- 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.
- 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.
- a pre-determined, flat-dollar fee for certain services, e.g. office visits.
On ODS medical plans, the co-pay does not count toward the deductible nor toward
the out-of-pocket maximum; on Kaiser medical the co-pay does count toward the
- usually a percentage of a fee for health care services that is paid by both
the employee and the insurance company after the deductible has been met.
- occurs with ODS medical plans; a specific, flat-dollar amount an individual
must pay out of their own pocket toward covered expenses before a plan begins
to pay toward expenses. Deductibles carry though a 12 month period, from October
1 to September 30 of the next year. Some plans have a family maximum annual deductible,
i.e. once a certain number of your family members meet the annual deductible,
services for all family members will be paid at the plan benefit level.
- Default Coverage:
- coverage in which employees will be enrolled by the college is they fail to
either enroll or opt out by the deadline for enrollment. PCC’s default plan is
ODS plan 8 with $1,000 deductible. Only the employee will be enrolled in this
default coverage with no opportunity to change coverage or add family members
until the next open enrollment.
- spouse, domestic partner and/or child of a benefit eligible
- Dependent Child:
- a biological, step and/or adopted child. Eligible
employees may also obtain coverage for dependent children that are legal wards
of the court or that they, their spouses, or domestic partners are required to
support. Federal health care reform legislation passed in March 2010 expanded eligibility for dependents in the 2010-11 OEBB plans: Effective October 1, 2010, all OEBB medical, dental and vision plans will extend coverage to dependents through age 25 with no residential, financial support, or student status requirements, regardless of marital status. Dependents no longer need to be “recertified” in the MyOEBB system. Dependent children older than age 26 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 though Reliant Behavioral Health (RBH) include counseling, crisis response, and work-life balance services, all with a focus on wellness. This program is paid for by PCC for eligible employees.
- Explanation of Coverage is a description of the medical, dental and/or vision services, written by the insurance carrier.
- a list of selected drugs compiled by the insurance company to indicate what they will cover under the insurance plan and the category to which they belong; i.e., value, generic, preferred or non-preferred. Value would be the least expensive medication (required for certain chronic conditions) and non-preferred would be the most expensive. Formularies generally include information regarding appropriate dosages, typical use and are felt to be most cost effective for patient care and disease management.
- 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 you request up to a fixed limit without requiring information about your health status and other underwriting (insurance company evaluation) processes. Offered for a limited time, such as only at Open Enrollment when first available.
- Incentive Tier Office Visits:
- OEBB medical plans through ODS will include lower co-pays for office visits related to the management of chronic conditions such as asthma, heart conditions(including congenital heart failure, cholesterol, high blood pressure) and diabetes program.
- Individual Coverage:
- health insurance secured and purchased by an individual, not associated with
employment or participation in a specific group.
- Mandatory Benefit:
- a benefit paid by PCC that requires 100% participation of eligible employees such as the college basic life/AD&D program. You will see the premiums for Basic coverage on your MyOEBB benefit summary; these premiums for Basic Life, ADD and LTD coverage are completely paid by PCC.
- Open Enrollment:
- the time period when benefited employees may change their coverage, elect new
coverage and add or drop family members without the occurrence of a qualifying
event. The Open Enrollment timeframe may change slightly each year, but is generally
mid-August to mid-September with changes becoming effective on October 1st.
- Optional Life/AD&D:
- life and/or AD&D insurance coverage the employee enrolls in and pays for over-and-above the insurance provided 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. Optional LTC insurance coverage paid for by the employee if they choose to enroll themselves or a family member. OEBB provides LTC insurance through Unum Life Insurance Company of America. Previously the college offered LT coverage through CNA.
- Opt Out:
- an employee eligible for benefits with PCC elects 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. PT faculty may opt out based on individual policies, but there is no opt-out incentive for PT faculty.
- Out-of-Pocket Maximum:
- also known as the “stop loss” amount. Once you have paid that amount in out
of pocket expenses, you no longer pay for most covered services during the remainder
of that plan year, although you do continue making the co-payment. On the ODS medical plans, deductibles and co-payments are not applied to the out-of-pocket maximum; on Kaiser medical the co-payment does count toward the out-of-pocket maximum
- PCP: Primary Care Physician:
- the health care provider who has the primary responsibility for the client’s
overall health care plan; under some plans, may be required for referral to a
- Plan Year:
- also called the Benefit Year; All PCC medical, dental and vision plan years
begin on October 1st and will end on the following September 30th.
- Portability Coverage:
- an alternative to continuing insurance coverage through COBRA. Plans are generally
less generous in terms of benefits provided and, therefore, tend to 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 that
have signed an agreement with the insurance carrier to participate in that company’s
directory of service providers. ODS 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., 90% vs. 70% of charges.
- Preventive Care:
- services performed in the absence of acute illness to monitor the health status
of an individual and to facilitate early diagnosis and to prevent the development
of serious health concerns.
- Qualified Status Change:
- an IRS-defined life event that allows changes to health insurance enrollment
at times apart from Open Enrollment. See “Guidelines for Mid-Year Changes” included
in this packet. A request for change must be initiated by the employee within
31 days of the event.
- the category of coverage available 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 ODS will include lower co-pays for certain medications related to the management of chronic conditions such as asthma, heart conditions (including congenital heart failure), cholesterol, high blood pressure and diabetes.
- term formerly used at PCC for those who elected not to take PCC group insurance
and received compensation in lieu of insurance. Proof of other group coverage
was required. In OEBB terminology, this situation is now called “opt out.”