Comprehensive Wellness Initiative -- Policy - Definitions

II. Definitions

  1. “Attestation Form” – a legally binding document that subscribers must complete to document eligibility to enroll in the 80/20 Standard Plan. Members who do not use tobacco products, have a BMI within the approved range, are participating in a tobacco cessation or weight management program or have a medical condition that prevents the member from attaining the specified weight range may be eligible for the 80/20 Standard Plan.
  2. “70/30 Basic Plan” -- the Plan's PPO option providing for 70/30 in network coverage after deductibles and copayments.
  3. “Body Mass Index (BMI)” – is a number calculated from a person's weight and height ratio. BMI is the clinically-based and Centers for Disease Control and Prevention (CDC) endorsed indicator of body fatness and is used to screen for weight categories that may lead to health problems.
  4. “BMI Chart” –the Plan-approved measurement table from the CDC that converts height and weight measures to BMI. BMI is determined on the chart by finding the appropriate height row in the left-hand column, then moving across the height row to the appropriate weight column. The number at the top of the weight column is the BMI for that height and weight. The table is located at http://www.cdc.gov/healthyweight/assessing/bmi/.
  5. “Dependent” – a non-Medicare primary member other than the subscriber enrolled in the Plan.
  6. “Exemption” – Subscribers who attest to qualifying for an exemption at enrollment must obtain a Physician Certification Form. The completed form must include the dated signature of a physician, nurse practitioner or physician’s assistant, as well as the tobacco cessation and/or weight management program start date(s). An exemption may also include a medical condition for the weight management component.
  7. “Enrollment Period” – the period of time when subscribers can enroll in the Plan or change from one benefit plan to another, usually occurring during the spring, or the period beginning at the date of hire and ending within 30 days of the date of hire.
  8. “NC HealthSmart” –the Plan’s healthy living initiative that provides members with disease and case management support and wellness programs, including resources for tobacco cessation and weight management. Click here for more information.
  9. “Non Tobacco User” – a member who attests to not using tobacco products or a member for whom such an attestation is made.
  10. “Physician Certification Form” - a declaration by the member’s physician, physician assistant or nurse practitioner confirming the member qualifies for exemption due to a medical condition that prevents the attainment of the required weight range or participation in a weight management and/or smoking cessation program(s), such as those provided by NC HealthSmart.  A new Physician Certification Form will be required for each affected member for each benefit year if a subscriber attests to qualifying for an exemption.
  11. “Plan member” or “member”– a non-Medicare eligible subscriber or covered dependent who is eligible and currently enrolled in the Plan and for whom a premium is paid. Eligible members for the Comprehensive Wellness Initiative also include non-Medicare eligible covered dependents of subscribers who have Medicare as their primary insurance.    
  12. “Plan” or “State Health Plan” is defined by G.S. 135-45.1(19). 
  13. “Physician” – duly licensed physician, nurse practitioner or physician assistant.
  14. “Tobacco Use and Types of Smoking/Tobacco products” –Members are considered to be using tobacco products if they smoke cigarettes, cigars, pipes and/or E-cigarettes, or use smokeless tobacco products, such as chewing tobacco and snuff.
  15. “80/20 Standard Plan”– the Plan’s PPO option providing for 80/20 in network coverage after deductibles and copayments.  
  16. “Subscriber” – the Plan member who is eligible for coverage under the Plan and requests coverage on behalf of himself and his dependents.
  17. “Tobacco or Smoking Cessation Program” – is a tobacco cessation benefit or service offered through NC HealthSmart or other comparable program, such as the NC Tobacco Use Quitline® Federal Drug Administration (FDA) approved tobacco cessation medications; telephonic, cessation coaching support; physician or behavioral health care provider cessation counseling, or other physician prescribed cessation treatments. 
  18. “Tobacco Use or Cotinine Testing” – the Plan-sponsored testing process to determine if an individual is using any form of tobacco as measured by the level of cotinine, a metabolic byproduct of nicotine, in saliva or blood. A test is “failed” or “positive” if the test results indicate a level of cotinine above the Plan-approved threshold.
  19. “Weight Management Program” – is a weight management benefit or service offered through NC HealthSmart or other comparable program, such as FDA-approved weight reduction medications, weight management/nutrition programs and nutrition counseling, or other physician prescribed weight management treatments.
  20. “Weight Management Testing” – the Plan-sponsored testing process to determine height and weight for BMI calculation.  A test is “failed” if the results indicate a BMI above the Plan specified weight range.
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