FY2011 Health Benefits Booklet

74 s u m m a r y o f g e n e r a l b e n e f i t s j u l y 2 0 1 0 – j u n e 2 0 1 1
Definitions
Allowed Benefit: The maximum fee a health plan will
pay for a covered service or treatment. The allowed
amount is determined by each health plan.
Cafeteria Plans: Plans under Section 125 of the
Internal Revenue Code that allow Employees to
choose from a menu of one or more qualified benefits
and to pay for those qualified benefits on a pre-tax
basis.
CMS: Centers for Medicare and Medicaid Services.
The agency of the U.S. Department of Health and
Human Services that is responsible for administering
the Medicare and Medicaid programs.
COB: Coordination of benefits. If an Employee,
Retiree, or eligible dependents are covered under
more than one insurance plan, the insurance plan of
the person with the earlier birthday in the calendar
year is primary and the other plan is secondary. The
Employee’s or Retiree’s primary coverage will pay its
benefits first, without regard to other coverage.
COBRA: The Consolidated Omnibus Budget
Reconciliation Act of 1985. This law amended by
ERISA, the PHSA, and the tax code to require
employers to offer the option of purchasing
continuation coverage to qualified beneficiaries who
would otherwise lose group health insurance coverage
as the result of a qualifying event. The federal statute
which applies to the State of Maryland Health is the
Public Health Service Act (PHSA).
Coinsurance: The portion of medical services that the
Employee must pay after the deductible.
Copayment: The amount an Employee, Retiree,
or covered dependent pays at the time service is
rendered. This money goes directly to the health care
provider. The amount of the copayment varies by type
of service.
Deductible: The amount an Employee or Retiree
is required to pay before direct payment or
reimbursement is available for out-of-network services.
DHMO: Dental Health Maintenance Organization. A
plan similar to a medical HMO, but provides dental
services. Participants can use only those designated
dental providers approved by and registered with the
DHMO.
Domestic Partner: (See Same Sex Domestic Partner)
Emergency services or medical emergency: Healthcare
services that are provided in a hospital emergency
facility after the sudden onset of a medical condition
that manifests itself by symptoms of sufficient severity,
including severe pain, that the absence of immediate
medical attention could reasonably be expected
by a prudent layperson, who possesses an average
knowledge of health and medicine, to result in:
• placing the patient’s health in jeopardy;
• serious impairment of bodily functions; or
• serious dysfunction of any bodily organ or part.
EPO (Exclusive Provider Organization): An EPO
is a type of managed care plan. The EPO utilizes
a network made up of providers from a specific
network from which members must choose. EPO
members are restricted to in-network providers
only. Some carriers require the member to select a
primary care physician and may require referrals.
Please see specific carrier’s benefits on pages 19-32
for more information.
ESRD (End Stage Renal Disease): A medical
condition of the kidneys and renal system.
Flexible Spending Account (FSA): A benefit option
that reimburses Employees for certain expenses
from pre-tax deductions taken from the Employee’s
paycheck. These arrangements are regulated by federal
tax law and may be used for health care expenses or
dependent care expenses.
FMlA (Family Medical leave Act): A type of Leave
of Absence, as governed by Federal and State statutes,
in which an Employee may obtain leave due to an
individual or family member medical condition.