Glossary of Terms

Accidental Death and Dismemberment
Provides benefits for loss of life, limbs or eyes resulting from an accident.

Additional Contributory Life Insurance
Employees can purchase additional coverage at group rates above and beyond that provided by their employer. This is paid for by the employee through payroll deduction.

Closed Panel HMO
A group of physicians who are salaried employees of an HMO and who work at facilities provided by the HMO. Also known as a Group Practice Association Model. Univera's network of seven Health Centers is an example of this.

Community-Rated Plans (Small Groups)
Effective August 1, 1993 the State of New York passed Community Rating Laws, which effect the small group health insurance market. All employer groups with 2-50 employees are in the “community pool”. Essentially, this means that all companies within a given geographic area have access to a carrier’s identical plan at the same rates. Renewal rates are then based on the claims experience, etc. of all the employers in the community pool, not the individual employer’s.

Comprehensive
A form of indemnity coverage. However, all services are subject to deductible, then coinsurance.

Dental Management Organization
The dental version of an HMO. The insurance carrier contracts with a list of providers at a set fee schedule. Members pay a co-pay for each service, with no deductibles or coinsurance.

Dependent Life Insurance
Employees can purchase coverage at group rates to cover their spouse and/or dependents after they have first selected coverage for themselves.

Experience Rated Plans (Large Groups)
Employers with 50 or more employees can choose to be “experience-rated” with certain carriers. This means that your rates are based on various factors such as your own claims experience and the demographics of your employees. Your actual rates can be lower or higher than a comparable community rated health plan depending on these factors.

Health Maintenance Organizations (HMOs)
Traditional managed care (strong gatekeeper concept). Member must select a Primary Care Physician who oversees all medical care. For a fixed monthly premium, covers most services a member needs, but controls which providers supply these. Features include small co-pays, no claim forms and the encouragement of preventive health care. Disadvantages include restricted network of providers and need for referrals or authorization.

Indemnity
Generally covers bills from any participating provider. Some services are subject to annual deductible and coinsurance. Typically has broad coverage, high lifetime limits and freedom of choice of doctors. May have to submit claim forms and wait for reimbursement. Does not encourage preventive care like HMOs.

Managed Indemnity
Same as indemnity, but includes certain restrictions, such as pre-clearance for operations, inpatient care, purchases, etc. Because of restrictions, premiums are slightly lower than pure indemnity plans.

Open Panel HMO
A network of independent physicians who contract with an insurer in an HMO. Also known as an Individual Practice Association Model. Most HMOs are set up this way.

Optional Life
Allows employees (at their own cost) to purchase life insurance at group rates (age-banded) through payroll deduction. A level of insurance is available on a Guaranteed Issue basis (no medical underwriting) whereas over that level it is subject to Evidence of Insurability. Coverage may also be available for spouses and dependents. Participation requirements apply.

Preferred Provider Organization
A looser form of Managed Care (weak gatekeeper concept). Establishes a network of providers who agree to supply care at discounted rates. Members pay a small co-payment (no deductible or coinsurance) when utilizing a network provider. PPOs also allow members to utilize non-network providers, but must pay deductibles/coinsurance similar to indemnity plans. There is no requirement to designate a primary care physician and no claim forms when utilizing the network.

Point of Service Plan
Similar to PPOs in that it allows members to choose "in network" providers or, for a lower level of benefit, go "out of network". There is a requirement for a Primary Care Physician who directs all the patient's care within the network. Small co-pays and no claim forms apply for "in network" services. Deductible/coinsurance/ claim forms apply "out of network".

Voluntary Dental
Allows employees (at their own cost) to purchase dental insurance at group rates through payroll deduction. Not all dental plans are available on this basis and patricipation requirements may apply.

Voluntary Health
Allows employees (at their own cost) to purchase health insurance at group rates through payroll deduction. Not all health plans are available on this basis and participation requirements may apply.

Voluntary LTD
Allows employees (at their own cost) to purchase supplemental long-term disability at group rates through payroll deduction. Participation requirements apply.

Voluntary STD
Allows employees (at their own cost) to purchase supplemental short-term disability at group rates through payroll deduction. Participation requirements apply.