A

ACCIDENT/ACCIDENTAL.
A happening by chance and without intention or design, a happening that is unforeseen, unexpected and unusual at the time it occurs.

ADDITIONAL BENEFITS.
Health care services not covered by Medicare, and reductions in premiums or cost-sharing for Medicare covered services, funded from adjusted excess amounts as calculated in the Adjusted Community Rate.

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C

CMS.
Centers for Medicare & Medicaid Services, the Federal Agency responsible for administering the Medicare and Medicaid programs.

COMPLETED ENROLLMENT APPLICATIONS.
An enrollment application is considered complete when: (1) the form is signed by the beneficiary or legal representative; (2) evidence of entitlement to Part A and enrollment in Part B is obtained by Gundersen Lutheran Health Plan; (3) all necessary elements on the form are completed; and (4) supporting documentation for a representative’s signature is obtained, if applicable.

CONFINEMENT/CONFINED.
The period of time between admission and discharge as an inpatient or outpatient to a hospital, alcohol and other drug abuse residential treatment center, skilled nursing facility, or freestanding surgical facility. Confinement shall also include time spent in a hospital receiving care for a sickness or injury. Hospital swing bed confinement is considered the same as confinement in a skilled nursing facility. If you are confined and transferred to another facility for continued treatment of the same or related condition, it is considered one confinement.

COPAYMENT.
A fee payable by a member to a Gundersen Lutheran Health Plan, Plan Provider, at the time of service.

COSMETIC SURGERY.
Any operative procedure performed primarily to: improve physical appearance; to treat a mental or nervous disorder through a change in bodily form; to change or restore bodily form without correcting or materially improving a bodily function.

COVERED SERVICES.
Those benefits, services and supplies for which Gundersen Lutheran Health Plan must pay or provide while you are a member.

CUSTODIAL CARE.
Provision of room and board, nursing care, personal care or other care designed to assist an individual in the activities of daily living. Such care does not entail or require the continuing attention of trained medical personnel, such as nurses. Custodial care includes those services which constitute personal care, such as help in: walking; getting in and out of bed; assistance in bathing or dressing; eating; using the toilet; preparing special diets; or supervision of medication, which usually can be self-administered. Care may still be custodial even though such care involves the use of technical medical skills if such skills can be easily taught to a lay person. In the case of an institutionalized person, Custodial care also includes: room and board, nursing care, or other care which is provided to an individual for whom it cannot reasonably be expected, in the opinion of the physician, that medical or surgical treatment will enable that person to live outside an institution. Custodial care includes: rest cures; respite care; and home care provided by family members.

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D

DISENROLLMENT.
Disenrollment means that your coverage under the policy ends.

DURABLE MEDICAL EQUIPMENT.
Equipment that must: Be able to withstand repeated use; Be primarily and customarily used to serve a medical purpose; Not be generally useful to a person except for the treatment of an injury or sickness; and Be medically necessary. Examples include, but are not limited to: crutches; wheelchairs; hospital beds; equipment used in the administration of oxygen; initial acquisition of artificial limbs or eyes; and custom-made orthotics.

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E

EFFECTIVE DATE.

The date, as shown in Gundersen Lutheran Health Plan’s records and on your Gundersen Lutheran Senior Preferred Identification Card, on which Gundersen Lutheran Senior Preferred coverage begins for you under this contract. You will receive written notification of your effective date once Gundersen Lutheran Health Plan, Inc. has submitted and confirmed your enrollment with the Centers for Medicare & Medicaid Services.

EMERGENCY MEDICAL CONDITION.
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: serious jeopardy to the health of the individual (or an unborn child); serious impairment to bodily functions; or seriously dysfunction of any bodily organ or part.

EMERGENCY SERVICES.
Covered inpatient or outpatient services that are furnished by a qualified provider and are needed to evaluate or stabilize an emergency medical condition. Emergency services includes emergency services provided both within and outside of the plan.

END STAGE RENAL DISEASE (ESRD).
That stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life. For eligibility purposes, individuals who have received a transplantation which restores kidney function, and who also no longer require a regular course of dialysis to maintain life are not considered to have ESRD.

EVIDENCE OF COVERAGE.
This document, which explains the services and benefits covered by Gundersen Lutheran Senior Preferred and defines the rights and responsibilities of the member and Gundersen Lutheran Health Plan.

EXCLUSION.
Items or services listed in the services not covered section or not listed as a covered service in the Evidence of Coverage.

EXPERIMENTAL OR INVESTIGATIONAL.
Experimental or investigational treatment, procedures, drugs and medicines are not covered under this contract. Treatments, procedures, drugs or medicines which our Medical Director determines are experimental or investigational, and that include one or more of the following: 1) the device, drug, or medicine cannot lawfully be marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the device, drug, or medicine is furnished; 2) reliable evidence shows that the treatment, procedure, device, drug or medicine is the subject of ongoing Phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy compared with the standard means of treatment or diagnosis; or 3) reliable evidence shows that the consensus of opinion among experts regarding the treatment, procedures, device, drug or medicine is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.Reliable evidence means only published reports and articles in the authoritative medical and scientific literature; the written protocols used by the treating facility or the protocols of another facility studying substantially the same treatment, procedure, device, drug or medicine; or the written informed consent used by the treating facility or by another facility studying substantially the same treatment, procedure, device, drug or medicine.

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F

FEE-FOR-SERVICE MEDICARE.
A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as it is rendered and identified by a claim for payment. Also known as traditional or regular Medicare.

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H

HOME HEALTH AGENCY.
A State-licensed and Medicare-certified agency which provides intermittent skilled nursing care and other therapeutic services in your home when medically necessary.

HOSPICE.
An organization or agency, certified by Medicare, that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people and their families.

HOSPICE CARE.
Services designed to meet the needs of patients where terminal sickness with a life expectancy of 6 months or less.

HOSPITAL.
An institution which: Is legally operated in the jurisdiction where it is located; Is engaged mainly in providing inpatient medical care and treatment for Injury and sickness in return for compensation; Has organized facilities for diagnosis and major surgery on its premises; Is supervised by a staff of at least 2 physicians; Has 24-hour-a-day nursing service staffed by registered nurses; and Is not a facility specializing in dentistry or an institution which is mainly: a rest home; a home for the aged; a place for drug addicts; a place for alcoholics; a convalescent home; a nursing home; or an extended care or skilled nursing facility or similar institution.

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I

IDENTIFICATION (ID) CARD.
After enrolling with the Health Plan, you will receive two member identification (ID) cards. These cards identify you (the subscriber) and your covered dependents. When you receive your cards, be sure to verify that all names and other information printed on the cards are correct. If any part is incorrect or you need more cards, please contact us. Show your card when you receive any healthcare services or fill a prescription. Your ID card is valid only as long as you are enrolled with our Health Plan.

IMMEDIATE FAMILY.
The spouse, children, parents, grandchildren, brothers and sisters of the member and their spouses.

INTERPRETER SERVICES.
Gundersen Lutheran Health Plan ensures availability of language services for our limited English proficient members and interpreter assistance for the hearing impaired. We have Hmong and Spanish-speaking representatives available at the Onalaska Support Services Building. If you would like to meet with a Health Plan representative in person at our Resource Center office at the main campus and would like an interpreter, one of our representatives will call the Gundersen Lutheran Interpreter Services Department. If unable to obtain assistance from the Gundersen Lutheran Interpreter Services Department, the Health Plan representative will call the Language Line. If you are hearing impaired and require assistance during a telephone call, the Health Plan representative will call the Wisconsin TTY Relay system for the hearing impaired. This service is available 24 hours a day, at no charge.

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L

LOCK-IN.
Under this contract you are “locked in” to the use of plan providers. All health care (other than emergencies anywhere in the world or urgently needed services when you are temporarily outside our service area) must be provided or authorized by us. The use of non-plan providers, except in the emergency or urgent care situations mentioned above, will result in your obligation to pay for routine care. NEITHER GUNDERSEN LUTHERAN HEALTH PLAN NOR MEDICARE WILL PAY FOR THESE SERVICES.

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M

MAINTENANCE THERAPY.
Ongoing therapy delivered after the acute phase of a sickness has passed. It begins when you have reached a plateau, or improvement in your condition has slowed or ceased entirely and only minimal rehabilitative gains can be demonstrated. We make the determination of what constitutes maintenance therapy after reviewing your case history or treatment plan submitted by a provider of health care.

MEDICAL DIRECTOR.
A physician employed by us to direct and manage the delivery of appropriate medical care in a cost-effective manner while maintaining the highest quality of care possible.

MEDICAL MANAGEMENT.
A department within Gundersen Lutheran Health Plan consisting of health professionals including physicians, nurses, and other support staff employed to assure appropriate and efficient utilization of resources for the delivery of high quality care, acceptable outcomes, and customer satisfaction. Examples include: Referral management; concurrent review of hospitalizations; and case management.

MEDICALLY NECESSARY.
Medical treatment, services or supplies that are required to identify or treat a sickness or Injury and which, as determined by us, are: Consistent with the symptoms, diagnosis or treatment of your medical condition; Appropriate with regard to standards of good medical practice; Not primarily for your convenience, or that of your physician or another provider; The most appropriate and cost-effective level of medical service or supplies which can be safely provided. When applied to inpatient care, it further means that the medical symptoms or conditions require that the medical services or supplies cannot be safely provided as an outpatient; and Of proven value or usefulness. The fact that a plan provider, or any other provider, has prescribed, ordered, recommended or approved a treatment, service or supply, or has informed you of its availability, does not in itself make it medically necessary.

MEDICARE.
The federal government health insurance program established by Title XVIII of the Social Security Act.

MEDICARE ADVANTAGE ORGANIZATION.
A public or private organization licensed by the state as a risk-bearing entity that is under contract with the Centers for Medicare & Medicaid Services (CMS) to provide covered services. Medicare Advantage Organizations can offer one or more MA Plans. Gundersen Lutheran Senior Preferred is a Medicare Advantage Organization.

MEDICARE ADVANTAGE PLAN.
A benefit package offered by a Medicare Advantage Organization that offers a specific set of health benefits at a uniform premium and uniform level of cost-sharing to all people with Medicare residing in the service area covered by the plan. A Medicare Advantage Organization may offer more than one plan in the same service area. Gundersen Lutheran Senior Preferred is a Medicare Advantage Plan.

MEMBER.
You, the Medicare beneficiary, entitled to receive health care services under the terms of this Gundersen Lutheran Senior Preferred Evidence of Coverage, who have voluntarily elected to enroll and whose enrollment in Gundersen Lutheran Senior Preferred has been confirmed by CMS.

MEMBER ADVOCATE.
An individual employed by Gundersen Lutheran Health Plan, Inc. specializing in the grievance and appeals process. The Member Advocate will receive and record all grievances and appeals submitted in writing and interview the Member who filed the grievance or appeal. This person will investigate grievances and appeals, assist the member through the grievance and appeals process and work with the appropriate department manager to effect resolution. This person will advise the member of the disposition of the grievance or appeal and the action taken.

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N

NON-PLAN PHYSICIAN.
A person who is a non-plan provider and who is duly licensed by an appropriate government authority as a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatric Medicine (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), acting within the scope of their license.

NON-PLAN PROVIDER.
Refers to a physician or other health care provider who has not signed a plan provider contract with Gundersen Lutheran Health Plan to provide medical treatment, services or supplies to members. Except for emergency services and urgently-needed services, benefits are excluded when you receive medical treatment, services or supplies from a non-plan provider without a written referral from a Plan Provider, which has been prior approved by our Medical Director.

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P

PERSONAL PHYSICIAN.
A plan physician who has been chosen by a member to coordinate and monitor the member’s health care.

PHYSICIAN.
A person who is duly licensed by an appropriate government authority as a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatric Medicine (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), acting within the scope of their license.PLAN.Gundersen Lutheran Health Plan, Inc.PLAN PHYSICIAN.A person who is a plan provider and who is duly licensed by an appropriate government authority as a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatric Medicine (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), acting within the scope of their license.

PLAN PROVIDER.
Although “provider” is a term the Medicare statute uses to refer to hospitals, nursing homes and home health agencies only, for the purpose of the Evidence of Coverage, the term means a physician, qualified practitioner, qualified treatment facility, pharmacy, hospital, clinic or other health care provider which has entered into a plan provider contract with Gundersen Lutheran Health Plan to provide medical treatment, services or supplies in our provider network and from which a member may seek services without a referral.

POLICY.
The agreement between you and Gundersen Lutheran Health Plan, Inc. that sets forth the contractual rights and obligations of each of the parties. The policy includes the Evidence of Coverage, the Member Handbook and your application form.

POST STABILIZATION CARE.
Covered services related to an emergency medical condition, that are provided after the member is stabilized in order to maintain the stabilized condition, or under the circumstances described below, to improve or resolve the member’s condition.If the plan does not respond to a request for pre-approval of Post Stabilization Care services within 1 hour; if the plan cannot be contacted; or if the plan representative and the treating physician cannot reach an agreement concerning the member’s care and a Personal Physician is not available for consultation, Post-Stabilization Care services shall include services administered not only to maintain the stabilized condition, but to improve or resolve the patient’s condition.

PREMIUM.
The monthly payment to Gundersen Lutheran Health Plan that, along with your Part B Premium paid to Medicare, entitles you, the member, to the benefits outlined in the Evidence of Coverage.

PRESCRIPTION.
The written physician order for any medicinal substance, the label of which, under the Federal Food, Drug and Cosmetic Act, is required to bear the legend: “Caution: Federal Law prohibits dispensing without prescription”.

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Q

QUALIFIED PRACTITIONER.
A licensed practitioner providing services within the scope of that license.

QUALIFIED TREATMENT FACILITY.
A facility, institution, or clinic duly licensed, primarily established, and operating within the scope of its license.

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R

RECEIPT OF ENROLLMENT APPLICATION.
Enrollment applications are considered received when Gundersen Lutheran Health Plan comes into possession of a completed enrollment application.

REFERRAL.
The form prepared in writing by a Personal Physician for you in order for you to receive coverage for medical treatment, services or supplies from a non-plan provider. Medical care, treatment, services or supplies that are received through a referral are subject to the exclusions and limitations of the Evidence of Coverage. If your Personal Physician feels that you require specialty care beyond that available from a plan provider or other network specialist, he/she may complete a Referral Request form. Referrals must be submitted to and approved in writing by our Medical Director before any recommended treatment, services or supplies are obtained for a covered service.

ROUTINE EXAMS/ROUTINE EXAMINATIONS.
Any physical exam or evaluation done, in accordance with our guidelines for age and sex, when an exam is otherwise not indicated for the treatment of an existing or known Injury or sickness.

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S

SERVICE AREA.
The area in which a person must live to be able to become or remain a member of Gundersen Lutheran Senior Preferred.

SICKNESS.
Any condition or disease that causes loss of, or affects, normal body function other than those resulting from an Injury.

SKILLED NURSING CARE.
Means medical services rendered by a registered or licensed practical nurse, physical, occupational or speech therapist. Patients receiving skilled nursing care are usually quite ill and often have been recently hospitalized. Examples are patients with complicated diabetes, recent stroke resulting in speech or ambulatory difficulties, fractures of the hip and patients requiring complicated wound care. In the majority of cases, skilled nursing care is necessary for only a limited period of time. After that, most patients have recuperated enough to be cared for by “nonskilled” persons such as spouses, children or other family or relatives. Examples of care provided by “nonskilled” persons include: range of motion exercises, strengthening exercises, sound care, ostomy care, tube and gastrotomy feedings, administration of medications, and maintenance of urinary catheters. Daily care such as assistance with getting out of bed, bathing, dressing, eating, maintenance of bowel and bladder function, preparing special diets, assisting patients with taking their medicines, or 24 hour supervision for potentially unsafe behavior, do not require skilled nursing care and are considered to be custodial care.

SKILLED NURSING FACILITY.
An institution which is licensed by the State of Wisconsin, certified by Medicare and that maintains and provides the following: Permanent and full-time bed care facilities for resident patients; A physician’s services available at all times; A registered nurse or physician in charge and on full-time duty and 1 or more registered nurses or licensed vocational or practical nurses on full-time duty; A daily record for each patient; and Continuous skilled nursing care for sick or injured persons during convalescence from sickness or injury. A skilled nursing facility is not, except by coincidence: a rest home; a home for care of the aged which furnishes primarily custodial care; or a facility engaged in the care and treatment of alcoholics, drug addicts, or persons with mental disorders.

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T

TEMPORARY ABSENCE.
A temporary absence from the service area is an absence of 6 months or less. If you travel and do not intend to return to the Gundersen Lutheran Health Plan Service Area within 6 months or less, it is considered a permanent move, and you must contact us.

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U

URGENTLY NEEDED SERVICES.
Covered services that you need when you are temporarily absent, as defined herein, from our service area, and that: are immediately required as a result of an unforeseen illness, Injury, or condition; and it is not reasonable given the circumstances to obtain the services through plan providers. Urgently needed services encompass only services provided outside of the plan’s service area, except in extraordinary circumstances because of temporary disruption of access to Gundersen Lutheran Health Plan’s provider network, such as: a strike; or possibly some temporary physical impediment to traveling to plan provider’s that are otherwise readily accessible.

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