Glossary

Accidental death and dismemberment

A type of insurance through which your beneficiary will receive money if your death is accidental or if you are accidentally injured in a specific way.

Indemnity plan

A medical or dental plan that allows you to choose any licensed provider to receive care. Members are reimbursed for eligible medical or dental expenses according to the benefit schedule in effect, including deductibles and coinsurance.

Actively at work

Plan provision that requires the employee to be performing the duties of the occupation where the employee normally works for coverage to commence. If the employee is absent due to illness or injury, the coverage does not commence until the employee returns. This rule does not include adding a newborn to health insurance (such as an employee on maternity leave) nor does it extend to absences for annual leave provided the employee was not ill on the last scheduled day before annual leave.

Long-term disability

A type of insurance through which you will receive a percentage of your income if you are unable to work for an extended period of time because of a non-work-related illness or injury.

Aggregate family deductible

The medical plan does not begin paying the eligible medical expenses of any covered family member until the entire family deductible has been met. The family deductible may be met with expenses from one or a combination of family members.

Mail-order pharmacy

A service through which members may receive prescription drugs by mail.

Allowed fees

Term used by some dental plans for their participating dentist fees and/or maximum payable for a non-participating dentist

Mandatory retirement plan

Arizona law requires certain government employers to provide defined benefit and/or contribution retirement plans to eligible employees.

Appeal

A request to a plan provider for review of a decision made by the plan provider. A process in which a member is billed for the amount of a provider’s fee that remains unpaid by the insurance plan. You should never be balance billed for an in-network service; out-of-network services and non-covered services are subject to balance billing.

Member

A person who is enrolled in the health plan.

Balance billing

Non-participating provider practice of billing the patient for any difference between the provider’s billed charges and the patient’s insurance plan maximum allowance – indemnity or PPO.

Medically necessary

Services or supplies that are, according to medical standards, appropriate for the diagnosis.

Beneficiary

The person you designate to receive your life insurance–or other benefits–in the event of your death.

Member services

A group of employees whose function is to help members resolve insurance-related problems.

Billed charge

The amount the provider bills for services rendered.

Network

The collection of contracted healthcare providers who provide care at a negotiated rate.

Brand name drug

A drug sold under a specific trade name as opposed to being sold under its generic name. For example, Motrin is the brand name for ibuprofen.

Non-participating provider

A provider with no contractual limitation on what he may bill and thus may practice balance-billing, as well as require payment at the time services are rendered.

Case management

A process used to identify members who are at risk for certain conditions and to assist and coordinate care for those members.

Out-of-pocket maximum

The annual amount the member will pay before the health plan pays 100 percent of the covered expenses. Out-of-pocket amounts do not carry over from year to year.

Claim

A request to be paid for services covered under the insurance plan. Usually, the provider files the claim, but sometimes, the member must file a claim for reimbursement

Over-the-counter drug

A drug that can be purchased without a prescription.

Coinsurance

The division of the allowed amount to be paid by the insurance company and the patient, i.e., 80/20 or 90/10. The first percentage is paid by the company; the second by the employee.

Pre-authorization 

The process of becoming approved for a health care service prior to receiving the service.

Coordination of benefits

An insurance industry practice that allocates the cost of services to each insurance plan for those members with multiple coverages.

Pre-certification 

Review process that verifies the medical necessity and appropriateness of proposed services or supplies.

Copay or copayment

A flat fee that a member pays for a service/prescription.

Pre-existing condition

A condition diagnosed or treated prior to the effective date of your coverage or for which a prudent person would have been treated.

Deductible

Fixed dollar amount a member pays before the health plan begins paying for covered medical services.

Preferred provider 

A provider who has signed an agreement with the insurance carrier not to charge more than the insurer’s allowed fees.

Dependent

An individual other than a health plan subscriber is eligible to receive health care services under the subscriber’s contract.

Preventive care 

The combination of services that contribute to good health or allow for early detection of disease.

Disease management

A program through which members with certain chronic conditions may receive educational materials and additional monitoring or support.

Rehabilitation

Usually physical therapy, speech therapy or occupational therapy.

Emergency

A medical or behavioral condition of sudden onset that manifests itself by acute symptoms of sufficient severity – including severe pain – such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the insured person in serious jeopardy, serious impairment to bodily functions, serious disfigurement of the insured person, serious impairment of any bodily organ or part of the insured person, or in the case of a behavioral condition, placing the health of the insured person or other persons in serious jeopardy.

Short-term disability

A type of insurance through which you will receive a percentage of your income if you are unable to work for a limited period of time because of a non-work-related illness or injury.

Exclusion

A condition, service or supply not covered by the health plan.

Subrogation

Subrogation is the right of an insurer to recover all amounts paid out on behalf of you, the insured. In the event, you, as a health plan member, suffer an injury or illness for which another party may be responsible, such as someone injuring you in an accident, and the plan pays benefits as a result of that injury or illness, the plan has the legal right to recover against the party responsible for your illness or injury or from any settlement or court judgment you may receive, up to the amount of benefits paid out by the plan. As a health plan member,  you are required to cooperate with the State of Arizona Department of Administration during the subrogation process. Failure to do so may result in legal action by the state of Arizona to recover funds received by you.

Explanation of benefits

A statement sent by a health plan to a covered person who files a claim. The EOB lists the services provided, the amount billed and the payment made. The EOB statement must also explain why a claim was or was not paid, and provide information about the individual’s rights of appeal.

Supplemental life

Life insurance is an amount above what the employer provides.

Formulary

The list designates which prescriptions are covered and at what copay level.

Usual and customary charges

The standard fee for a specific procedure in a specific regional area.

Generic drug

A drug that is chemically equivalent to a brand-name drug whose patent has expired and which is approved by the FDA.

Voluntary retirement plan

ASU provides voluntary retirement plans to its eligible employees to encourage voluntary participation and saving toward retirement.

Grievance

A written expression of dissatisfaction about any benefits matter other than a decision by a plan provider.

Waiting period

The number of calendar days that must elapse before an employee is eligible for a specific benefit.

Health savings account

An account that allows individuals to pay for current health expenses and save for future health expenses on a tax-free basis. Only certain plans are HSA-eligible.

Waiver of premium

A clause in an insurance policy that waives the policyholder’s obligation to pay any further premiums should he or she become seriously ill or disabled. A waiver of premium allows a person to benefit from an insurance policy, even when he cannot work.

ID card

The card is provided to you as a member of a health plan. It contains important information such as your member identification number.

In network

Services provided by a contracted provider in accordance with all the plan requirements.

Indemnity plan

A medical or dental plan that allows you to choose any licensed provider to receive care. Members are reimbursed for eligible medical or dental expenses according to the benefit schedule in effect, including deductibles and coinsurance.