Glossary
Approved 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 plans' criteria, or immediately upon satisfying the plans' criteria if you previously did not qualify. To obtain spousal or domestic partner coverage, you will need to complete an Affidavit of Eligible Family Membership via PeopleLink (www.mmcpeoplelink.com), declaring that:
Spouse / Domestic Partner
  • You have already received a marriage license from a U.S. state or local authority, or registered your domestic partnership with a U.S. state or local authority.
Spouse Only
  • Although not registered with a U.S. state or local authority, your relationship constitutes a marriage under U.S. state or local law (e.g. common law marriage or a marriage outside the U.S. that is honored under U.S. state or local law).
Domestic Partner Only
  • Although not registered with a U.S. 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.
The Company 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.
Once your Affidavit of Eligible Family Membership is completed and processed, you may cover the dependent child(ren) of your spouse or domestic partner.
Complete your affidavit, via PeopleLink (www.mmcpeoplelink.com). Select the Health tab and under Medical Plans, click Comprehensive Medical Plan. Then go to Take Action in the right navigation bar and select Enroll, view, change benefits.
Case Management Review
When the precertification review service identifies a major medical condition, that condition will be subject to case management review, which aims at identifying major medical conditions early in the treatment plan and makes recommendations regarding the medical necessity of requested health care services.
Claims Administrator/Pharmacy Benefits Manager
Provider that administers the Plan and processes claims; the provider's decisions are final and binding.
Coinsurance
The percentage of expenses you are responsible for paying after you meet your deductible.
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.
COBRA coverage is considered alternative coverage to retiree medical coverage. If you elect retiree medical coverage, you will not be eligible for COBRA in the future. In addition, if you waive retiree medical coverage (at retirement or later), you will not be eligible for coverage under this Plan in the future.
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.
Covered Service(s)
Medically necessary health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, 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
  • 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 supply is covered under the plan and not whether the service or supply 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 supply 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.
Durable Medical Equipment
Durable medical equipment is equipment that is:
  • for repeated use and is not a consumable or disposable item
  • used primarily for a medical purpose, and
  • appropriate for use in the home
Eligible Child(ren)
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 an approved domestic partner
  • your stepchild
  • your unmarried child over the limiting age, who is incapable of self support by reason of a total physical or mental disability as determined by the Claims Administrator
  • your legally adopted child or a child or child placed with you for adoption.
For your child to be covered, your child must be:
  • dependent on you for maintenance and support, and
  • under 19 years of age or
  • under 25 years of age if a full-time student in a college or other accredited institution (generally those with 12 or more accredited hours of course work per semester, or full-time as determined by the school) and not employed on a full-time basis and
  • unmarried.
  • The Company has the right to require documentation to verify dependency (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.
Note: Age 26 dependent eligibility (See "Children" under "Eligible Family Members" in the Participating in Healthcare Benefits section for details.) pertains only to dependents of those retirees that were initially enrolled in one of the Marsh & McLennan Companies pre-65 retiree plans (See Participating in Pre-65 Retiree Medical Coverage section for details) and then enrolled in the Comprehensive Medical Plan on or after 1/1/2011.
Eligible Retirees
You are eligible if you are a:
  • retiree age 65 or over or a retiree who is under age 65 but has a covered dependent who is age 65 or over*,
  • had five or more years of vesting service,
  • were at least age 55 when you terminated from the Company, and
  • retired from the Company, a Company operating company (other than Marsh & McLennan Agency, LLC and any of its subsidiaries) or Johnson & Higgins January 1, 1983 or later.
*You are treated as a "retiree" if you are not currently employed by the Company or any subsidiary or affiliate of the Company and have previously met the eligibility requirements under this Plan.
You can also cover your eligible family members.
Explanation of Benefits (EOB)
A summary of benefits processed by the Claims Administrator.
Global Benefits Department
Refers to the Marsh & McLennan Companies 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 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.
Inpatient
A covered individual who is admitted to 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:
  • 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.
Lifetime Maximum
The maximum amount of benefits payable during a person's lifetime for such person covered under the plan.
Marsh & McLennan Companies Medical Plans and Medicare Prescription Drug Coverage for Retirees and Disabled Employees
Marsh & McLennan Companies newsletter that provides an overview of how Medicare Part D could affect your Company prescription drug coverage. It highlights issues you'll want to think about as you consider your prescription drug options.
Medicare
The U.S. 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.
Medicare Cross-Over
To sign-up for Medicare Cross-Over, complete the Medicare Cross-Over Enrollment Form, available on PeopleLink or by calling the Claims Administrator.
Medicare Cross-Over applies to Medicare Part B (medical) services. With this feature, Medicare pays first and then automatically forwards claims electronically to the Claims Administrator for processing. This means that you will not have to file separate claims with the Claims Administrator for these services.
Medicare Cross-Over does not apply to Medicare Part A (e.g., inpatient) claims or prescription drugs. You still need to file a claim with the Claims Administrator to be reimbursed for these expenses.
Non-custodial Care
Non-custodial care is skilled nursing care or physical, occupational, or speech therapy visits rendered by an agency or organization licensed or certified as a home health care agency in the state where the health care is given.
Non-preferred Providers
Health care providers who are not preferred providers and do not charge reduced fees.
Notice of Creditable Coverage
The Medicare Modernization Act (MMA) 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).
Outpatient
Treatment/care received by a covered individual at a clinic, emergency room or health facility without being admitted as an overnight patient.
Out-of-pocket Maximum
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 and speech therapy for a child.
Preauthorization/Precertification/Utilization Review
A review service that helps ensure you receive proper treatment and services and that these services are provided in the appropriate setting.
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.
Pre-existing Condition
A health problem you had and received treatment for before your current benefit elections took effect.
Preferred Providers
Preferred health care providers who have agreed to charge reduced fees to members.
Prescription Drugs
  • 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.
Qualified Family Status Change (Status Change, Qualified Change in Family Status)
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 include up to the 90th percentile of providers' charges in the area.
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.
Second Opinions
The Plan may require that you receive a second opinion before concluding that your suggested course of treatment is appropriate for plan coverage.
Urgent Care Services
Urgent care is non-preventive or non-routine health care services which are required in order to prevent serious deterioration of a member's health following an unforeseen illness, injury or condition. Urgent care includes conditions that could not be adequately managed without immediate care or treatment, but do not require the level of care provided in the emergency room.
The services must be a covered service under the contract to be subject to reimbursement. Routine care, including follow-up care, is not covered as urgent care.
Waiting Period/Elimination Period
The amount of time you must wait before being able to participate in a plan.
Wellness Benefit
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.