Insurer: Company licensed to take on risk. An individual or group pays premiums to the insurer. If claims are higher than premiums, the insurer pays the difference. If claims are lower than premiums, the insurer keeps the balance.

 

Self-insure: Group or organization takes on risk instead of paying an insurer to do so. If claims are higher than premiums, the organization pays the difference using funds held in reserve. If claims are lower than premiums, the organization keeps the difference to build the reserve.

 

Administrator: TPA or ASO that receives a fee for such services as processing claims, collecting premiums, contracting with provider networks and processing enrollment

 

Claim: Bill a provider or member submits to the plan for covered goods or services

 

Co-insurance: A percentage of the cost of covered goods or services paid by the subscriber

 

Co-payment (co-pay): A set amount the subscriber pays for covered goods or services

 

Coverage: Goods and services included in the design of a health plan.

 

Deductible: The amount a subscriber pays for covered goods or services before the plan begins to pay claims

 

Health Plan: Medical and dental benefits available through enrollment

 

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

 

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

 

Provider: Individual or facility licensed to provide healthcare services

Decline: Choose not to participate in the benefit program and the employer’s contribution to benefits

Eligible: Meets PEBB rules for participation in benefits

 

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 through rules on eligibility for other group coverage

 

Plan Year: January 1 - December 31

 

Subscriber: Eligible individual who enrolls in a health plan and whose premium pays for coverage for the subscriber and eligible dependents

ASO: Administrative services only

 

COBRA: Consolidated Omnibus Budget Reconciliation Act; federal law on continuing coverage through a group health plan after losing eligibility in the group

 

FSA: Flexible spending account; annual account for qualified healthcare or dependent care expenses not otherwise covered

 

HMO: Health maintenance organization

 

PPO: Preferred provider organization

 

QSC: Qualified status change; affects eligibility for enrollment in a PEBB benefit

 

TPA: Third-party administrator

• Locating medical care providers
• Communication among patients, families and providers
• Translation and interpreter services on international travel
• Coordination with insurance companies in medical emergencies
• Arrangements for convalescing in a hotel
• Obtaining refills for forgotten, lost or depleted prescriptions