Glossary

Coinsurance – The member’s share of the costs of a medical service, calculated as a percent of the allowed amount for the service. For example, if the coinsurance was 10%, the plan would pay 90% of the allowed amount and you would be responsible for the remaining 10%. Coinsurance applies after the deductible is met until an applicable out-of-pocket maximum is reached.


Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – A federal law providing certain eligible participants the right to continue health care coverage at group rates for a set period of time.


Coordination of Benefit (COB) – When there is duplication of coverage–two plans paying for benefits for the same expense–these rules determine who pays health care claims first to ensure the same benefit is not paid for twice.


Copayment (or Copay) – A fixed-dollar amount that a primary enrollee may be required to pay to a provider for specific covered services or supplies (such as emergency room visits or prescription drugs) at the time the service or supply is provided. Primary enrollees are responsible for any required copayments, regardless of the status of any applicable deductibles or out-of-pocket maximums. 


Deductible – The amount a primary enrollee may be responsible for paying each calendar year for covered services prior to the plan making a payment. “Single” and “family” deductibles may apply. Once the deductible is met, co-insurance may apply. 


Dependent Child(ren) – Generally, a child whom the enrollee can legally claim as an exemption on his or her federal income tax return. To be eligible for coverage under the Trust, the child must meet certain eligibility requirements.


Durable Medical Equipment (DME) – Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses. DME includes, but is not limited to, wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, oxygen equipment, ventilators, lifts, and blood testing strips for diabetics.


Elective Service – Elective services are a surgery or procedure that is scheduled in advance because it does not involve a medical emergency.


Emergency – An emergency means medical care may be needed immediately and waiting may be dangerous.


Explanation of Benefits (EOB) – A statement from insurers about individual health claims. The EOB should include information about the provider, the date of service, the service itself, charges for the service, how much the insurer considers to be a reasonable price for the service, and the amount paid to the health care provider.


Generic Drugs – A generic drug is a drug which is produced by one or more manufacturers other than the one producing the brand version. The active ingredient in the generic drug is the same as the one in the brand drug. The FDA approves all generic drugs to be functionally the same as brand drugs.


Health Maintenance Organization (HMO) – HMOs only cover care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO’s guidelines and restrictions. Generally, a Primary Care Physician coordinates all of the care.


In-Network – The term refers to physicians, facilities, or services that are contracted to a particular carrier.


MedicareA federal health care program for individuals age 65 or older, and for certain individuals under age 65 who have a severe long-term disability including end-stage renal disease (ESRD). It has four main parts:

Part A: Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

Part B: Part B covers certain doctors’ services, outpatient care, medical supplies, certain drugs and preventive services.

Part C: A type of Medicare health plan offered by private companies that contracts with Medicare to provide all Part A and Part B benefits.

Part D: Part D covers prescription drug coverage through private plans.


Medicare Advantage Plan (MA) – A type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and Part B benefits. Medicare Advantage plans include Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). If you’re enrolled in a MA plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare.


Monthly Contribution – The amount an enrollee may be required to pay monthly for health care coverage. The amount can vary based on enrollment as a "single" or "family," “Protected” or “General,” or the plan option selected (e.g., TCN or HMO).   


Out-of-Network – Hospitals, pharmacies, providers, and special services that are not in the network of the Plan are considered ‘out-of-network’. When you use an out-of-network provider, you generally are responsible for paying the out-of-network deductible and coinsurance, as well as any amounts in excess of the allowed amount billed by the provider.


Out-of-Pocket Maximum – A limit on the amount you pay during the year after which the plan will pay for your covered services at 100%. Some cost-sharing, such as coinsurance and deductibles, from in-network providers count toward your out-of-pocket maximum. Copay services generally do not count toward out-of-pocket maximums. A separate out-of-pocket maximum may apply for in-network services and out-of-network services.


Preferred Provider Organization (PPO) – A PPO is a plan design that offers a network of physicians, hospitals, and other medical providers that have agreed to provide health care at discounted fees. Participants who are covered under a PPO plan do not need referrals to receive care from in-network or out-of-network physicians, however, out-of-network charges are not paid in full unless referred and approved through the PPO network.


Preventive Services – Services provided for the detection or prevention of illnesses. Preventive services – like most vaccinations and many screening tests – are covered at 100% and excluded from the annual deductible, copayment, and coinsurance requirements.


Rolling Enrollment – A contract holder is able to change their benefit elections once every 12 months.  The 12 month period begins when the new elections have been made. The 12-month restriction may be waived when a new health plan is offered in your service area.


Sanction – An amount of otherwise covered or potentially covered expense that a primary enrollee incurs for failure to follow plan provisions (such as additional amounts incurred for failure to predetermine a Hospital admission).  Please note that certain expenses may not be applied toward your deductible or out-of-pocket maximum. In addition, some expenses may not be paid at 100% even after you meet your out-of-pocket Maximum


Spouse (same-sex or opposite-sex) – An individual who is married to a Retiree with a valid marriage certificate from a state, the District of Columbia, a U.S. territory, or a foreign country (“Jurisdiction”) where such marriage has been recognized as legal according to the laws of that Jurisdiction.


Traditional Care Network (TCN) – The base plan option available to all Trust members in all 50 states. This plan is based on a nationwide network of providers and allows services to be performed both in-network and out-of-network.


Urgent Care – Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.


VEBA – A Voluntary Employee’s Beneficiary Association, which is a tax-exempt employee welfare benefit fund that is held in trust for the benefit of covered participants. Legally, the Trust is structured as a VEBA, and people sometimes refer to the Trust as “the VEBA.”