Here are some common terms used in the world of health and welfare and their definitions, which we hope will help you understand your plan better.  It is not a complete list, so when you're talking to us, if we use a term that you don't know, ask us to explain.

COB (Coordination of Benefits) - A group health plan policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two plans.

COBRA (Consolidated Omnibus Reconciliation Act) - A Federal law that allows you to extend health and welfare benefits (by paying the appropriate contribution) following a qualifying event.

Coinsurance - A policy provision by which the member and the plan share the hospital and medical expenses resulting from an illness or injury in a specified ratio (e.g., 80%:20%), after the deductible is met.

Co-Payments - Payments made by patients, in addition to deductibles and coinsurance.

Contract/Network/Preferred Provider Organization - A managed care plan that contracts with plans to provide comprehensive medical service.  Providers exchange discounted services for increased volume and prompt payment.  Participants' out-of-pocket costs are usually lower than under a fee-for-service plan.

Deductible -The amount of out-of-pocket expenses that must be paid for health services by the participant before becoming payable by the Plan.

EAP (Employee Assistance Program) - A health service program designed to assist in the resolution of a broad range of member personal concerns such as substance abuse, marital problems, family troubles, stress and domestic violence.

EOB (Explanation of Benefits) - A statement from the plan sent to a member who files a claim giving specific details about how and why benefit payments were or were not made.  It summarizes the charge submitted and processed, the amount allowed, the amount paid, and the member's responsibility, if any.

HIPAA (Health Insurance Portability and Accountability Act of 1996) - Federal legislation that improves access to health insurance when changing jobs by restricting certain preexisting condition limitations.  

HMO (Health Maintenance Organization) - A prepaid medical group practice plan that provides a comprehensive predetermined medical care benefit package. 

MRP (Medical Reimbursement Plan/Indemnity/Fee for Service) - In these traditional fee-for-service group health plans, the patient chooses whichever doctor and hospital he or she wants to use.

Medicare Part A - U. S. federal government plan which provides coverage  for inpatient hospital services and post-hospital care.

Medicare Part  B - U. S. federal government plan which provides coverage for outpatient services. 

Mental Health Parity Act (AB88) - Prohibits plans that offer mental health benefits from imposing aggregate lifetime or annual dollar limits for mental health benefits that are less than those imposed on medical/surgical benefits.  Substance abuse treatment is excluded.

Non-Contracting Provider - A health care provider of service who does not have a contract with the plan to provide services at a discounted rate. 

PPO (Preferred Provider Organization) - A managed care plan that contracts with a plan to provide comprehensive medical service.  Providers exchange discounted services for increased volume and prompt payment.

Pre-Certification - The process of obtaining approval prior to hospital admissions (inpatient or outpatient) based on the judgment of medically appropriate care by a qualified utilization review organization.  Failure to obtain pre-certification may result in the reduction or denial of benefits.  Please refer to your Summary Plan Description Book, Evidence of Coverage Brochure, Fund Identification card or contact your Area Administrative Office for pre-admission certification instructions.

Prior-Authorization - The process that requires the service, treatment, supply or medication to be approved in advance by the doctor or provider of service.  Failure to obtain prior authorization may result in the reduction or denial of benefits.  Please refer to your Summary Plan Description book, Fund Identification Card or contact your Area Administrative Office for Prior-authorization instructions.

SPD (Summary Plan Description) - A written statement of a plan in an easy-to-read form, including a statement of eligibility, coverage, employee rights and appeal procedure. 

UCR (Usual, Customary and Reasonable) - Usual is the fee usually charged for a given service by a health care provider; customary is a fee in the range of usual fees charged by similar providers in the area; reasonable is a fee that, according to the review committee, meets the lesser of the two criteria or is justified in the circumstances. Reimbursement is limited to the lowest of the three charges.