This list provides general definition of common insurance terms. Please refer to your plan for specific information.
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Accidental Death and Dismemberment
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Group insurance that provides benefits for loss of life or certain body members as a consequence of accidental bodily injury.
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Administration
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The broad aspect of handling all functions of the group insurance plan.
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Administrator
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The firm that performs the administrative function for a group insurance plan.
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Age Discrimination in Employment Act of 1967 (ADEA)
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Amended in 1978, this act applies to age discrimination in employment and in employee benefits.
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Allowable Expense
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Any necessary, reasonable or customary item of expense that is covered, at least in part, by one or more of the plans under which an individual is insured.
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Assignment of Benefits
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The signed transfer of certain benefits by the insured person to a third party.
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Beneficiary
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Person named by the participant in an insurance policy or pension plan to receive any benefits provided by the plan after the participant dies.
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Benefit Booklet
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A booklet for the employee that contains a general explanation of benefits and related provisions of the health plan.
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Benefit percentage
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The percentage of the eligible expenses payable by the plan.
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Benefit Period
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Period for application of deductible, after which time deductible must again be satisfied.
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Board of Trustees
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The governing body of a voluntary health care institution or agency.
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CHAMPUS
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Medical benefits and programs provided by the Civilian Health and Medical Program of the Uniformed Services.
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Claim
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A demand to the Plan (pension or health and welfare) by the covered person or beneficiary of the payment of benefits under a policy.
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Claimant
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A person who submits a claim.
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Co-insurance
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A requirement under a health plan where the member is responsible for a portion or percentage of the cost of covered services.
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COBRA
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The coverage provided under the provision of the Consolidated Omnibus Budget Reconciliation Act of 1985 and its amendments.
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Coordination of Benefits (COB)
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A policy provision permitting coordination of medical care benefits.
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Cost Containment
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Activities aimed at holding down the cost of medical care or reducing its rate of increase.
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Covered Charges
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Charges for medical care or supplies that, if incurred by an insured or other covered person, create a liability for the insurer or plan under terms of a policy.
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Date of Service (DOS)
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The date you received services from a provider of service.
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Deductible
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A specified dollar amount of Covered Expenses that must be incurred before the Plan will pay any amount for any Covered Expense during each benefit year.
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Disability
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Physical or mental incapacity of an individual to perform work. A dependent is considered to be disabled when they are unable to perform functions of like sex and age.
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EAP
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Employee Assistance Program
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EDI
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Electronic Data Interchange
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Eligibility
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The provisions of the policy or plan that state requirements members of the group must satisfy to become insured with respect to themselves or their dependents.
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ERISA
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Employee Retirement Income Security Act
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Exclusions
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Specific conditions or services not paid for under a health insurance plan.
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Explanation of Benefits (EOB)
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A description, sent to members by health plans, of benefits received and services for which the health care provider has requested payment.
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Fiduciary
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One who occupies a position of confidence or trust and who exercises any power of control, management or disposition with respect to monies or other property of an employee benefit fund or who has authority or responsibility to do so.
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FMLA
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Family and Medical Leave Act
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HCRA
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Health Care Reimbursement Account: Sometimes called a flexible spending account. A type of "savings account" that allows you to set aside funds to help offset some expenses not covered by your health plan.
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HIPAA
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Health Insurance Portability and Accountability Act of 1996, as amended.
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Limitation
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A restriction in benefits under certain conditions or circumstances specified in the policy or plan.
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Medicaid (TitleXIX)
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A medical benefits program administered by the states and subsidized by the federal government that pays certain medical expenses for those who meet income and other guidelines.
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Medicare
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Administered by the Social Security Administration, Medicare is the US federal government plan for paying certain hospital and medical expenses for those who qualify, primarily those 65 and older. The program is government subsidized and government operated.
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Member
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The primary person, generally the employee, that is enrolled on a plan.
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NAIC
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National Association of Insurance Commissioners
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Necessity
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Determination that a condition exists that requires a professional health service.
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OTC Drug
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Over-the-counter drug
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Out-of-Pocket (OOP)
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The amount of money you pay, not including your deductible, towards covered medical expenses.
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PHI
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Protected Health Information
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Plan Participant
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Any employee or former employee of an employer, or any member or former member of an employee organization, who is or may become eligible to receive a benefit of any type from an employee benefit plan, or whose beneficiaries may be eligible to receive any such benefit.
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Pre-existing Condition
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A physical and/or mental condition of a participant that existed prior to the initial date of coverage. Some plans exclude pre-existing conditions from coverage for a period of time.
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Preferred Provider Organization (PPO)
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Having a PPO means that you can see the provider of your choice. Providers may be "in-network" with the PPO or "out-of-network". Providers who join a network offer their services to the members at a discounted rate. If your provider is not contracted with the plan, your PPO may still provide coverage, but often at a reduced benefit rate.
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QDRO
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Qualified Domestic Relations Order
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Reasonable and Customary Charge
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A charge for medical/dental treatment or service customarily performed for the condition treated, which fairly reflects its value.
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Right of Recovery
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A provision that allows a plan to recover an overpayment.
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SAR
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Summary Annual Report
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Scheduled Benefits
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A specific maximum amount that will be considered as the covered expense as listed for each procedure in a schedule.
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Statement of Support (SOS)
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A statement that provides information regarding which parent provides support and is responsible for insurance ocverage for dependent children.
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Subrogation
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In an employee benefit plan, the right of the plan to recoup benefits paid to participants through legal suit, if the action causing the disability and subsequent medical expenses was the fault of another individual.
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Summary Plan Description (SPD)
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A requirement of ERISA for a written statement of a plan in an easy-to-read form, including a statement of eligibility, coverage, employee rights and appeal procedures.
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Third Party Administration
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Administration of a group insurance plan by some person or firm other than the insurer or the policyholder.
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Third Party Administrator (TPA)
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The party to an employee benefit plan that may collect premiums, pay claims and/or provide administrative services.
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Trust Fund
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A fund whose assets are managed by a trustee or a board of trustees for the benefit of another party or parties.
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USERRA
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Uniformed Services Employment and Reemployment Rights Act
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Weekly Income Benefit
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Group coverage that provides weekly income benefits for disability, usually for a term of 13 or 26 weeks.
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