| CAL-COBRA |
A state law which allows employees to
continue their health coverage (at their own expense) after they
leave their jobs, either voluntarily or involuntarily. Applies to
employers with 2 to 19 employees. |
| CARRIER |
An Insurance Risk Taker such as Anthem
Health or a Health Maintenance Organization such as
Kaiser |
| COBRA (Consolidated Omnibus Budget
Reconciliation Act) |
A Federal law which allows employees to
continue their insurance coverage (at their own expense) after they
leave their jobs, either voluntarily or involuntarily. Applies to
employers with 20 or more employees. |
| COINSURANCE |
The amount shared by the insured and the
insurer. For example: PPO (90%), Non-PPO (70%), the insurer
(carrier) pays 90%, the insured (individual) pays 10% for PPO
covered services. Or, the insurer pays 70% and the insured 30% for
Non-PPO covered services. |
| COPAY |
The amount the insured must pay for
medical services, such as doctors visits, prescription drugs and
hospitalization. Usually stated in dollars, i.e., $10 office visit
copay; $10 prescription. |
| COVERAGE |
A choice of coverage that can be
selected to fit the needs of a family. There are usually 4 coverage
selections: employee, employee/spouse, employee/child(ren),
employee/family. |
| DEDUCTIBLE |
The amount the member must pay for
non-network and some network (PPO) services before benefits are
payable. |
| DEPENDENT |
Your legal spouse; your unmarried
children under age 19 and your unmarried children age 19 or older
(each carriers may differ on ultimate age) who are full-time
students at an accredited schools or college and fully supported by
you. |
| FORMULARY |
A term used by individual insurance
carriers to list or determine prescription drugs that are used as a
basis for payment determination/limitation or exemption. Usually
consists of all covered generic medications and a broad selection of
brand name drugs. Generally covers all therapeutic classes of drugs
to treat both acute (cold, flu and other short-term illnesses), and
chronic (glaucoma, diabetes, high blood pressure, heart disease,
asthma, etc) conditions. |
| FULL-TIME STUDENT |
An eligible dependant of the covered
employee who meets the criteria of "full-time" as determined by the
respective carrier. |
| HEALTH MAINTENANCE ORGANIZATION
(HMO) |
A health care plan that coordinates and
offers medical services through a group of contracted individual
doctors (or groups of doctors), area hospitals, and other medical
service providers. Normally requires selection of a Primary Care
Physician (PCP) or a Primary Medical Group (PMG). |
| HEALTH PLAN
ADMINISTRATOR |
An employee designated by the employer
to coordinate all aspects of your company's health
coverage. |
| MIX & MATCH |
The employer's option to choose one plan
from each of the sponsored carriers, thereby allowing each employee
to select HMO, or PPO coverage. |
| NETWORK |
Independent health care facilities and
professionals, such as hospitals, physicians, labs, and others
professionals who are contracted to provide health services for
insured members. |
| OPEN ACCESS (HMO) |
An HMO plan that provides the
flexibility of using other contracted physicians within the network
without requiring a referral from the insured's primary care
physician. Generally require a higher copay for any contracted
physician other the the primary care physician. |
| OPEN ENROLLMENT |
An annual "sign-up" period during which
employees can enroll in a group health plan offered by their
employer. In addition, employees already participating are allowed
to change carriers or enroll dependents not previously covered. Open
enrollment for BESA is usually held January 15 through February 15
each year with an effective date of April 1. |
| OUT OF NETWORK |
Health Care Facilities and professionals
who have not contracted to provide health services on a discounted
basis. |
| POINT OF SERVICE (POS) |
A health plan that allows the insured to
choose between HMO benefits and providers and PPO benefits and
providers at the time the service is selected. Requires the insured
to be more knowledgeable of and responsible for decisions of
choice. |
| PORTABILITY |
Credit given toward meeting the
pre-existing condition clause of the PPO plan. Full credit
(portability) will be given for time covered under an
employer-sponsored plan (whether the prior carrier's plan of another
employer-sponsored plan). |
| PRE-EXISTING CONDITION |
Under the PPO plans, pre-existing
conditions are excluded unless continuously insured for six months.
A pre-existing condition is an injury, sickness, or pregnancy for
which the covered person consulted with a doctor, took medication,
or received medical care or advice within six months before becoming
covered by BESA's PPO carrier. See "Portability". |
| PREFERRED PROVIDER ORGANIZATION
(PPO) |
A network of doctors, hospitals and
pharmacies which provide services based on a discounted
predetermined fee. Care can be provided by either a network or
non-network provider. Unlike an HMO, PPO's do not require the
selection of a Primary Care Physician. |
| PARTICIPATING PROVIDER |
A medical professional, service or
institutions employed by, or under contract to provide health care
services to member insured. |
| PRIMARY CARE PHYSICIAN
(PCP) |
The doctor who coordinates all the
health care and medical needs of an insured, including basic care,
preventive services, referrals to specialists and hospitalization
arrangements. A Primary Care Physician can be a General
Practitioner, Internist, Pediatrician or an
Obstetrician/Gynecologist if he/she is contracted to serve as a PCP
by the insurer. Typically required in an HMO (Health Maintenance
Organization). |
| RENEWAL |
April 1 of each year for BESA. Rates may
be adjusted with prior notification. Plan benefit changes are made
at renewal. |
| SERVICE AREA |
A geographic area in which a carrier is
licensed to offer and provide health care service
products. |
| WAITING PERIOD |
The length of employment required by an
employer in order to obtain coverage. BESA allows each employer to
choose from five options based upon their need.
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