Glossary of Benefit
Approved Benefit (AB)
A term used by insurance carriers (like reasonable and
customary) which represents the amount of benefit allowed to
be paid by the carrier for a procedure or service.
COBRA is the
abbreviated term for the Consolidated Omnibus Reconciliation
Act. COBRA requires employers to provide continuation of
coverage to terminating employees or eligible dependents
losing coverage up to a minimum of 18 months. Other terms of
coverage also apply. Employers may charge up to 102 percent
of the premium.
Your share of medical expenses normally after you have paid
of Benefits (COB)
COB applies if you or a family member is covered under
another medical plan in addition to the coverage you have
through AACPS. The benefits payable under you AACPS-sponsored
coverage are coordinated with the other plan so that your
total benefits from both plans will not exceed 100 percent
of the benefit.
Your out-of-pocket payment when you visit your physician or
other healthcare provider (i.e. a $5 co-payment applies to
Routine medical care and specific medical expenses incurred
as a result of a non-occupational illness, injury or disease
which are benefits provided by your health plan.
The amount of
medical expenses that must be paid in full each calendar
year before benefits are usually paid from the plan.
Allowable expenses for necessary medical care, which are
determined by the healthcare plan in which you participate.
Reasonable and customary guidelines may apply (see
definition of reasonable & customary).
Spending Accounts (FSA’s)
FSA’s provide employees with the opportunity to save money
on a pre-tax basis and reduce their taxable income up to
permitted IRS limits to save for related expenses. AACPS
provides a Dependent Care Account and Healthcare Spending
Account option to employees. Careful planning is required
for funding the FSA because there is a use or lose concept
if funds are not requested by the annual deadline.
A term associated with applying for coverage with no
evidence of insurability required up to certain limits
(i.e., long-term care or supplemental life insurance
A doctor, hospital, laboratory, nurse, or anyone who
delivers medical or health related care. This is not to be
confused with Primary Care Provider.
Insurance Portability & Accountability Act (HIPAA)
legislation passed to ensure confidentiality of plan members
and to ensure safeguards for transmitting healthcare
information in a confidential and secure fashion.
Maintenance Organization (HMO)
HMO’s provide health care services for a fixed fee and a low
co-payment for services. You are covered only for treatment
approved by the HMO and you must use HMO physicians and
facilities (refer to page 13).
Benefits are maximized when you use in-network providers
(i.e. CareFirst PPN or UCCI POS). In-Network providers have
agreements with health insurance companies to accept the
health insurance companies payment for services rendered
along with your co-payment.
involves the addition or loss of a dependent family member
or a change in your or your spouse’s employment or
healthcare coverage. You have 31 days to notify the HR
Payroll/Benefits to change your benefits (refer to page 5).
Maintenance medications are considered medications as
defined by the prescription drug plan which are usually
utilized over a long-term. In this program’s case, if a
medication is taken typically over 90 days it is considered
a maintenance medication. Examples include blood pressure
medication, diabetic products, and birth control pills.
Maintenance medications must be ordered through the
mail-order plan with CAREMARK.
Managed care is a concept that permits healthcare plans and
employers to administer healthcare plans in a more efficient
and cost effective manner. Examples of managed care include
networks of providers, pre-certification, preventive care,
and health education programs (refer to page 6).
Some plans such as the CareFirst PPN and UCCI allow you
additional flexibility to seek care outside of your network
and still provide coverage but at reduced benefits. Coverage
includes satisfying a deductible and then co-insurance where
you pay usually 20 percent or 30 percent of the service.
Claims forms must be submitted to the carriers for
POS is a category of healthcare plans in which carriers
negotiate agreements with a network of participating
physicians to provide healthcare at a reasonable co-payment
Provider Network (PPN)
A PPN healthcare plan is provided by an insurance carrier
whereby the insurance carrier has negotiated agreements with
a network of participating providers to accept the carrier’s
payment for services rendered and provide a reasonable
co-payment to participants. A PPN does not require
participants to select a physician and they may seek care
from specialists on their own. Most PPN’s provide benefits
in and out-of-network (refer to page 11).
A charge applied
either to an employer and/or participant that represents the
costs of healthcare.
An old fashioned family doctor called by a new name. A
general physician, pediatrician, and gynecologist can
qualify depending on your healthcare plan. You must specify
a PCP if you select an HMO or POS plan.
If your primary
care physician determines that you have a condition that
requires the attention of a specialist, a written referral
will be provided for you to see a specialist.
A charge that is determined by the insurance carrier to be
considered a reasonable or fair charge for services rendered
and the maximum amount the carrier will pay for the
A Traditional Plan is a type of healthcare plan that is
provided by an insurance carrier which provides benefits
subject to a deductible and co-insurance and reasonable and
customary charges. Participants may see any provider they
wish with this type of program. Premiums are generally more
expensive due to lack of managed care components.