MMC Benefits Handbook
Glossary
Actively-At-Work
If you are eligible for coverage and enroll as a new hire, you are "Actively-At-Work" on the first day that you begin fulfilling your job responsibilities with the Company at a Company-approved location. If you are absent for any reason on your scheduled first day of work, your coverage will not begin on that date. For example, if you are scheduled to begin work on August 3rd, but are unable to begin work on that day (e.g., because of illness, jury duty, bereavement or otherwise), your coverage will not begin on August 3rd. Thereafter, if you report for your first day of work on August 4th, your coverage will be effective on August 4th.
After-tax (Post-tax) Contributions
Contributions taken from your paycheck after taxes are withheld.
Before-tax (Pre-tax) Contributions
Contributions taken from your paycheck generally before Social Security (FICA and Medicare) and federal unemployment insurance (FUTA) taxes and other applicable federal, state, and other income taxes are withheld.
Claims Administrator/Pharmacy Benefits Manager
Vendor that administers the Plan and processes claims; the vendor's decisions are final and binding.
Coinsurance
The percentage of expenses the plan pays after you meet your deductible. For purposes of the charts in this document, the percentages represent the portion of the costs that the Plan pays for covered services. So, for example, if the chart indicates 80%, the portion you will be responsible for is 20%.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that lets you and your eligible family members covered by a group health plan extend group health coverage temporarily, at their own expense, at group rates plus an administrative fee, in certain circumstances when their coverage would otherwise end due to a "qualifying event", as defined under COBRA.
A "qualifying event" under COBRA includes loss of coverage as a result of your leaving the Company (other than for gross misconduct); a reduction in hours, your death, divorce or legal separation; your eligibility for Medicare, or a dependent child's loss of dependent status; or, if you are a retiree, loss of coverage due to the Company filing for bankruptcy.
Coordination of Benefits
You or a covered family member may be entitled to benefits under another group health plan (such as a plan sponsored by your spouse's employer) that pays part or all of your health treatment costs. If this is the case, benefits from this plan will be "coordinated" with the benefits from the other plan. In addition to having your benefits coordinated with other group health plans, benefits from this plan are coordinated with "no fault" automobile insurance and any payments recoverable under any workers' compensation law, occupational disease law or similar legislation.
Copayment
The flat dollar amount you pay for a certain type of health care expense.
Covered Service(s)
Medically necessary health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance use, or their symptoms.
Covered health services must be provided:
  • When the Plan is in effect,
  • Prior to the effective date of any of the individual termination conditions set forth in this Summary Plan Description, and
  • Only when the person who receives services is a covered person and meets all eligibility requirements specified in the Plan.
Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions of prevailing medical research based on well-conducted randomized trials or group studies.
The Claims Administrator determines only the extent to which a service or goods or supplies is covered under the plan and not whether the service or goods or supplies should be rendered. The coverage determination is made using the descriptions of covered charges included in this section and the Claims Administrator's own internal guidelines. The decision to accept a service or obtain a goods or supplies is yours.
Deductible
The amount of out-of-pocket expenses you must pay for covered services before the plan pays any expenses.
Disability
A physical or mental impairment that substantially limits one or more of an individual's major life activities.
Eligible Family Members
Child/Dependent Child means:
  • Your biological child
  • A child for whom you or your spouse are the legally appointed guardian with full financial responsibility
  • The child of a domestic partner
  • Your stepchild
  • Your legally adopted child or a child or child placed with you for adoption.
Note: Any child that meets one of these eligibility requirements and who is incapable of self support by reason of a total physical or mental disability as determined by the Claims Administrator, may be covered beyond the end of the calendar year in which the child attains age 26.
Dependent children are eligible for healthcare coverage until the end of the calendar year in which they attain age 26. This eligibility provision applies even if your child is married, has access to coverage through his or her employer, doesn't attend school full-time or live with you, and is not your tax dependent.
Note: While married children are eligible for healthcare coverage under your plan until the end of the calendar year in which they attain age 26, this provision does not apply to your child's spouse and/or child(ren), unless you or your spouse is the child's legally appointed guardian with full financial responsibility.
The Company has the right to require documentation to verify the relationship (such as a copy of the court order appointing legal guardianship). Company medical coverage does not cover foster children or other children living with you, including your grandchildren, unless you are their legal guardian with full financial responsibility—that is, you or your spouse claims them as a dependent on your annual tax return.
Eligible Retiree
An employee is eligible for coverage under this plan if he/she is a US regular employee of Marsh & McLennan Companies or any subsidiary or affiliate of Marsh & McLennan Companies (other MMA and any of its subsidiaries) who terminates employment with five or more years of vesting service at age 55 or later, or at age 65 and eligible for active employee medical coverage at retirement or is a current retiree (under or over age 65) enrolled in retiree medical coverage.
When you or a covered family member reach age 65 or is deemed to be eligible for Medicare, the person who is age 65 or is eligible for Medicare is no longer eligible for coverage under the Pre-65 Retiree Medical Plan.
Evidence of Insurability (EOI)
Evidence of Insurability (EOI) is proof of good health and is generally required if you do not enroll for coverage when you first become eligible. If the coverage level you are requesting requires such evidence or if you are increasing coverage. Establishing EOI may require a physical examination at the employee's expense. The EOI must be provided to and approved by the insurer/vendor before coverage can go into effect.
Explanation of Benefits (EOB)
A summary of benefits processed by the Claims Administrator.
Global Benefits Department
Refers to the Global Benefits Department, located at 121 River Street, Hoboken, NJ 07030.
Health Insurance Portability and Accountability Act (HIPAA)
A Federal law, HIPAA imposes requirements on employer health plans including concerning the use and disclosure of individual health information.
Hospice
A hospice is an institution that provides counseling and medical services that could include room and board to terminally ill individuals. The hospice must have required state or governmental Certificate of Need approval and must provide 24 hour-a-day service under the direct supervision of a physician. The staff must include a registered nurse, a licensed social service worker and a full-time claims administrator. If state licensing exists, the hospice must be licensed.
In-network Providers
Preferred health care providers who have agreed to charge reduced fees to members.
Inpatient
Being treated and admitted at a covered facility for an overnight stay either by a physician or from the emergency room.
Life Threatening Illness or Injury– Emergency Room Coverage
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part.
Some examples of emergencies include:
  • Heart attack, suspected heart attack or stroke
  • Suspected overdose of medication
  • Poisoning
  • Severe burns
  • Severe shortness of breath
  • High fever (103 degrees or higher), especially in infants
  • Uncontrolled or severe bleeding
  • Loss of consciousness
  • Severe abdominal pain
  • Persistent vomiting
  • Severe allergic reactions.
The Plan covers emergency services necessary to screen and stabilize a member when:
  • A primary care physician or specialist physician directs the member to the emergency room
  • A plan representative (employee or contractor) directs the member to the emergency room
  • The member acting as a prudent layperson and a reasonable person would reasonably have believed that an emergency condition existed.
Marsh & McLennan Companies Medical Plans and Medicare Prescription Drug Coverage for Disabled Employees
Marsh & McLennan Companies newsletter that provides an overview of how Medicare Part D could affect your Marsh & McLennan Companies prescription drug coverage. It highlights issues you'll want to think about as you consider your prescription drug options.
The US Federal government's health insurance program, administered by the Social Security Administration, that pays certain hospital and medical expenses for those who qualify, primarily those who are over age 65 or under age 65 and are totally and permanently disabled. Medicare coverage is available regardless of income level. The program is government subsidized and operated.
Medically Necessary
Healthcare services provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, injury, mental Illness, substance use disorder, condition, disease or its symptoms, that are all of the following as determined by the Claims Administrator or its designee, within the Claims Administrator's sole discretion. The services must be:
  • in accordance with Generally Accepted Standards of Medical Practice;
  • clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, mental illness, substance use disorder disease or its symptoms;
  • not mainly for your convenience or that of your doctor or other health care provider; and
  • not more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms.
Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.
If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. The Claims Administrator reserves the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within the Claims Administrator's sole discretion.
Services or supplies for the diagnosis or treatment of mental illness, alcoholism or substance disorders that, in reasonable judgment of the Plan's preauthorization review service, are any of the following:
  • Not consistent with prevailing national standards of clinical practice for the treatment of such conditions
  • Not consistent with prevailing professional research demonstrating that the services or supplies will have a measurable and beneficial health outcome
  • Typically, do not result in outcomes demonstrably better than other available treatment alternatives that are less intensive or more cost effective
The Claims Administrator develops and maintains clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. These clinical policies (as developed by the Claims Administrator and revised from time to time), are available to Covered Persons on Anthem medical policy and clinical guidelines on www.anthem.com/cptsearch_shared.html or by calling the number on your ID card.
Medicare
The US Federal government's health insurance program, administered by the Social Security Administration, that pays certain hospital and medical expenses for those who qualify, primarily those who are over age 65 or under age 65 and are totally and permanently disabled. Medicare coverage is available regardless of income level. The program is government subsidized and operated.
Notice of Creditable Coverage
The Medicare Modernization Act requires all group health plan sponsors that offer prescription drug coverage to provide notices to covered employees, retirees, and their dependents who are eligible for Medicare's new prescription drug benefit (Part D).
Out-of-network Providers
Non-preferred health care providers who do not charge reduced fees to members.
Out-of-pocket Expenses
Subject to the following, the maximum amount you have to pay (excluding your contributions to participate in the plan) toward the cost of your medical care in the course of one year. There are some services and charges that do not count towards the out-of-pocket maximum, such as amounts exceeding plan limits, amounts exceeding the network negotiated price for prescription drugs, amounts your physician or health care provider may charge above the reasonable and customary charge.
Outpatient
Treatment/care received at a clinic, emergency room or health facility without being admitted as an overnight patient.
Predetermination of Benefits
This feature helps you estimate how much the Plan may pay (subject to your deductible and Plan maximum at the time the estimate is provided) before you begin treatment. It is intended to avoid any misunderstanding about coverage or reimbursement, and it is not intended to interfere with your course of treatment.
A review service that helps ensure you receive proper treatment and services and that these services are provided in the appropriate setting.
Preauthorization/Precertification/Utilization Review
You are responsible for preauthorizing out-of-network services only. Your in-network provider will preauthorize all other services inpatient admissions, but you are responsible for authorizing all other required services.
Pre-existing Condition
A health problem you had and received treatment for before your current benefit elections took effect.
Prescription Drugs
  • Formulary/Brand Name (Preferred) Prescription Drugs. A comprehensive list of preferred brand-name drug products that are covered under the plan. Preferred drugs are selected based on safety, effectiveness, and cost.
  • Generic Prescription Drugs. Prescription drugs, whether identified by chemicals, proprietary or non-proprietary name, that are accepted by the FDA as therapeutically effective and interchangeable with drugs having an identical amount of the same active ingredient as its brand name equivalent.
  • Non-Formulary (Non-Preferred) Prescription Drugs. Prescription drugs that do not appear on the formulary list are considered non-formulary or non-preferred; these drugs may either be excluded from coverage or may cost more.
Preventive/Wellness Care
Annual examinations or routine care covered under the plan; care that prevents or slows the course of an illness or disease or care that maintains good health.
Qualified Family Status Change (Status Change, Qualified Change in Family Status, Life or Family Change)
An event that changes your benefit eligibility. For example, getting married and having a child or your spouse or dependent lose other coverage. You can make certain changes to your before-tax benefit elections that are due to and consistent with the change in family status.
Qualified Medical Child Support Order (QMCSO)
A court order, judgment or decree that (1) provides for child support relating to health benefits under a plan with respect to the child of a group health plan participant or requires health benefit coverage of such child in such plan and is ordered under state domestic relations law or (2) is made pursuant to a state medical child support law enacted under Section 1908 of the Social Security Act. A QMCSO is usually issued requiring you to cover your child under your health care plan when a parent receiving post-divorce custody of the child is not an employee.
Qualifying Event
A "qualifying event" under COBRA includes loss of coverage as a result of your leaving the Company (other than for gross misconduct); a reduction in hours, your death, divorce or legal separation; your eligibility for Medicare, or a dependent child's loss of dependent status; or, if you are a retiree, loss of coverage due to the Company filing for bankruptcy.
Reasonable & Customary (R&C) Charges/Fees
Charges/fees that do not exceed the prevailing charges for comparable services in your provider's area. The Claims Administrator determines these limits based on the complexity of the service, the range of services provided and the prevailing charge level in the geographic area where the provider is located. The plan's reasonable and customary guidelines for professional services include up to the 315% of Medicare-based charges in the area, and the full eligible charge for facility charges.
The plan does not cover amounts charged by providers in excess of the reasonable and customary charge for any service or supply. The Claims Administrator regularly reviews the reasonable and customary charge schedule. To confirm whether your provider's charges are within the reasonable and customary limit, obtain a Predetermination of Benefits.
Spouse and Domestic Partner
Adding a spouse or same gender or opposite gender domestic partner to certain benefits coverage is permitted upon employment or during the Annual Enrollment period for coverage effective the following January 1st if you satisfy the Plan's criteria, or immediately upon satisfying the Plan's criteria if you previously did not qualify. To obtain domestic partner coverage, you will need to agree to the Affidavit of Eligible Family Membership declaring that:
Spouse / Domestic Partner
  • You have already received a marriage license from a US state or local authority, or registered your domestic partnership with a US state or local authority.
Spouse Only
  • Although not registered with a US state or local authority, your relationship constitutes a marriage under US state or local law (e.g. common law marriage or a marriage outside the US that is honored under US state or local law).
Domestic Partner Only
  • Although not registered with a US state or local authority, your relationship constitutes an eligible domestic partnership. To establish that your relationship constitutes an eligible domestic partnership you and your domestic partner must:
    • Be at least 18 years old
    • Not be legally married, under federal law, to each other or anyone else or part of another domestic partnership during the previous 12 months
    • Currently be in an exclusive, committed relationship with each other that has existed for at least 12 months and is intended to be permanent
    • Currently reside together, and have resided together for at least the previous 12 months, and intend to do so permanently
    • Have agreed to share responsibility for each other's common welfare and basic financial obligations
    • Not be related by blood to a degree of closeness that would prohibit marriage under applicable state law.
Marsh & McLennan Companies reserves the right to require documentary proof of your domestic partnership or marriage at any time, for the purpose of determining benefits eligibility. If requested, you must provide documents verifying the registration of your domestic partnership with a state or local authority, your cohabitation and/or mutual commitment, or a marriage license that has been approved by a state or local government authority.
In order to cover the child(ren) of a domestic partner, you will be required to agree to the Affidavit of Eligible Family Membership. Go to Colleague Connect (https://colleagueconnect.mmc.com), click Career & Rewards and select Mercer Marketplace Benefits Enrollment Website under Tools.
Waiting Period/Elimination Period
The amount of time you must wait before being able to participate in a plan.