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GLOSSARY

This section provides brief explanations in non-technical language of important terms used in this Summary Plan Description.

Term Definition
Claim Administrator The vendor that MILA has chosen to administer its health benefits is the Claim Administrator. Cigna is our medical Claim Administrator. Cigna Behavioral Health (CBH) is our behavioral health Claism Administrator. CVS Caremark is our prescription drug Claim Administrator. Aetna is our dental Claims Administrator. EyeMed is our vision Claims Administrator.
COBRA The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA). COBRA is an act that requires group health plans to offer continuation health coverage when a Member or dependent is no longer eligible for coverage (for example, if you leave the Plan or if your dependent reaches the maximum age for coverage).
Coinsurance The percentage of the medical cost that is paid by the Member and by the Plan. For example, if you are covered by the Core Plan and need to stay in the hospital for a medical service, you pay 40% of the “reasonable and customary” charges (after the deductible) and the Plan pays 60%.
Contract Year The 12-month period beginning on October 1 and ending the following September 30 during which an active Member must receive credited hours necessary for coverage under MILA during the following calendar year.
Copayment (Copay) The flat dollar amount you pay for doctor’s office visits, hospital admission, emergency room or urgent care centers. You also pay a set copay for prescription drugs. See the plan benefit summaries for specific Plan copay requirements.
Credited Hours You are eligible for the Core, Basic or Premier Plan benefits based on the number of credited hours you receive during the Contract Year (October 1 through September 30).
Deductible The dollar amount you must pay for medical services or prescription drugs before the Plan begins paying benefits.
Dental Accident A sudden, unexpected, and unforeseen, identifiable occurrence or event producing, at the time, objective symptoms of a bodily injury. The accident must occur while the person is covered under this Plan. The occurrence or event must be definite as to time and place. It must not be due to, or contributed by, an illness or disease of any kind.
Dental Emergency Any dental condition that:
  • Occurs unexpectedly;
  • Requires immediate diagnosis and treatment in order to stabilize the condition; and
  • Is characterized by symptoms such as severe pain and bleeding.
Dental Occurence A period of disease or injury. An occurrence ends when 60 consecutive days have passed during which the covered person:
  • Receives no dental treatment, services, or supplies, for a disease or injury; and
  • Neither takes any medication, nor has any medication prescribed, for a disease or injury.
Dentist A legally qualified dentist, or physician licensed to do the dental work he or she performs.
Dependent Any of your family members who meet all of the eligibility requirements for coverage outlined in the SPD and this website.
Directory A listing of all network providers. For an up-to-date list, you can call Cigna, CBH, CVS Caremark, Aetna or EyeMed or visit their websites.
Emergency Under the Plan, an emergency exists if you believe that the person’s condition, sickness or injury is such that failure to receive immediate medical care could put that patient’s health in serious jeopardy. Examples of an emergency include—but are not limited to—chest pain, stroke, poisoning, serious breathing difficulty, uncontrolled bleeding, unconsciousness and severe burns or cuts.
ERISA The Employee Retirement Income Security Act of 1974 (ERISA), as amended, protects Member rights under qualified pension and welfare benefit plans.
Generic Drugs These drugs are the most affordable way for you to obtain quality medications at your lowest copayment level. These drugs contain the same active ingredients and are available in the same strength and dosage as their brand name counterparts.
HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPPA), as amended, provides privacy protections for Plan participants and portability requirements on qualified benefit plans.
Medically Necessary Generally, a service or supply furnished by a particular provider is medically necessary if the Plan determines, using generally accepted standards, that it is appropriate for the diagnosis, the care or the treatment of the disease or injury involved. See here for more information.
Member A person who is actively employed under the terms of the USMX-MILA Master Contract or by a Participating Employer approved for coverage by the MILA Trustees and is eligible for coverage through one of MILA’s benefit Plans.
Network Provider A health care provider that has contracted to furnish services or supplies for a negotiated charge and is included in the Plan’s provider network.
Non-Preferred Brand Drugs These are brand name drugs that generally can be effectively substituted with a preferred drug from the formulary.
Orthodontic Treatment Any dental service or supply that is furnished to prevent or to diagnose or to correct a misalignment, whether or not for the purpose of relieving pain:
  • of the teeth;
  • of the bite; or
  • of the jaws or jaw joint relationship.
Out-of-Network Care This is a health care service or supply furnished by a health care provider that is not a part of the Claims Administrator’s provider network.
Out-of-Pocket Limit The out-of-pocket limit is the maximum deductible and coinsurance you pay for covered expenses in a calendar year. If your deductible and coinsurance payments reach this limit, the Plan will pay 100% of the charge for covered expenses for the rest of the calendar year.
Pensioner A former Member in the longshore industry who is retired under a local Port longshore pension plan and is eligible for post-employment benefits through MILA.
Plan Year The benefits plan year begins on January 1st and ends on December 31st.
Port Association or Employer Association A Port association or an employer association is a local association comprised of Members who employ ILA employees who work under the USMX-ILA Master Contract.
Preferred Brand Drugs These are brand name drugs that either do not have a generic equivalent or are considered to be an effective alternative under the formulary.
Preventive Care This care does not treat a particular condition but is meant to help the patient get and stay healthy. Preventive care includes well-child check-ups, immunizations, annual exams, and many cancer screenings such as mammograms.
Primary Care Physician (PCP) A family or general practitioner, internist or pediatrician who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. An OB/GYN is considered a PCP when providing routine care. Each covered family member may choose his/her own PCP from the Plan’s network physicians.
Qualified Domestic Relations Order (QDRO) Any judgment, decree or order that provides for child support, alimony, and/or marital property rights to a spouse, former spouse, child or other dependents under a state domestic relations law.
Reasonable and Customary Charges (R&C) If you use Out-of-Network providers, benefits may be based on reasonable and customary charges. These are the fees determined from claims data to be the usual charge in your geographic area for a particular service or supply. See here for more information.
Specialist A provider whose practice is limited to treating a specific disease, specific parts of the body or specific procedures. Usually (although not always) a specialist is certified as competent to perform by the Medical Board in his or her specialty. Examples of specialists include dermatologists, cardiologists, oncologists, and surgeons.
Transition of Care If you are currently receiving medical treatment (for example, if you’re in the hospital) on January 1st and your MILA benefit Plan level changes, your benefits will change over to the new Plan. You do have COBRA rights if you would like to continue your former Plan’s benefits.