40 POINT OF SERVICE (POS): A plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). The insured may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or non-discounted charges from the providers. PRE-EXISTING CONDITION: A pre-existing condition is a health problem that existed before you apply for a health insurance policy or enroll in a new health plan. PREMIUM: A payment made by or on your behalf for ongoing health insurance coverage. You might pay a premium to Medicare, an insurance company, or a health care plan. It does not include any deductibles or co-payments the plan may require. PRE-TAX CONTRIBUTIONS: Contributions made to a benefit plan that are exempt from all applicable state or federal tax withholding requirements. PRESCRIPTION DRUG BENEFITS: Typically a provision included in a group health plan designed to provide covered employees and their dependents with payment assistance for medically prescribed drugs. PREVENTIVE CARE: Care that keeps you healthy or prevents illness. Examples are routine physical exams, colorectal cancer screenings, mammograms, and immunizations. PRIMARY CARE PHYSICIAN (PCP): A physician who serves as a group member’s primary contact within the health plan. In a HMO or managed care plan, the primary care physician provides basic medical services, coordinates, and if required by the plan, authorizes referrals to specialists and hospitals. QUALIFIED DEPENDENT CHILD(REN) AGE 19–26: Dependent child(ren) that you may add to your health insurance plans upon completion of WSSC’s affidavit form and birth certificate. WSSC will not require that the dependent child(ren) live with his or her parent(s), is a dependent on a parents tax return, or is a full time student. Both married and unmarried dependent children may have access to coverage. REFERRAL: Authorization from your primary care physician or health insurer to see a specialist or receive a special test or procedure. HMO’s often require that you obtain a referral for most specialty care. It is important to know what your health insurer’s rules and procedures are for referrals. REHABILITATIVE SERVICES: Health care ordered by your doctor to help you recover from an illness or injury. These services are given by skilled nurses, and physical, occupational, and speech therapists. Examples are working with a physical therapist to help you walk and/or with an occupational therapist to help you take a shower or get dressed. SELF-FUNDED/SELF-INSURED: A benefit plan whereby the employer assumes all the risk, paying for claims while saving the cost of any associated premiums. SKILLED NURSING CARE: Care ordered by your doctor that must be given or supervised by a licensed registered nurse. Examples are giving shots, providing oxygen to help you breathe, and changing the dressing on a wound. Help from family members or care you give yourself is not considered skilled nursing care. SKILLED NURSING HOME OR (SKILLED NURSING FACILITY): A place with the staff and equipment to give skilled nursing and/or rehabilitative care. SPECIALIST: A specialist is a physician who provides non-routine care. Examples include: Cardiologists (heart), Psychiatrists (Mental Health), Oncologists (cancer), and Rheumatologists (arthritis). SUMMARY OF BENEFITS AND COVERAGE (SBC): The Summary of Benefits and Coverage document is intended to provide consumers with a concise document explaining, in plain language, simple and consistent information about health plan benefits and coverage. It will summarize the key features of the plan, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. SUMMARY PLAN DESCRIPTION (SPD): A document which describes your Benefits, as well as your rights and responsibilities, under the Plan. UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA): The Act provides for the continuation of health benefits for persons who are absent from work to serve in the military services. The three employee regulatory requirements include (1) the right to continue health benefit coverage, (2) a right to reinstate and, (3) the maximum payable in premiums. URGENT CARE: Walk-in center that should be considered for problems that are urgent but not severe enough to warrant a trip to the ER, such as a fracture or deep cut that may need stitches. USUAL, CUSTOMARY, AND REASONABLE (UCR) CHARGES: Conventional indemnity plans (80/20) operate based on usual, customary, and reasonable (UCR) charges. UCR charges mean that the charge is the provider’s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount. WELLNESS PROGRAM: Programs, such as on-site or subsidized fitness centers, health screenings, smoking cessation, weight reduction/management, health awareness and education, that target keeping employees healthy, thereby lowering employer’s costs associated with absenteeism, lost productivity and increased health insurance claims. WORKERS’ COMPENSATION: State laws enacted to provide workers with protection and income replacement benefits due to an illness or injury suffered on the job. Employers must carry appropriate workers’ compensation insurance, as required by state law, or have a sufficient source of funding for claims incurred. Glossary of Insurance Terms