ACA Out-of-Pocket Maximum
ACA Out-of-Pocket Maximum is $9100 per person and $18,200 per family in 2023. Except as otherwise specified, unreimbursed in-network covered services that are medical or prescription drug expenses (except for chiropractic services, refractive eye surgery, and all services that are covered under the SHARP DVH Option other than under age 19 pediatric preventive dental, pediatric annual eye examination, and pediatric eyeglasses) are applied to the ACA out-of-pocket maximum includes any co-payments, co-insurances, and deductibles, but does not include the member share contribution costs. Amounts in excess of usual, reasonable, and customary do not apply to the ACA out-of-pocket maximum.
Adventist Retirement Board
Adventist Retirement Board means the board established by the NAD to maintain and amend from time to time SHARP and the various other NAD programs available to NAD retirees.
Adventist Retirement Plan
Adventist Retirement Plan means the Seventh-day Adventist Retirement Plan of the North American Division and Auxiliary Benefits and the Adventist Retirement Plan.
Adverse Benefit Determination
An adverse benefit determination is any of the following (i) a denial, reduction, or termination of a Plan benefit, (ii) a failure to provide or make payment (in whole or in part) for a Plan benefit, or (iii) a rescission of coverage (whether or not the rescission has an adverse effect on any particular Plan benefit at the time of the rescission).
Affordable Care Act
Affordable Care Act means The Patient Protection and Affordable Care Act (PPACA) – also known as the Affordable Care Act or ACA.
Ambulatory Services
Ambulatory Services means medical care provided on an outpatient basis. Ambulatory care is given to persons who are not confined to a hospital.
Ancillary Services
Ancillary Services are support services provided to a patient in the course of care. They include such services as laboratory and radiology.
ARM
ARM means Adventist Risk Management, Inc.
Base Option
Base Option means a medical benefits option that supplements Medicare benefits as described in this document.
Beneficiary
The person you designate to receive death benefits payable in the event of your death (typically your spouse).
Benefit Rate Factor
The average of your 10 highest Yearly Rate Factors.
Break in Service
A break in service occurs during a calendar year in which you are either not employed by a participating Church Plan organization, or are denominationally employed by a Church Plan organization but are not paid for more than 500 hours or more than three months on a full time salary basis.
Canadian Retirement Plan
Canadian Retirement Plan means the retirement plan sponsored by the Seventh-day Adventist – Canadian Division.
Claim
Claim means any request for a Plan benefit or benefits made in accordance with the Claims Procedures. A communication regarding benefits that is not made in accordance with the procedures will not be treated as a claim.
Claim Determination Period
Claim Determination Period means the plan year or portion thereof.
Claimant
Claimant is an individual who has made a claim in accordance with the Claims Procedures.
CMS
CMS means the Centers for Medicare and Medicaid Services, the agency that administers Medicare, Medicaid, and Child Health Insurance Program.
Co-insurance
Co-insurance means the shared percentage cost of covered services that the enrollee pays.
Condition
Condition means a medical condition.
Co-payment
Co-payment means the fixed dollar amounts of covered services to be paid by the enrollee.
Covered Service
Covered Service is a service or supply that is specifically described as a benefit of this Plan.
Custodial Care
Custodial Care means care that helps a person conduct such common activities as bathing, eating, dressing or getting in and out of bed. It is care that can be provided by people without medical or paramedical certification or license. Custodial care also includes care that is primarily for the purpose of separating a patient from others, or for preventing a patient from harming himself or herself. Custodial care and services are services and supplies that are furnished mainly to train or assist a person in personal hygiene and other activities of daily living rather than to provide therapeutic treatment. Activities of daily living includes such things as bathing, feeding, dressing, walking, and taking oral medicines and any other services which can safely and adequately be provided by persons without the technical skills of a nurse or healthcare professional. Such care is considered to be custodial regardless of who recommends, provides or directs the care, where the care is provided and whether or not the individual family member can be or is being trained to care for him or herself. The Plan also considers any care or services to be custodial if they are or would be considered custodial for Medicare purposes.
Day
Day, when used in the Claims Procedures, means calendar day.
Defined Benefit (DB) Plan
The retirement plan in the form of a pension that applies to denominational service up through the year 1999.
Defined Contribution (DC) Plan
The retirement plan that applies to denominational service after the year 1999.
Dental Implant
Dental Implant means a device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement; endosteal (endosseous); eposteal (subperiosteal); transosteal (transosseous).
Durable Medical Equipment
Durable Medical Equipment is equipment and related supplies which the Plan determines (1) are able to stand repeated use, and be of a type that could normally be rented and used by successive patients, (2) are used primarily and customarily to serve a medical purpose (e.g., not items like humidifiers, exercise equipment, gel pads, water mattresses, heat lamps, etc.), (3) are not generally useful to a person in the absence of an injury or illness, (4) are appropriate for home use, and (5) meet the guidelines used by the CMS. Examples of durable medical equipment include a wheelchair, a hospital-type bed, orthotics and oxygen tanks.
DVH
DVH means the SHARP dental, vision and hearing coverage option described in this document.
Earned Credit
Earned Credit means the amount of health care assistance under SHARP based on Retirement Plan Service described in this document.
Eligible Dependent
Eligible Dependent means a child of an Eligible Retiree who satisfies the requirements for eligibility described in the Eligibility section of this document.
Eligible Retiree
Eligible Retiree means a retiree of a NAD participating employer organization hired before July 1, 2020, who satisfies the requirements for eligibility described in the Eligibility section of this document.
Eligible Spouse
Eligible Spouse means a spouse of an Eligible Retiree who satisfies the requirements for eligibility described in the Eligibility section of this document, or an ex-spouse who is an Eligible Spouse with rights to coverage as an Eligible Spouse pursuant to a court order recognized by SHARP. A Spouse must be married to the retiree at least one year prior to the effective retirement date. A Spouse married after the retiree’s effective retirement date is considered a non-eligible spouse for purposes of the Plan. [See “Spouse”]
Emergency Medical Condition
Emergency Medical Condition means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) cause serious impairment to bodily functions or (iii) cause serious dysfunction of any bodily organ or part.
Emergency Services
Emergency Services means, as provided in 26 CFR §54.9815-2719AT, or any successor law or regulation, with respect to an emergency medical condition, a medical screening examination which is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required to stabilize the patient (including in-patient services). For purposes of this section, the term “to stabilize,” with respect to an emergency medical condition, means to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to a pregnant woman who is having contractions, to deliver (including the placenta).
Empower Retirement
The retirement brand name of Great West, the company currently contracted to provide DC Plan administration for Adventist Retirement Plan.
Enroll
Enroll (enrolled, enrolling, enrollment) means to submit, and be accepted by the plan administrator, a complete and signed application for Plan coverage in accordance with the rules in the Eligibility chapter.
Enrollee
Enrollee means a covered retiree, a covered spouse or a covered dependent child.
Genetic Information
Genetic Information means information about genes, gene products, and inherited characteristics that may derive from the individual or a family member. This includes information regarding carrier status and information derived from laboratory tests to identify mutations in specific genes or chromosomes, physical medical examinations, family histories, and direct analysis of genes or chromosomes.
Health Reimbursement Account (HRA)
A tax-free account opened for eligible retirees and/or spouses. The account receives annual contributions from SHARP to reimburse the retiree for qualifying healthcare expenses.
HIPAA
HIPAA means the Health Insurance Portability and Accountability Act of 1996, as amended.
Home Hospice
Home Hospice means a program licensed and operated according to the law, which is approved by the attending physician to provide palliative, supportive and other related care in the home for a covered person diagnosed as terminally ill.
Hospice Facility
Hospice Facility a public or private organization, licensed and operated according to the law, primarily engaged in providing palliative, supportive, and other related care for a covered person diagnosed as terminally ill. The facility must have an interdisciplinary medical team consisting of at least one physician, one registered nurse, one social worker, one volunteer and a volunteer program. A hospice facility is not a facility or part thereof which is primarily a place for rest, custodial care, the aged, drug addicts, alcoholics or a hotel or similar institution.
Hospital
Hospital means a facility that is licensed as an acute care general hospital and provides in-patient surgical and medical care to persons who are acutely ill. Additionally, the facility’s services must be under the supervision of a staff of licensed physicians and must include 24-hour-a-day nursing service by registered nurses. Facilities that are primarily rest, old age or convalescent homes are not considered to be hospitals. Facilities operated by agencies of the federal government are not considered hospitals. However, the Plan will cover expenses incurred in facilities operated by the federal government where benefit payment is mandated by law.
Illness
Illness means a disease or bodily disorder.
Implant
Implant means a material inserted or grafted into tissue.
Incorrectly Filed Claim
Incorrectly Filed Claim means any request for Plan benefits that is not made in accordance with the Claims Procedures.
Independent Review Organization (IRO)
Independent Review Organization (IRO) means an entity that conducts independent external reviews of adverse benefit determinations in accordance with the Patient Protection and Affordable Care Act of 2010 and associated regulations and is accredited by URAC or a similar nationally recognized accrediting organization to conduct external review.
Infusion Therapy
Infusion Therapy is the administration of fluids, nutrients or medications by means of a catheter or needle into a vein. Infusion therapy is not the same as an injection.
Injury
Injury means a personal bodily injury to you or your covered dependent.
In-Network Facility
In-Network Facility means a hospital, hospice facility, skilled nursing facility, or mental health or substance abuse residential facility that is a PPO facility.
In-Network Provider
In-Network Provider means a physician or professional provider who is a PPO provider.
International Service Employee (ISE)
An employee who is formally assigned by the General Conference to serve in a division other than his or her home division under the General Conference ISE policies. Previously known as interdivision employees, these employees retain a link to their home division.
Joint and Survivor Annuity
The form of retirement benefit that provides benefits to the participant and spouse while both are living, and to the spouse who survives the participant.
Joint and Survivor Benefit
A benefit option for a married retiree. A reduction from the Single Life Benefit nominally pays for survivor benefits and healthcare provisions for the spouse.
Medical Condition
Medical Condition means any condition of an enrollee resulting from illness, injury (whether or not the injury is accidental), pregnancy or congenital malformation. However, genetic information is not a medical condition.
Medical Necessity Pre-Certification
Medical Necessity Pre-Certification refers to obtaining the utilization review manager’s determination in advance that proposed medical services requiring pre-certification are medically necessary, appropriate, and neither Experimental nor Investigational Procedures as defined in Limitations and Exclusions.
Medically Necessary/Medical Necessity
Medically Necessary/Medical Necessity means those services and supplies that are required for diagnosis or treatment of illness or injury and which, in the judgment of the utilization review manager, are:
- Appropriate and consistent with the symptoms or diagnosis of the enrollee’s condition.
- Appropriate with regard to standards of good medical practice in the area in which they are provided as supported by peer reviewed medical
- Not primarily for the convenience of the enrollee or a physician or provider of services or
- The least costly of the alternative supplies or levels of service that can be safely provided to the enrollee. This means, for example, that care rendered in a hospital inpatient setting is not medically necessary if it could have been provided in a less expensive setting, such as a skilled nursing facility, or by a nurse in the patient’s home without harm to the pa
- Likely to enable the enrollee to make reasonable progress in treatment
Please Note: The fact that a physician or provider prescribes, orders, recommends or approves a service or supply does not, of itself, make the service medically necessary or a covered service.
Member
Member means enrollee.
Mental Health Condition
Mental Health Condition for the purposes of this Plan means those conditions listed in the “Diagnostic and Statistical Manual of Mental Disorders Fifth Edition” (DSM-5), or any successor volumes, except as stated herein, and no other conditions. Mental health conditions include Severe Mental Illness and Serious Emotional Disturbances of a child but do not include any services related to the following:
- Diagnosis or treatment of conditions represented by V codes in the DSM-5 (i.e., diagnoses related to family problems, illegal behavior, low income, loneliness, abuse, neglect, deployment, imprisonment, discrimination, lifestyle, etc.,) or any successor volumes.
- Diagnosis or the treatment of any conditions with the following ICD-10 Classification of Mental and Behavioral Disorders codes: F06.0, F06.8, F60.9, F65.4, F65.1, F65.2, F64.2, R37, F52.0, F52.21, F528, F52.31, F552.32, F52.4, F52.6, F52.1, F65.0, F65.3, F65.51, F65.52, F64.1, F65.81, F66, F65.9, F98.4, F63.3, R45.1, F91.9, F63.9, F63.2, F63.81, F81.0, F81.2, F81.81, F81.89, F80.89, F54.
Mental Health Services
Mental Health Services means services provided to treat a mental health condition.
Network
The terms network and in-network refer to PPO providers and PPO facilities.
Network rate
The network rate is the negotiated amount for each service/supply that is pre-contracted and agreed upon between the PPO Network and its participating providers and facilities. A network rate is also known as a “negotiated rate.”
No Surprises Act
No Surprises Act means the “No Surprises Act,” which was enacted to curtail “surprise billing” in Title I of Division BB of the Consolidated Appropriations Act of 2021, including the regulations and binding guidance issued thereunder, which generally governs patient cost sharing, balance billing, and payments to providers/facilities for emergency services (including certain post-stabilization care) rendered in out-of-network facilities, services rendered by out-of-network providers in in-network facilities, and services rendered by air ambulance providers. (For more details, see the Surprise Medical Bills Notice.)
Non-Medicare SHARP
Non-Medicare SHARP means the health care plan offered to a child of an Eligible Retiree.
North American Division or NAD
North American Division or NAD means the North American Division of the General Conference of Seventh-day Adventists.
Out-of-Network Facilities
Out-of-Network Facilities refers to any health care facility that is not an in-network facility. With the exception of emergency services (including certain post-stabilization care subject to the provisions of the No Surprises Act), urgent care, and approved Unavailable Service Request Form services, care received at out-of-network facilities is not covered.
Out-of-Network Providers
Out-of-Network Providers refers to physicians and professional providers that are not in-network providers. Except for the following exceptions, services received from out-of-network providers are not covered:
- Emergency services including emergency ground ambulance transportation, and including emergency air ambulance transportation (but only with pre-certification or when ground transportation would endanger the life of the member);
- Urgent care: Approved Unavailable Service Request Form (“USRF”) services;
- Service received at an in-network facility that is prescribed by a PPO provider (in which case the service will be covered at the PPO level even if performed by an out-of-network provider);
- Any other medically necessary covered service if coverage is required by the No Surprises Act; and
- Service received in an included territory by an employee stationed in an included territory (or the employee’s eligible dependent).
Outpatient Surgery
Outpatient Surgery means surgery that does not require an inpatient admission or overnight stay.
Participant
An employee of a participating employer who is eligible to earn service credit in the plan, or a former employee who is receiving benefits from the plan.
Pension Factor
A dollar amount voted each year by the North American Division (NAD) to calculate the retirement benefit for the Defined Benefit Plan. This provides for the annual Cost of Living Adjustment.
Physician
Physician means a Doctor of Medicine or Osteopathy.
Plan
Plan means this SHARP Pre-Medicare/Non-Medicare Plan.
Plan Administrator
Plan Administrator means Adventist Risk Management, Inc. (ARM). ARM shall have full discretionary power to administer the Plan and to interpret, construe, and apply all of its provisions and adjudicate claims as provided herein. ARM may delegate any of these duties as it deems reasonable and appropriate. In administering the Plan, the plan administrator shall be guided by and adhere to the teachings and tenets of the Seventh-day Adventist Church.
Plan Sponsor
Plan Sponsor is North America Division of Seventh-day Adventist, Adventist Retirement Board.
Plan Year
Plan Year means a calendar year (January 1 through December 31) or portion thereof. See definition for Claim Determination Period.
PPO
PPO means Preferred Provider Organization, a type of managed care health insurance plan that provides maximum benefits if you visit an in-network physician or provider.
PPO Facility
PPO Facility means a hospital, hospice facility, skilled nursing facility, or mental health or substance abuse residential facility that is a participating provider in the PPO Network.
PPO Network
PPO Network means the preferred provider networks arranged by Aetna Signature Administrators PPO for medical services.
PPO Provider
PPO Provider means a physician or professional provider who is in the PPO Network.
Pre-Certification/Pre-Certified/Pre-Certify (Medical Necessity Pre-Certification)
Pre-Certification/Pre-Certified/Pre-Certify (Medical Necessity Pre-Certification) refers to obtaining approval from the utilization review manager prior to the date of service for services that have been ordered by a physician or professional provider.
Pre-Medicare SHARP
The health care plan offered to retirees and their spouses who are not currently entitled to enroll for Medicare benefits, but who otherwise meet eligibility requirements.
Primary Care Providers
Primary Care Providers are physicians and professional providers specializing in family practice, general practice, internal medicine, and pediatrics. Note: You are not required to designate a primary care provider under this Plan.
Professional Provider
Professional Provider means a licensed professional, when providing medically necessary services within the scope of their license. In all cases, the services must be covered services under this Plan to be eligible for benefits.
Retirement Allowance
The one-time lump-sum benefit, based on years of pre-2000 service credit, granted at the time of admission to the Plan for those who go directly from active service on to retirement.
Rx Option
The SHARP option for prescription drug coverage.
Service Credit
A measure of time, expressed in years and percentage of years up to a maximum of 40, used in determining the amount of a participant’s retirement benefit.
SHARP
SHARP means the Supplemental Healthcare, Adventist Retirement Plan and the plan of benefit options described in the current SHARP document.
SHARP Office
SHARP Office means the SHARP administrative staff of the NAD Adventist Retirement Plans office listed in the Contact Information section of this document.
SHARP-Ex
SHARP-Ex means the medical and prescription drug benefits offered through the private Medicare Exchange Marketplace vendor, Alight Retiree Health Solutions.
Single Life Benefit
A benefit for the retiree only, providing no benefits for the retiree’s spouse. It is also the foundational calculation for all retirees.
SPD
SPD means Summary Plan Description.
Specialist
Specialist means physicians and professional providers who are not defined as primary care providers.
Spouse
Spouse means a participant’s spouse, as determined under the policies of the participating employer or parent organization of the participant.
Substance Abuse
Substance Abuse means substance abuse as defined in the most recent version of the Diagnostic and Statistical Manual, as published by the American Psychological Association. For purposes of this Plan, substance abuse does not include addiction to, or dependency on, foods, tobacco or tobacco products.
Urgent Care
Urgent Care means the provision of immediate, short-term medical care for minor but urgent medical conditions that do not pose a significant threat to life or health at the time the services are rendered.
Usual, Reasonable, & Customary Charge (“U&C”)
Usual, Reasonable, & Customary Charge (“U&C”) means:
(i) For out-of-network providers, the normal and necessary charges submitted or made for similar services or supplies provided by other providers of medical or dental services with like experience, education and training in the same geographical area. The term “geographic area” as it applies to any particular service, medicine, or supply means a county or such greater area as is necessary to obtain a statistically representative cross-section of the level of charges. Determination of the U&C for a medicine, service, or supply shall be made by the U&C contract administrator, using the 80th percentile of all charges for the same service or supply in the geographic area based on survey data collected and maintained by the U&C contract administrator (except that the U&C for anesthesia will be a flat rate of $95 per unit in the 2023 plan year). (The “U&C contract administrator” is the entity with which the plan administrator or PPO Network has contracted to provide usual and customary rate services and access to usual and customary rate databases.)
In the event a claim is received from an out-of-network facility/provider and there is no U&C for the services provided, the claim will pay at no more than 120% of Medicare.
For unlisted CPT codes ending in “99” for which there is no U&C for the service provided and Medicare rate, the U&C will be 50% of billed charges.
In the event a claim is received for emergency services rendered outside of the United States, the billed charges will be considered the U&C for the services rendered unless the Plan Administrator or its delegate determines that the billed charges are unreasonable when compared to the charges submitted or made for similar service or supplies provided by other providers with like experience, education and training in the same country.
Notwithstanding the above, if a different rate is negotiated between an out-of-network provider/facility and the plan administrator, the PPO Network, or their delegates, then that negotiated rate will be used and will be considered the U&C for the services rendered that are submit to such different negotiated rates.
For purposes of emergency services rendered in the United States and any other services covered by the No Surprises Act, the lower of billed charges or the “qualifying payment amount” (as defined by the No Surprises Act) will be the U&C unless a different amount is negotiated per the above paragraph or unless a different amount is determined at independent dispute resolution (in which case such different amount will be the U&C).
(ii) For in-network providers, the network rate. If no network rate is in place for the service or supply, the U&C will be determined as though it was provided by an out-of-network provider.
(iii) After hours surcharges in any 24-hour facility are not U&C and will not be covered by this Plan. This applies to both in-network providers and out-of-network providers.
(iv) Note on alternative phraseology: In some Plan materials, the usual, reasonable, & customary charge may be referred to as the Usual and Customary Charge, the Usual and Customary Rate, the Reasonable and Customary Charge, the Reasonable and Customary Rate, the UCR, or some other, similar phrase.
Utilization Review Manager/Utilization Management
Utilization Review Manager/Utilization Management means Adventist Health Benefits Administration’s in-house utilization review department, which is responsible for determining whether requested medical care is medically necessary. However, for all prescription drug benefits, the utilization review manager is Express Scripts. Adventist Health Benefits Administration also hears non-prescription drug appeals of adverse benefit determinations involving medical judgment.
Vesting Employee
A vesting employee has reached a service requirement which grants unconditional entitlement to future retirement benefits.
Yearly Rate Factor
The Yearly Rate Factor is a percentage of your remuneration factor assigned at the end of each calendar year prior to January 1, 2000 in which you earned service credit.
