Glossary

AD&D:
refers to accidental death and dismemberment insurance coverage.
Additional Cost Tier:
ODS plans will cover certain treatment procedures (outpatient upper endoscopy; spine surgery for pain; knee and hip replacement; knee and shoulder arthroscopies) under a separate tier with higher co-pays.
Alternative Care:
the practices of medicine that are outside the scope of Western medical practice. Services may include acupuncture, chiropractic and naturopathic care. There may be plan specific limitations on Alternative Care benefits through OEBB – please see the individual plan documents.
Ambulatory Care:
may also be called ‘out-patient’ or ‘day’ surgery/procedure. Health care services provided without the patient being admitted to a hospital or in-patient facility. Types of services may include tests and procedures performed in hospital outpatient departments, physician’s offices, and home health services.
“Cap” Amounts:
the amount of money PCC pays each month toward an individual’s selected medical, vision, and/or dental insurance. For most employees, the amount paid by the college is based on the tier selected by the employee for medical coverage and is pro-rated for part-time employees. Part-time Faculty get a flat amount regardless of tier of coverage.
COBRA:
Consolidated Omnibus Budget Reconciliation Act: a federal law that allows employees and their dependents who are no longer eligible for employer-sponsored health insurance due to resignation, termination, reduction in work hours, divorce or loss of dependent status to continue enrollment in employer group health plans on a self-pay basis for a limited time.
Co-payment:
a pre-determined flat-dollar fee for certain services, such as, office visits. See specific plan information for details.
Coinsurance:
a percentage of the cost of health care paid by the employee after the deductible has been met.
Deductible:
the amount a subscriber pays for covered goods or services before the plan begins to pay claims. See specific plan information for details.
Default Coverage:
coverage in which employees are automatically enrolled by the college if they fail to either enroll or opt out by the deadline for enrollment. PCC's default plan is Moda Plan E, employee-only coverage. Once defaulted, there is no opportunity to change coverage or add family members until the next open enrollment unless there is a qualified status change such as marriage, birth, or loss of other coverage.
Dependent:
spouse, domestic partner and/or child of a benefit eligible PCC employee.
Dependent Child:
an eligible employee's, spouse's, or domestic partner's biological son, daughter, stepson, or stepdaughter; adopted child, child placed for adoption, or legally placed child, who is 25 or younger on the first day of the month. Dependent children 26 and older are eligible for benefit coverage if they are incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability and were covered under an educational entity plan prior to reaching the age of 26.
Employee Assistance Program:
services provided through Reliant Behavioral Health (RBH), including counseling, crisis response, and work-life balance services, all with a focus on wellness.
EOC:
Explanation of Coverage is a description of the medical, dental and/or vision services, written by the insurance carrier.
Formulary:
a preferred list of drug products that typically limits the number of drugs available within a therapeutic class for purposes of drug purchasing, dispensing or reimbursement.
Group Coverage:
enrollment in health insurance coverage that is restricted to a specific group of individuals, usually employees and their dependents.
Guarantee issue:
an insurance company guarantees the coverage an employee requests up to a fixed limit without requiring information about health status and other underwriting (insurance company evaluation) processes. Offered only to new hires or when a new plan is introduced.
In-Network:
health care providers and facilities who have signed an agreement with the insurance carrier to participate in that company's directory of service providers. Moda plans may have financial incentives for members using an in-network provider, such as negotiated lower fees and higher levels of insurance coverage; i.e., 80% vs. 50% of charges.
Incentive Tier Office Visits:
OEBB medical plans through Moda include lower co-pays for office visits related to the management of chronic conditions such as asthma, heart conditions (including congestive heart failure, cholesterol, high blood pressure) and diabetes.
Individual Coverage:
health insurance secured and purchased by an individual, not associated with employment or participation in a specific group.
Mandatory Benefit:
a benefit provided by PCC that requires 100% participation of eligible employees, such as the basic life/AD&D program. Premiums for Basic coverage are shown on your MyOEBB benefit summary and on your pay statement; premiums for these benefits (Basic Life, ADD, LTD and EAP coverage) are completely paid by PCC.
Medical Home:
a medical home, also known as a "patient-centered medical home," offers a coordinated team approach to providing healthcare. The patient has one doctor or primary care provider who works with the rest of the care team to bring the best treatments to the patient. A patient's medical home coordinates all of his/her providers and services, so the patient isn't left to navigate the system on their own. It's designed around one goal: to achieve the best possible health outcome. Moda Plans C, E and H offer financial incentives for voluntarily using a medical home. Under those plans, a patient may also use an in-network provider or an out-of-network provider if they choose.
Open Enrollment:
the time period when benefited employees may change their coverage, elect new coverage and add or drop family members without a qualified status change.. Open Enrollment is generally mid-August to mid-September with changes becoming effective October 1st.
Opt-Out:
an employee eligible for PCC benefits may choose not to enroll in the PCC group health insurance. Evidence of other group health insurance is required to opt out and must be entered into the OEBB system. The opt-out incentive paid to employees is $200/month and is pro-rated for part-time employees. Part-time faculty may opt out based on group or individual policies, but there is no opt-out incentive payment.
Optional Life/AD&D:
life and/or AD&D insurance coverage the employee enrolls in and pays for through payroll deduction in addition to the basic insurance provided and paid for by the College. OEBB provides these optional plans through The Standard Insurance Company.
Optional Long Term Care (LTC):
Long term care insurance (LTC) provides a monthly benefit amount when someone needs assistance with activities of daily living, such as bathing and dressing, due to an accident, illness, or advancing age. An employee may purchase optional LTC insurance coverage for him- or herself, or a spouse/domestic partner through payroll deduction. OEBB provides LTC insurance through Unum Life Insurance Company of America.
Out-of-Network:
health care providers and facilities who are not members of the plan network and do not have an agreement with the insurance carrier. Services from these providers are typically more expensive than those from preferred or in-network providers.
Out-of-Pocket Maximum:
also known as the "stop loss" amount. Once you have paid that amount in out-of-pocket expenses, you may no longer pay for most covered services during the remainder of that plan year, although you do continue making the co-payment. See specific plan information for details.
PCP: Primary Care Physician:
the health care provider who has the primary responsibility for the patient's overall health care plan. Under some plans, a PCP referral may be required to see a specialty provider.
Plan Year:
also called the Benefit Year; All PCC medical, dental and vision plan years begin on October 1st and end the following September 30th.
Portability Coverage:
coverage that can be purchased after employment ends, allowing the subscriber to continue his/her coverage on a self-pay basis. In Oregon, health care portability is offered as an alternative to continuing insurance coverage through COBRA. Portability plans are generally less generous in terms of benefits provided and may be less expensive than COBRA. Some restrictions apply; contact insurance company for details.
Preferred provider:
also known as "in-network;" those health care providers and facilities who have signed an agreement with the insurance carrier to participate in that company's directory of service providers. Moda plans may have financial incentives for members using an in-network provider, such as negotiated lower fees and higher levels of insurance coverage; i.e., 80% vs. 50% of charges.
Preventive Care:
services performed in the absence of acute illness to monitor the health status of an individual, facilitate early diagnosis and prevent the development of serious health concerns.
Qualified Status Change:
an IRS-defined life event that allows changes to health insurance outside of Open Enrollment. A request for change must be initiated by the employee within 31 days of the event. Examples include marriage, divorce, birth or adoption, and loss of other coverage.
System of Care:
a select group of in-network providers.
Tier:
the category of coverage such as Employee only, Employee + child(ren), Employee + spouse or domestic partner, and Employee + family (spouse and child(ren).
Value Tier medications:
OEBB medical plans through Moda include lower co-pays for certain medications related to the management of chronic conditions such as asthma, heart conditions (including congestive heart failure), cholesterol, high blood pressure and diabetes.