative, laboratory, diagnostic or therapeutic services.
It may also provide Mental Health Care Services or Substance-Related and Addictive Disorders Services
on an outpatient or inpatient basis.
Amendment - any attached written description of added or changed provisions to the Plan. It is effective
only when distributed by the Plan Sponsor or Plan Administrator. It is subject to all conditions, limitations
and exclusions of the Plan, except for those that are specifically amended.
Annual Deductible - the total of the Allowed Amount you must pay for Covered Health Care Services per
year before the Plan will begin paying for Benefits. It does not include any amount that exceeds Allowed
Amounts. The Schedule of Benefits will tell you if your plan is subject to payment of an Annual Deductible
and how it applies.
Autism Spectrum Disorder - a condition marked by enduring problems communicating and interacting
with others, along with restricted and repetitive behavior, interests or activities.
Benefits - your right to payment for Covered Health Care Services that are available under the Plan.

Cellular Therapy - administration of living whole cells into a patient for the treatment of disease.
Claims Administrator - the organization that provides certain claim administration and other services for
the Plan.
Coinsurance - the charge, stated as a percentage of the Allowed Amount, that you are required to pay
for certain Covered Health Care Services.

110 Section 9: Defined Terms