Benefits
Accident Death and Dismemberment (AD&D) - This insurance provides coverage for death and dismemberment resulting directly from accidental causes. Provides benefits in the event of loss of life, limbs or eyesight as the result of an accident. Allowable Expense - Any item of expense covered by the benefits plan that is necessary, reasonable, and customary. Such items are usually reimbursable. Balance Billing - The practice of sending a bill to the patient for the difference between the original charge for health care services and the amount allowed and paid by the insurance plan. Beneficiary - A person named by the participant in an insurance policy or retirement plan to receive any benefits provided by the plan if the participant dies. Brand Name Drug - A drug that is sold under a specific trademark name. Calendar Year Deductible - A deductible that applies to any eligible medical expenses incurred by the insured during any one calendar year. Centers for Medicare & Medicaid Services (CMS) - The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services. CMS runs the Medicare and Medicaid programs - two national health care programs that benefit about 75 million Americans. And with the Health Resources and Services Administration, CMS runs the State Children's Health Insurance Program (SCHIP), a program that is expected to cover many of the approximately 10 million uninsured children in the United States. (previously called Health Care Financing Administration - HCFA) Consolidated Omnibus Budget Reconciliation Act (COBRA) - A federal law passed in 1986, requires that most employers sponsoring group health plans offer employees and their dependents the opportunity for a temporary extension of health coverage, called "continuation of coverage", in certain circumstances where coverage under the plan would otherwise end. Coinsurance - A policy provision, frequently found in medical insurance, by which both the insured person and the insurer share in a specified ratio (i.e. 80%, 20%), after the deductible is met. Contingent Beneficiary - Person(s) named to receive policy benefits if the primary beneficiary is deceased. Contribution - The transfer of funds or property by either an employer or an employee to an employee retirement plan. Coordination of Benefits (COB) - A group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts. Copayment - The out-of-pocket expenses to the patient (employee) for health care. May be a percentage or a flat dollar amount. Deductible - Payments that are necessary to make prior to the health plan beginning to pay. Defined Contribution Plan - Defined by the Internal Revenue Code and ERISA as a plan that provides for an individual account for each participant and for benefits solely on (1) the amount contributed to the participant's account plus (2) any income, expenses, gains and losses, and forfeitures of accounts of other participants that may be allocated to the participant's account. Dental Benefit Plan - A group plan providing coverage, which usually includes preventative, maintenance and major restorative treatment. Disease Management Programs - Education and support programs for patients in the self-management of their condition. Eligibility Period - A period of time, usually 31 days, when potential members of a group health insurance plan can enroll without evidence of insurability. Employee Retirement Income Security Act (ERISA) - A federal law passed in 1974 that regulates health & welfare, pension and profit sharing plans employee benefit plans. The act covers eligibility, funding arrangements, fiduciary responsibilities, and other standards, including financing, vesting and administration of pension plans in most private businesses and industries. Explanation of Benefits (EOB) - A description, sent to patients by health plans, of benefits received and services for which the health care provider has requested payment. Flexible Benefit Plan - Provides employees a choice of reducing their salary and contribute this reduction into a pre-tax funded reimbursement plan. This plan can be used for many out-of-pocket health care or dependent care expenses. Formulary Drug - A brand-name drug on a list of prescription drugs specifically approved for special benefit consideration after assessment of their value, efficacy and utilization by a formulary committee, usually consisting of a group of physicians and pharmacologists. 403(b) - See defined contribution plan. Generic Drug - A drug that is sold under its chemical name. Generic drugs are required by law to meet the same standards of purity, effectiveness, and strength, and they are usually less expensive than their brand name drug counterpart. Health Maintenance Organization (HMO) - A pre-paid medical group practice plan that provides a comprehensive predetermined medical care benefit package in a specified geographical location. Health Insurance Portability and Accountability Act (HIPAA) - A federal law passed in 1996. HIPAA applies to health information created or maintained by health care providers who engage in certain electronic transactions, health plans, and health care clearinghouses. The Department of Health and Human Services (HHS) has issued the regulation, "Standards for Privacy of Individually Identifiable Health Information," applicable to entities covered by HIPAA. The Office for Civil Rights (OCR) is the Departmental component responsible for implementing and enforcing the privacy regulation. Life Insurance - A type of insurance that provides a sum of money if the person who is insured dies while the policy is in effect. Long-Term Care - Includes all forms of services, both institutional and noninstitutional, that are required by all people with chronic health conditions. Long-Term Disability Insurance - Insurance issued to an employer to provide a reasonable replacement of a portion of an employee's earned income lost through serious and prolonged illness or injury. Maximum Plan Limits - The maximum amount payable under a health plan. Medically Necessary - The reasonable and appropriate diagnosis, treatment and followup care as determined and prescribed by qualified, appropriate health care providers in treating a condition, illness or disease. Medicare - A federal health insurance program for people 65 or older and certain disabled people under 65 designed to cover medical needs. Medicare Part A, hospital insurance, which helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, and hospice care. Medicare Part B, medical insurance, helps pay for medically necessary physician's services, outpatient hospital services, home health care, and a number of other medical services and supplies that are not covered by the hospital insurance part of Medicare. Medicare Supplement Insurance Plans - A voluntary, contributory private health insurance plan available to Medicare eligible participants to cover the costs of deductions, coinsurance, physician's services and other medical and health services not covered by Medicare. Certain plans are now called Medicare + Choice plans. National Committee for Quality Assurance (NCQA) - is a profit, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. NCQA's accreditation process provides an overview of how a health plan's systems are operating by using standards that are meaningful to purchasers, health plans and consumers. Out-of-Area Benefits (HMO) - Those benefits that the plan supplies to its subscribers when outside the geographical limits of the HMO. Out-of-Pocket Maximum Payment - The maximum amount of money a person will pay in addition to the premium payments and possibly co-payments and other payments depending upon the plan design. Paid Claims - The dollar value of all claims paid (i.e. hospital, medical, surgical) during the plan year, regardless of the date that the service was performed. Physician Adviser - A physician representing the claim administrator who provides advice on claims that are questioned for medical necessity or other medical questions. Physician advisers do not approve or deny claims but rather provide advice to the claim administrator, who makes the final determination as to eligibility and coverage. Point-of-Service Plan (POS) - A plan in which members do not have to choose how to receive services until services are needed. In some plans, for example, members decide whether to use a preferred provider or an outside provider. Although the services of an outside provider are covered, benefits are great if members select a preferred provider. Preferred Provider Organization (PPO) - A group of hospitals and physicians that contract on a fee-for-service basis with employers, insurance companies or other third party administrators to provide comprehensive medical service. Providers' exchange discounted services for increased volume. Preventive Care - Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunization and well person care. Primary Care Physician (PCP) - A health care practitioner selected from a list of network physicians who is responsible for coordinating and referring every aspect of the medical care received under certain types of health plans. Plan Participant - Any employee or former employee of an employer, member or former member of an employee organization, who is or may be eligible to receive a benefit of any type from an employee plan, or whose beneficiaries may be eligible to receive any such benefit. Qualifying Event - An occurrence entitling a person to elect or make certain changes to their benefit plans, such as termination of employment of self or spouse, divorce or marriage. There are specified events that under the IRS allow such changes. Reasonable and Customary (R&C) Charge - The prevailing charge made by surgeons of similar expertise for a similar procedure in a particular geographic area. Retirement Annuity - See defined contribution plan. Summary Plan Description - A written statement of a group benefit plan in an easy-to-read form. Supplemental Retirement Annuity (SRA) - This plan is also called a Tax Deferred Annuity (TDA). SRAs are a tax-deferred way to help build extra retirement assets funded through a voluntary payroll deduction. Total Compensation - Value of direct pay plus benefit package. Vision Insurance - A separate plan covering medical treatment relating to the eye conditions. Opthalmologists, optometrists or opticians can render care. Most plans limit an eye examination to not more than once in a 12 month period, and new lenses and frames may be provided every 24 months.
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Wellness and Disease Management |
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Human Resources Office |
