This glossary is intended as an educational resource and contains many commonly used terms, but it is not a complete list. Definitions may vary between different policies and plan documents; consult your policy or plan document to understand how terms are defined in the particular case.
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Allowed amount 每 Maximum amount on which payment is based for covered health care services. This may be called ※eligible expense,§ ※payment allowance§ or ※negotiated rate.§ If your provider charges more than the allowed amount, you may have to pay the difference.
Annual enrollment 每 Annual enrollment is the period of time determined by the university each year, generally in the fall, during which benefit-eligible employees are able to make changes to the options selected for university insurance plans for themselves and their dependents. Because the university offers you the option of paying your portion of insurance premiums before your income is taxed, the U.S. Internal Revenue Service (IRS) requires us to allow changes only one time per year〞except in instances in which you have experienced a Qualifying Family/Employment Status Change. A separate annual enrollment period is set by the university each year for retiree university insurance plans. Elections made during both the employee and retiree annual enrollments will be effective the following January 1.
Appeal 每 A request for your health insurer or plan to review a decision or a grievance again.
Balance billing 每 When an out-of-network provider bills you for the difference between the provider＊s charge and the eligible expense (allowed amount). For example, if the provider＊s charge is $100 and the eligible expense is $70, the provider may bill you for the remaining $30. An in-network provider may not balance bill you for covered services.
Benefit-eligible employee 每 You are a benefit-eligible employee if you meet the definitions as described in the 嬝伎弝け Collected Rules and Regulations (CRR). Generally, a benefit-eligible employee is one who is expected to work at least 75% full-time equivalence and has an indicated appointment duration of at least nine months. You should ensure the details of your status are clear to you by visiting CRR-320.050: Employee Status.
Coinsurance 每 Refers to the percentage of the eligible expense an insurance plan member is required to pay for services after any required deductible has been met. The health insurance or plan pays the rest of the eligible expense. If an out-of-network provider charges more than the eligible expense, you may have to pay the difference. (See Balance Billing.)
Complications of pregnancy 每 Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren＊t complications of pregnancy.
Copay (or copayment) 每 ※Copay" is an abbreviation of ※copayment.§ A fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible 每 The amount you owe for covered health care services before your health insurance or plan begins to pay. For the Healthy Savings Plan, only the individual or family deductible must be satisfied based on self or family coverage. For the Custom Network Plan and PPO Plan, individual deductibles must be satisfied for all individuals covered until the family deductible is met. Expenses that are included in the deductible vary by plan. This amount does not include eligible preventive services, which are covered at 100% even before the deductible is met.
Dependent 每 Eligible individuals covered under your insurance plan(s). Dependents may include the spouse or Sponsored Adult Dependent of an employee; a child of an employee who is less than 26 years of age; a child of an employee over the age of 26 who is mentally or physically incapable of self-sustaining employment and meets other plan requirements; and a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court/administrative order. You should ensure you understand the details of your status by accessing the applicable Summary Plan Description (SPD) for your insurance plan and reading the full definition.
Durable medical equipment (DME) 每 Equipment and supplies ordered by a health care provider for everyday or extended use to serve a medical purpose with respect to treatment of a sickness, injury or their symptoms.
Eligible expense 每 Maximum amount on which payment is based for covered services. This may be called ※allowed amount,§ ※payment allowance§ or ※negotiated rate.§ If your provider charges more than the eligible expense, you might have to pay the difference. (See Balance Billing.)
Emergency 每 A serious medical condition or symptom resulting from injury, sickness or mental illness that arises suddenly and, in the judgment of a reasonable person, requires immediate care and treatment to avoid jeopardy to life and health.
Emergency medical condition 每 An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency medical transportation 每 Ambulance services for a medical emergency.
Emergency room care 每 Emergency services received in an emergency room.
Emergency services 每 Evaluation of an emergency medical condition or symptom and treatment to keep it from worsening.
Excluded services 每 Health care services your health insurance plan does not pay for or cover.
Family coverage 每 Employee enrolled in the benefit plan who has at least one dependent covered on the plan as well. This encompasses the ※self and spouse,§ ※self and child(ren),§ and ※self, spouse, and child(ren)§ categories. See the definition for ※deductible§ and ※out-of-pocket limit§ for explanations of how the Healthy Savings Plan＊s family coverage is different than the other two plan options.
Family status change 每 see Qualifying Family/Employment Status Change.
Flexible Spending Account 每 If you enroll in the Custom Network Plan or the PPO Plan, you＊ll have the option to enroll in a Health Care Flexible Spending Account (FSA). A Dependent Care FSA is an option no matter which medical plan you choose. Visit the Flexible Spending Accounts page for more information.
Formulary 每 A list of prescription medications selected for coverage under a medical insurance plan. Drugs may be included on a drug formulary based on efficacy, safety, and cost-effectiveness. While you may choose to use non-formulary drugs, you will pay a greater share of the cost.
Grievance 每 A complaint you communicate to your health insurer or plan.
Habilitation services 每 Health care services that help a person keep, learn, or improve skills and functioning for daily living. May include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Health insurance 每 A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Health Savings Account (HSA) 每 If you enroll in the Healthy Savings Plan, you may be eligible to sign up for a Health Savings Account (HSA) to help cover your health care related expenses. Visit the understanding your HSA webpage for more information.
High deductible health plan (HDHP) 每 A type of medical insurance plan approved by the U.S. Internal Revenue Service (IRS) as being able to offer a . These plans generally have higher deductibles than other types of isnurance plans, but generally offer lower premiums. The Healthy Savings Plan is a high deductible health plan.
Home health care 每 Health care services a person receives at home.
Hospice services 每 Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization 每 Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
In-network 每 Providers or facilities that are part of an insurance plan＊s network of contracted providers with which it has negotiated a discount. Employees enrolled in the plan pay less when using an in-network provider because these providers deliver services at a lower cost for UM members. For the UM insurance plans, provider directories can be accessed through the Plan Contacts webpage.
Medically necessary 每 Health care services or supplies needed to prevent, evaluate, diagnose or treat a sickness, injury, mental illness, substance-related and addictive disorders, condition, disease or its symptoms and that meet generally accepted standards of medical practice.
Network 每 The facilities, providers and suppliers your insurance plan has contracted with to provide services. (See In-network.)
Non-preferred provider 每 A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance plan, or if your plan has a ※tiered§ network and you must pay extra to see some providers.
Out-of-network 每 Providers or health care facilities who do not contract with your health insurance or plan. Services received at an out-of-network provider/facility will result in greater out-of-pocket expense for you.
Out-of-pocket limit 每 The most you pay during the calendar year before your health insurance or plan begins to pay 100% of the eligible expense. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn＊t cover.
Outpatient care and/or services 每 Treatment including services, supplies and medicines provided and used at a hospital under the direction of a physician to a person not admitted as a registered bed patient; or services rendered in a physician＊s office, laboratory or X-ray facility, ambulatory surgical center or the patient＊s home.
Physician services 每 Health care services a licensed medical physician (M.D. 每 Medical Doctor or D.O. 每 Doctor of Osteopathic Medicine) provides or coordinates.
Plan 每 A benefit your employer, union, or other group sponsor provides to you to pay for health care services.
Preauthorization 每 A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called ※prior authorization,§ ※prior approval,§ or ※precertification.§ Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization is not a promise that your plan will cover the cost.
Preferred provider 每 A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a ※tiered§ network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also ※participating§ providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great.
Premium 每 The monthly cost the employee pays to be enrolled in a medical insurance plan. This premium can be deducted from your paycheck on a pre-tax or after-tax basis. Learn more about the tax options by watching the video.
Prescription drug coverage 每 Health insurance or plan that helps pay for prescription drugs and medications.
Prescription drugs 每 Drugs and medications that by law require a prescription.
Preventive care 每 Medical care rendered focused on prevention and early-detection of disease, such as an annual physical, mammogram and colonoscopies as recommended by the Centers for Disease Control and Prevention (CDC). All UM plans cover preventive care at 100%.
Primary care physician 每 A physician (M.D. 每 Medical Doctor or D.O. 每 Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary care provider 每 A physician (M.D. 每 Medical Doctor or D.O. 每 Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Provider 每 A physician, health care professional, or health care facility licensed, certified, or accredited as required by state law.
Qualifying Family/Employment Status Change - An event that allows you to change your insurance coverage level (including beginning or ending coverage or adding or dropping dependents) or Flexible Spending Account (FSA) during a time that falls outside of the university＊s normal Annual Enrollment period. Qualifying events are too numerous to list in this definition. Examples include marriage, birth of a child and becoming newly eligible for Medicare. Access the applicable Summary Plan Description (SPD) for your insurance plan to read the full definition of a Qualifying Family/Employment Status Change.
If you have not experienced a Qualifying Family/Employment Status Change, then you may change or add someone to your insurance or FSA only during the university's Annual Enrollment period. (If you happen to have enrolled in your insurance plan on an after-tax basis, which most people do not do, then you can discontinue your insurance coverage outside of the Annual Enrollment period. But an after-tax enrollment does not allow you to change your coverage or add someone to your insurance plan.)
If you are an active faculty or staff member, have a Qualifying Family/Employment Status Change and are outside of the Annual Enrollment period, use the University＊s employee portal, myHR, to make change(s) to your insurance plan(s). Once you are logged in, select the 'My Benefits' tile and then click on 'Life Events' from the left-hand menu.
If you are a retiree, have a Qualifying Family/Employment Status Change and are outside of the Annual Enrollment period, use the (PDF, 902KB) to make changes to your insurance plan(s).
Visit the HSA and FSA webpages for more information about changing those accounts.
Reasonable and customary charges/fees 每 Used to refer to the commonly charged or prevailing fees for health services within a geographic area. This generally applies when a contracted rate is not available. Members may be asked to pay the difference between reasonable and customary charges/fees and what the provider bills for out-of-network services. Sometimes used to determine the allowed amount.
Rehabilitation services 每 Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Self coverage 每 An employee is solely enrolled in the benefit plan; no dependents are listed on the plan.
Skilled care 每 Skilled nursing, teaching and rehabilitation services ordered by a physician and delivered or supervised by licensed technical or professional personnel to obtain the specified medical outcome and provide the safety of the patient. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Specialist 每 A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Sponsored Adult Dependent 每 An unmarried partner who is eligible for certain university benefits. Review the Sponsored Adult Dependent FAQs to learn who qualifies as a Sponsored Adult Dependent and how to affirm this status.
Subscriber 每 The person that completes the enrollment for coverage and pays the insurance premiums.
University HSA contribution 每 What the 嬝伎弝け would contribute to your health savings account (HSA) if you are a benefit-eligible employee and enroll in the Healthy Savings Plan . The amount you receive depends on when you enroll in the HSA. If you enroll before or in the first quarter of the plan year, then you will receive the full amount offered by the university. Visit the webpage understanding your HSA webpage for more details.
Your own contributions to your HSA, which are completely voluntary, can be made on a pre-tax or an after-tax basis. Pre-tax contributions are made via equal deductions from your paycheck, spread out over the year.
Urgent care 每 Treatment of an unexpected sickness or injury that is not life-threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as a high fever, skin rash or an ear infection.
Usual, customary and reasonable (UCR) 每 The amount paid for a health service in a geographic area based on what providers in the area usually charge for the same or similar health service. The UCR amount sometimes is used to determine the eligible expense.
Reviewed 2021-02-17
