Glossary

AD&D:
Accidental death and dismemberment insurance coverage. Pays benefits for accidental loss of life or appendage or function of certain sensory organs.
Additional Cost Tier:
Moda plans cover certain treatments (outpatient upper endoscopy, spine surgery for pain, knee and hip replacement, knee and shoulder arthroscopies, uncomplicated inguinal hernia repair, and certain tonsillectomies) under a separate tier with higher co-pays. See http://www.modahealth.com/oebb.
Alternative Care:
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:
Also called out-patient or day surgery/procedure. Health care services provided without the patient being admitted to a hospital or in-patient facility. 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, dental, and/or vision 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 members receive a flat amount regardless of tier of coverage. Their cap cannot be applied to dental 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 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.
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.
Disability Insurance:
Insurance that replaces a certain amount of income when an individual is disabled, according to the plan’s criteria.
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.
EOB:
Explanation of Benefits is a description of the medical, dental and/or vision services, provided 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 newly benefits-eligible employees or when a new plan is introduced.
Health Savings Account
An HSA is a tax-advantaged account established to pay for qualified medical expenses for those who are covered under a High Deductible Health Plan (Moda Medical Plan H). With money from this account, you pay for healthcare expenses. Any unused funds are yours to retain in your HSA and accumulate toward your future healthcare expenses or your retirement. Enrollment in an HSA is required for all employees who enroll in Moda Plan H.
Healthy Futures:
Healthy Futures is a voluntary wellness program offered by OEBB. If you and your spouse/partner (if applicable) decide to participate, you must complete a secure and confidential online health assessment provided by your medical carrier. Based on the results of your health assessment, you must take two actions. These actions may include a tobacco cessation program, a weight management program such as Weight Watchers, a walking program, preventive services such as annual dental cleaning or a mammogram, and many more. Report your actions during Open Enrollment and you will receive a lower deductible or reduced copays the following plan year.
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 no co-pay or a lower co-pay 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.
Life Insurance:
Insurance that pays benefits to survivors on the insured person’s death.
Long Term Care Insurance:
Insurance that pays benefits when the insured person requires assistance with activities of daily living.
Long-term Disability:
A benefit that pays you monthly in the event you cannot work because of a covered illness or injury. This benefit replaces a portion of your income.
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 August 15th to September 15th 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. It is taxable income. Part-time faculty may opt out based on group or individual policies, but there is no opt-out incentive payment.
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. The maximum you will pay out of pocket for covered services. Out-of-pocket maximums are calculated on an individual basis.
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. Flexible spending accounts run on a calendar year.
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.
Specialty Medications:
Medications that are often indicated to treat complex chronic health conditions. Due to the complexities, each individual insurance carrier has an enhanced member services department to help.
Subscriber:
Eligible individual who enrolls in a health plan and whose premium pays for coverage for the subscriber and eligible dependents.
Tier:
The category of coverage such as Self only, Self + child(ren), Self + spouse or domestic partner, and Self + family (spouse and child(ren).
Value Tier medications:
OEBB medical plans through Moda include no 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.