Glossary of Terms

 

 

The following terms are used throughout this web site and their definitions will help you to understand your benefit plan.


Active Participant  A person who is employed by a Contributing Employer and who is eligible for benefits under any of the UFCW benefit plans.


Benefit Fund or Fund  Abbreviated version of United Food & Commercial Workers Unions and Food Employers Benefit Fund.


Brand Name Drug  The marketing name of a drug that has been patented by a pharmaceutical company. These drugs are generally more expensive than generic drugs.


COBRA Continuation Coverage  Extended coverage under a federal law that requires the Benefit Fund to extend health care coverage for a limited time at group rates.


Collective Bargaining Agreement  The current Retail Food, Bakery, Candy and General Merchandise Agreement and any other approved agreement providing for contributions to the Fund.


Covered Charges or Covered Expenses  The charges or expenses incurred by a Participant while eligible under the Plan, which are

 

  • Expressly covered under the applicable provisions of the Plan,
  • Medically Necessary,
  • The lesser of the following:

    • The negotiated rate of a Preferred Provider
    • The Usual, Customary and Reasonable charge
    • The charge billed by the Physician or other provider
    • The amount determined under the applicable plan provision

 

Covered Employment  Employment or work covered by the Collective Bargaining Agreement or for the Union or related entities.


Current Employee  is an Employee hired by the Employer prior to the ratification of the Collective Bargaining Agreement with a Date of Hire prior to March 1, 2004.


Custodial Care/Custodial Services  Care and/or services that are provided to help a person to perform activities of daily living, including personal hygiene. Custodial Services include personal care, homemaking services, moving the patient, acting as companion or sitter, or supervising medication which can usually be self-administered. Such services will be considered custodial regardless of who recommends, orders, provides or directs the care or the location for the care.


Date of Hire  The first day of a Participant’s employment as determined by the Employer.


Dependent  An Active Participant’s

 

  • Legal spouse or Registered Domestic Partner
     
  • Children covered under a valid Qualified Medical Child Support Order (QMCSO), as defined by ERISA
     
  • Natural child, legally adopted child, step-child, or a foster child placed by a governmental agency or court order, all under 26 years of age 
     
  • Unmarried child of your domestic partner or a foster child over the age of 14 days, provided:

     

    • The child is entirely supported by and resides with the Participant;
       
    • The child is subject to the Participant’s parental authority to the same degree as a natural child, and the natural parents, if living, have relinquished, on a permanent basis, such authority in writing. If one of the child’s natural parents is living in the home, the child will not be considered a foster child unless the natural parent is under the age of 18, is unmarried and is entirely dependent upon the Participant for support; or
       
    • The relationship with the child has been established other than by a governmental agency or court order

 

  •  Totally and permanently disabled unmarried natural, adopted child, step-child, or a foster child placed by a governmental agency or court order, over age 25, who are both:

     

    •  Unemployable because of a physical or mental disability which commenced prior to attaining age 26 
       
    • Fully dependent on the Participant for all support and maintenance (Children are not considered fully dependent on a Participant if they do not reside with the Participant or if they receive, or will receive, regular income of more than $2,500 during the calendar year.)

 

Unmarried foster children over age 19 who have been foster children of the Participant for at least five years prior to attaining age 19, and who satisfy the preceding requirements (other than age), will be treated as Dependents for the purposes of the total disability and full-time student extensions.

A Retired Participant’s

  • Legal spouse or Registered Domestic Partner
     
  • Child covered under a valid Qualified Medical Child Support Order (QMCSO), as defined by ERISA
     
  • Unmarried children (including legally adopted children, children who have been placed for adoption and stepchildren and Registered Domestic Partner’s children who are principally supported by the Participant) who are under age 19
     
  • Unmarried foster children under age 19 but over the age of 14 days, provided:

    • The child is entirely supported by and resides with the Participant;
       
    • The child is subject to the Participant’s parental authority to the same degree as a natural child, and the natural parents, if living, have relinquished, on a permanent basis, such authority in writing. If one of the child’s natural parents is living in the home, the child will not be considered a foster child unless the natural parent is under the age of 18, is unmarried and is entirely dependent upon the Participant for support; or
       
    • The relationship with the child has been established by a court decree or by order of a state, county or federal governmental agency
       
  • Unmarried children age 19 through age 23 who are dependent on the Participant for support and are enrolled in and attending an accredited educational, technical or trade school on a full-time basis (at least 12 semester units or the equivalent). After a Dependent has attained age 19, eligibility will not be extended without a school’s certification of enrollment. Such certification is required at the beginning of each school term (quarter, semester).
     
  •  Totally and permanently disabled unmarried children who are age 19 and older, and who are both:

     Unemployable because of a physical or mental disability which commenced prior to attaining age 19, or age 24 if the child was then enrolled as a full-time student in a recognized educational institution (A physician’s certification must be submitted before eligibility can be extended beyond age 19.)

    • Fully dependent on the Participant for all support and maintenance (Children are not considered fully dependent on a Participant if they do not reside with the Participant or if they receive, or will receive, regular income of more than $2,500 during the calendar year.)

 

Unmarried foster children over age 19 who have been foster children of the Participant for at least five years prior to attaining age 19, and who satisfy the preceding requirements (other than age), will be treated as Dependents for the purposes of the total disability and full-time student extensions
 

Dual Coverage  Coverage under the Benefit Fund both as a Participant and as a Dependent of another Participant (this may occur when two family members are eligible for Fund benefit plans).


Emergency  An accidental injury or the sudden onset of a medical condition with symptoms so severe, including severe pain, which without immediate medical attention the Participant could reasonably expect

  • That his or her health would be in serious jeopardy;
     
  • That a body organ or part would be seriously damaged;
     
  • Permanent disability or prolonged temporary disability;
     
  • Prolongation or more complex or hazardous treatment; or
     
  • Inordinate physical or psychological suffering.

 

Final determination as to whether services were rendered in connection with an Emergency will be made by the Fund.


Employer  An employer who is required to make a contribution on the Participant’s behalf to the Fund under the terms of the Collective Bargaining Agreement.


Experimental/Investigative Services  Any of the following

  • Any medical procedure, equipment, treatment or course of treatment, drug or medicine which is not normally and regularly used or prescribed by the medical community of Southern California for the reason that it remains under clinical or laboratory investigation or has not been exposed to clinical or laboratory investigation;
     
  • Any drug, device or medical treatment or procedure that 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 as compared with the standard means of treatment or diagnosis; or
     
  • If Reliable Evidence shows that the consensus among experts in the relevant field of clinical practice regarding the drug, device, or medical treatment or procedure 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 protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.
The Trustees may rely on the advice of medical consultants in determining whether a service or supply is “Experimental” or “Investigational” under this definition.


Explanation of Benefits (EOB)  A statement sent to the Participant that summarizes the charges billed by a provider, the portion of the charge that is covered by the Plan, the benefit amount paid by the Plan and the remaining cost, if any, that is the Participant’s responsibility to pay. If benefits are denied in part or entirely, the EOB statement will also include the reason that benefits were denied.


FMLA  The Family and Medical Leave Act of 1993. Under the terms of the FMLA, eligible employees may receive up to 12 weeks of leave in any 12-month period for

  • Their own serious health condition;
     
  • The care of a child, spouse or parent with a serious health condition; or
     
  • The birth or adoption of a child.

 

Fund  United Food & Commercial Workers Unions and Food Employers Benefit Fund.


Health and Welfare Benefits  A term generally used to describe benefits that are governed by ERISA and are not related to pension, retirement or savings plans. Includes benefits under all medical and dental plans, disability insurance plans, life insurance plans and accidental death and dismemberment insurance plans.


Health Care Plan  “Umbrella” term for all of the Fund’s medical plans the Indemnity Medical Plan and HMOs.


Hospital  A state or federally licensed institution that meets all of the following requirements

  • It is engaged primarily in providing diagnostic, surgical and therapeutic facilities for medical and surgical care of sick and injured persons on an inpatient basis at the patient’s expense.
     
  • It continuously provides 24-hour-a-day supervision by a staff of Physicians licensed to practice medicine (other than Physicians whose license limits their practice to one or more specified fields) and 24-hour-aday nursing care by or under the supervision of Registered Nurses (R.N.’s).
     
  • It is not, other than incidentally, a place of rest, a nursing home, a convalescent home, a place for the aged, a pain clinic, a place for drug addicts, a place for alcoholics or a similar institution.

 

Industry  means work covered under the terms of a collective bargaining agreement that requires contributions to the Benefit Fund.


Licensed Vocational Nurse (L.V.N.)  An individual licensed by the state of California or comparable authority to provide routine health care. This professional cannot perform all of the duties that a Registered Nurse can perform.


Medically Necessary  Services or supplies that are determined by the Plan to be

  • Appropriate and necessary for the symptoms, diagnosis or treatment of injury or illness;
     
  • Not Experimental, educational or Investigational;
     
  • Within the standards of good medical practice within the organized medical community in Southern California;
     
  • Not primarily for the convenience of the Participant, the Participant’s Physician or another provider; and
     
  • The most appropriate supply or level of service which can be safely provided. For Hospital stays, this means that acute care as an inpatient is necessary due to the kind of services the Participant is receiving or the severity of the Participant’s condition, and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.

 

Network Hospital  A Hospital that is part of the Prudent Buyer Network and which provides care and treatment at a specified rate.


New Hire Employee  is an Employee who was hired after February 29, 2004 or the date of ratification of the Collective Bargaining Agreement thereafter.


Nurse Midwife, Licensed  An individual licensed by the Board of Registered Nursing of the state of California or comparable legal authority and thereby authorized, under the supervision of a licensed Physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intra-partum and postpartum care, including family-planning care, care for the mother and immediate care for the newborn. All complications must be referred to a Physician immediately. The practice of midwifery does not include the assisting of childbirth by any artificial, forcible or mechanical means, or the performance of any version thereof. A midwife is not authorized to practice medicine or surgery.


Orthopedic Appliance  An appliance worn on the body that is specifically for the purpose of preserving and restoring the function of the skeletal system, its articulations and associated structures.


Outpatient Pulmonary Rehabilitation Treatment for chronic pulmonary diseases such as emphysema, bronchiectasis and chronic obstructive pulmonary disease (COPD). Rehabilitation can include the following services

  • Respiratory therapy to maintain bronchial hygiene
     
  • Education about the patient’s illness, managing the illness and handling usual activities of daily living
     
  • Physical activities to improve the patient’s ability to function at the optimal level

 

Outpatient Surgical Center or Surgi-center  A state licensed facility which is not a Hospital, but meets all of the following requirements:

  • It is primarily engaged in providing diagnostic and surgical facilities for ambulatory, outpatient surgical care.
     
  • It is equipped with permanent facilities for diagnosis and surgery and is staffed by Registered Nurses, Physicians and anesthetists licensed to practice medicine.
     
  • It is a place other than the Doctor’s office or Doctor’s surgical suite.

 

Participant  An individual employed by a Contributing Employer in a position covered by the Collective Bargaining Agreement, on whose behalf the Employer is required to make contributions to the Fund and who satisfies the eligibility requirements of the Plan. Includes employees of the Union and related entities for whom contributions are required and who satisfy the Fund’s eligibility requirements.


Period of Disability  A continuous Hospital stay or a series of Hospital stays where the dates of discharge and admission are separated by fewer than 28 days. A new Period of Disability for a Participant will begin if he or she could have returned to active employment before 28 days from discharge. Should readmission to a Hospital be required as a result of an accidental injury occurring during the 28-day period, such readmission constitutes a new disability. A new Period of Disability for an eligible Dependent commences if he or she is able to resume normal activities before 28 days from discharge.


Physician (Doctor)  A licensed Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.). A Dentist (D.D.S.), licensed Podiatrist (D.P.M.), Chiropodist and Chiropractor (D.C.), and Acupuncturist are included within the scope of their license. A Dentist (D.D.S.) is not covered as a Physician, surgeon or Doctor under the indemnity or ancillary services and supplies sections of the Indemnity Medical Plan. A Certified Optometrist shall be considered a Physician, for diagnosis and treatment of eye conditions within the scope of his license. Christian Science Practitioners are included if listed in the current Christian Science Journal. Where a Physician is specifically defined in a benefit provision, that definition shall prevail over this general definition.


QMCSO  A Qualified Medical Child Support Order, as defined by the Employee Retirement Income Security Act (ERISA).


Qualifying Event  An event that entitles eligible employees and eligible Dependents to choose Continuation Coverage (COBRA) if their coverage under the Plan would otherwise end. Qualifying Events for eligible employees include

  • Termination for any reason other than gross misconduct; and
     
  • Layoff or reduction in work-hours

 

Qualifying Events for eligible Dependents include

  • Death of the eligible employee;
     
  • Spouse’s divorce or legal separation from eligible employee; and
     
  • Termination of a child’s qualification as an eligible Dependent.

 

Registered Domestic Partner   An individual who has entered into a domestic partnership with a Participant, and whose domestic partnership with the Participant meet all of the following requirements:


The Participant and the Registered Domestic Partner must share an intimate and committed relationship of mutual caring;

  • The Participant and the Registered Domestic Partner must have established a domestic partnership by filing a Declaration of Domestic Partnership with the California Secretary of State;
     
  • The Participant and the Registered Domestic Partner must share a common residence;
     
  • Neither the Participant nor the Registered Domestic Partner may be married to someone else or is a member of another domestic partnership that has not been terminated, dissolved, or adjudged a nullity;
     
  • The Participant and the Registered Domestic Partner must not be related by blood in a way that would prevent them from being married to each other in the State of California;
     
  • Both the Participant and the Registered Domestic Partner must be 18 years of age or older;
     
  • The Participant and the Registered Domestic Partner must either be members of the same sex, or if they are members of the opposite sex, one or both are over the age of 62; and

 

Both the Participant and the Registered Domestic Partner must be capable of consenting to the domestic partnership.


Registered Nurse (R.N.)  An individual licensed by the Board of Registered Nursing of the state of California or comparable authority to operate within the scope of his or her license.


Required Hours  The hours you must work in Covered Employment during each month to earn eligibility for Health and Welfare Benefits.


Retiree (Retired Participant)  A former employee of a Contributing Employer who may be eligible for one or more Retiree benefit plans.


Serious Emotional Disturbances of a Child  A condition in which a child

  • Has one or more mental disorders as defined by the DSM-IV, other than a primary substance use disorder or developmental disorder, that results in behavior inappropriate to the child’s age according to expected developmental norms; and
  • Is under the age of 18; and
  • Meets one or more of the following criteria:

    • As a result of the mental disorder, the child has substantial impairment in at least two of the following areas self-care, school functioning, family relationships or ability to function in the community; and either of the following occurs (i) the child is at risk of removal from the home or already has been removed from the home, or (ii) the mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment
       
    •  The child displays one of the following psychotic features, risk of suicide or risk of violence due to a mental disorder
       
    •  The child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570 of Division 7 of Title 1 of the Government Code).

 

Severe Mental Illness  Schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa and bulimia nervosa.


Skilled Nursing Facility  A facility, as defined by Medicare, that has the staff and equipment to provide skilled nursing care or rehabilitation services, as well as related health services.


Union or Union Local  Any one of the United Food & Commercial Workers 135, 324, 770, 1036, 1167, 1428 and 1442 Union Locals named in this book.


Usual, Customary and Reasonable  The fee charged for a service by a Hospital, Physician, surgeon or any other covered provider that meets the following criteria, as determined by the Board of Trustees at its sole discretion.
A charge is considered “usual” if it is the charge the provider most frequently makes to the majority of his or her patients for a given service. A charge is considered “reasonable” when the service is within reasonable utilization limits, and is justifiable considering the circumstances involved, as determined by the Board of Trustees. A charge is considered “customary” when it is within the range of the typical charges made by other providers of similar training and experience for the same service within a similar geographic area.


Vesting Credit, Year(s) of  A measure used to determine whether a Participant is entitled to retirement benefits provided by the Pension Plan. A Participant earns one Year of Vesting Credit by accruing 150 Hours of Service in a calendar year. Partial credit is not given for years in which a Participant accrues fewer than 150 Hours of Service.