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Glossary

A

A Message from Liberty Mutual Insurance

A Message From Liberty Mutual Insurance

Liberty Mutual has partnered with Standard Motor Products to offer employees special savings on quality auto and home insurance during your open enrollment period.1 And with benefits such as Loss Forgiveness2 and Accident Forgiveness3, and discounts such as Multi-Policy and Protective Devices, you’ll worry less and save more. You can also sign up for Payroll Deduction, and your Liberty Mutual Insurance monthly premium will be automatically deducted from your paycheck.4 Call 800-699-5298  or visit  Liberty Mutual to learn more or get a free quote.

1Auto and home insurance is a voluntary benefit, and you can switch anytime throughout the year. You are not limited to the open enrollment period.
2Subject to eligibility requirements. Benefits and eligibility requirements may vary by state.

3Accident Forgiveness is subject to terms and conditions of Liberty Mutual’s eligibility guidelines. Not available in CA and may vary by state.

4Payroll deduction available only through employer affinity groups.

Adjudication

The process used by health benefit plans (in our case, this is Anthem) to determine eligibility for benefits and the amount of payment, if any, for a claim. Also called an “adjustment.”

Allowable Charge

The maximum amount that a health benefit plan will pay for a given covered service or supply.  Also called maximum benefit allowance, maximum allowance or referred to as “reasonable and customary.”

Appeals

A process used to request the health plan re-consider a previous decision made by the health benefit plan or provider.  There may be different appeal processes for members, providers, types of products, or state of issue.

Authorization

The approval of care, for hospitalization, outpatient procedures, certain specialty, etc., by a managed care or insurance company for its member, subscriber, or insured. 

B

Benefit

Covered services to which the member is entitled under the terms of the policy.  Benefit payments may be paid to the member (or subscriber), or on his behalf, to the medical provider.  Benefit design includes the types of benefits offered, limits e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility ( cost sharing components), or subscriber incentives to use network providers.

Benefit Period

The period of time for which we pay benefits for covered services rendered while the contract was in effect. 

Brand Name Drug

The initial version of a medication developed by a pharmaceutical manufacturer, or a version marketed under a pharmaceutical manufacturer’s own registered trade name or trademark.

 

A drug sold by the company that invented it, either under patent (no other company can manufacture it), or there are substitutes (but no one else can use the name).  The cost tends to be higher, and the copay therefore is greater. 

C

Case Management

A utilization management program that assists the patient in determining the most appropriate and cost effective treatment plan.  It is used for patients who have prolonged, expensive or chronic conditions, helps determine the treatment location (hospital or other institution) and authorizes payment for such care if it is not covered under the patient’s benefit agreement.  The purpose of case management is to provide optimum patient care in the most cost effective manner. 

Claim

A request made to the insurance company for payment for benefits received or services rendered under the terms of the plan.  An in-network claim is always filed by the provider.  An out of network claim may be filed by either the provider or by you. 

Co-Insurance

A fixed percentage of the total cost of healthcare services, which must be paid by the employee, after a deductible has ben satisfied.  

Co-Insurance Maximum

The maximum Co-Insurance amount you can pay each year for covered benefits after your deductible has been met.

Co-Payment

A fixed dollar amount you pay for prescription drugs.  This amount does not change, regardless of the total amount of the drug.  Drugs in different tier levels will have different copay amounts, and you can save money by using generic drugs.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

The federal law that requires employers with more than 20 employees to extend group health insurance coverage for up to 36 months after a qualifying event (e.g. termination of employment, reduction in hours, divorce).  The law contains detail provisions relating, among other things, to an employer’s obligation to provide notice of these rights and the circumstance under which such continuation may end. 

Coordination of Benefits (COB)

The provision of our plan which applies when a member (or dependent) is covered by multiple health benefit plans at the same time.  The provision is designed so that in total, you will never receive more than what the SMP Plan would have paid, if you did not have a second plan. 

The provision also designates the order in which the multiple health plans are to pay benefits.  Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first.  The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus “coordinated” among all of the health benefit plans.

Covered Services

Those services which will be paid for by the plan in whole or in part (subject to copays, deductibles and coinsurance).

D

Deductible

A fixed dollar amount which must be paid by an employee before they are eligible to receive any payment or reimbursement from the plan (except for those services subject to copays).

Dependent Care FSA

A Dependent Care Flexible Spending Account (FSA) is designed to reimburse for expenses incurred to care for your eligible dependents. Examples of eligible expenses are daycare, after school care and elder care.

Click here to view a list of eligible Dependent Care expenses

Click here to view a list of ineligible Dependent Care expenses

Diagnostic Tests

Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient.  Such diagnostic tools include, but are not limited to, radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Drug Formulary

A list of drugs that will be paid for by the plan and the Tier Level of the drug, which can be used to determine what the copay for that drug will be.

E

Eligible Dependent

A person who is eligible to receive medical coverage through the benefit eligible employee.

 

Who is an Eligible Dependent?

 

The Employee’s Spouse.  

The Employee’s children up to age 26.  Dependent children may remain on the plan until the end of the calendar year in which they turn age 26. Also eligible are legally adopted children, and children for whom the Employee assumes legal guardianship and stepchildren (from the date the Employee assumes legal responsibility). Also included are the Employee’s children (or children of the Employee’s Spouse) for whom the Employee has legal responsibility resulting from a valid court decree.


Children who are mentally or physically handicapped and totally dependent on the Employee for support, regardless of age.  Certification of the handicap is required within 31 days of attainment of age 26. A certification form is available from the Employer or from the Claims Administrator and may be required periodically.


Grandchildren, Domestic Partners, Nieces/Nephews and Elder Parents are some examples of those who are not eligible to receive benefits through your Employer Sponsored coverage.  Final determination of eligible dependent will be made by Anthem BlueCross BlueShield.

Emergency Care

Those health care services that are provided in an emergency facility or setting after the onset of illness or medical condition that manifests itself by symptoms of sufficient severity that without immediate medial attention could be reasonably expected by the prudent lay person, who processes an average knowledge of health and medicine, to result in: a) placing the Member’s physical and or mental health in serious jeopardy; b) serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Explanation of Benefits (EOB)

A form, known as an EOB, will be sent to the member after a claim has been processed by the health benefit plan.  The form explains the action taken on that claim.  This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the claims appeal process. Click here to view a helpful EOB Reference Guide!

F

G

Generic Drug

A drug which is the pharmaceutical equivalent to one or more brand name drugs.  Such generic drugs have been approved by the Food and Drug Administration (FDA) as meeting the same standards of safety, purity, strength, dosage form and effectiveness as the brand name drug.

H

I

Inpatient

An individual receiving care for 24 hours or more as a registered bed patient in a hospital or other facility, where a room and board charge is made.

J

K

L

M

Medically Necessary

Procedures, treatment, supplies, equipment or servicers determined to be: a) appropriate for the symptoms, diagnosis or treatment of a medical condtion; b) provided  for the diagnosis or direct care and treatment of the medical condition; c) within generally accepted standards of good medical practice; d) not primarily for the convenience of the member of the member’s provider and e) the most appropriate procedure, treatment, supply, equipment, or level of services which can safely be provided. 

N

Network Provider

Doctors, hospitals, pharmacies and labs who meet quality standards and have agreed to accept lower payments from Anthem BCBS.

Non-network Provider

A medical provider who has not contracted with a health benefit plan to participate in the network.  Also known as a non-participating provider or out-of-network provider.

O

Open Enrollment

Open Enrollment is the scheduled time period each year, and the only time each year, when employees can enroll in benefits offered for the following plan year, which begins on January 1. 

For the 2012 Plan Year, Open Enrollment will take place from November 7, 2011 through November 18, 2011

 

All employees who want to participate in the FSA program in 2012 must enroll during the Open Enrollment Period, otherwise

Click here to log on to ADP H&W to begin  your enrollment now!

Out-of-pocket Maximum

Your deductible plus your co-insurance maximum.  Once you meet your out-of-pocket maximum in a given year, SMP pays 100% of covered expenses, except for copays.

P

Payroll Contributions

The amount deducted from your paycheck for your medical coverage.  As a benefits eligible employee, you receive the benefit of making this payment before you are taxed on your earnings (for certain benefits only).

Pre-Authorization

A procedure governed by the contract used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency care before the services are provided.  Also called pre-certification and prior authorization.

Preventive Care

Care rendered by a physician to promote heath and prevent future health problems for a member who does not exhibit any symptom (for example: routine physical examination and immunizations).

Q

R

S

Subscriber

Eligible employees or members of the group whose coverage is in effect and whose name appears on I.D. cards.  It also means the individual in whose name a contract is issued.  The subscriber can enroll dependents under family coverage.  Eligible dependents include one’s legal spouse, and one’s children up to age 26. 

T

Traditional FSA Account

Account opened on your behalf by SMP that you fund through pre-tax payroll deductions, and are used to pay for deductibles, prescription co-pays and other non-covered medical expenses.   

Click here for a list of eligible FSA expenses

 

Click here for a list of ineligible FSA expenses
 

U

Urgent Care

Services received for an unexpected episode of illness or injury requiring treatment which cannot be postponed, but is not Emergency Care.  Urgent care conditions include, but are not limited to, ear ache, sore throat, and fever not higher than 104 degrees.  Treatment of an urgent care condition does not require the use of an emergency room at a hospital.

V

W

Well Baby/ Well Child Care

Routine care, testing, checkups and immunizations for a generally healthy child typically from birth through the age of six.

Wellness Program

A health management program which incorporates the components of disease prevention, medical self-care, and health promotion.  It utilizes proven health behavior techniques that focus on preventive illness and disability which responds positively to lifestyle related interventions. 

X

Y

Z