Everyday Benefit Terms

A.

After Tax Contributions
Dollars that are deducted after the tax deductions have been withheld from your paycheck.

B.

Balance Billed
This is where a service is completed outside of the network and the charge for the service exceeds the total cost of the service. You may be billed for the difference and the amount does not go towards your max-out-of-pocket. An example would be an overnight stay at an out of network hospital. The allowed amount is $1000, and your bill is $1500. You could be charged for the $500.

Beneficiary
The person, trust, or estate you name to receive your benefits at death. Beneficiaries may receive benefits from retirement plans, life insurance, and/or tax-deferred annuities.

Benefit Period Maximum
The maximum benefit each Covered Person is eligible to receive for certain covered services in a benefit period.

Bill
What you receive when there is a portion of the bill that is owed to the provider.

C.

Claim
Communication with your health insurance company that you have received a service that you would like them to pay for.

Coinsurance
Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service. All coinsurance amounts apply towards your maximum out-of-pocket. Once your out-of-pocket is met, all covered services are paid at 100% for the remainder of the calendar year.

Contract Holder
The contract holder is the person that is enrolled as the primary on the plan.

Contribution
Money placed into a retirement or annuity plan.

Copayment
A fixed amount you pay for a covered health care service, usually when you receive the service. All copayments apply towards your maximum out-of-pocket. Once your out-of-pocket is met, all covered services are paid at 100% for the remainder of the calendar year.

D.

Deductible
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. All deductible amounts apply towards your maximum out-of-pocket. Once your out-of-pocket is met, all covered services are paid at 100% for the remainder of the calendar year.

Defined Benefit Plan
This is a retirement plan that provides a specified monthly benefit at retirement. The employee's retirement distributions are calculated according to length of service, age, and salary history.

Defined Contribution Plan
This retirement plan allows an employee to contribute a percentage of their salary and the employer may also make contributions to the plan on behalf of the employee. The contributions are generally at a set rate and the value of the account is based on investment returns.

Dependent
A dependent is a person who is covered under the contract holder's plan.

Designated Personal Doctor
Your designated personal doctor, which may also be referred to as your designated Primary Care Physician, evaluates your medical condition and either treats your condition or coordinates services you require. You must choose a personal doctor from the Wellmark Health Plan Network. You have the right to choose any personal doctor who participates in the Wellmark Health Plan Network and who is available to accept you or your family members. You may select one of the following types of providers as your designated personal doctor: family practitioners, general practitioners, internists, nurse practitioners, physicians assistants, and pediatricians.

Dual Spouse Discount
A health and dental option for when two UNI employees are both employed in benefits-eligible positions.

E.

Early Withdrawal Penalty
A penalty tax that is due when funds are withdrawn prior to reaching age 59 ½.

Emergency
When treatment is for a medical condition manifested by acute symptoms of sufficient severity, including pain that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect absence of immediate medical attention to result in:

• Placing the health of the individual or, with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy; or
• Serious impairment to bodily function; or
• Serious dysfunction of any bodily organ or part.

Explanation of Benefits (EOB)
Your explanation of benefits is a summary of what your insurance has paid for.

F.

Flexible Spending Account (FSA)
The account where you may have pre-tax dollars set aside to offset medical and/or dependent care costs on an annual basis. If you have unused dollars at year-end, you will lose them.

H.

Health Maintenance Organization (HMO)
Groups of doctors, clinics, hospitals, pharmacies and other providers who work together to take care of their members' health care needs.

Health Plan Account
Account to set aside money (including both employee and employer contributions) to pay claims as they occur.

I.

Indemnity Plan
Indemnity plans allow you to direct your own health care and visit almost any doctor or hospital you like. The insurance plan then pays a set portion of your total charges.

In-Network
Providers who contract with your health plan. Co-payment may be less when seeking treatment in-network.

L.

Life Event
This is when something happens and it makes you eligible to make changes to your coverage. Examples would be; marriage, birth or adoption of a child, divorce, spouse gains coverage, spouse loses coverage, and death.

Lifetime Maximum
In a Covered Person’s lifetime, total benefits are limited by dollar amount for a defined benefit category

M.

Managed Care Organization (MCO)
A managed care organization is a group or organization of medical service providers who offer managed care health plans.

Max out of pocket (MOP)
This designated amount is the most you will pay during a plan year. This amount does not include your premium, and may or may not, include co-payments, deductibles, and co-insurance payments.

Medicare
An federal insurance program that begins coverage at age 65, younger people with disabilities and people with End-Stage Renal Disease (ESRD). The four-part of Medicare are Part A (hospital costs), Part B (medical expenses), Part C (both Part A & B), and Part D (prescription drug coverage). For more information please go to www.medicare.gov.

O.

Out-of-Network
Providers who do not contract with your health plan. Co-payment may be higher if seeking treatment out-of-network.

Out of Pocket Maximum (OPM)
This designated amount is the most you will pay during a plan year. This amount does not include your premium, and may or may not, include co-payments, deductibles, and co-insurance payments.

P.

Preferred Provider Organization (PPO)
PPO plans allow you to visit any in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician.

Premium
The amount that is designated to be paid for your health insurance.

Pre-Authorization
Each plan covers services that could require preauthorization. Examples would be an MRI or a PET scan. An individual cannot typically walk into a provider's office requesting these services without a need written by qualified professionals. This could also indicate a drug which requires preauthorization before it is covered under your health plan. Your health care provider will need to contact our Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST.

Pre-Certification
Each plan covers services that could require pre-certification as well. Examples of this would be home health care and skilled nursing.

Pre-Service Reviews
The type of pre-service review depends on the health care services being considered, and are applicable to all three UNI self-insured plans. These types of review are put into place so that each service can be considered as to whether it was medically necessary or not. Example: A person truly not needing a service, shouldn't have it covered under a UNI health insurance plan.

Pre-tax Contributions
Dollars that are deducted from your Gross income prior to any tax deductions.

Primary Care Physician (PCP)
A physician who directly provides health care services for a patient. See also Designated Personal Doctor.

Prior Authorization (PA)
Each plan covers services that could require prior authorization. Examples would be an MRI or a PET scan. An individual cannot typically walk into a provider's office requesting these services without a need written by qualified professionals. This could also indicate a drug which requires prior authorization before it is covered under your health plan. Your health care provider will need to contact our Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST.

Product Selection Penalty Rule
When a member chooses to receive a brand name prescription when a generic equivalent is available. Wellmark will pay only what it would have paid for the equivalent generic drug, and the member would be responsible for their payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug.

Q.

Qualifying Employment Event
A change in employment which makes a person eligible for benefits.

R.

Required Minimum Distribution
When an employee reaches age 70 ½ they are required to make a yearly distribution from their retirement plan.

Roth Tax-Deferred Annuity
A retirement plan that allows you to set aside after tax dollars from your paycheck.

S.

Salary Reduction
Indicates the amount the employee would like to contribute.

Self-insured
When a plan is self-insured, it means the employer collects the premiums and takes the responsibility of paying the employee's, and their dependents', medical claims.

Social Security
A federal program that pays benefits for retirement and disability income, along with many other benefits.

Specialist
Doctors who have advanced training and degrees in a particular branch of medicine such as heart health or bone health. Depending on the field, many are able to perform surgery.

The following are considered Designated Personal Doctors (also known as Primary Care Physician or PCP):

• Family practitioners
• General practitioners
• Internal medicine practitioners
• Obstetricians/gynecologists
• Pediatricians
• Physician assistants
• Advanced registered nurse practitioners

Other providers (not designated personal doctors) include: chiropractors, speech pathologists, occupational therapists and physical therapists. Mental Health would also be considered as non-specialist treatment in order to pass mental health parity testing.

All other providers are considered specialists.

Examples of these include cardiologists, dermatologists, and orthopedists.

T.

Tax-Deferred Annuity Plan (TDA)
A retirement plan that allows you to set aside pre-tax dollars from your paycheck.

Third-Party Administrator (TPA)
A Third Party Administrator is a person or organization that processes claims and performs other administrative services in accordance with a service contract, usually in the field of employee benefits.

U.

University Sponsored Retirement Plan
Retirement plans that you and the university contribute to on your behalf.

Urgent Care
Urgent and Convenient Care are available to you when you have an urgent need for treatment, but the situation is not life-threatening.

V.

Vesting
A predetermined length of time an employee must satisfy to receive full benefits from the plan.