Text Size:   A+ A- A   •   Text Only
Find     
Site Image

OEBB Glossary
 
This information may help members understand terms that are used in discussions of benefits and insurance. 
 


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 Domestic Partnership. A written document kept on file by the educational entity, in which an employee and another individual attest to meeting the criteria set forth in the OEBB administrative rules on the date the document is signed by the employee and the individual.
Appeal. Process through which a member asks an administrator to reconsider a determination.
ASO. An administrator that provides administrative services only.
 
 
 

C

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.
 
 

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 18 or younger who may be covered in a OEBB plan if they meet criteria.
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 for the affidavit of domestic partnership; or a member of a couple that has registered a domestic partnership with the state of Oregon.
 
 

E
 
EAP. Employee assistance program
Early retiree. Someone who retires before the age of 65
Eligible. Meets OEBB rules for participation in benefits.
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.

F

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.
Guarantee Issue. This means that you will not have to answer medical questions to purchase coverage up to the guarantee issue amount.
 
 

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 value of OEBB healthcare coverage for a domestic partner is imputed in the employee’s pay; the employee’s payroll deducts income tax on that imputed value.
Ineligible Individual. An individual who does not meet the definition of spouse, domestic partner, or dependent child as set forth in OEBB's administrative rules.
 
 

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.
Long-term Disability. A benefit that pays you monthly in the event you cannot work because of a covered illness or injury. This benefit replaces a portion of your income.
 
 

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 Opt-out. When an employee decides not to enroll in an OEBB medical plan and receives a financial incentive for doing so. The employee must provide proof of coverage to their educational entity within five days of opting out.
Member. An active employee of the employer, a COBRA or an eligible retiree who meets the terms of eligibility outlined in OEBB's administrative rules.
Multisource nonpreferred brand-name drug. A brand-name prescription drug not on the plan’s formulary that has a generic version with the exact same therapeutic ingredient.
MyOEBB. The online benefits management system

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

O
 
Open Enrollment. Annual period during which eligible individuals may enroll in benefits for the next plan year. OEBB’s Open Enrollment is from August 15 to September 15.
Opt Out. (see Medical Opt-Out)
Out-of-pocket maximum. The maximum you will have to pay out of your pocket for covered services. Out-of-pocket maximums are calculated on an individual basis.

P

PCP. Primary Care Physician
Period Of Coverage. Plan Year, with the following exceptions: 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 OEBB Plan Year is Oct. 1 through Sept. 30. Benefit year refers to the twelve month period where deductibles, out-of-pocket maximums, or any annual benefit maximums accrue and apply. OEBB’s benefit year and plan year are the same.
POS. Point of Service.
Portability of Medical Insurance. Ongoing private medical coverage available from the employee’s current medical plan after termination of coverage in a group plan state.
Pre-authorization (Prior Authorization). An insurance plan requirement that covered services be approved by the plan prior to the date of service.
Preferred Brand Drug. A brand-name drug on a plan’s formulary.
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.
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 Status Change (QSC).  The  most frequent allowable midyear plan change event. It encompasses a number of different 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.
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, and adult day care).

S
 
Self-insure. A plan that does not use insurance to pay benefits.
Short-term Disability. A benefit that pays you weekly in the event that you are unable to work because of a covered illness or injury. This benefit replaces a portion of your income.
Specialty Medications. Medications that are often indicated to treat complex chronic health conditions. Due to the complexities, each individual insurance carrier has a enhanced member services to help.
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.
State Contribution. The amount of money paid by the educational entity on behalf of employees for the purchase of the benefits provided through OEBB. The amount of the contribution varies.
Subscriber. Eligible individual who enrolls in a health plan and whose premium pays for coverage for the subscriber and eligible dependents.

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

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 designated period during which insurance benefits are excluded or limited.
Waive. When an employee decides they do not want benefits and they do not receive any financial incentive.