Noblesville Schools Medical Plan 110 Section 9: Defined Terms Service Fee - the periodic fee required for each Participant and each Enrolled Dependent, in accordance with the terms of the Plan. Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this SPD includes Mental Illness or substance-related and addictive disorders. Skilled Care - skilled nursing, skilled teaching, skilled habilitation and skilled rehabilitation services when all of the following are true: • Must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient. • Ordered by a Physician. • Not delivered for the purpose of helping with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair. • Requires clinical training in order to be delivered safely and effectively. • Not Custodial Care, which can safely and effectively be performed by trained non-medical personnel. Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law. Specialist - a Physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine. Specialty Pharmaceutical Products - Pharmaceutical Products that are generally high cost biotechnology drugs used to treat patients with certain illnesses. Spouse - an individual to whom you are legally married. Substance-Related and Addictive Disorders Services - services for the diagnosis and treatment of alcoholism and substance-related and addictive disorders that are listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The fact that a disorder is listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association does not mean that treatment of the disorder is a Covered Health Care Service. Summary Material Modification (SMM) - any attached written description of additional Covered Health Care Services not described in this SPD. Covered Health Care Services provided by a SMM may be subject to payment of additional Service Fees. SMMs are subject to all conditions, limitations and exclusions of the Plan except for those that are specifically amended in the SMM. Surrogate - a female who becomes pregnant by artificial insemination or transfer of a fertilized egg (embryo) for the purpose of carrying the fetus for another person. A surrogate provides the egg and therefore is biologically (genetically) related to the child. Telehealth/Telemedicine - live, interactive audio with visual transmissions, and/or transmissions through federally compliant secure messaging applications of a Physician-patient encounter from one site to another using telecommunications technology. The site may be a CMS defined originating facility or another location such as a Covered Person's home or place of work. Telehealth/Telemedicine does not include virtual care services provided by a Designated Virtual Network Provider. Transitional Living - Mental Health Care Services and Substance-Related and Addictive Disorders Services provided through facilities, group homes and supervised apartments which provide 24-hour supervision, including those defined in the American Society of Addiction Medicine (ASAM) Criteria and are either: