Citi Benefits Handbook
Definitions of certain terms used in the Citigroup Health and Insurance Benefits Handbook are included in this section.
Coinsurance: The portion of a covered expense that a participant pays after satisfying the deductible. For example, if a plan pays 80% of certain covered expenses, coinsurance for these expenses is 20%.
Covered expenses: Medical and related costs incurred by participants who qualify for reimbursement under the terms of the insurance contract.
Custodial care: Services and supplies furnished to a person mainly to help him or her in the activities of daily life (such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, and eating or preparing foods). These services include room and board and other institutional care. The person does not have to be disabled. Such services and supplies are custodial care without regard:
Deductible: The amount of eligible expenses the participant and each covered dependent must pay each calendar year before a plan begins to pay benefits.
Goal amount: The total annual amount a participant elects to contribute on a before-tax basis to a Health Care Spending Account, Limited Purpose Health Care Spending Account or Dependent Day Care Spending Account. The annual contribution elected will be divided by the number of pay periods in the plan year and deducted from the employee's pay. For elections made during the plan year, the annual contribution amount will be divided by the number of remaining pay periods in the plan year and deducted from the employee's pay.
Health Insurance Portability and Accountability Act of 1996 (HIPAA): A U.S. law designed to, among other things, ensure the portability of health insurance coverage and the ability to add family members to health coverage, as well as protect the privacy and security of health information.
Maximum allowed amount (MAA): Any charge that, for services rendered by or on behalf of an out-of-network physician, does not exceed the amount determined by the Claims Administrator in accordance with the applicable fee schedule. This amount is determined by taking into account all pertinent factors, including:
- The complexity of the service;
- The range of services provided; and
- The geographic area where the provider is located.
How the MAA is calculated varies depending on which plan option you are enrolled in and which carrier you have. Contact your Plan for more details.
Medically necessary or medical necessity: Health care services and supplies that are determined by the Claims Administrator to be medically appropriate and:
- Necessary to meet the basic health needs of the covered person;
- Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the service or supply;
- Consistent in type, frequency and duration of treatment with scientifically based guidelines of national medical, research or health care coverage organizations or governmental agencies that are accepted by the Plan;
- Consistent with the diagnosis of the condition;
- Required for reasons other than the convenience of the covered person or his or her physician;
- Must be provided by a physician, hospital or other covered provider under the Plan;
- With regard to an inpatient, it must mean the patient's illness or injury requires that the service or supply cannot be safely provided to that person on an outpatient basis;
- Not be primarily scholastic, vocational, educational, developmental, experimental or investigational in nature; and
- Demonstrated through prevailing peer-reviewed medical literature to be either:
- Safe and effective for treating or diagnosing the condition or sickness for which their use is proposed; or
- Safe with promising efficacy:
(For the purpose of this definition, the term "life threatening" is used to describe sicknesses or conditions that are more likely than not to cause death within one year of the date of the request for treatment.)
The fact that a physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, mental illness or pregnancy does not mean that it is medically necessary as defined above. The definition of medically necessary used in this document relates only to coverage and differs from the way in which a physician engaged in the practice of medicine may define medically necessary. The Plans Administration Committee may delegate the discretionary authority to determine medical necessity under the Plans. No benefit will be paid for services that are not considered medically necessary.
Network provider: A health care provider on a list of providers contracted with the Claims Administrator. Coinsurance or copays are discounted when plan members utilize network providers and facilities.
Non-occupational disease: A disease that does not:
- Arise out of (or in the course of) any work for pay or profit; or
- Result in any way from a disease that does.
A disease will be deemed non-occupational regardless of the cause if proof is furnished that the person:
- Is covered under any type of Workers' Compensation law; and
- Is not covered for that disease under such law.
Non-occupational injury: An accidental bodily injury that does not:
- Arise out of (or in the course of) any work for pay or profit; or
- Result in any way from an injury that does.
Notification: A requirement that a participant calls his or her health plan option to coordinate any inpatient surgery and hospitalization and certain outpatient diagnostic/surgical procedures. Notification helps ensure that the participant obtains the most appropriate care for his or her condition in the most appropriate setting. Call your Plan for more information.
Out-of-pocket maximum: Total payments (includes copays, deductibles and coinsurance) toward eligible expenses that a covered person pays for him- or herself and/or dependents as defined by the applicable Plans.
Once the maximum out-of-pocket amount has been met, the Plan will pay 100% of maximum allowed amount (MAA) charges. For out-of-network services, when expenses incurred are higher than the MAA, the individual receiving the service is responsible for paying the difference between the provider's charge and the allowed amount, even if the out-of-pocket maximum has been reached.
Precertification/prior authorization: A requirement that a participant calls his or her health plan option to coordinate any inpatient surgery and hospitalization and certain outpatient diagnostic/surgical procedures. Precertification determines medical necessity and helps ensure that the participant obtains the most appropriate care for his or her condition in the most appropriate setting. Call your Plan for more information.
Obtaining a precertification means that the administrator has confirmed medical necessity of the service, but it does not guarantee coverage. Plan participants should contact Member Services to determine coverage.
No benefit will be paid for services that are not considered medically necessary.
Preventive care: Routine care exams based on:
- Guidelines from the American Medical Association and the United States Preventive Care Task Force;
- Guidelines from the Advisory Committee on Immunization Practices that have been adopted by the director of the Centers for Disease Control and Prevention;
- The Comprehensive Guidelines Supported by the Health Resources and Services Administration; and
- Physician recommendations.
Provider: An individual or institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities. An individual health care provider may include, but is not limited to, a health care professional, a physician assistant, a nurse practitioner, a chiropractor, an institution, a facility, a primary care center, a patient-centered medical home, a clinic, an ambulatory surgical center, an outpatient center, an urgent care center or a pharmacy.
Recognized charge: See "Maximum allowed amount (MAA)."
Wellness services: See "Preventive care."