Glossary of terms
- 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 procedures under a separate tier with higher co-pays. These include MRI, CT and PET scans, spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies, spine surgery, knee and hip replacement*, knee and shoulder arthroscopy, and uncomplicated hernia repair. See the Moda OEBB additional cost tier website. *Subject to reference pricing. See the Moda OEBB reference price program website. - 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 Cap amount based on their medical enrollment 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 a particular service, such as an office visit. See specific plan information for details. - Coinsurance:
A percentage of the cost of health care paid by the employee. - Deductible:
The amount an employee 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 Kaiser Medical Plan 3, 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 Evergreen Medical Plan or Kaiser Medical Plan 3). 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 Evergreen Plan. - 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 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. - Maximum cost share:
The maximum you will pay out of pocket for covered medical services including additional cost tier and pharmacy copays. - 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 their 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 Birch and Cedar Medical Plans 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 15 to September 15th with changes becoming effective October 1. - 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 who opt out of medical, dental and vision coverage 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. Participation or enrollment in the Oregon Health Plan/Medicaid, veterans health benefits, or student health insurance does not qualify for OEBB opt out. - 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:
The maximum you will pay out of pocket for covered medical services. Once you reach this amount in medical deductible, copays and coinsurance, you will continue to pay additional cost tier copays and pharmacy coinsurance and copays until you reach the maximum cost share. - 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 1 and end the following September 30. Flexible spending accounts run on a calendar year. - Portability coverage:
Coverage that can be purchased after employment ends, allowing the subscriber to continue their 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 your 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. - Reference pricing:
In a reference price program, the plan sponsor limits their contributions toward the cost of a specific health care service, and health plan members must pay the difference in price if a more costly health care provider or service is selected. This reference price program means OEBB members in need of bariatric surgery, a joint replacement or an oral appliance for sleep apnea will be encouraged to seek this care from specific facilities located throughout the State. - 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 lower copays 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.