|Accidental Death and Dismemberment (AD&D): AD&D benefits pay in addition to life insurance when a covered employee dies or loses a limb or the sight of an eye as a result of an accident.
|Accidental Injury: Bodily injury sustained as the direct result of an accident, independent of any other cause, which occurs while insurance coverage is in force.
|Allowed Charges: The set dollar amount allowed under the Plans for a covered service or supply.
Base Salary: The rate of earnings in effect on the date disability begins. Base salary does not include overtime, commissions, bonuses, longevity pay, productivity enhancement program payments, or any other compensation.
Basic Life: The first $20,000 of term life insurance coverage available to an eligible employee under the HealthChoice Life Insurance Plan.
Benefit Period: The period during which benefits are paid. The first day of the benefit period is the day the member becomes eligible for benefits. The end of the benefit period is the last day of eligibility as determined by the maximum benefit period and/or eligibility limits.
Case Management: The function of coordinating a patient’s medical care. The care usually involves multiple services from multiple providers.
Centers for Medicare and Medicaid Services (CMS): The federal agency that manages the Medicare and Medicaid programs.
Certification: A review process performed by either the certification administrator or the HealthChoice Health Care Management Division depending on the type of medical services.
COBRA: The acronym for Consolidated Omnibus Budget Reconciliation Act of 1985 which gives workers and their families who lose their health benefits the right to continue group health benefits provided by their group health plan. COBRA is available for limited periods of time and under certain circumstances, such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events.
COBRA Qualifying Event: Certain events that result in a loss of health, dental, and/or vision insurance by an employee and/or covered dependent.
Coinsurance: The percentage of Allowed Charges paid by the member once the deductible is satisfied.
Copay: A cost sharing arrangement in which a set dollar amount is paid for specific services.
Current Annual Salary: An individual’s annual gross pay. Current annual salary does not include overtime, longevity pay, benefit allowances, or retirement contributions.
Deductible: The out-of-pocket amount that must be paid before a benefit is paid. Deductible amounts are addressed in the Employee Benefit Options Guide, and in each plan’s handbook, if applicable.
Disability: An employee is considered disabled if, as a result of injury or illness, they are unable to perform the material duties of their own occupation for 31 consecutive days or longer. After 24 months of disability, it is defined as the inability to perform each of the material duties of any gainful occupation an employee is or may become reasonably qualified by training, education, or experience.
- An employee’s legal spouse (including common-law)
- An employee’s daughter, son, stepdaughter, stepson, eligible foster child, adopted child or child legally placed with the employee for adoption up to age 26, whether married or unmarried
- An employee’s dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior to age 26, subject to medical review and approval
- Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for Other Dependent Children. Guardianship papers or a tax return showing dependency may be provided in lieu of the application.
Eligible Employee: An employee of a participating employer who receives compensation for services rendered and is listed on that employer’s payroll.
Eligible Participating Former Employee: An employee who participates in any of the Plans authorized by or through the State and Education Employees Group Insurance Act who retired or vested their rights with a state funded retirement plan, or has the required years of service with a participating employer.
Elimination Period: The first 30 consecutive calendar days of disability when no benefits are paid.
Guaranteed Issue: Two times an employee’s current annual salary rounded up to the next $20,000. This is available only during the employee’s initial enrollment. A Life Insurance Application is not required.
HealthChoice: The name for the insurance plans administered by the Oklahoma State and Education Employees Group Insurance Board.
Health Maintenance Organization (HMO): A type of managed care plan that contracts with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs, x-ray centers, and medical equipment vendors. An HMO typically requires the use of a primary care physician to manage and coordinate all care.
Indemnity Plan: An indemnity plan is a traditional fee-for-service insurance plan that gives the employee the freedom to visit any licensed health care professional without a referral. The member is responsible for deductibles and coinsurance and a calendar-year out-of-pocket limit or maximum typically applies. Once the out-of-pocket limit or maximum is reached, the plan typically pays 100% of all Allowed Charges for covered services for the rest of the year.
Initial Enrollment: The 30 days following an employee’s date of employment or date they became eligible with a participating employer. An initial enrollment is not created when an employee transfers employment between participating employers sharing the same Section 125 Plan; e.g., state agency to state agency or school to school within the same district.
Late Enrollee: Any eligible employee and/or eligible dependents who waived coverage or failed to enroll within 30 days of the initial enrollment period, or any participating member or dependent who voluntarily terminates coverage and re-enrolls.
Life Insurance Application: Documentation of medical fitness by an applicant.
Medically Necessary: Direct care and treatment within the standards of good medical practice within the community that are appropriate and necessary for the symptoms, diagnosis, and treatment of the condition.
Network Provider: A provider who has entered into a contract with an insurance plan to accept the plan’s Allowed Charges for services and/or supplies provided to plan participants.
Non-Covered Service: Any service, procedure, or supply excluded from coverage and not paid for by a plan.
Non-Vest: An employee who has worked long enough to keep benefits, but who did not contribute to a retirement system, or who has withdrawn all contributions and no longer qualifies for retirement or vest status.
Option Period: The annual time period established by OSEEGIB when changes can be made to coverage.
OSEEGIB: The Oklahoma State and Education Employees Group Insurance Board.
Orthodontia Limitation: A waiting period for orthodontia benefits.
Out-of-Pocket Limit or Maximum for Network Providers: The amounts for which a member is responsible based on the use of Network or non-Network services, including deductibles and coinsurance before eligible claims and charges are paid at 100% of Allowed Charges.
Participant: An employee or former employee of a participating employer who is eligible and is participating in coverage through OSEEGIB.
Participating Employer: Any municipality, county, education employer, or other state agency whose employees or members are eligible to participate in any plan authorized by or through the State and Education Employees Group Insurance Act.
Plan: The insurance product for a specific benefit, such as health or dental.
Preexisting Condition: A preexisting condition refers to an illness or injury for which the employee received medical care, diagnosis, consultation, treatment, or took prescribed drugs or medicines during the 90-day period immediately preceding the employees’ employment date. The term preexisting condition also includes any condition which is related to such injury or illness.
Proof of Claim: Written documentation submitted to OSEEGIB and/or the disability claims administrator confirming a claim for benefits.
Qualified Beneficiary (QB): An employee, their spouse, and/or dependent children who were covered under the employee’s group health, dental. and/or vision plan on the day before a COBRA qualifying event. This includes any child who is born to or placed for adoption with the employee during COBRA coverage.
Qualifying Event: A life status change that allows an individual to make midyear changes to insurance benefits.
Reconciliation: Making the net difference in credits and debits of a premium bill agree with the balance.
Retiree: An employee who has worked long enough to retire and draw a retirement check.
Section 125 Plan: A type of employee benefit plan offered pursuant to Section 125 of the Internal Revenue Code that allows employees to participate pre-tax in different types of benefits.
Social Security Disability: An insurance program offered by the federal government that pays benefits to those who are determined to be unable to work.
Term Life: A policy that furnishes life insurance for a limited period of time. If death occurs during this period of time, insurance benefits are paid. If death occurs after the policy has expired, no insurance benefits are paid. A term policy has no cash surrender value.
Third-Party Administrator (TPA): An entity or company that an insurance company contracts with to process claims and administer certain business functions; also called Claims Administrator.
Vested: An employee who has worked long enough to keep benefits, and who contributed to a retirement system, but who is not ready to retire or draw retirement benefits.
Years of Service: Time spent as an active employee performing full-time duties with an employer that participates in one of the state of Oklahoma retirement systems.