June 19, 2013   TABLE OF CONTENTS   11.0 DEFINITIONS   "Ambulatory Surgical Center" means any public or private establishment with an organized medical staff of Physicians, permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures, continuous Physician services and registered professional nursing services whenever a patient is in the facility, and which does not provide services or other accommodations for patients to stay overnight. "Certificate of Creditable Coverage" A form showing the length of time a person had creditable coverage with a carrier or plan, and indicating the waiting period starting date and the coverage effective and termination dates without a break of 63 days or more. This plan will furnish such a certificate when regular coverage under this plan ends, when COBRA coverage ends, and upon the request of (or on behalf of) a covered person while covered under the plan or within the two years following the termination of coverage. A detailed copy of the plan’s procedures for requesting a certificate of creditable coverage is available from the Fund Office. "Chemical Dependency" means the psychological or physiological dependence upon and abuse of drugs, including alcohol, characterized by drug tolerance or withdrawal and impairment of social or occupational role functioning or both. "Contribution Hour" means a straight-time hour worked or paid for under an Agreement requiring an employer contribution to this Fund for that hour under the 70 or 80-hour monthly contribution rule (see eligibility rules in Section 1.1). Contributions must be actually received by the Fund, except in the case of hours worked during the first four months of employment of an Employee who is new to the industry (for which contributions are not required by the collective bargaining agreement between Local 6-505M and the Employee’s employer). "Cosmetic Surgery" means surgery performed to alter (a) the texture or configuration of the skin or (b) the configuration or relationship with contiguous structures of and features of the human body, which surgery is performed primarily for psychological purposes or which does not correct or materially improve a bodily function. "Covered Employee or Eligible Employee" means an Employee who is covered by the Plan (See Section 1.1.1, 1.1.2 and 1.1.3). "Covered Person" means a Covered Employee or an eligible Dependent of an Employee who is covered under the Plan. "Custodial Care" means that type of care or service, wherever furnished and by whatever name called, which is designed primarily to assist a covered person, whether or not totally disabled, in the activities of daily living. Such activities include, but are not limited to: bathing, dressing, feeding, preparation of special diets, assistance in walking or in getting in and out of bed, and supervision over medication which can normally be self administered. "Durable Medical Equipment" means equipment which (a) can withstand repeated use, (b) is primarily and customarily used to serve a medical purpose, (c) is generally not useful to a person in the absence of Illness or Injury and (d) is appropriate for use in the home. Equipment which does not fully meet this definition is not covered. For example, the Plan does not cover such things as exercise equipment and saunas. "Emergency" means an Illness or Injury which arises suddenly and unexpectedly and manifests itself by acute symptoms of sufficient severity that the absence of immediate medical attention would result in (a) serious jeopardy to the patient’s health, or (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Examples of conditions that would qualify as emergencies are severe bleeding, heart attacks, loss of consciousness and acute appendicitis. Examples of conditions that would not qualify are elective surgery (surgery that is scheduled in advance), influenza and colds. Disputes over whether an Emergency existed will be referred to the Fund’s medical consultant. "Employee" means any person who works one or more Contribution Hours. "Fund" means the St. Louis Graphic Arts Joint Health and Welfare Fund. "Experimental/Investigative" describes any service or supply which is judged to be experimental or investigative by the Trustees or the Appeals Committee in their sole discretion. The Trustees or the Appeals Committee will use the following criteria: a. Any supply or drug used must have received final approval to market by the U.S. Food and Drug Administration. b. There must be enough information in the peer reviewed medical and scientific literature to let the Trustees or Appeals Committee judge the safety and efficacy. c. The scientific evidence must show a positive effect on health outcomes outside a research setting. d. The service or supply must be as safe and effective outside a research setting as current diagnostic or therapeutic options. A service or supply will be Experimental or Investigative if the Trustees or the Appeals Committee decides that any one of the four criteria is not met. "Health Benefits" means weekly disability income benefits (described in Part III), medical benefits (described in Parts IV, VI and VII), dental benefits (described in Part XIV), prescription drug benefits (described in Parts V, VI and VII) and wellness benefits (described in Part XIII). "HMO Provider" means a participating health care provider that has entered into an agreement with the health maintenance organization, HealthLink, HMO, Inc. to provide certain health care services, supplies or accommodations to Participants and eligible Dependents. "Hospice Care Program" means a program providing home care, basic nursing care and supportive therapy to the terminally ill and their families in a non Hospital setting which is (a) accredited by the Joint Commission for Accreditation of Hospitals or the National Hospice Organization, (b) approved by Medicare or (c) certified or accredited under applicable State law. "Hospital" means a constituted Hospital operated for the care and treatment of resident inpatients, with a graduate registered nurse (R.N.) always on duty and with a laboratory and organized facilities for surgery. In no event shall the term "Hospital" mean any Hospital or institution or part of such Hospital or institution which is licensed or used principally as a clinic, continued or extended care facility, convalescent home, rest home, nursing home or home for the aged, or treatment center for drug addicts or alcoholics. For purposes of treatment of Mental Illness, "Hospital" also means a place, other than a convalescent, nursing or rest home, which has accommodations for resident bed patients, facilities for the treatment of nervous or mental disorders, a resident psychiatrist always on duty, and which as a regular practice charges the patient for the expense of confinement. "Illness" means a deviation from the normal healthy state resulting from disease which requires treatment by a Physician and is not otherwise excluded from coverage under the Plan, or pregnancy. "Injury" means unforeseen bodily harm caused by a sudden, traumatic and external event definite as to time and place. "Licensed Clinical Psychologist" means only a person who specializes in clinical psychology and fulfills the requirements specified in item (a) or (b) below, whichever is applicable. (a) A person who is licensed or certified as a psychologist by the appropriate governmental authority having jurisdiction over such licensure or certification, as the case may be, in the jurisdiction where such person renders service to the Covered Individual. (b) If there is no licensure or certification in the jurisdiction where such person renders service to the Covered Individual, a person who is Member or Fellow of the American Psychological Association. "Licensed Clinical Social Worker" means a person who is (a) trained and experienced as a clinical social worker and who holds a current, valid license to practice as a clinical social worker in the state in which he practices; or (b) a graduate of an accredited school of social work and meets all requirements for licensure as a clinical social worker. "Licensed Professional Counselor" means a person who is (a) registered, certified or licensed as a professional counselor by the state in which he practices; or (b) a graduate of an accredited educational institution with at least a master’s degree with a major in counseling or its equivalent, meets all requirements for certification or licensure as a professional counselor other than the requirement of supervised counseling experience and who is supervised by a person who meets the requirements of (a) above. "Life Insurance" means the $10,000 of life insurance described in Part II. "Maintenance Care" means care intended primarily to maintain a level of physical or mental function; including, but not limited to manipulation of spinal subluxation which is symptomatically stationary or physical therapy which is not expected to result in significant improvement in the patient’s condition. "Medical Child Support Order" means an order, typically issued in divorce proceedings, which may create or recognize the right of a child of a Participant to be covered under this Plan. Such an order must be qualified and issued by a court of competent jurisdiction or through an administrative process having the force and effect of law for this Plan to be bound by it. Upon request, the Fund Office will provide covered persons with the guidelines used to determine whether a medical child support order is qualified. "Mental Illness" means psychiatric or psychological disorders, other than Chemical Dependency, including, but not limited to, such disorders that are biologically based or due to biochemical imbalances. "Non Residential Chemical Dependency Treatment Facility" means a non residential program for structured, intensive treatment of Chemical Dependency which is licensed or certified by the Department of Mental Health or similar department of the State in which the program is located. "Nurse Practitioner" means a person who is recognized by the state in which he or she practices as an advance practice nurse who meets the following criteria: (a) holds a current license to practice as a registered professional nurse; and (b) is certified in his or her respective advances practice nursing clinical specialty area by a nationally recognized certifying body accepted by the state board of nursing, (c) submits documented evidence of satisfactory, active, up-to-date certification/ recertification/ maintenance and/or continuing education/competency status to the state board of nursing as required and (d) is practicing within the scope and standards of his or her license and advanced practice clinical specialty area as defined by the state board of nursing. In order to meet this definition, a Nurse Practitioner must clearly identify him/herself as a Nurse Practitioner and shall not refer to him/herself as a doctor, a physician or surgeon. "Occupational Therapist" means a person who is licensed to perform occupational therapy services by the state in which he performs such services and who is acting within the scope of that license. "Participant" means an Employee or retiree covered under the Plan. "Physical Therapist" means a person who is licensed to perform physical therapy services by the state in which he performs such services and who is acting within the scope of that license. "Physician" means only a legally qualified Physician or surgeon (Doctor of Medicine or Doctor of Osteopathy); with respect to certain Covered Expenses under the Plan, the term "Physician" shall also include a duly licensed Dentist, Podiatrist or Chiropractor practicing within the scope of his or her license and Optometrist but only when providing services that would be covered if provided by an Ophthalmologist; the term "Physician" does not include Naturopaths, Nurse Midwives, Speech Therapists or Christian Science Practitioners. "Physician Assistant" means a person who (a) has graduated from a Physician Assistant program accredited by the American Medical Association’s Committee on Allied Health Education and Accreditation (or by its successor agency), (b) has passed the certifying examination administered by the National Commission on Certification of Physician Assistants, (c) has active certification by the National Commission on Certification of Physician Assistants and (d) provides health care services delegated by a licensed physician. A person who had been employed as a physician assistant for three years prior to August 28, 1989 and who had passed the National Commission on Certification of Physician Assistants examination and has an active certification of the National Commission on Certification of Physician Assistants is also included in this definition. In order to meet this definition a Physician Assistant must clearly identify him/herself as a Physician Assistant and shall not refer to him/herself as a doctor, a physician or a surgeon. "Plan" means the Benefit Plan (described in this Summary Plan Description) provided by the Fund. "Plan Year" means July 1 through June 30 of the next year. "PPO Provider" means a participating health care provider that has entered into an agreement with one of the Plan’s preferred provider organizations (HealthLink, Inc. or USA Managed Care) to provide certain health care services, supplies or accommodations to Participants and eligible Dependents. "Primary Care Physician" means a family practice Physician, internist, pediatrician or geriatrician. Any other Physician will be considered a Specialist for the purposes of determining required office visit co-pays. "Residential Chemical Dependency Treatment Facility" means a residential program for structured, intensive treatment of Chemical Dependency which is licensed or certified by the Department of Mental Health or similar department of the State in which the program is located. "Skilled Nursing Facility" means only an institution, other than a Hospital which meets all of the following requirements: (a) maintains permanent and full time facilities for bed care of 10 or more resident patients, (b) has available at all times the services of a Physician, (c) has a Registered Nurse (R.N.) or Physician on full time duty in charge of patient care and one or more Registered Nurses (R.N.) or Licensed Practical Nurses (L.P.N.) on duty at all times, (d) maintains a daily medical record for each patient, (e) is primarily engaged in providing continuous skilled nursing care for sick or injured persons during the convalescent stage of their Illnesses or injuries and is not, other than incidentally, a rest home or a home for Custodial Care or for the aged, and (f) is operating lawfully as a nursing home in the jurisdiction where it is located; in no event, however, shall such term include an institution primarily engaged in the care and treatment of drug addicts or alcoholics. "Supervision Agreement" means a written agreement with jointly agreed-upon protocols or standing orders between a supervising Physician and a Physician Assistant or Nurse Practitioner, which provides for the delegation of health services from a supervising Physician to the Physician Assistant or Nurse Practitioner and the review of the Physician Assistant’s services by the supervising Physician. The supervising Physician must accept responsibility for the oversight of the Physician Assistant’s or Nurse Practitioner’s activities and the health care services rendered by the Physician Assistant or Nurse Practitioner. "Totally Disabled" A Covered Person is considered "Totally Disabled" if, in the case of a Participant, he is prevented by Injury or Illness from engaging in any occupation for which his education, training or experience might reasonably qualify him, or in the case of an eligible Dependent, he is prevented by Injury or Illness from performing normal activities of a person of like age and sex who is in good health.   TABLE OF CONTENTS   St. Louis Graphic Arts Joint Health & Welfare Fund 14323 South Outer Forty Rd. - Suite S106 Chesterfield, Missouri 63017 Fund Office: (314) 878-1579 twesthues@slgahw.org Fax: (314) 275-2640   If you have any comments about this web site, please contact us at twesthues@slgahw.org.   Site Concept and Design ©2002 jWeb. Maintenance and Hosting provided by jWeb.