Glossary of Terms
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CNC |
= | Configurable Network Computing |
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COBRA |
= | Consolidated Omnibus Budget Reconciliation Act of 1985 |
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Coinsurance |
= | The amount you must pay as a portion of a health care expense. Coinsurance is applied to your maximum out-of-pocket. |
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Co-pay, Co-payment |
= | The fixed or set amount you must pay before a plan will pay for specific services. Co-pays do not apply to maximum out-of-pocket. |
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Coverage, persons covered |
= | An employee, retiree, COBRA enrollee, or dependent, who has met the eligibility requirements and is enrolled in a plan and to whom benefits are payable. This might include:
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Cox-2 Inhibitor Pre-authorization Program |
= | Used to treat inflammation and reduce pain, and includes the brand name prescription medications Celebrex and Bextra. They work the same as drugs like naproxen and ibuprofen (non-steroidal anti-inflammatory drugs or NSAIDs). NSAIDs are a safe and effective choice to treat inflammation and/or reduce pain for the majority of people, and are several times less expensive. This program requires pre-authorization of benefits for Cox-2 drugs. |
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Deductible |
= | The amount you must pay before health care expenses are paid by a plan. |
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Durable Medical Equipment (Durable Medical Goods) |
= | Devices which are
They include items such as wheelchairs, hospital beds, artificial limbs, etc. |
Eligible Dependent |
= | Eligible dependents include your:
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ESS |
= | Employee Self Service |
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Family Coverage |
= | Employee + Spouse + Dependent Children. |
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Flexible Spending Account |
= | A benefit offered to an employee by an employer which allows a fixed amount of pre-tax wages to be set aside for qualified expenses. Qualified expenses may include child care or out-of-pocket medical, dental, or vision expenses. The amount set aside must be determined in advance and employees lose any unused dollars in the account at year-end. |
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Formulary |
= | Formulary (or preferred) brand name drugs are brand name medications that have higher copays than generics but are usually less costly than Non-formulary (or non-preferred) medications. |
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Four Party Coverage |
= | Employee + Dependent Children. |
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Generics |
= | Contain the same active ingredient as their brand name equivalents. Generics often help you save on your prescriptions. You get the same quality and effectiveness as that of a brand name drug, and help keep medical care more affordable for everyone. |
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Immediate Care or Urgency Care Clinic |
= | Clinics offering extended office hours providing emergency or urgent care, which are usually not affiliated with local hospitals. |
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In-network benefits |
= | Coverage when a provider is used within the plans' network. |
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Late entrant |
= | If you do not sign up as a new hire or with a qualified event, you may be subject to a penalty. As a late entrant, you and/or your dependent(s) benefits will be limited to all preventive procedures for the first 12 months of coverage. |
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Maximum Out-of-Pocket |
= | The amount of expenses you must pay (deductible + coinsurance) before a plan pays for all eligible expenses in full. |
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Maximum Lifetime Benefits |
= | Total lifetime benefits available per covered person while contract is in effect. |
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Non-Formulary |
= | Non-formulary (or non-preferred) medications have the highest copays and are not listed on Express Scripts' National Preferred Formulary List. Visit www.express-scripts.com to view the Formulary List. |
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Open Enrollment |
= | A period during which eligible employees, retirees, and COBRA subscribers may make a change to current elections (certain limitations may apply). |
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Out-of-network benefits |
= | Coverage when a provider is used outside of the plans' network. |
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Plan Year |
= | July 1 through June 30. |
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PPO |
= | Preferred Provider Organization |
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Preauthorization |
= | Process of obtaining approval by a carrier to determine if you are receiving the proper level of care in the appropriate setting. |
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Preadmission Certification |
= | Requires you to pre-certify benefits for all non-emergency hospital and treatment center stays. Benefits for covered services may be reduced if not certified. |
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Pre-Existing Condition |
= | A condition which is diagnosed or treated, or for which medication was prescribed or taken, previous to your application for coverage. |
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Premium |
= | The amount a covered person pays in exchange for insurance coverage. |
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Provider |
= | Any person (i.e., doctor, nurse, behavioral health provider, dentist) or facility (i.e., hospital or clinic) who provides medical, dental, vision, or behavioral care. |
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Qualified Event (status change) |
= | A life event which may allow you to make a change to your current elections. Change must be consistent and on account of the event; change must be made within 30 days of event. Examples: marriage, birth or adoption, divorce or legal separation, unmarried dependent between ages of 19 and 24 years of age with a change in student status, change in employment status for you or your spouse, or change in provider (dependent care FSA). |
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Referral |
= | Authorization from PCP to seek care from a specialists or another care provider. |
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Retiree (Early) |
= | Allows for continuation of health/dental/vision/EAP/flex insurance for any covered employee who retires under the State of Nebraska Retirement System. Provides continuation for employee and covered dependent(s) until the employee reaches the age of 65. |
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Section 125 – IRS |
= | Allows tax-sheltered deductions for health, dental, vision and FSA accounts; deductions are taken before Federal, State and FICA taxes are figured. Must have a qualified event to make changes to current elections. |
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Single Coverage |
= | Employee only. |
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Two Party Coverage |
= | Employee + Spouse. |
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UCR |
= | Usual, Customary & Reasonable Charge(s) |