Text Size:   A+ A- A   •   Text Only
Find     
Site Image
PEBB Glossary
 
This information is provided to help you understand terms used in discussions of benefits and insurance.
 
Make suggestions on additions to this glossary at hottopics.pebb@state.or.us.
 


A ]
[ B ]
C ]
D ]
E ]
F ]
G ]
H ]
I ]
[ J ]
[ K ]
L ]
M ]
N ]
O ]
P ]
Q ]
R ]
S ]
T ]
U ]
[ V ]
W ]
[ X ]
[ Y ]
[ Z ]
 
 
 
 
 

A

Administrator. Contracted entity that receives a fee for such services as processing claims, collecting premiums, contracting with provider networks and processing enrollment.
Accidental Death and Dismemberment (AD&D) Insurance.   Insurance that pays benefits on accidental loss of life or appendage or function of certain sensory organs.
Affidavit of Dependency. A written document in which an eligible employee attests that the dependent meets the criteria set forth in OAR 101-010-0005(7) on the date the document is signed by the insured individual.
Affidavit of Domestic Partnership. A written document kept on file by the agency, in which an employee and another individual attest to meeting the criteria set forth in PEBB Administrative Rules OAR 101-015-0026 on the date the document is signed by the employee and the individual. Form available online and from PEBB or your agency.
Agency. An administrative division of Oregon government that includes a payroll, personnel or campus benefits office.
Allowed Amount. This is the maximum amount a health plan will pay for a service provided by an in-network provider, even if the provider bills them for a larger amount.
Appeal. Process through which a member asks an administrator to reconsider a determination.
ASO. An administrator that provides administrative services only.
 
 
 

B
Balance Billing. The billing of a patient for the difference between the provider's actual charge and the allowed amount reimbursed under the patient's health plan. This may happen when the provider does not participate in the plan.
Brand Drug. A drug on which an entity (usually a manufacturer) holds a patent that allows for the drug to be marketed and sold only as that entity’s branded product.

C

Cafeteria Plan. A written plan that meets the requirements of Internal Revenue Code 125 and offers eligible employees a choice between cash (or other permitted taxable benefits) and certain nontaxable benefits (such as health insurance), thereby allowing employees to pay for the benefits they choose on a pre-tax basis.
Claim. Bill a provider or member submits to the plan to be reimbursed for covered goods or services.
COBRA. Consolidated Omnibus Budget Reconciliation Act; federal law on continuing coverage through a group health plan after losing eligibility in the group.
Coinsurance. The cost of a covered service that is shared by the plan and by the member, typically expressed in percentages; e.g., 85% plan and 15% member. The provider typically bills the member after the plan has paid.
Co-payment (or co-pay). A fixed dollar amount (e.g., $10) paid by the member to the provider at the time of service.
Coverage. Goods and services included in the design of a health plan.
Covered Services. Services a health plan will pay for when a provider submits a claim. Not all services are covered in a health plan, even if they are recommended by a provider.
  
D
 
Decline. Choose not to participate in the benefits program and the employer’s contribution to benefits.
Deductible. The amount a subscriber pays for covered goods or services before the plan begins to pay claims.
Dependent Child(ren). Children An eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legally placed child who  will not have attained age 27 as of December 31 of the plan year. See “dependent child” in the Summary Plan Description or in PEBB rules.
Disability Insurance. Insurance that replaces a certain amount of income when an individual is disabled, according to the plan’s criteria.
Domestic Partner. An individual who attests with an employee that both meet all the criteria outlined in the Summary Plan Description; or a member of a couple that has registered a domestic partnership with the state of Oregon.
 
 

E
 
EAP. Employee assistance program
Eligible. Meets PEBB rules for participation in benefits. Review the Summary Plan Description sections on criteria for eligibility, enrollment and dates of coverage.
Emergency Care. Services and supplies furnished by a facility that are required to stabilize a patient with symptoms of such severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the individual’s health (or the health of the fetus in the case of a pregnant woman) in serious jeopardy.
 Exclusion. Conditions, treatments, situations or classes of individuals not covered under an insurance contract or plan document.
​ Explanation of Benefits (EOB). Claims documentation from the plan to a member showing the amount the provider billed, the amount the plan allowed, the copayment or coinsurance that applies, and the amount for which the member is responsible.

F

Flexible Spending Arrangements or Accounts (FSAs). IRS-qualified accounts through which the account holder may receive certain tax advantages through pre-tax deductions used for reimbursement of qualified health or dependent care expenses.
  • Healthcare Flexible Spending Arrangements (Accounts)
  • Dependent Care Flexible Spending Arrangements (Accounts)
FMLA. The federal Family and Medical Leave Act, which allows eligible employees of covered employers to take certain upaid, job-protected family and medical leave each year, and requires employers to continue benefits during the leave.
Formulary. A preferred list of drug products that typically limits the number of drugs available within a therapeutic class for purposes of drug purchasing, dispensing or reimbursement.
 
 

G

Generic Drug. A drug whose patent has expired and that usually has a lower price than brand-name drugs still on patent. Members pay the least for generic drugs.
Grace Period. For flexible spending arrangements (FSAs), the period that begins immediately following the close of a plan year and ends on the day that is two months and 15 days following the close of the plan year.
Group Medical Plan or Other Group Coverage. For purposes of opting out of PEBB medical coverage, this is an employer sponsored group medical plan as determined by PEBB. Medicare, Medicaid, VA Health and Tribal health plans are not employer sponsored group medical plans as determined by PEBB.
Guarantee Issue. An amount of coverage an insurer offers for purchase without requiring a review of medical history.
 
 

H
 
Health Maintenance Organization (HMO). A type of health plan in which members must receive all covered care from network providers, usually under the direction of a primary care physician (PCP), such as a family practitioner, internist or pediatrician. Members must work or reside in the HMO’s service area. 
Health Plan. Medical and dental benefit coverage available through enrollment.
 
 

I
 
Imputed Value. The value of an asset that is not recorded in any accounts but is implicit in the product. The fair market value of PEBB health care coverage for a domestic partner is imputed in the employee’s pay (added to salary amount); the employee’s payroll deducts income tax on the total (salary plus imputed value).
Ineligible Individual. An individual who does not meet the definition of spouse, domestic partner, or dependent child as set forth in Oregon Administrative Rules Division 101-15.
Irrevocable.  Elections under a Cafeteria Plan that may not be revoked during the plan year (subject to certain exceptions).
 
 

L
 
Life Insurance.  Insurance that pays benefits to survivors on the insured person’s death.
Long Term Care Insurance. Insurance that pays benefits when the insured person requires assistance with activities of daily living.
 
 

M
 
Mail-order Prescriptions. Method of obtaining prescription fills through the mail.
Maximum Benefit. The total amount payable by a plan.
Medical History Statement. A form to be completed by an applicant on aspects of the applicant’s health when an insurer requires Evidence of Insurability.
Medical Home Plan. A plan in which a primary care provider leads a coordinated health-care team to ensure effective, efficient care tailored to patient needs and makes referrals for all medical care not offered in the medical home.
Medicare Secondary Payer. Federal law making Medicare the secondary payer in most situations in which other coverage exists in addition to Medicare.
Member. An active employee of the employer, a COBRA or self-pay participant or an eligible retiree who meets the terms of eligibility outlined in PEBB Administrative Rules.
Mid-year Plan Change Event. An event that allows an eligible member to change elections when certain conditions are met. The change must be consistent with the event

N
 
Network Provider. A provider who contracts to be in the Plan’s network.

O
 
OAR. Oregon Administrative Rule.
Open Enrollment. Annual period during which eligible individuals may enroll in benefits for the next plan year.
Opt Out. Choose not to enroll in a PEBB medical plan because the member has other employer sponsored group medical insurance.
​Out-of-pocket Maximum. The maximum amount that a member will have to pay out of their own pocket for medical services during the year.  After the maximum amount has been paid, no further co-payments or coinsurance is charged to the member. 

P

PEBB. Public Employees' Benefit Board.
Pebb.benefits. The PEBB online benefits management system.
PEBB Statewide Plan. A participating-provider-organization (PPO) plan design that offers lower out-of-pocket costs for most services when the member uses network providers.
Period Of Coverage. Plan Year, with the following excetions: a) for employees who first become eligible to participate it means the portion of he Plan Year following the date on which the participation commences, and b) for employees who terminate participation, it means the portion of the plan year prior to the date on which participation terminates.
Plan Design. Selection of goods and services that are included in premium payments and paid in part or full through claims, co-insurance or co-payments.
Plan Year. A period of 12 consecutive months as designated by the Board. Currently, the PEBB Plan Year is Jan.1 through Dec. 31.
Portability of Medical Insurance. Ongoing private medical coverage available from the employee’s current medical plan after termination of coverage in a group plan. Portability is not available from PEBB’s self-insured plans.
Pre-authorization (Prior Authorization). An insurance plan requirement that covered services be approved by the plan prior to the date of service.
Pre-existing Condition. A physical or mental condition that was diagnosed or treated, or for which medication was prescribed or taken during a specified time before the effective date of coverage of a health plan. A condition is diagnosed whenever a physician tells a person that he or she has that condition or makes an entry to that effect in the person’s medical records. This diagnosis of condition applies even if the physician is examining or treating the person for a different condition. Currently, PEBB medical and dental plans elected during Open Enrollment impose no pre-existing condition limitations. However, specified benefits in certain circumstances such as transplants may impose a waiting period or limitation. For life and disability insurance coverage in PEBB, it must be a mental or physical condition for which an individual has consulted a physician, received medical treatment or services or taken prescribed drugs or medication six months prior to the effective date of insurance.
Preferred (Network) Provider Organization (PPO). A plan design that provides different benefit levels for services provided by preferred (network) providers and providers who are not in the network (out-of-network). Members who choose care from preferred (network) providers will pay less.
Preferred (Network) Provider. For PPO plans, a medical care provider or facility that has agreed contractually to accept discounted fees as payment (with the member’s coinsurance) for covered services from the plan.
Premium Share. For health care coverage, the amount (e.g., dollars) or part (e.g., percentage) of premium paid by participants in health care benefits – usually the employee and the employer.
Provider. Individual or facility licensed to provide healthcare services
Provider Network. Set of providers who contract to provide goods and services of the health plan, submit claims for those goods and services, and accept contracted rates.

Q

  Qualified Medical Child Support Order (QMCSO). A judgment, decree, or order issued by a court or through a state administrative process) that requires a group health plan to provide coverage to a participant’s child and meets other specific requirements.
Qualified Status Change (QSC).  The  most frequent allowable midyear plan change event. It encompasses a number of participant “life events” (e.g., marriage, birth, adoption of a chilled and various employment status changes).
 
 

R

Referral. When a provider refers a patient to another provider. In an HMO, the primary care provider makes any referrals, including those who substitute when the primary care provider will be unavailable, as well as any specialists who are also part of the HMO.
Reinstate. Reactivate previous benefits and enrollments, if available, to an eligible employee returning to eligible status within a specific time frame. Reinstated does not include FSA or Long Term Care enrollments; employees returning may enroll in these plans.
Required Notices. Notices a group health plan must provide by law or regulation to members in the plan.
Respite Care. Services that provide people with temporary relief from tasks associated with care giving (e.g., in-home assistance, short nursing home stays, adult day care).

S
 
Self-insured Plan. A plan that uses its own funds to pay claims for covered benefits.
Spouse. A person of the opposite sex who is a husband or wife. A relationship recognized as a marriage in another state between two opposite sex partners will be recognized in Oregon even though such a relationship would not be a marriage if the same facts had been relied upon to create a marriage in Oregon. PEBB’s definition of spouse for purposes of enrollment does not include a former spouse and a former spouse does not qualify as a dependent.
State Contribution. The amount of money paid by the state of Oregon on behalf of employees for the purchase of the benefits provided through PEBB. The amount of the contribution can vary depending on the employee group or collective bargaining agreement. Part-time and job-share positions typically receive a prorated contribution. PEBB plays no role in determining the contribution.
Subscriber. Eligible individual who enrolls in a health plan and whose premium pays for coverage for the subscriber and eligible dependents.
Summary Plan Description. A summary, written in plan language, that describes the features and benefits of a group plan of health and other benefits.

T

Tobacco Cessation. Cessation of the habit of using tobacco products for smoking or chewing, including the use of snuff. 
TPA. Third-party administrator

U

Use-or-lose Rule. A requirement applicable to the Cafeteria Plan under which employees must forfeit any contributions from a plan year that are not used to reimburse expenses incurred during that plan (or during a “grace period” immediately following the end of the plan if provided under the plan).
Usual, Customary, Reasonable (UCR) Charges. UCR applies to fees that are:
  • Usual. A fee that is not more than the provider’s usual charge for a given service or supply.
  • Customary. An amount within the range of usual charges for the service or supply billed by most providers of the same or similar service or supply in the service area.
  • Reasonable. A usual or customary amount; or an amount that, because of unusual circumstances, inadequacy of data or other reasons is established on an individual basis.
 

W

Waiting Period. A period of time that must pass before coverage or benefits begin for an employee or dependent who is eligible to enroll or is enrolled under the terms of the plan.