Glossary of Benefits Terms
Actively at Work
Plan provision that requires the employee to be performing the
duties of his occupation where the employee normally works in
order for coverage to commence. If the employee is absent due to
illness or injury, the coverage does not commence until the
employee returns. This rule does not include adding a newborn to
health insurance (such as an employee on maternity leave) nor
does it extend to absences for annual leave provided the employee
was not ill on the last scheduled day before annual leave.
Allowed Fees
Term used by some dental plans for their participating dentist
fees and/or maximum payable for a non-participating dentist.
Balance Billing
Non-participating provider practice of billing the patient for
any difference between the provider's billed charges and the
patient's insurance plan maximum allowance (indemnity or
PPO).
Benefits Plan Year
(Oct 1 - Sept 30) Plan year for Health, Dental, Life and Disability Insurance plans (for purposes of enrollment and limitations for annual maximum benefits/out-of-pocket expenses).
Billed Charge
The amount the provider bills for services rendered.
Calendar Year
(Jan 1 - Dec 30) Tax Sheltered Annuity plan year (for purpose of maximum contributions); Flexible Speding Account plan year (for purpose of annual enrollment and reimbursement).
Coinsurance
The division of the allowed amount to be paid by the insurance
company and the patient, i.e., 80/20 or 90/10. (The first
percentage is paid by the company - 80 or 90).
Copayment
The fixed fee that must be paid to the provider at the time
services are provided, such as the pharmacist for a prescription.
(RX).
Deductible
The initial amount the patient must pay out of their pocket for
covered services before benefits are payable by the insurance
carrier in indemnity and PPO plans.
Emergency
Defined by each plan in accordance with their standard
definitions.
Fiscal Year
(July 1 - June 30) Retirement plan year for purposes of maximum contributions and possible changes to established contribution rates.
Exclusive Provider Organization (EPO)
A prepaid medical group plan that provides a predetermined medical care benefit package. EPO is the acronym used by a plan that is self insured.
Indemnity Plan
A medical or dental plan which allows you to choose any licensed
provider to provide health care. Members are reimbursed for
eligible medical or dental expenses according to the benefit
schedule in effect, including deductibles and coinsurance.
In-Network
Services provided by a contracted provider in accordance with all
plan requirements.
Non-participating Provider
A provider with no contractual limitation on what he may bill and
thus may practice balance-billing, as well as require payment at
the time services are rendered.
Preferred Provider
A provider who has signed an agreement with the insurance carrier
not to charge that carrier's members more than the insurer's
allowed fees.
Precertification
Review processes that verifies the medical necessity and
appropriateness of proposed services or supplies.
Pre-existing Condition
A condition diagnosed and/or treated prior to the effective data
of your coverage or for which a prudent person would have been
treated.
Preferred Provider Organization (PPO) Plan
A plan that provides benefits in an indemnity fashion, but pays a
higher percentage of the cost of services if patients use a
PPO-network provider than if they use non-PPO providers.
Primary Care Physician (PCP)
The physician responsible in an HMO for directing all patient
care including referrals to specialists and obtaining necessary
precertifications. This physician is usually a General Practice,
Family Practice, Pediatric or Internal Medicine specialist. In
some plays, women may choose an OB/GYN as their primary care
physician.
Rehabilitation
Usually physical therapy, speech therapy and/or occupational
therapy.
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