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/Prescription Drug Benefits Manager
Vendor that administers the Plan and processes claims; the vendor's decisions are final and binding.
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.
Copay
The flat dollar amount you pay for covered services and prescription drugs under the Plan.
Covered Health Service(s)
Covered Health services, including supplies or Pharmaceutical Products, which are determined to be all of the following:
  • Provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and addictive disorders, condition, disease or its symptoms.
  • Medically Necessary.
  • Described as a Covered Health Service in Summary Plan Description.
  • Not excluded in this the Summary Plan Description.
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 Expenses
Charges for Covered Health Services that are provided while the Surest Plan is in effect and determined by the Claims Administrator.
Eligible Expenses are determined solely in accordance with the Claims Administrator's reimbursement policy guidelines. The Claims Administrator develops the reimbursement policy guidelines, in the Claims Administrator's discretion, following evaluation and validation of all Provider billings in accordance with one or more of the following methodologies:
  • As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).
  • As indicated in the most recent editions of the Healthcare Common Procedure Coding System (HCPCS), or Diagnosis-Related Group (DRG) Codes.
  • As reported by generally recognized professionals or publications.
  • As used for Medicare.
  • As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that the Claims Administrator accepts.
Network Providers are reimbursed based on contracted rates. Out-of-network Providers are reimbursed at 200% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market.
Note: Out-of-network Providers may bill you for any difference between the Provider's billed charges and the Eligible Expense described above, except as required under the No Surprises Act, which is a part of the Consolidated Appropriations Act of 2021.
Eligible Family Members
To cover an eligible family member, you will be required to certify in the Aptia365 Benefits Enrollment Website that your eligible family member meets the eligibility criteria as defined below.
Spouse/Domestic Partner means:
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 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.
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.
Emergency
The sudden onset or change of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in:
  • Placing the Participant's health in serious jeopardy.
  • Serious impairment to bodily functions.
  • Serious dysfunction of any bodily organ or part.
Emergency Health Care Services
With respect to an Emergency:
  • A medical screening exam (as required under section 1867 of the Social Security Act or as would be required under such section if such section applied to an Independent Freestanding Emergency Department) that is within the capability of the emergency department of a hospital, or an Independent Freestanding Emergency Department, as applicable, including ancillary services routinely available to the emergency department to evaluate such Emergency, and
  • Such further medical exam and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital or an Independent Freestanding Emergency Department, as applicable, as are required under section 1867 of the Social Security Act, or as would be required under such section if such section applied to an Independent Freestanding Emergency Department, to stabilize the patient (regardless of the department of the Hospital in which such further exam or treatment is provided).
  • Emergency Health Care Services include items and services otherwise covered under the Plan when provided by an out-of-network Provider or facility (regardless of the department of the hospital in which the items and services are provided) after the patient is stabilized and as part of outpatient observation or an inpatient stay or outpatient stay that is connected to the original Emergency, unless each of the following conditions are met:
    • The Provider or facility, as described above, determines the patient is able to travel using nonmedical transportation or non-Emergency medical transportation.
    • The provider furnishing the additional items and services satisfies notice and consent criteria in accordance with applicable law.
    • The patient is in such a condition to receive information as stated in b above and to provide informed consent in accordance with applicable law.
    • Any other conditions as specified by the Secretary of the Department of Health and Human Services
Experimental or Investigational Services
A procedure, study, test, drug, equipment, or supply will be considered Experimental and/or Investigational if it is not covered under Surest Coverage with Evidence Development Policy and any of the following criteria/guidelines is met:
  • It is being provided pursuant to a written protocol that describes among its objectives the determination of safety, efficacy, toxicity, maximum tolerated dose, or effectiveness in comparison to conventional treatments.
  • It is being delivered or should be delivered subject to approval and supervision of an institutional review board (IRB) as required and defined by federal regulations or other official actions (especially those of the FDA or DHHS).
  • Other facilities/Providers/etc. studying substantially the same drug, device, medical treatment, or procedure refer to it as Experimental or as a research project, a study, an invention, a test, a trial, or other words of similar effect.
  • The predominant opinion among experts as expressed in published, authoritative medical literature is that usage should be confined to research settings.
  • It is not Experimental or Investigational itself pursuant to the above criteria but would not be Medically Necessary except for its use in conjunction with a drug, device or treatment that is Experimental or Investigational (e.g., lab tests or imaging ordered to evaluate the effectiveness of an Experimental therapy).
  • It cannot lawfully be marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use.
  • It is a subject of a current investigation of new drug or new device (IND) application on file with the FDA.
  • It is the subject of an ongoing Clinical Trial (Phase I, II or the research arm of Phase III) as defined in regulations and other official publications issued by the FDA and Department of Health and Human Services (DHHS).
  • It is being used for off-label therapies for a non-indicated condition – even if FDA approve for another condition.
Explanation of Benefits (EOB)
A summary of benefits processed by the Claims Administrator.
Global Benefits Department
Refers to the Global Benefits Department, located at 1166 Avenue of the Americas, 31st Floor, New York 10036.
Habilitative Services
Habilitative services help people learn skills and functions for daily living. Habilitative services benefits include the diagnosis categories of autism, pervasive developmental disorder, developmental delay and attention deficit disorder.
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.
Independent Freestanding Emergency Department
A health care facility that:
  • Is geographically separate and distinct and licensed separately from a hospital under applicable state law; and
  • Provides Emergency Health Care services
In-network Providers
A health care professional, Physician, clinic, or facility licensed, certified, or otherwise qualified under applicable state law to provide health care services to you. The term "Provider" refers to an in-network Provider unless otherwise specified.
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 Medical Plans and Medicare Prescription Drug Coverage for Disabled Employees
Marsh McLennan newsletter that provides an overview of how Medicare Part D could affect your Marsh McLennan 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
Medically Necessary- services that are all of the following as determined by the Claims Administrator or the Claims Administrator's designee.
  • In accordance with Generally Accepted Standards of Medical Practice.
  • Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for your Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms.
  • Not mainly for your convenience or that of your doctor or other health care provider.
  • Not more costly than an alternative drug, service(s), service site 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 has 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 determined by the Claims Administrator.
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 the Claims Administrator's determinations regarding specific services. These clinical policies (as developed by the Claims Administrator and revised from time to time), are available to Covered Persons, Physicians and other health care professionals on Benefits.Surest.com. Covered Persons may also call the telephone 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 usual and customary charge.
Outpatient
Treatment/care received at a clinic, emergency room or health facility without being admitted as an overnight patient.
Participant
The eligible employee or dependent properly enrolled in the Surest Copay Plan under the eligibility rules and only while such person(s) is enrolled and eligible for Benefits under the Surest Copay Plan.
Physician
Any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law.
Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist or other Provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that a Provider is described as a Physician does not mean that Benefits for services from that Provider are available to you under the Surest Plan.
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.
Private Duty Nursing
Nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an inpatient or an office/home setting when any of the following are true:
  • No skilled services are identified.
  • Skilled nursing resources are available in the facility.
  • The skilled care can be provided by a Home Health Agency on a per visit basis for a specific purpose.
  • The service is provided to a Participant by an independent nurse who is hired directly by the Participant or his/her family. This includes nursing services provided on an inpatient or a home-care basis, whether the service is skilled or non-skilled independent nursing.
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.
Recognized Amount
The amount which the copay is based on for the below Covered Health Care Services when provided by out-of-network providers:
  • Out-of-network Emergency Health Care Services.
  • Non-Emergency Covered Health Care Services received at certain Network facilities by out-of-network Physicians, when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Service Act. For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.
The amount is based on one of the following in the order listed below as applicable:
1. An All Payer Model Agreement if adopted;
2. Applicable State law; or
3. The lesser of the qualifying payment amount as determined under applicable law or the amount billed by the provider or facility.
The Recognized Amount for Air Ambulance services provided by an out-of-Network provider will be calculated based on the lesser of the qualifying payment amount as determined under applicable law or the amount billed by the Air Ambulance service provider.
Note: Covered Health Care Services that use the Recognized Amount to determine your cost sharing may be higher or lower than if cost sharing for these Covered Health Care Services were determined based upon an Eligible Expense.
Reconstructive
Surgery or procedure to restore or correct:
  • A defective body part when such defect is incidental to or follows surgery resulting from illness, injury, or other diseases of the involved body part.
  • A congenital disease or anomaly which has resulted in a functional defect as determined by a Physician.
  • A physical defect that directly adversely affects the physical health of a body part, and the restoration or correction is determined by the Claim Administrator to be Medically Necessary.
Residential Treatment Facility
A facility that is licensed by the appropriate state agency and satisfies certain additional criteria as determined by Surest.
Shared Savings Program
A program in which the network partner may obtain a discount to a non-network Provider's billed charges. This discount is usually based on a schedule previously agreed to by the non-network Provider. When this happens, you may experience lower out-of-pocket amounts. Surest Plan out-of-network copays would still apply to the reduced charge. Sometimes the Surest Plan provisions or administrative practices conflict with the scheduled rate, and a different rate is determined by the network partner, such as:
  • 200% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for the same or similar service within the geographic market.
  • An amount determined based on available data resources of competitive fees in that geographic area.
  • A fee schedule established by a third party vendor.
  • A negotiated rate with the Provider.
In this case the non-network Provider may bill you for the difference between the billed amount and the rate determined by the network partner. If this happens you should call the number on your medical member ID Card. Shared Savings Program Providers are not network Providers and are not credentialed by the network partner.
Skilled Nursing Facility
A Medicare licensed bed or facility (including an extended care facility, a long-term acute care facility, a hospital swing-bed, and a transitional care unit) that provides skilled care.
Specialist
Providers other than those practicing in the areas of family practice, general medicine, internal medicine, obstetrics/gynecology or general pediatrics.
Third Party Administrator
Each self-insured medical plan has a third party administrator (TPA) that sets the provider network for that medical plan.
The TPA also provides administrative services for that medical plan including record-keeping, enrollment and claims and appeals adjudication, and serves as the sole "Claims Administrator" for that plan. The TPA's decisions as claims administrator are final and binding.
Unproven / Unproven Services
Health services, including medications that are not determined to be effective for treatment of the medical condition or not determined to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature:
  • Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received.
  • Well-conducted cohort studies from more than one institution are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.
Surest has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time Surest issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can contact Surest Member Services for additional information.
Please note: If you have a life-threatening illness or condition (one that is likely to cause death within one year of the request for treatment), Surest may, at its discretion, consider an otherwise Unproven service to be a Covered Health Service for that illness or condition. Prior to such a consideration, Surest must first establish that there is sufficient evidence to conclude that, albeit Unproven, the service has significant potential as an effective treatment for that illness or condition.
Utilization Management
Utilization Management processes are conducted by Surest to ensure that certain services are Medically Necessary. Utilization Management processes include clinical, medical, pre-service review (e.g., Prior Authorization), concurrent review (e.g., during a hospital stay), and post-service review (review of Claims to ensure services were Medically Necessary).
Waiting Period/Elimination Period
The amount of time you must wait before being able to participate in a plan.