The amount you have to pay each year for health care expenses (except for copays) before the plan “kicks in” and starts to pay a share of the cost.
The time period when you can choose your benefits for the next year. This usually happens in the fall of each year.
A health and welfare employee benefit plan sponsored by Walmart Inc., and governed under the Employee Retirement Income Security Act of 1974, as amended (ERISA).
An overall name for the medical plans offered by Walmart. It includes the Premier Plan, Contribution Plan, Saver Plan, Local Plans, and the eComm PPO Plan.
Walmart’s benefits for mental health and substance abuse, including alcohol and drug abuse.
A medical facility that provides 24-hour inpatient care, intensive outpatient care, or residential treatment.
A drug that’s made by only a single company. It might or might not have a generic version. You can find all brand-name drugs covered by Walmart plans on the plan formulary.
If you’re 50 or older, the IRS will let you make extra contributions to your 401(k) plan. And if you’re 55 or older and enrolled in the Saver Plan, the IRS will let you make a $1,000 catch-up contribution to your health savings account.
COBRA lets you and your eligible dependents continue medical, dental, and vision benefits if you lose coverage because of a qualifying event — for example, if you lose your job.
The amount you pay for eligible medical and dental expenses after you’ve met your deductible. For example, if you pay 25% coinsurance, the plan pays the other 75% of the cost. See the Associate Benefits Book for details.
If you’re covered by two benefit plans for the same thing, this is the behind-the-scenes process of deciding which plan will pay out. This means you might not receive the entire benefit from both plans.
A fixed amount of money you may need to pay for certain covered services or supplies, like doctor visits, prescriptions, or vision care.
Charges for procedures, supplies, equipment, or services that are covered by your medical plan. To be covered, they must be:
- medically necessary;
- not more than the maximum allowable charge;
- not more than any other plan limits; and
- not excluded under the plan
For all coverage options under the long-term disability (LTD) and truck driver LTD plans, "disability" means that, due to a covered injury or sickness during the benefit waiting period and for the next 24 months of disability, you are unable to perform the material and substantial duties of your job (or, under the truck driver LTD plan, you lose medical certification in accordance with the Federal Motor Carrier Safety Regulations). After 24 months of benefit payments, "disability" means that you are unable to perform the material and substantial duties of any occupation.
In determining whether you are disabled, Lincoln will not consider employment factors, including but not limited to: interpersonal conflict in the workplace, recession, job obsolescence, pay cuts, job sharing, or loss of professional or occupational license or certification for reasons other than a covered injury or sickness.
To qualify for LTD benefits:
- You must be unable to return to work after the initial benefit waiting period of disability.
- You must continue to be under the appropriate care of a qualified doctor (qualified doctors include legally licensed physicians and practitioners who are not related to you and who are performing services within the scope of their licenses).
- Lincoln must receive and approve certification with accompanying medical documentation of a disability from your qualified doctor before benefits are considered for payment.
With respect to short-term disability coverage, see also "total disability."
People who can be legally considered as the following:
- Your spouse, as long as you are not legally separated.
- Your domestic partner (or "partner"), as long as you and your domestic partner:
- are in an ongoing, exclusive, and committed relationship similar to marriage and have been for at least 12 months and intend to continue indefinitely;
- are not married to each other or anyone else;
- meet the age for marriage in your home state and are mentally competent to consent to contract;
- are not related in a manner that would bar a legal marriage in the state in which you live; and
- are not in the relationship solely for the purpose of obtaining benefits coverage.
- Any other person to whom you are joined in a legal relationship recognized as creating some or all of the rights of marriage in the state or country in which the relationship was created (also referred to as "partner").
- Your dependent children, through the end of the month in which the child reaches age 26 (or older, if incapable of self- support) who are:
- your natural children;
- your adopted children or children placed with you for adoption;
- your stepchildren;
- your foster children;
- the children of your partner, provided your relationship qualifies under the definition of spouse/partner; or
- someone for whom you have legal custody or legal guardianship, provided he or she is living as a member of your household and you provide more than half of his or her support.
If a court order requires you to provide medical, dental, or vision coverage for children, the children must meet the plan's eligibility requirements for dependent coverage.
The time between the date you’re hired and the date you can enroll for benefits.
Evidence of your health condition, which includes answering a questionnaire about your medical history and possibly having a medical exam. It’s also known as Proof of Good Health. The Proof of Good Health questionnaire is available when you enroll.
A document sent to you that explains how a medical plan claim was paid or applied.
The list of generic and brand‐name medications that are covered by Walmart’s medical plans. The plan formulary is maintained by OptumRx.
If you’re enrolled in a medical plan, your health care advisor is an actual person who is your single point of contact for all questions and communication with your medical plan administrator. Your health care advisor can answer questions about your health care benefits, help you with claims, and resolve administrative questions and concerns.
An account to which the company credits a specific amount of money to help pay your eligible medical expenses before you have to pay (excluding prescriptions). If you choose the Contribution Plan, Walmart will contribute $250 to associates who choose associate-only coverage, or $500 to associates who cover their dependents.
If you’re enrolled in the Saver Plan, you can save money tax-free in this account, then use it to pay for qualified medical expenses (as defined by the IRS). Walmart will match your contributions dollar for dollar up to $350 if you choose associate-only coverage, or $700 if you cover your dependents.
The Health Insurance Portability and Accountability Act of 1996, which protects the privacy of your personal health information.
The first time you’re eligible to enroll for benefits under the plan. Initial enrollment periods are different for different jobs, and you might also have a waiting period. See the charts in the Eligibility and Enrollment chapter in the Associate Benefits Book.
If you need time away from work, a leave of absence is typically unpaid but lets you continue to use your benefits and keep your job during your time away. Walmart provides three types of leave:
- Family and Medical Leave Act (FMLA)
- Personal
- Military
These plans feature a proven network of doctors, clinics, hospitals, and other providers who work together to give you the best possible care. The plans are designed to build close relationships between you and your doctors.
The most the plan will pay for any health care services, drugs, medical devices, equipment, supplies, or benefits. This applies to both covered in-network and covered out-of-network medical services, and in certain areas, preferred and non-preferred doctors. For details, see the Medical Plan chapter of the Associate Benefits Book.
The most the plan will pay for dental services. This applies to both covered in-network and covered out-of-network dental services. For details, see the Dental Plan chapter of the Associate Benefits Book.
Procedures, supplies, equipment, or services determined by the Plan to be:
- appropriate for the symptoms, diagnosis, or treatment of a medical condition;
- provided for the diagnosis or direct care and treatment of the medical condition;
- within the standards of good medical practice within the organized medical community;
- not primarily for the convenience of the patient or the patient's doctor or other provider; and
- the most appropriate procedure, supply, equipment, or service that can be safely provided, which means:
- there must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications for the patient with the particular medical condition being treated, than other possible alternatives;
- generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and
- for hospital stays, acute care as an inpatient is necessary due to the kind of services the patient is receiving or the severity of the medical condition, and safe and adequate care cannot be received as an outpatient or in a less intensive medical setting.
Each third-party administrator (TPA) follows its own policies and procedures determining whether a procedure, supply, equipment, or service is medically necessary; the policies and procedures may vary by TPA. Your plan benefits are subject to the terms of such policies. For details, see the Medical Plan chapter in the Associate Benefits Book.
Doctors and other health care providers like hospitals and therapists that have a written agreement to provide services to people on the plan.
Doctors and other providers that don’t have a written agreement to provide services. Getting care from these providers may cost you more or may not be covered by your plan.
Covered expenses that are provided by a non-network provider and don’t meet the standards outlined in the Medical Plan chapter of the Associate Benefits Book in the “What is covered by the Associates’ Medical Plan” section.
If you’re enrolled in a local plan or you work in Dallas/Fort Worth, Texas, or northwest Arkansas, out-of-network expenses are not covered except in an emergency.
The most you’ll pay each year for eligible network services, including prescriptions. There is no maximum for out-of-network services.
Under all coverage options available under the long-term disability (LTD) and truck driver LTD plans, "partially disabled" means that, as a result of sickness or injury, you are able to:
- perform one or more, but not all, of the material and substantial duties of your own or any occupation on a full-time or part-time basis;
- or perform all of the material and substantial duties of your own occupation on a part-time basis; and
- earn between 20% and 80% of your indexed pre-disability earnings.
An organization, also called a third-party administrator, that handles claims and internal appeals for your medical plan. Administrators also provide health care advisors to help you with claims and other issues.
A notification that may be required from your plan’s administrator before you can get coverage for certain services or get certain medications. See Preauthorization.
Precertification requirements name the conditions, medical setting, or other limits to the plan's coverage. Network providers and hospitals typically use the precertification process before inpatient admissions or some ambulatory procedures.
Evidence of your health condition, which includes answering a questionnaire about your medical history and possibly having a medical exam. The Proof of Good Health questionnaire is available when you enroll. Also known as “evidence of insurability.”
A final court or administrative order requiring you to provide health care coverage for your eligible dependents under the plan, usually following a divorce or child custody proceeding.
Medications that target and treat specific chronic or genetic conditions. These include biopharmaceuticals (bioengineered proteins), blood-derived products, and complex molecules. They are available in oral, injectable, or infused forms. See Pharmacy.
A person who’s properly enrolled for coverage, as described in the Eligibility and Enrollment chapter of the Associate Benefits Book:
- Your spouse, as long as you are not legally separated.
- Your domestic partner (or "partner"), as long as you and your domestic partner:
- are in an ongoing, exclusive, and committed relationship similar to marriage and have been for at least 12 months and intend to continue indefinitely;
- are not married to each other or anyone else;
- meet the age for marriage in your home state and are mentally competent to consent to contract;
- are not related in a manner that would bar a legal marriage in the state in which you live; and
- are not in the relationship solely for the purpose of obtaining benefits coverage.
- Any other person to whom you are joined in a legal relationship recognized as creating some or all of the rights of marriage in the state or country in which the relationship was created (also referred to as "partner").
A major event, like marriage or birth, that allows you to make changes to your coverage outside of the initial enrollment period or annual enrollment period. These events are listed in the Eligibility and Enrollment chapter of the Associate Benefits Book.
Under the short-term disability plan, "total disability" means that you are unable to perform the essential duties of your job for your normal work schedule, or a license required for your job duties has been suspended due to a mental or physical illness or injury, or pregnancy.
Benefits will be payable during a loss of license only while you are disabled or pursuing reinstatement of your license on a timely basis. Timely pursuit of reinstatement means you apply for reinstatement when your condition meets the criteria and you provide information and forms requested by the licensing agency on a timely basis until your license is reinstated.
The determination of whether you are disabled will be made by Sedgwick on the basis of objective medical evidence. Objective medical evidence consists of facts and findings, including but not limited to: X-rays, laboratory reports, tests, consulting physician reports, and reports and chart notes from your physician; and you must be under the continuous care of a qualified doctor and following the course of treatment prescribed. Loss of license in and of itself is not sufficient for meeting the definition of disability.
