A group life insurance feature that lets a member or spouse
who is diagnosed with a terminal illness or life-limiting medical
condition get a percentage of the life benefits as an early payment.
Accidental Death and Dismemberment (AD&D)
A benefit that is payable to a beneficiary for loss of life or to a member for an accidental injury, as specified in a policy.
Accidental Death and Personal Loss Coverage (AD&PL) or AD&D
Covers the same losses as AD&D, but also pays a benefit for
unexpected events that result in the loss of sight, speech and hearing;
paralysis; coma; and third-degree burns. In case of loss of life,
benefits may also be available for education, child care and return of
remains. An additional benefit may be available if the member dies
while properly using a passenger restraint system.
Active Full-Time Employee
An
employee who works on a regular basis in the usual course of the
employer's business. An employee must work at least the number of hours
in the employer's normal workweek or the number of hours as shown in
the plan's Schedule of Insurance.
Adjudication
The
determination by an insurer or health plan of the availability of
health insurance or health benefits for a claim and the level of
benefit to be paid.
Age Discrimination Employment Act (ADEA)
A federal law that bans unfair and discriminatory treatment in employment on the basis of age.
Alcohol & Drug Restriction
Any limit on length of benefits for disabilities related to alcoholism and/or drug addiction.
Allowable Expense(s)(also known as Covered Expense(s))
Any
medically necessary and reasonable health expense, part or all of which
is covered under any of the health benefits or health insurance plans
of the member for whom the claim is made.
Amalgam
A
type of filling made up of a mixture of several metallic materials.
Amalgams are silver in color and usually used on posterior, or back,
teeth.
Ambulatory Surgery
See Outpatient Surgery
Americans with Disabilities Act (ADA)
A
federal antidiscrimination law that entitles qualified people with
disabilities to the same employment consideration as anyone else.
Any Occupation
A job for which a person is qualified by education, training or experience.
Appeals
A process available to a member to ask that the health plan reconsider a benefit denial or claim decision.
Authorization
See Preauthorization/Precertification
B
Balance Billing
The
process of billing a member the difference between the fee amount that
the participating doctor or hospital negotiated with the insurer and
that doctor's or hospital's usual fee for a service or supply.
Participating doctors and hospitals agree not to bill the member for
the difference between these two amounts.
Beneficiary
The
person(s) or entity that is named by the member to receive the amount
of his/her life insurance and/or AD&D insurance, in the event of
his/her death.
Benefit
Payment
received for covered services under the terms of a health
insurance/health benefits plan or policy. Or the amount payable by an
insurer to a person making a claim, assignee or beneficiary under each
coverage in a group contract.
Benefit Duration
The
maximum length of time for which benefits are paid while an employee is
out on short-term disability (STD) and long-term disability (LTD),
after the employee meets the plan's qualification period. Called
"commencement period" for STD and "elimination period" for LTD.
Benefit Period
The maximum length of time for which benefits will be paid.
Brand-Name Drug
A
drug that is sold under a specific trade name by a pharmaceutical
manufacturer. These drugs are under patent protection. A patent gives
the company that developed the drug exclusive rights to make and sell
that drug for a time period - usually 20 years. When these rights run
out, other drug companies can make and sell generic versions of the
drug.
C
Calculus (Also known as Tartar)
If left untreated, plaque can begin to mineralize and harden into calculus or tartar.
Capitation
A fixed, prepaid amount a doctor or hospital receives for each person served.
Caries
A term that means cavities or tooth decay.
Case Management
A process of:
identifying people at high risk for problems related to complex health care needs and
reviewing ways to coordinate care.
Certification
See Preauthorization/Precertification
Certification of a Period of Disability
A process used to determine and communicate whether an employee meets the definition of disabled under a disability policy.
Chemotherapy
Treatment of cancer by chemical or biological drugs.
Chiropractic Care
Therapy
provided by a licensed professional - a chiropractor - who adjusts the
spine and joints to treat pain and improve general health.
Claim
A request for benefits payment to an insured employee or beneficiary (the claimant).
Closed Formulary
Refers
to pharmacy plans covering eligible prescription drugs listed on a
Preferred Drug List. It does not include drugs on the Formulary
Exclusions List. A medical exception is needed to cover prescription
drugs on the Formulary Exclusions List.
Combined Life Insurance Maximum
The
highest total amount of basic employer-paid and supplemental
employee-paid life insurance that may be issued to applicants who have
provided satisfactory Evidence of Insurability.
Common Law Marriage
A
marriage that is not made official by ceremony, but is created by an
agreement to marry, followed by living together. It is only recognized
in some states.
Complication of Pregnancy
An event or process that occurs during pregnancy that is not associated with a normal pregnancy.
Composite
A type of filling that matches the natural tooth color. Composites are white and usually used on anterior, or front, teeth.
Congenitally Missing Teeth
Teeth
that never existed. This should not be confused with impacted teeth
(teeth that never erupted). This is a condition existing at or dating
from birth.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A
1986 federal law for group health plans covering 20 or more employees.
The law requires these plans to continue offering coverage to
individuals who would otherwise lose it. COBRA does not require
continuation of life or disability insurance coverage.
Contract(also known as a Benefit Certificate or Policy)
A
legal agreement between an individual subscriber or an employer group
(contract-holder) and a health insurance or health benefits plan that
describes the benefits and limitations of the coverage.
Contributory
Indicates that the cost of a group insurance plan is made in part by the employer and in part by employees.
Conversion Charge
The amount charged to the policyholder when a covered member chooses to convert group policy coverage to an individual policy.
Conversion Option
An option that allows a member to buy individual life insurance coverage if he/she:
loses group coverage because of employment termination or retirement
has less existing group coverage because of a reduced amount due to age.
Coordination of Benefits (COB)
A
provision to help avoid claims payment delays and duplication of
benefits when a person is covered by two or more plans providing
benefits or services for medical, dental or other care or treatment.
One plan becomes the "primary" plan and the other becomes the
"secondary" plan. This establishes an order in which the plans pay
their benefits.
Copayment
The
specific dollar amount or percentage that the member must pay, or that
must be paid on behalf of a member, when covered services are provided.
Cost of Living Adjustment (COLA)
Optional
long-term disability benefit that provides a yearly percentage increase
to the monthly benefit received after deductions, usually for a defined
period.
Covered Benefits (also known as Covered Services)
Necessary
services and supplies that are covered under the plan. They must follow
all the terms and conditions of the group agreement or group insurance
policy.
Covered Monthly Payroll (also known as Covered Monthly Salary)
The
amount of monthly earnings used to calculate the long-term disability
premium and disability benefit, taking into account the maximum monthly
benefit in the plan.
Covered Weekly Benefit
The
amount used to calculate the short-term disability premium and
disability benefit, taking into account the maximum weekly benefit in
the plan.
Credentialing
A
process to evaluate a doctor's qualifications and record of
professional competence and conduct. The process includes a review of
related training, academic background, experience, licensing,
certification and/or registration to practice in a health care field.
Crown Lengthening
The
removal of gum tissue (gingiva) and bone, to expose more of the tooth's
structure. A dentist will usually perform crown lengthening when a
tooth needs to be restored, but there is not enough tooth above the gum
line to support the crown or filling.
D
Date Claim Incurred (DCI)
Under a disability contract, the day the doctor who is responsible for the claimant considers him/her to be disabled.
Date Claim Received
The date the claim is received.
Date Last Worked (DLW)
For
long-term disability, the last day a claimant worked any part of the
day. For short-term disability, if a claimant worked less than half of
a normal scheduled day, the DLW is changed to previous day worked. If a
claimant worked a half day or more, then the DLW is that day.
Date of Disability (also known as Date of Claim or Incurred Date)
The date the claimant became disabled according to the policy or plan definition.
Day Treatment Center
A
psychiatric facility that is licensed to provide outpatient care and
treatment of mental and nervous conditions and/or substance abuse under
a doctor's supervision.
Death Benefit (also known as Face Amount or Specified Amount)
The amount of money paid to the beneficiary if the insured dies.
Debridement
The
removal of excessive amounts of plaque and tartar, which impair the
dentist's ability to examine the teeth. This is performed in rare
instances when the patient has not had a dental cleaning in a very long
time and a gross amount of debris has built up.
Deductible
An
amount of money that a member must pay for covered services, including
prescription drugs, in a specified time period, before the plan will
pay benefits.
Dependent
A
person who is eligible to receive life and/or health insurance/health
benefits coverage under a plan's provisions. Examples would be the plan
subscriber's spouse, child or domestic partner, if offered.
Diagnostic Tests
Tests
and procedures ordered by a health care professional to determine if a
person has a specific condition or disease based on signs or symptoms.
These may include radiology, ultrasound, nuclear medicine, and
laboratory and pathology services or tests.
Direct Access (also known as Open Access)
Refers
to health benefits/health insurance plans that let a member visit a
participating health care professional without a referral.
Disability
See Long-Term Disability and Short-Term Disability
Disability and Absence Management
An inclusive term for the family of disability and absence management products and services.
Disability - Extended Life
A
provision that allows the member's life insurance to remain in effect
if he/she is unable to work at his/her own job for pay or profit. The
disability must also prevent the employee from working at any
reasonable job that he/she may be suitable for by education, training
or experience.
Disability Extension
A
provision that allows for continued life insurance while an employee is
disabled. Certain conditions must be met for coverage to be continued.
Premiums for continued coverage will be required. The disability
extension applies only to employee basic and supplemental life
insurance.
Disability - Life
When
the employee is unable to work at his/her own job for pay or profit.
The disability must also prevent the employee from working at any
reasonable job that he/she may be suitable for by education, training
or experience.
Disability Payment
A payment received by an insured person because of a disability.
Disability Provision
A common provision that continues life insurance for an employee who becomes permanently and totally disabled.
Disability Waiting Period - Extended Life
The
period an employee must continuously be absent from work, because of
disease or injury, in order to be eligible for extended life insurance.
Disease Management Program
A
program available under some health insurance/health benefits plans
that supports members with chronic - or long term - conditions such as
diabetes, asthma and heart disease. The program may include educational
materials and member support for monitoring the condition and
treatment.
DocFind�
A
directory of health care professionals that is available on the
website. Used to help members find information about participating
doctors, hospitals, dentists, pharmacists and other providers in an
area.
Domestic Partners
Generally
refers to unmarried, unrelated individuals who live together and are
responsible for each other's welfare and financial obligations. May or
may not be same-sex couples.
Durable Medical Equipment (DME)
Equipment that is:
made for and mainly used in the treatment of a disease or injury
made to be used over a long period of time
suited for use by someone who is not an inpatient in the hospital
not normally of use to people who do not have a disease or injury
not for use in altering air quality or temperature
not for exercise or training.
E
Earnings Definition
Refers
to the base weekly (short-term disability) or monthly (long-term
disability) payments that exclude a person's bonuses, overtime or other
extra compensation. Some types of compensation, such as commissions,
are included or excluded depending on the policy.
Effective Date
The date on which the coverage under a member's plan goes into effect at 12:01 a.m.
Eligibility
Insurance
policy terms that define who is eligible to get coverage and the
requirements for receiving coverage. These may include length of
employment with the plan sponsor, job status and other provisions.
Elimination Period
A period of time that an employee must be continuously disabled before disability benefits are payable.
Emergency (also known as Medical Emergency)
An
emergency medical condition having symptoms that are severe enough
(including sharp pain) that it causes a careful person, who has an
average knowledge of health and medicine, to reasonably expect the
absence of immediate medical attention to result in:
placing the
health of the individual (or, with a pregnant woman, the health of the
woman and her unborn child) in serious jeopardy
serious harm to bodily functions
serious dysfunction of any body organ or part.
Emergency Facility
A
health facility that provides short-term care for medical situations or
procedures needing immediate treatment. Includes urgent care centers,
hospitals and walk-in clinics.
Endodontist
A
dental specialist who treats diseases of the tooth's nerves or pulp,
which is located in the center of the tooth and in canals (called root
canals) within each tooth root.
Enrollee
See Member
Evidence of Insurability (EOI) (also known as Medical Underwriting)
The
process of doing an individual and/or group risk analysis for someone
applying for new or increased coverage, where good health must be
shown. The EOI process might include:
EOI statement - questions about health and medical conditions answered by an applicant
Medical exam - done by a paramedical professional
Tests, such as an EKG
Report from the applicant's doctor
Additional information if required.
Exclusions
Specific conditions or circumstances that are not covered for benefits under a plan.
Experimental Services or Procedures (also known as Investigational)
Health
care services, supplies, treatments or drug therapies that have not yet
been determined to be effective and safe in treating the illness or
injury for which their use is proposed.
Explanation of Benefits (EOB)
A
form that explains how the payment amount for a health benefit/health
insurance claim was calculated. It also may explain the claims appeal
process and provide other information.
F
Face Amount
See Death Benefit
Facility-of-Payment Provision
Allows
an insurer to deduct an amount from the life insurance benefit and pay
it to a beneficiary, friend or relative before the final settlement of
the claim.
Family Medical Leave Act (FMLA)
A
federal law for employers with 50 or more employees that entitles
eligible employees to a total of 12 workweeks of unpaid leave during
any 12-month period for:
care of a newborn child within the first 12 months of life
adoption of or foster care for a child within the first 12 months of placement
care of a spouse, child or parent of the employee if afflicted with a serious health condition
medical leave for the employee who has a serious health condition and cannot perform duties of the job.
Formulary (also known as Preferred Drug List)
A
list of the prescription drugs that are approved for coverage by many
of the pharmacy benefits plans. It includes many brand-name and generic
drugs approved by the U.S. Food and Drug Administration (FDA). Based on
a member's plan, preferred drugs on the formulary may have lower copay
than nonpreferred drugs.
Formulary Exclusion List
A
list of prescription drugs that a pharmacy benefits plan does not cover
if a member belongs to a closed-formulary plan. If it is medically
necessary for a member in this type of plan to use a drug on the
Exclusion List, the member's doctor must contact the Pharmacy
Management Precertification Unit to request coverage as a medical
exception.
Functional Capacity Evaluation
An
assessment of someone's ability and willingness to perform a full range
of activities, mostly relating to a job. It might evaluate how well the
person can lift, bend, stand, climb or make fine-hand motions, and is
usually done by an occupational or physical therapist.
G
Generic Drug
A
prescription drug that contains the same active ingredients in the same
amounts as its brand-name counterpart. The U.S. Food and Drug
Administration (FDA) considers generic drugs to be as effective as
brand-name drugs. A generic drug can usually be sold when the patent on
a brand-name drug expires.
Gingivitis
Swelling
of the gum - or gingival -- tissue caused by plaque. Gums may appear
red, swollen, and bleed easily during brushing. This is the beginning
stage of periodontal disease.
Group Insurance
Insurance
coverage that is available to members through a plan sponsor - usually
an employer. The available benefits are defined by the plan sponsor's
policy with the insurer. Policies contain detailed plan descriptions,
limitations and exclusions for each type of coverage.
Group Universal Life (GUL)
A product that provides ongoing life insurance coverage while allowing the member to build up a fund that has tax advantages.
Guarantee Issue Maximum
The
amount of life insurance coverage up to which an applicant is
guaranteed coverage under the group plan without needing to provide
Evidence of Insurability.
H
Health Benefits Plan
The
health insurance or health maintenance organization (HMO) product
offered by a licensed health benefits/health insurance company. The
plan is based on a contract and includes a set of covered services or
expenses that are obtained through:
a network of doctors and other health care professionals or
direct access to licensed health care providers - like doctors - and facilities
Health Insurance Portability and Accountability Act (HIPAA)
A federal law that was created to improve availability and portability - or transferability - of health coverage by:
limiting exclusions for pre-existing conditions
giving credit for prior health coverage
allowing transfer of coverage information (such as covered family members and coverage period) to a new insurer
ensuring that people can sign up for health coverage when they lose existing coverage or have a new dependent
banning discrimination in sign-up and payment costs
guaranteeing availability of health insurance coverage for small employers.
HIPAA rules also improve the efficiency of the health care system, by:
providing a standard way to electronically send health information and
protecting the security and privacy of information that can identify a member.
Health Maintenance Organization (HMO)
A
form of health benefits plan that arranges for health services that its
members need. In a traditional HMO plan, non-emergency services must be
received from a network of health care professionals, although some HMO
plans may offer reduced benefits for care received outside of the
network. In most HMO plans, members must choose a primary care
physician (PCP) from the network to provide routine care and make
referrals for specialty and hospital services when appropriate.
Home Health Care
Skilled
nursing and other therapy provided by a home health care agency in the
home instead of in a hospital or skilled nursing facility.
Home Infusion Therapy
Treating someone at home with drug therapy that is given through a vein.
Hospice Care
Care
to support and reduce pain for a terminally ill person, either on an
inpatient or outpatient basis, and to support his or her family. The
goal is to let terminally ill patients remain in familiar surroundings
for as long as possible.
Hospital
An
organization providing inpatient and outpatient medical services, which
is accredited as a hospital by the appropriate industry organizations,
or otherwise determined as meeting reasonable standards. A hospital may
be a general, acute care, rehabilitation or specialty institution.
I-L
ID Card
A
card given out by a health insurance company that provides information
about the coverage. It includes a unique member identification number
and a toll-free phone number to contact member services.
Indemnity Plan
A
traditional plan that gives members flexibility in their choice of
health care professionals for covered expenses. Members are responsible
for finding care, getting precertification, paying for services
provided, and sending in claims for repayment of covered services.
Indemnity plans usually have out-of-pocket expenses such as deductibles
and copayments. The member must pay these before any expenses are paid
under the plan. Benefit and lifetime maximums also apply.
Independent Medical Exam (IME)
A medical examination, by an unbiased doctor, that is required to help determine disability.
Independent Practice Association (IPA)
A
legal entity or group of doctors that contracts with managed care plans
while maintaining a separate practice. A member who selects an IPA as a
primary care office generally will be referred to specialists and
hospitals connected with the IPA, unless the member's medical needs go
beyond the capability of those doctors.
Indexed Pre-disability Earnings
Basic
monthly earnings in effect just before the date that disability
started, adjusted on January 1 following the first anniversary of
benefit payments and each following anniversary. Each adjustment is
based on the lesser of 10% or the current annual percentage increase in
the Consumer Price Index, which is published by the U.S. Department of
Labor. Applies to long-term disability only.
Infusion Therapy
A
treatment that gives therapeutic agents through the vein. This includes
intravenous feeding and enteral nutrition, which is the delivery of
nutrients into the stomach by tube.
Injectable Drug
A
liquid medicine that is put into the body with a needle or a tool
called a syringe. The medicine may start as a powder that is mixed with
water. The medicine is put under the skin, into a muscle, or into a
vein.
In-Network
Refers to the use of health care professionals who participate in the health plan's provider and hospital network.
Inpatient Care
Service provided after a patient is admitted to the hospital. Inpatient care lasts 24 hours or more.
Integrated Health and Disability (IHD)
For
members who have medical and disability coverage, refers to the service
that combines focused case management with individual contact.
InteliHealth�
An online health website for finding valuable information about current health issues, fitness tips and health-related products.
Job Analysis
A
detailed breakdown of a person's job requirements. It is conducted by
interviewing the worker and supervisor or observing the work place and
the job being performed.
Lapse
Termination - or ending - of a policy because premiums were not paid to the insurer or health plan.
LASIK (also known as laser-assisted in situ keratomileusis)
A vision correction procedure that is performed using a laser.
Late Entrant (also known as Late Enrollee)
An employee who:
does not choose
coverage within 31 days of first being eligible to do so, whether under
the current policy or any prior group policy the person was eligible to
elect coverage under, and who enrolls for coverage after the end of the
yearly enrollment period or open enrollment period, or
does not choose coverage within 31 days of obtaining a dependent, but chooses coverage at a later date.
Length of Disability (LOD)
The period for which disability is certified.
Level Amount Schedule (also known as Flat Amount)
A
benefits schedule under which all employees receive the same amount of
benefit. This might differ based on the employee's title.
Life Insurance
A
benefit that pays a specific dollar amount to a member's beneficiary
upon the death of the member. It is offered through plan sponsors as a
group product or sold to individuals. There are many types, including
term life, whole life, group universal life and others. The policy
defines eligibility, elimination periods, and terms and conditions.
Long-Term Disability (LTD)
A
benefit that pays an employee a percentage of his/her income if the
employee is unable to work for an extended period of time because of a
non-work-related illness or injury. The policy defines eligibility,
elimination period, and terms and conditions.
LTD Pension Accrual
Benefit
that provides pension fund payments at the same time that an insured
person is collecting disability benefits (for the period of the
disability). It lets the insured collect a regular pension at
retirement, without penalty for the period of disability.
LTD Pension Supplement
Benefit
that provides for an annuity, or a series of payments made to the
insured person on a regular basis, after retirement. It replaces
pension benefits that were unearned because of a disability period.
M
Mail-Order Drugs (also known Rx Home Delivery)
Prescription
drug service for pharmacy members, who receive medications by mail.
These are prescription drugs used to treat chronic - or long-term -
conditions, such as arthritis, asthma, diabetes, high cholesterol,
heart conditions and hypertension.
Managed Care
Any
form of health plan in which members have access to a network of
contracted health care professionals and hospitals, and that requires
approval of some services.
Maximum Benefit Amount
The
highest benefit amount payable under the plan design. It can be a
weekly amount (short-term disability), monthly amount (long-term
disability) or annual amount (life).
Maximum Benefit Period
The longest time period for which disability benefits are payable, once all plan conditions are met.
Maximum Drug Benefit
The
highest amount a health benefits/health insurance plan will pay to
cover the costs of prescription drugs for a member and a member's
family during a time period. These periods may be a quarter year, a
calendar year or contract year.
Medical Emergency
See Emergency
Medically Necessary
See Necessary
Medical Underwriting
See Evidence of Insurability
Medicare
The
federal health insurance program for people 65 years of age or older,
certain people with disabilities, and people with End-Stage Renal
Disease (permanent kidney failure with dialysis or a transplant,
sometimes called ESRD).
Member (also known as Enrollee, or Subscriber)
A subscriber or subscriber's dependent who is enrolled in and covered by a health benefits/health insurance plan.
Member Services
A
department in a health insurance/health benefits company that helps
members with questions about plan benefits and exclusions and, if part
of a plan, choosing or changing a primary care physician (PCP). It is
reached by calling the toll-free phone number on the member ID card.
Mental Disorder
A
condition that shows itself through poor or unusual physical,
psychological or behavioral functioning. Treatment is generally
provided by a mental health professional such as a psychiatrist,
psychologist or psychiatric social worker.
Minimum Benefit
The least benefit amount payable under a disability period regardless of income from other sources.
Monthly Benefit
A monthly sum payable to a claimant while he/she is disabled.
N
National Advantage Program (NAP)
Offers agreed-on rates for:
many medical claims that would otherwise be paid as billed under many indemnity plans
the out-of-network portion of managed care plans
emergency/medically necessary services not provided within the standard network.
National Committee for Quality Assurance (NCQA)
An
independent, not-for-profit organization that evaluates how well a
health insurance/health benefits plan manages all parts of its medical
delivery system and continues to improve health care for members.
National Medical Excellence Program�
Helps
eligible members get covered treatment for solid organ transplants,
bone marrow transplants, and some other rare or complicated conditions
at participating facilities experienced in performing these services.
Necessary, Medically Necessary, Medically Necessary Services or Medical Necessity
Services
or supplies that are appropriate for or consistent with the diagnosis
according to accepted medical standards as described in the Covered
Benefits section of the plan. The term applies only to the
determination by the plan whether health care services are covered
benefits. All services are subject to the exclusions and limitations
described in the plan documents.
Network (also known as Provider Network)
Doctors,
hospitals and other health care providers who have a contract with a
health insurance/health benefits company to provide services at a
negotiated rate of repayment.
Noncontributory
The part of the cost of a group insurance plan that is paid by the employer (may be a part of or the entire cost).
Non-Occupational Disease
A
disease that is not, in any way, connected with employment or
self-employment, or does not result, in any way, from a disease or
injury that occurs from such an activity.
Non-Occupational Injury
An
accidental injury that does not occur from or during any act connected
with employment or self-employment, whether or not on a full-time
basis.
Nonparticipating Provider (also known as Out-of-Network or Nonpreferred Care Provider)
Generally
used to mean health care professionals - like doctors - and hospitals
that have not contracted with a health plan to provide services at
reduced fees.
O
Occupational Injury/Disease
An
injury or disease resulting from performing a job. In most states, an
occupational injury or disease is covered by workers' compensation.
Occupational Therapy
Treatment
to restore a physically disabled person's ability to perform activities
such as walking, eating, drinking, dressing, toileting and bathing.
Open Formulary
Refers
to specific pharmacy benefits plans that cover all eligible
prescription drugs. In these plans, prescription drugs may be covered
at lower copays if they are preferred and higher copays if they are
nonpreferred.
Oral and Maxillofacial Surgeon
A dental specialist whose practice is limited to surgical treatment in and around the oral cavity and jaws.
Orthodontist
A
dental specialist whose practice is limited to the detection,
prevention, and correction of abnormalities in the positioning of the
teeth in their relationship to the jaws.
Other Income Benefits (also known as Offsets or Reductions)
Income
provided to an employee (and family members) because of the disability
period for which the employee is claiming benefits under the plan.
Other income benefits, such as Social Security disability, workers'
compensation and pensions, may reduce benefits payments and reserves.
Out-of-Pocket Maximum
The
highest amount a health plan member is required to pay for covered
services outside of his/her benefits plan. Once the member reaches the
out-of-pocket maximum(s), the plan pays 100% of expenses for covered
services.
Outpatient Care
Care provided in a clinic, emergency room, hospital or non-hospital surgical center, without admitting the patient.
Outpatient Surgery (also known as Ambulatory Surgery)
Procedures
that do not require an overnight stay in the hospital or ambulatory
surgery facility. These procedures can be performed in the hospital, a
surgery center or physician office.
Over-the-Counter (OTC) Drugs
Drugs that can be bought without a prescription. They are not covered under most standard prescription benefits plans.
P-Q
Palliative
Treatments that are used for the immediate (temporary) relief of pain, not as a final treatment for the patient's condition.
Partial Day Treatment
An
outpatient program offered by licensed psychiatric facilities that
includes a day or evening treatment program for mental health or
substance abuse issues.
Partial Disability
An
illness or injury that prevents an insured employee from performing one
or more functions of his/her regular job and causes the employee to
earn 80% or less of pre-disability earnings.
Participating Pharmacy
A pharmacy that has a contract with a health plan to fill covered prescriptions for its customers.
Participating Provider (also known as Preferred Care Provider)
Any
doctor, hospital, skilled nursing facility, other individual or entity
involved in the delivery of health care or related services that
contracts to provide covered services to members for a negotiated
charge.
PCP
See Primary Care Physician
Pediatric Dentist (also known as a Pedodontist)
A dental specialist who treats only children.
Pending Claim
A claim that has not yet been approved or denied.
Periapical
The tissues surrounding the end of the tooth root.
Periodontal Disease (also known as Periodontitis)
A
condition that affects the gums and other structures supporting the
teeth. Periodontal disease is a chronic bacterial infection combined
with inflammation. Bacteria grow in dental plaque, which sticks to the
tooth or root surface next to the gums, causing swelling. If left
untreated, the bacteria and inflammation will spread and destroy the
gums and supporting bone around the teeth.
Periodontist
A
dental specialist whose practice is limited to the prevention,
diagnosis, and treatment of diseases of the surrounding and supporting
structures of the teeth.
Permanent and Total Disability
An
insurance contract provision that provides installment or lump-sum
payments if a person becomes permanently and totally disabled.
Permanent Partial Disability
Type
of workers' compensation disability benefit that repays an employee a
percentage or a flat dollar amount of the income he/she lost because of
an occupational injury or disease.
Pharmacy Copay (also known as Pharmacy Copayment)
The amount of money a member pays to a participating pharmacy for prescription drugs covered by a pharmacy benefits plan.
Physical Therapy
Treatment
that uses exercise and physical movement to relieve pain, restore use,
promote healing and prevent disability in a part of the body. The
treatment can be a part of care after a disease, illness, injury or
operation.
Plan Documents
The
contractual plan documents, describing the terms and conditions of
coverage, that are provided to the plan sponsor. They may include the
Group Agreement, Group Policy, and Certificate or Evidence of Coverage
(or Certificate of Insurance) or Summary of Coverage or Benefits.
Plan Exclusions and Limitations.
Binding
terms and conditions that are applied to insurance plans. They may
refer to services, specific types of coverage, pre-existing conditions
and/or other limitations.
Plan Maximum
The greatest amount of benefits that will be paid under an insurance plan.
Plan Sponsor
The organization, usually an employer, to which a health benefits/health insurance or group insurance policy is issued.
Point-of-Service (POS)
A
health benefits plan that provides coverage for care received from both
participating providers - such as doctors and hospitals - and
non-participating providers. In many POS plans, patients whose care is
directed through referrals from their primary care physician (PCP)
receive a higher level of benefits, while patients who go directly to
other physicians or facilities receive a lower level of benefits.
Policy (also known as a Group Plan or Contract)
A
contract between an insurer and a group (usually an employer) or an
individual subscriber, which describes the provisions, benefits and
limitations of coverage.
Portability
The
right of a covered person to keep group life coverage in the form of an
individual policy that is issued without Evidence of Insurability.
Generally, an employee must choose to convert - or switch - within 31
days of the date that coverage under the group policy ends or is
reduced because of age or retirement.
A
health condition (other than pregnancy) or medical problem that was
diagnosed or treated during a specified time before enrollment in a new
insurance plan. Some pre-existing conditions may be excluded from
coverage during a specified time after the effective date of coverage
in a new plan.
Preferred Care Provider
See Participating Provider
Preferred Provider Organization (PPO)
A
health benefits plan that lets members choose any doctor or hospital
without naming a primary care doctor. It offers incentives, usually in
the form of lower payments for services, to members who choose
preferred, or in-network, doctors or hospitals.
Premium Waiver (PW)
A
contract feature in which the insurer agrees to continue life insurance
coverage for a disabled employee without premium payments, based on the
policy terms and conditions.
Prescription
A doctor's order for a prescription drug. If it is a verbal order, it must promptly be put in writing by the pharmacy.
Prescription Drug
A drug that, by law, is sold only with a doctor's written or verbal order.
Preventive Care
Programs
or services that can help maintain good health, such as annual physical
exams, or are meant to detect early signs of health problems or
disease, such as mammograms and colon cancer screenings.
Primary Care Physician (PCP)
A
participating doctor who coordinates and provides care to members, and
also gives referrals for specialist care. A PCP can be a general or
family care doctor, an internist or pediatrician.
Prophylaxis
A
routine service performed for the prevention of dental problems such as
periodontal disease and caries. It includes a thorough scaling (removal
of tartar above the gum line) and polishing of the teeth to remove
plaque and stains.
Prosthetic Devices
Something
that replaces all or a portion of a human body part. These devices are
necessary because the body part is permanently damaged, missing or not
working properly.
Prosthodontist
A dental specialist whose practice is limited to the restoration or maintenance of function by replacement of natural teeth.
Provider
A licensed health care facility, program, agency, doctor or health professional that delivers health care services.
Provider Network
See Network
Quadrant
One
of the four equal sections into which the dental arches can be divided.
A quadrant begins at the midline of the arch and extends to the last
tooth located at the back of the mouth.
R
Radiation Therapy
Treatment of a disease by X-ray, radium, cobalt or high-energy particle sources.
Reasonable Occupation or Job
Any paid job for which a disabled employee is, or may reasonably become, suited by training, education or experience.
Rebase
The
replacement of the entire base of a denture without changing the teeth.
This is usually done to balance changes in the supporting tissues.
Recurrent Disability
Occurs
after a person has met the benefit Elimination Period and qualified for
disability benefits under the plan. It is followed by a recovery period
and a second period of "total disability." The second period of
disability may not be separated from the first period of disability for
longer than a specified period of time and must be caused by the same
or related condition. In most cases, the policy must remain in force
for the provision to apply.
Referral
Specific
directions or instructions from a member's PCP that direct a member to
a participating health care professional for medically necessary care.
A referral may be written or electronic.
Rehabilitation Engineering
Using
knowledge, skills, techniques or technology to help a disabled person
fully participate in his/her job, community and activities of daily
living. It can be as complex as a voice-activated computer or as simple
as a block of wood under a desk to make it more accessible to a person
in a wheelchair. It can also involve restructuring job duties.
Rehabilitation Program
Involves
physical, mental or vocational services and supplies that help improve
or restore an employee's health and well-being so he/she can return to
work. The program is based on medical evidence and the potential for
return to "own occupation" or a reasonable occupation on a full-time
basis or for the greatest amount of time possible.
Related Absences
Two
or more periods of absence from work that are related in diagnosis and
separated by a time period defined by the contract. However, the return
to work/nondisabled period falls within the qualifying period.
Reline
A procedure performed to resurface the part of the denture that fits against the gum tissue.
Respiratory Therapy
Treatment of illness or disease done by bringing dry or moist gases into the lungs.
Retiree
A former employee who meets minimum age and years-of-service requirements, which are determined by the employer.
Retirement Rule
Rule that determines the benefit amounts available to retired employees.
Return-To-Work Incentive (RTW)
Lets
employees return to work part-time as long as the sum of disability
benefits and current income is less than 100% of adjusted
pre-disability earnings.
Root Canal
The
removal of inflamed, infected or damaged pulp (connective tissue,
nerves and blood vessels that nourish the tooth) from either the center
of the tooth or from the canals within each tooth root. Once the
infection is treated the empty canals are filled with an inert, or
inactive, material, with the goal of eliminating the need for
extraction.
Root Planing and Scaling
The
removal of plaque and calculus from the area below the gum line, along
the root. This smoothing of the root surface is performed to help
remove the uneven surface that would allow bacteria to attach easily.
S
Salary Continuation
A
formal benefits program in which an employer continues all or a
percentage of an employee's salary while the employee is disabled on a
short-term basis.
Second Opinion
The
choice or requirement to visit another doctor or surgeon for an opinion
about a diagnosis, treatment or type of optional surgery to be
performed.
Service Area
The
geographic area the HMO or PPO is licensed to operate in or, when
licensing is not required, the area where an adequate network exists to
provide covered services.
Short-Term Disability (STD)
A
benefit that pays an employee a percentage of his/her income if the
employee is unable to work for a limited period of time because of a
non-work-related illness or injury. The STD policy defines eligibility
requirements, elimination periods, and terms and conditions.
Skilled Nursing Facility (SNF)
An
institution or a part of an institution that is licensed or approved
under state or local law to provide skilled nursing care and related
services as a Skilled Nursing Facility, extended care facility or
nursing care facility. It must be approved by the appropriate industry
organizations.
Specialist
A doctor who provides medical care in any generally accepted medical or surgical specialty area.
Speech Therapy
Treatment to correct a speech problem present from birth, or caused by disease, injury or earlier medical treatment.
Subscriber
The
employee covered under an employer's group agreement or group insurance
policy. The subscriber can sign up eligible dependents, as determined
by the policy, under family coverage.
Successive Disabilities
Two or more periods of disability that are related in diagnosis and separated by a period of time defined by the contract.
Supplemental Life Insurance
Additional life insurance which members buy beyond the amount of basic coverage paid for by the employer.
Survivor Benefit
Provides benefits payment to an eligible survivor after a disabled insured person has died.
T
Temporary Partial Disability
Type
of a workers' compensation benefit that provides for a loss of income
to an employee who has a temporary partial disability.
Temporary Total Disability
Type of a workers' compensation benefit that provides for a loss of income to an employee who has a temporary total disability.
Temporomandibular Joint Dysfunction (TMJ)
A group of conditions that affect the jaw joint, and/or the muscles that control chewing and moving the jaw.
Term Insurance
Life
insurance that remains in force only during the period - or term - for
which premiums are paid. It does not build up cash value.
Tertiary Care
Specialized
medical care, usually over a long time period, that involves complex
procedures done by medical specialists in state-of-the-art facilities.
Total Disability - Any Occupation
The
inability to perform the functions of any job because of an illness or
injury. It is determined by factors such work experience, job history
or the job market.
Total Disability - Own Occupation
The inability to perform the functions of one's own job because of illness or injury.
Transferable Skills Analysis
A
detailed examination of specific skills a person can perform in spite
of any disabling conditions. It includes a review of past jobs and
education, as well as hobbies and household activities, in order to
create a list of skills that might be transferred to other types of
employment.
U-V
Urgent Care
Services
received for an unexpected illness or injury that is not life
threatening but requires immediate outpatient medical care. An urgent
situation requires prompt medical attention to avoid problems and
unnecessary or severe pain, such as a high fever.
Voluntary Plans
Indicates
that the entire cost of a group insurance plan is the responsibility of
the employee, with no contributions by the employer.
W
W-2
A form that is used to report a person's income to the Internal Revenue Service.
Weekly Benefit
A
weekly sum payable to a claimant while he/she is disabled. It is
subject to the terms of the group short-term disability insurance
policy (fully insured) or short-term disability plan document (ASC).
Well Baby/Well Child Care
The routine care, testing, checkups and shots for a generally healthy child from birth through the age of eight.
Wellness Program
A
health management program that includes disease prevention, medical
self-care and health promotion. It focuses on preventing illness and
disability.
Work Adjustment
A
technique to help a worker improve work skills and attitudes so that
he/she functions at a competitive level on the job. This can take the
form of one-on-one counseling or a trial period of closely supervised
work in a rehabilitation center. It is often used when employees have
been out of the workforce for a long period of time, and with
individuals who have learning or psychiatric impairments.
Workers' Compensation
Legally
protected benefits, including medical and disability income, for
injuries related to the job. It is available in all 50 states, American
Samoa, Guam, Puerto Rico and the U.S. Virgin Islands.
