Glossary of Health Fund Terms
To help you understand your benefits, we’ve put together this list of basic terms related to TeamCare. Highlighted text indicates that the word or phrase is defined in this section. For precise legal definitions of these terms, please refer to the Summary Plan Description (Forms and Documents or Your Participant Dashboard).
In addition, under the Affordable Care Act, the Department of Health and Human Services (HHS) and Labor posted a uniform Glossary of Terms on their website.
- Accidental Bodily Injury:
Physical damage to the body, e.g. a hurt, a wound, a trauma, resulting from a sudden and unexpected event, injury or external force occurring without forewarning.
- Accidental Death:
Any death directly and solely resulting from external means or an external cause, as opposed to a death caused or contributed to by a disease or infirmity. Benefits are not payable if death occurs in a manner excluded by the Plan Document.
- Active Employee:
A person who is actively working for a contributing employer. An employee on a layoff or otherwise unable to actively work, is not an active employee.
- Annual Major Medical Out-of-Pocket Expense:
The Major Medical Out-of-Pocket Expense Limit is your portion of eligible covered medical expenses that you must pay after the Plan has paid its required percentage.
- Annual Plan Deductible:
The Plan deductible is the amount of covered medical expenses that you or your dependents must pay each calendar year before the Plan begins paying benefits.
- Annual Plan Maximum:
Your Plan has a Plan Maximum that is determined per person, per calendar year. All medical benefits paid by the Plan are applied to the Plan Maximum. Once you reach the annual plan maximum, you are responsible for the costs for the remainder of the year.
- Collective Bargaining Agreement:
An agreement reached by bargaining as to wages and conditions of work and to which the Union is a party.
Care, treatment, services or supplies the primary effect of which is to improve the physical appearance of a Covered Individual. The fact that there may be an incidental medical benefit does not prevent a determination that the care, treatment, services or supplies are cosmetic.
Full entitlement to all benefits of this Plan by a Participant or Dependent, unless limited or excluded by any provision of this Plan.
A participant’s spouse or child.
- All persons who are accepted by the Trustees for participation in the Fund, under the terms and conditions stated by the Trustees for participation, and who are Active Employees of an Employer under the terms and conditions of a Collective Bargaining Agreement which requires Employer contributions be made to the Fund, and such other employees of the Employer as are proposed and accepted by the Trustees for participation, on whose behalf payments are required by the agreement of the Employer or applicable law to be made to the Fund;
- All persons employed by the Union upon being proposed by the Union and accepted by the Trustees; as to such Union personnel, the Union shall be considered an Employer solely for the purpose of contributions within the meaning of the Trust Agreement, as herein defined, and shall, on behalf of such personnel, make payments to the Trust Fund at the same times and at the rate of payment equal to that made by any other Employer who is a party to the Trust Agreement;
- All persons employed by Central States, Southeast and Southwest Areas Health and Welfare Fund or Central States, Southeast and Southwest Areas Pension Fund upon acceptance by the Trustees; as to such Trust Fund personnel, the Trustees shall be deemed an Employer solely for the purpose of contributions within the meaning of the Trust Agreement, on behalf of such personnel, make payments to the Trust Fund at the times and at the rate of payment equal to that made by any other Employer who is a party to the Trust Agreement; or All persons who are Trustees of Central States, Southeast and Southwest Areas Health and Welfare Fund or Central States, Southeast and Southwest Areas Pension Fund upon acceptance by the Trustees; on behalf of such persons who are Trustees, their Employers shall make contributions to the Trust Fund at the times and at the rate of payment equal to that required by any other Employer who is a party to the Trust Agreement.
In all instances the common-law test for, or the applicable statutory definition of, master-servant relationship shall control Employee status. The continuation of employee status shall be subject to such rules as the Trustees may adopt.
Any Employer (including an Association of Employers) who is or becomes a party to a Collective Bargaining Agreement and who, with the acquiescence of the Trustees, agrees to be bound by the Trust Agreement and this Plan and is accepted for participation in the Plan by the Trustees, subject to such rules as the Trustees may in their discretion adopt. The Union, the Health Fund and the Pension Fund shall be deemed to be Employers of those persons employed and proposed by such organizations and accepted by the Trustees.
- Employer Contributions:
Contributions made by Employers to the Plan; contributions made by the Union or the Plan on behalf of their Employees; and, amounts set aside by the Plan on behalf of its Employees.
- Explanation of Benefits:
After your claim is processed, you will receive an Explanation of Benefits (EOB), which details what was paid on your claim. The EOB will also indicate a reason if your claim was denied either in full or in part. You can also review your EOBs on your My Claims page once you log in. If you disagree with how the claim was processed, you can file an appeal. To file an appeal, go to the Contact Us page.
- Family Protection Benefit:
Through the exclusive use of TeamCare medical providers (for all non-emergency care), you can ensure continued healthcare coverage under the Family Protection Benefit for your family members after your death - at no cost in most instances. Simply use TeamCare medical providers for all your non-emergency medical care, and your covered spouse and dependents will be eligible for up to five years of continued health coverage at no cost.
- Family Medical Leave:
A voluntary absence from work taken by an Employee pursuant to the provisions of the federal Family Medical Leave Act.
The Central States, Southeast and Southwest Areas Health and Welfare Fund.
A formulary is a list of prescription drugs that are covered by your plan. Drugs may be removed from your list from time to time; in that case you may be given generic or other options to switch to. If you choose to continue to use a drug once it's been removed from your list, you may be required to pay full cost.
- Hospital Confinement:
A hospital stay of at least overnight duration. An emergency room visit is not part of a Hospital Confinement unless it leads directly to a stay in a hospital room.
A Health Maintenance Organization plan requires members to visit an in-network provider, as well as have a primary care physician set for referrals.
- Initial Contribution Period:
A period of consecutive days beginning on the day an Employer becomes obligated to make Employer Contributions for a Participant and ending on the Sunday of the eighth (8th) week thereafter, provided the Employer remains obligated to make weekly Employer Contributions on behalf of the Participant throughout the period.
An involuntary separation from employment caused by an Employer suspending Employees. Individuals shall not be deemed on Lay-off if they engage in gainful employment for any other employer, nor shall Lay-Off status continue when an individual retires or otherwise terminates the employment relationship.
- Leave of Absence:
An employee’s voluntary temporary absence from employment, approved by the employer. Individuals on Leave of Absence shall not engage in gainful employment for any other employer, nor shall Leave of Absence status continue when an individual retires.
- Local Union:
Those Local Unions affiliated with the International Brotherhood of Teamsters who have executed Collective Bargaining Agreements that require contributions to be made to the Plan on behalf of the covered employees, and such other Unions the Trustees may agree upon.
- Maintenance Care:
Maintenance Care is care provided to a person who needs assistance or support for the essence of daily living but who is not under a course of treatment which will improve his condition to the extent necessary to enable him to function without such assistance or support, except for care which is necessary to treat a curable illness. A Maintenance Care determination is not precluded by the fact that a patient is under the care of a Physician and that the services are provided at the Physician’s request.
- Major Medical Benefits:
Benefits for covered medical expenses.
An employee who is eligible for coverage under this Plan through required employer contributions or an employee who is entitled to and who does make Self-Payments to the Plan.
- Pension Fund:
The Central States, Southeast and Southwest Areas Pension Fund.
The Central States, Southeast and Southwest Areas Health and Welfare Plan, or TeamCare. In general use, a Plan is a benefit your employer, union or other group sponsor provides to you to pay for your health care services.
- Plan Document:
The legal document by which the Fund administers the Plan.
- Prescription Drug:
A drug or medicine prescribed by a Physician or Dentist, dispensed by a pharmacist, not available over the counter (except for insulin and insulin syringes) and bearing the Federal or State Legend.
- Psychiatric Treatment Facility:
A facility that is:
- Primarily engaged in providing, under the supervision of a Physician, psychiatric services for the diagnosis and treatment of mentally ill persons; and
- Licensed, certified or approved as a Psychiatric Treatment Facility, and not as a Hospital, by the state or jurisdiction in which it is located.
A Preferred Provider Organization allows members to receive service from any provider, although choosing a provider who is in-network will typically cost less. Under a PPO plan members are not required to have a primary care physician, and they can receive healthcare services from other providers without a referral. TeamCare members have access to one of the largest PPO networks available in the country.
- Qualified Medical Child Support Order:
Any order entered by a court of competent jurisdiction that complies with requirements of the federal Qualified Medical Child Support Act and which requires coverage for one or more dependent children.
A permanent termination of employment initiated by the Employee.
- Reasonable and Customary:
The usual, Reasonable and Customary charge for the treatment, supply or service, determined by comparison with the charges customarily made for similar treatments, supplies or services to individuals with similar medical conditions within a given geographical area.
Contributions to the Plan by a participant on his own behalf.
- Sick Leave:
A temporary absence from work caused by an employee’s illness, injury or pregnancy.
An individual who is married to a participant in a legally recognized civil or religious ceremony. A Participant’s common-law spouse shall be considered a spouse for purposes of the Plan, if: the participant’s state of domicile recognizes common-law marriage; and the Participant furnishes the Fund with appropriate documentation that the couple has fulfilled all conditions which his state of domicile requires for such a marriage.
- Standard Medical Care, Treatment, Services, or Supplies:
Care, treatment, services or supplies which are uniformly and professionally endorsed by the general medical community as Standard Medical Care, Treatment Services or Supplies.
The International Brotherhood of Teamsters, and its affiliated Local Unions.
- Temporary Work Stoppage:
A strike by Participants which is sanctioned by the Teamsters.
- Terminated Employee:
An individual who is separated from his employment by reason of Quit or Discharge.
- Total and Permanent Disability:
A disease or bodily injury which will permanently, continuously and wholly prevent a person from engaging in any occupation or employment for wage or profit for the duration of his life. Additionally, the complete and irrecoverable loss of the sight of both eyes, or the use of both hands, or of both feet, or of one hand and one foot.
- Trust Agreement:
The Agreement and Declaration of Trust made and entered into on the fourteenth (14th) day of March, 1950, by and between Central Conference of Teamsters, Southern Conference of Teamsters and their affiliated Local Unions, and the Southeastern Area Motor Carriers Labor Relations Association; Southwest Operators Association; and Motor Carriers Employers Conference – Central States, and as amended from time to time thereafter by the Trustees.