Health Benefits Glossary

Allowed Amount:

The maximum fee a health plan will pay for a covered service or treatment. The allowed amount is determined by each health plan.

 

Cafeteria Plans:

Plans allowing employees to choose from a "menu" of one or more qualified benefits. Under Section 125 of the Internal Revenue Service Code, benefits from a cafeteria plan are not taxed to the employee who selects them.

 

COB:

Coordination of benefits. If an employee, retiree, or eligible dependents are covered under more than one insurance plan, the insurance companies determine which coverage is primary. The employee's or retiree's primary coverage will pay its benefits first, without regard to other coverage.

 

COBRA:

The Consolidated Omnibus Budget Reconciliation Act of 1985. This statute requires employers to offer the option of purchasing continued coverage to qualified beneficiaries who would otherwise lose group health insurance coverage as the result of a qualifying event.

 

Copayment:

The amount of money an employee, retiree, or covered dependent pays at the time service is rendered. This money goes directly to the health care provider. The amount of the copayment varies by plan.

 

Coverage, Limitations, Exclusions, or Preauthorization Requirements:

The amount or extent to which any particular treatment or service is covered by a health plan.

 

Deductible:

The amount of money an employee or retiree is required to pay before direct payment or reimbursement is available from the plan.

 

Dental Plan:

A health plan that partially or fully reimburses employees and retirees for dental services

 

DMO:

Dental Maintenance Organization. A plan similar to an HMO, but provides dental services. Participants can use only those designated dental providers approved or employed by the DMO.

 

ERISA:

Employee Retirement Income Security Act of 1974. ERISA is the basic law designed to protect the rights of beneficiaries of employee benefit plans offered by employers.

 

Flexible Spending Account (FSA):

A benefit option that reimburses employees for certain expenses they incur. Money is deducted from pay checks on a pre-tax basis. It most often covers reimbursements for medical expenses not covered under other insurance, or child care expenses.

 

HCFA:

Health Care Financing Administration. The agency of the U.S. Department of Health and Human Services that is responsible for administering the Medicare and Medicaid programs.

 

HIPPA:

Health Insurance Portability and Accountability Act of 1996. A Federal Law which requires employers to provide certificates of coverage to minimize pre-existing condition exclusions.

 

HMO:

Health Maintenance Organization. A network of medical providers that offers low-cost medical care to participants. Participants receive all medical care through their HMO.

 

In-Network Service:

Service provided by a participating provider, Primary Care Physician, or provider approved by the plan.

 

IPA:

Independent Practice Association. A type of HMO consisting of coordinated groups of physicians practicing out of individual offices.

 

LAW:

Leave of Absence Without Pay. An approved period of leave during which the employee is not paid, but does not terminate State service. Any approved leave of absence of two pay periods or less is considered a Short Term LAW. Any approved leave of absence more than two pay periods is considered a Long Term LAW.

 

Medical Necessity:

All health plans require that a service or treatment must be considered a medical necessity to be covered. The definition of "medical necessity" varies by plan. Please contact your plan to determine what types of treatment and service are considered medical necessities.

 

Medical Plan:

A health plan that partially or fully reimburses employees or retirees for costs of personal injuries or illness.

 

Medicare:

A federal health insurance program administered by the Social Security administration for disabled individuals and those age 65 or older.

 

Network:

A group of providers that have contracted with an insurance agency to provide services and treatment to individuals.

 

Open Enrollment Period:

An annual period during which employees and retirees are given the option of enrolling in one or more health care plans.

 

Out-of-Network Service:

Service received from providers outside of the plan's network. Such services are subject to up-front deductibles.

 

Plan:

A health care program offered by the State that partially pays or reimburses the employee or retiree for covered health care services or treatments.

 

POS:

Point-of-Service. An HMO plan that allows members to "self-refer" out of the network, subject to higher fees than if care were received from the HMO network.

 

PPO:

Preferred Provider Organization. A network of medical care providers that provides various medical care services to covered employees and retirees for specified fees. Although fees charged by PPO providers are usually less than those charged by non-PPO providers, the employee may seek treatment from any provider.

 

Preauthorization:

A Plan's prior approval is required for treatments or services, most often in an HMO or POS plan.

 

Premium:

The amount of money an employee or retiree pays for insurance coverage. A premium does not include additional copayments or deductibles incurred for treatment.

 

Primary Care Physician (PCP):

The health care professional who belongs to an HMO or POS network and provides primary care for employees, retirees, or covered dependents. An employee or retiree must select a PCP when using an HMO or POS plan.

 

Provider:

Any approved health care professional who provides treatment or services.

 

Qualified Medical Child Support Orders (QMCSO):

A court order that requires a parent to provide health care coverage for dependent children.

 

Qualifying Event:

An event such as marriage, divorce, or the birth of a child, that allows a change in health care coverage outside of the Open Enrollment period.

 

State Subsidy:

The portion of your insurance premium(s) that the State pays as a benefit to employees and retirees.

 

Term Life Insurance:

Insurance that provides death benefit coverage for a specified period, without permanent policy benefits such as cash or loan value

 

TIAA-CREF:

Teachers' Insurance and Annuity Association - College Retirement Equities Fund. A nationwide retirement and annuity association set up for university and college employees.