Glossary of Terms
ACA Maximum Cost Share - Effective October 1, 2015, this limits the amount a member could pay out-of-pocket for in-network medical and prescription services combined, including Additional Cost Tier (ACT) copayments. For OEBB plan offerings, this applies only to Moda Health Medical Plans A – G.
Additional Cost Tier (ACT) - Services in this tier require an additional copayment of $100 or $500. These copayments do not apply toward the deductible or the annual medical out-of-pocket maximum and are in addition to any other applicable copayment or coinsurance you must pay under your specific medical plan benefits. These copayments do apply toward the annual ACA Maximum Cost Share. Services in this tier have been shown to have alternatives that are often as safe or safer, less expensive and/or produce better health outcomes. The additional copayment serves as financial incentive for members to discuss other options with their doctor before proceeding.
Annual Out-of-Pocket (OOP) Maximum – The maximum you will have to pay “out of your pocket” for covered services in a plan year. Effective October 1, 2015, the out-of-pocket maximums include the deductible and any copayments for medical (non-pharmacy) services. Deductibles are calculated on an individual basis, but are limited to no more than three per family on the Moda Health plans and no more than two per family on the Kaiser Permanente plans. Under Kaiser Plan 3 and Moda Health Medical Plan H, the maximum amount is determined by the number of individuals covered on the plan (individual or family).
Appeal (also Grievance) – A formal request by, or on behalf of, a plan participant, for reconsideration of a decision (such as a benefit payment, an administrative action, a quality of care or service issue, or a utilization review recommendation), with the goal of finding a mutually acceptable solution.
Before-Tax Contributions – Contributions for benefit premiums or FSAs, which are deducted from your pay before any taxes are withheld.
Beneficiary – The person(s) you name to receive certain benefits (such as life insurance) upon your death.
Benefits – A term that is commonly used in two different ways: (1) “Benefits” refer to the full range of programs sponsored by your employer (that is, your medical, dental, vision, life & AD&D, disability, pension, savings, and all other plans). For example, you might say that your employer provides comprehensive benefits for employees. (2) Also, the word “benefits” is used to indicate what a specific plan pays toward your expenses. For example, “The medical plan pays benefits at 80% after you meet the deductible.
Brand-Name Drugs – Prescription drugs that carry a specific trademark or brand name. Brand-name drugs may be significantly higher in cost than generic drugs, even though, by law, both must have the equivalent active ingredients.
Change in Family Status (also family status change) – Certain life-changing events that qualify you to change your level of medical coverage during the year (without waiting until Annual Enrollment). These events include changes in your family status (such as marriage, divorce, or childbirth) or employment status (for example, termination of your spouse’s job).
Claim – The invoice or receipt you submit, or your provider submits on your behalf, to the insurance company (under which you have plan coverage) to receive payment or reimbursement for eligible expenses incurred by you or a covered family member.
COBRA - This acronym stands for the Consolidated Omnibus Budget Reconciliation Act, which is the federal law requiring employers to allow for continued coverage through a group health plan after losing eligibility in the group, on a self-pay basis. For OEBB members, COBRA coverage is guaranteed continuation of your previous OEBB coverage and administered by BenefitHelp Solutions (BHS). Regardless of your health status, COBRA law allows eligible parties losing OEBB coverage to continue that same coverage for at least 18 months. COBRA premiums are equal to the full OEBB premium plus two percent. Keep in mind, your employer may have been contributing toward your premium when you were eligible for OEBB coverage, so the amount you were paying may not have been the full premium amount. More information about COBRA and other options after loss of OEBB coverage can be found in the COBRA category FAQs on the OEBB website: www.oregon.gov/oha/OEBB/Pages/FAQs.aspx
Coinsurance – The cost of a covered service that is shared by the plan and you, typically expressed in percentages, once the deductible has been met. Example: 20 percent coinsurance = Member pays 20 percent, Plan pays 80 percent.
Copayment – A fixed dollar amount (e.g., $20) you pay to the provider at the time of service.
Coverage Level or Type – Under the health care program, the election you make regarding benefit coverage for yourself and your dependents. For example, many plans offer coverage for Employee Only (yourself), Employee + One (you and one dependent), or Family (you and more than one dependent).
Covered Expense – Any expense for medical or dental services or products that is eligible for benefits under your plan.
Date of Service – The date on which you receive services from a physician, dentist, or other health care provider.
Deductible – The amount you pay for covered services before the plan begins to pay claims at a coinsurance level. Effective October 1, 2015, the deductible does apply toward the annual medical out-of-pocket maximum on all plans.
Dental Emergency – Extreme dental pain or worsening of an existing condition that requires immediate treatment.
Dental Maintenance Organization (DMO) – A dental plan that offers services through specific dentists and dental facilities. Generally, to receive DMO benefits, you must use participating dentists and facilities.
Dependent – A person or persons, including your spouse, domestic partner, son, daughter, spouse’s, or domestic partner’s biological son, daughter, stepson, or stepdaughter; adopted child, child placed for adoption, or legally placed child, who is 25 or younger on the first day of the month. who are eligible for benefit coverage.
Dependent Care Flexible Spending Account (FSA) – A before-tax account that lets you pay for qualified expenses incurred in caring for your eligible dependents while you work. (Eligible dependents include children under age 13 who qualify as a dependent for federal income tax purposes; and your spouse, elderly parent, or any other dependent who is physically or mentally incapable of self-care.) To participate, you must be single – or married with a spouse who works or is a full-time student. It's important to note that a "use it or lose it" rule applies to the FSA. Any money remaining in your account after year-end (December 31) will be forfeited; it cannot be rolled over or refunded to you.
Disability – Any illness or injury that causes you to be unable to perform your job for an extended period of time.
Early Retiree – An individual who retires before the age of 65. In order to be eligible for OEBB benefits, an early retiree must not be eligible for Medicare and must be eligible to receive a service retirement allowance under PERS or a retirement benefit plan or system offered by an OEBB-participating organization. For more information specific to Early Retirees, see pages 42 - 43 of this Enrollment Guide.
Effective Date – The date on which you and your dependents become eligible for benefits under a specific plan.
Eligibility – The rules under a specific benefit program that determine who is eligible for coverage (employees and dependents) and when qualified participants can enroll in the options available to them.
Emergency Care – Care for any illness or injury that, without immediate medical attention, could result in loss of life or limb, or cause serious harm to bodily functions (for example, an apparent heart attack, severe bleeding, loss of consciousness, or severe or multiple injuries).
Employee Assistance Program (EAP) - A program of counseling and other forms of assistance for alcoholism, substance abuse or emotional and family problems.
Employer Contribution – The amount your employer pays toward your benefits package or health insurance premium.
ERISA – A federal law (Employee Retirement Income Security Act of 1974, as amended), that sets minimum standards to protect participants in employer-provided benefit plans. Key provisions require that plans provide participants with important information about plan features and funding, and that they establish a grievance and appeals process for participants to obtain benefits from their plans.
Explanation of Benefits (EOB) – The document you receive from the insurance company after your claim is filed and processed. The EOB shows how much of the expense the plan covered and how much you may be expected to pay. If part or all of the expense is not covered, the EOB should explain why.
Family and Medical Leave Act (FMLA) – A federal law that permits employees to take up to 12 weeks of unpaid leave, during any 12-month period, for the following reasons: birth and care of the employee’s newborn child; care of an adopted child or a child placed with the employee for foster care; care for an immediate family member (spouse, child, or parent) with a serious health condition; or medical leave for the employee due to a serious health condition.
Family Status Change – See Change in family status.
Flexible Spending Account (FSA) – A special before-tax account that lets you pay for certain qualified expenses tax-free. There are two types of flexible spending accounts: the Dependent Care FSA, which lets you pay for expenses incurred in caring for your eligible dependents while you work; and the Health Care FSA, which you can use for health care costs (medical, dental, and vision) not covered under your plan. It’s important to note that the FSAs have a “use it or lose it” rule: Any money remaining in your account at year-end (December 31, for the Dependent Care account; March 15 of the following year, for the Health Care FSA) will be forfeited.
Formulary – A list showing which prescription drugs are covered by a health insurance plan and which coverage tier they fall under (e.g., generic, preferred, non-preferred).
Generic Drugs – Prescription drugs that meet the same standards for safety, purity, strength, and quality as their brand-name counterparts. These drugs, however, bear only a chemical or general-classification name – not a brand name.
Grievance – see Appeal.
Health Care Flexible Spending Account (FSA) – An account that lets you pay for qualified expenses not covered by your health plan – tax-free. These expenses include deductibles, co-payments, and coinsurance, as well as over-the-counter medications. It's important to note that you must use all of the money in your account by March 15 of the following year. Any money remaining in your account after that date will be forfeited; it cannot be rolled over or refunded to you.
Health Maintenance Organization (HMO) – A medical plan that offers services through specific physicians, hospitals, and other health care professionals. To receive HMO plan benefits, you must use participating HMO doctors and facilities.
Health Reimbursement Arrangement (HRA) – A health reimbursement arrangement (HRA) is an account-based health plan you can use after becoming claims-eligible, to reimburse your qualified out-of-pocket medical care costs as defined by the IRS. Common qualified expenses include co-pays, deductibles, prescription drugs, retiree insurance premiums, etc. An HRA is not an insurance plan, and you do not pay a premium. Your account is funded with contributions from your employer. Employer contributions, investment earnings, and withdrawals (claims) are tax-free. Contribution amounts are not required to be included on Form W-2 from your employer,
and you will not receive a Form 1099 for earnings or withdrawals (claims).
Health Risk Appraisal (also Health Risk Assessment) – A personal assessment, usually offered under the wellness program, which considers your lifestyle, medical history, and current health, to evaluate your health status and identify potential problems that put you at risk for serious illnesses.
Health Savings Account (HSA) – A special savings account, linked to a high-deductible health plan. You contribute before-tax dollars to your account, and then use your savings to pay eligible health care expenses tax-free. Any money left in your HSA at year-end simply rolls over into the next. So, you can use your account to pay current health expenses – or save to meet potentially higher medical costs at retirement.
High-Deductible Health Plan (HDHP) – A plan with a high annual deductible (generally, an amount above $1,000 for individual coverage and $2,000 for family) that you must meet before any benefits are paid.
HIPAA (Health Insurance Portability and Accountability Act of 1996) - A federal law that addresses the privacy of patient health information and the portability of insurance plans as employees change jobs. The “privacy” regulations give patients greater access to their own medical records and more control over how their personal health information is used. Also, the law defines the obligations of health care providers and health plans to protect patient records. With regard to “portability,” HIPAA guarantees that an individual with a pre-existing condition, who has had continuous health coverage for 12 months, can leave a job and not be turned down for health insurance at a new job.
Home Health Care – Products and services provided, as needed, in a patient’s home, by a home health agency or other provider. Services range from skilled nursing care and physical therapy to personal care and help with household chores.
Incentive Office Visit – A regularly scheduled visit with a healthcare provider to manage asthma, heart conditions, high cholesterol, high blood pressure, or diabetes. This is only applicable to OEBB Moda Health medical plans.s.
In-Network Services – Under a PPO, care or treatment you receive from physicians, hospitals, or other health care professionals that participate in the network. In the PPO, in-network services receive the highest level of coverage.
Inpatient Hospital Care – A hospital stay (usually 24 hours or more) for which a room and board charge is made by the hospital.
Life Event – Significant events (such as marriage, birth, adoption, divorce, and death) that create major changes in a person’s life. Generally, when one of these events occurs, you will need to review and make appropriate changes in your benefits. (For example, you may want to add a new baby to your health coverage, drop your ex-wife from coverage after the divorce, or change your beneficiary in the event of your spouse’s death.)
Long-term care (LTC) – An optional insurance policy that provides a daily benefit amount for services required when the covered individual becomes incapable of self-care. Benefits generally cover care in a nursing home or skilled nursing facility.
Long-term disability (LTD) – An insurance policy that can replace a percentage of your income (usually 60%), under certain circumstances, if you are ill or injured, and unable to work. Generally, for eligible conditions, benefits can begin after you have been off from work for 180 days.
Maintenance Drug – A prescription drug that must be taken on an ongoing basis. These drugs are used to treat chronic medical conditions, such as congestive heart failure, glaucoma, hypertension, and thyroid disease.
Managed Care - Systems and techniques used to help direct the utilization, cost and quality of healthcare services. Includes a review of medical necessity, incentives to use certain providers and case management. Managed care is a broad term and encompasses many types of organizations, but it’s generally used to describe the activity of organizing doctors, hospitals and other providers into groups to enhance the quality and cost-effectiveness of healthcare.
Maximum Annual Benefit – The total amount payable by a plan per plan year. Examples: Alternative Care under OEBB medical plans and all Moda Health dental and vision plans.
Maximum Lifetime Benefit – The maximum amount the plan will pay in covered charges for any one individual over his or her lifetime.
Medical Home - A select group of healthcare providers who practice team-based medicine and have met the state’s criteria to be certified as a Patient-Centered Primary Care Home and are participating in the Moda Health Connexus provider network. OEBB members enrolled in a Moda Health Statewide medical plan will receive a better benefit on certain services if they use one of these providers. Each individual enrolled in a Moda Health Synergy or Summit plan must select a Moda Health Medical Home to coordinate their care, and ensure that medical home is formally on record with Moda Health prior to utilizing services. You can search for a Moda Health Medical Home provider on the Moda Health website: www.modahealth.com/oebb/members/medical_home/find_provider.shtml
Medically Necessary – Services and supplies, including tests and examinations, that the insurance company determines to be consistent with generally accepted practices for the diagnosis of an illness or injury, or the medical care of a diagnosed illness or injury. Only medically necessary services and supplies are covered by the plan.
Network – Medical providers and facilities that agree to provide quality services at reduced costs. In-network services are therefore both less expensive and covered at a higher rate. Out-of-network services, on the other hand, are not discounted, so they’ll cost you more.
Non-Covered Services – Services and products not covered by your plan (for example, most cosmetic procedures are not covered under the health plan). If you receive non-covered services, no plan benefits will be paid – you’ll be responsible for the full cost.
Non-Preferred Brand-Name Drugs – These brand-name medications are not on the formulary list of preferred drugs, and have the highest cost.
Open Enrollment – The annual period during which you may choose to make changes in your benefits (for example, change your medical coverage level or switch plans) for the next year. Enrollment is usually held two or three months before the beginning of the new plan year.
Out-of-Pocket (OOP) Maximum – See Annual out-of-pocket maximum.
Out-of-Area Services – Care or treatment you receive from health care providers while you are outside your plan’s service area.
Out-of-Network Services – Under a PPO, care of treatment you receive from physicians, hospitals, or other health care professionals who are not participating in the PPO network. In the PPO, out-of-network services are covered, but at a lower level.
Outpatient Hospital Care – A hospital stay (usually less than 24 hours) for which no room and board charge is made by the hospital.
Over-the-Counter Drugs – Medications that do not require a prescription, which you can buy at a local pharmacy or other retail store. Over-the-counter drugs include pain relievers (such as aspirin and ibuprofen), antacids, cough and cold remedies, and eye drops, as well as vitamins and dietary supplements.
Plan – An individual policy or program that offers a specific type of insurance coverage or benefits to participants. (For example, your employer-provided benefits may include a number of different plans, offering medical, dental, and vision coverage; life, disability, and AD&D insurance; and retirement benefits, through pension and savings plans.)
Plan Year – The period of time on which plan coverage and records are based. It may be a calendar, fiscal, or policy year, as specifically defined by your plan. (For example, the annual deductible, annual out-of-pocket maximum, and maximum annual benefit all apply to expenses incurred during the plan year.)
Pre-Authorization of Treatment – An insurance plan requirement that covered services be approved by the plan prior to the date of service. Only certain services require pre-authorization under the OEBB benefit plans.
Preferred Brand-Name Drugs – Brand-name medications on the formulary’s preferred drug list, based on their clinical effectiveness and cost. These drugs cost you more than generic, but less than non-preferred brand drugs.
Preferred Provider Organization (PPO) – A medical plan that offers benefits for both in-network and out-of-network services. Generally, in this type of plan, you can choose any doctor – but you’ll pay significantly less inside the network.
Premiums (or contributions) – The amount you pay for your health care coverage and other benefits, usually through payroll deductions.
Preventive Care – Medical or dental treatment, such as examinations, inoculations, and tests, to help promote good medical and dental health and prevent illness.
Primary Care Physician (PCP) – Also referred to as General Practitioner, provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions not limited by cause, organ system, or diagnosis. Examples: Internist, Family Practice, ObGyn, Pediatrician, Nurse Practitioner.
Qualified Medical Child Support Order (QMCSO) – A court order that directs the employer to cover a child for benefits under the medical/dental plan (for example, a child who does not live with a parent, a child born out of wedlock, or a child not claimed as a dependent on a parent’s federal income-tax return.)
Qualified Status Change (QSC) - A life event that allows a member to change their plan elections outside the annual Open Enrollment period. The QSC Matrix lists all the events that qualify as a QSC. The QSC Matrix is available online at:
Self-Referral – In an HMO, physicians in certain specialties (such as dermatology, obstetrics/gynecology, and psychiatry) do not require a referral from your primary care or personal physician. You may see those specialists, as needed, on your own.
Short-Term Disability (STD) – An insurance policy that continues to provide you with all or part of your salary while you are unable to work due to a qualifying illness or injury. Benefits could continue for up to 26 weeks.
Specialist Provider – Provides services specific to a particular cause, organ system, or diagnosis on which they have chosen to focus their medical expertise. Examples: Allergist, Neurologist, Oncologist, Dermatologist.
Term Life Insurance – An insurance policy that provides a specific dollar benefit to a designated beneficiary upon the policyholder’s death.
Value Tier – A tier of medications under the Moda Health pharmacy benefit available at no cost to the member when used to manage asthma, heart conditions, high cholesterol, high blood pressure, diabetes, or osteoporosis. Under Moda Health Medical Plans A – G, some medications used to treat depression or pain/arthritis are also included in this tier.
Urgent Care – An illness or injury that requires immediate, but not emergency, care (that is, the condition is neither life- or limb-threatening). Examples include high fever, flu, earaches, sprains, nausea, and headaches.
Voluntary Benefits – Optional benefit plans sponsored by the employer, but fully paid for by employees who elect coverage. These benefits are generally available at special group rates or discounts, making them more cost-effective than employees could obtain on their own. Examples include vision benefits, life insurance, disability insurance, long-term care insurance, legal services, and college savings plans.
Wellness Visit – A covered service under all OEBB medical plans. On the Moda Health Statewide plans, this service is only covered if provided by a Moda Health Medical Home provider. This is a visit with a physician focused on overall wellness rather than treating a specific condition. The visit could focus on drug/alcohol/tobacco use, exercise, weight, physical activity, nutrition, depression, or other wellness-related topics.