Accidental Death and Dismemberment: AD&D benefits are available only to current employees and apply when death, dismemberment or loss of sight occurs as the result of an accident.
Accidental injury: Bodily injury sustained as the direct result of an accident, independent of any other cause, which occurs while insurance coverage is in force.
Allowable fee: The set dollar amount allowed under an insurance plan for a covered service or supply.
Base salary: The rate of earnings in effect on the date disability begins. Base salary does not include overtime, commissions, bonuses, longevity pay, productivity enhancement program payments or any other compensation.
Basic life: The first $20,000 of term life insurance coverage available to an eligible employee under the HealthChoice Life Insurance Plan.
Benefit period: The period during which benefits are paid. The first day of the benefit period is the day the member becomes eligible for benefits. The end of the benefit period is the last day of eligibility as determined by the maximum benefit period and/or eligibility limits.
Case Management: The function of coordinating a patient’s medical care. The care usually involves multiple services from multiple providers.
Centers for Medicare & Medicaid Services: The federal agency that manages the Medicare and Medicaid programs.
COBRA: The acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985, which gives workers and their families who lose their health, dental and/or vision benefits the right to continue group coverage provided by their group insurance plan. COBRA is available for limited periods of time and under certain circumstances, such as voluntary or involuntary job loss, reduction in hours worked, transition between jobs, death, divorce and other life events.
COBRA qualifying event: Certain events resulting in a loss of health, dental and/or vision coverage for an employee and/or covered dependent that allow them to continue coverage under COBRA.
Coinsurance: The percentage of allowable fees paid by the member once the deductible is satisfied.
Copay: A set amount the member pays for certain services as a cost-sharing agreement. Current annual salary: An individual’s annual gross pay. Current annual salary does not include overtime, longevity pay, benefit allowance or retirement contribution.
Deductible: The out-of-pocket amount that typically must be paid before the insurance pays benefits.
Disability: The inability to perform each of the material duties of any gainful occupation an employee is or may become reasonably qualified for by training, education or experience.
EGID: The Office of Management and Enterprise Services Employees Group Insurance Division.
- An employee’s legal spouse (including common-law).
- An employee’s daughter, son, stepdaughter, stepson, eligible foster child, child for whom the employee has been granted legal guardianship or child legally placed with the employee for adoption, up to age 26, whether married or unmarried.
- An employee’s dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior to age 26. Refer to Special Rules for a Disabled Dependent.
- Other unmarried dependent children up to age 26, upon approval of an Application for Coverage for Other Dependent Children. A tax return showing dependency may be provided in lieu of the application.
Eligible employee: An employee of a participating employer who receives compensation for services rendered and is listed on that employer’s payroll.
Eligible participating former employee: An employee who participates in any of the plans authorized by or through the Oklahoma Employees Insurance and Benefits Act who retired or vested their rights with a state funded retirement plan, or has the required years of service with a participating employer.
Elimination period: The first 30 consecutive calendar days of disability when no benefits are paid.
Excepted benefits: The four categories of benefits as established in section 2791 of the PHS Act, section 733 of ERISA and section 9832 of the Internal Revenue Code, as summarized in IRS Bulletin 2015-14 and subsequent regulatory guidance. These excepted benefits include but are not limited to vision coverage, dental coverage, long-term care insurance, Medicare supplement coverage, automobile liability insurance, workers compensation, accidental death and dismemberment insurance and specific disease coverage (such as cancer).
Guaranteed issue: Two times an employee’s current annual salary rounded up to the next $20,000. This is available only during the employee’s initial enrollment. A life insurance application is not required.
HealthChoice: The name for the insurance plans administered by EGID.
Health Maintenance Organization: A type of managed care plan that contracts with doctors, hospitals, clinics and other health care providers such as pharmacies, labs, X-ray centers and medical equipment vendors. An HMO typically requires the use of a primary care physician to manage and coordinate all care.
Indemnity plan: A traditional fee-for-service insurance plan that gives the employee the freedom to visit any licensed health care professional without a referral. The member is responsible for deductibles and coinsurance, and a calendar year out-of-pocket maximum typically applies. Once the out-of-pocket maximum is reached, the plan typically pays 100% of allowable fees for covered services for the rest of the year. Initial enrollment: The 30 days following an employee’s date of employment or date they become eligible with a participating employer. An initial enrollment is not created when an employee transfers employment between participating employers sharing the same Section 125 Plan, e.g., state agency to state agency or school to school within the same district.
Life insurance application: Documentation of an employee’s medical fitness for review of insurability.
Medically necessary: Health care services or supplies within the standards of good medical practice that are necessary to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms.
Network provider: A provider who has entered into a contract with an insurance plan to accept the plan’s allowable fees for services and/or supplies provided to plan participants.
Non-covered service: Any service, procedure or supply excluded from coverage and not paid for by a plan.
Non-vested: An employee who has worked long enough to keep benefits but did not contribute to a retirement system, or who has withdrawn all contributions and no longer qualifies for retirement or vested status.
Option Period: The annual time period established by EGID when changes can be made to coverage.
Orthodontic limitation: A waiting period for orthodontic benefits.
Out-of-pocket maximum: The amount for which a member is responsible based on the use of network or non-network providers, including deductible and coinsurance, before eligible charges are paid at 100% of allowable fees. The out-of-pocket maximum does not include charges for non-covered services or balance billing charges from non-network providers.
Participant: An employee or former employee of a participating employer who is eligible and is participating in coverage through EGID.
Participating employer: Any municipality, county, education employer, or state agency whose employees or members are eligible to participate in any plan authorized by or through the Oklahoma Employees Insurance and Benefits Act.
Plan: The insurance product for a specific benefit, such as health or dental.
Preexisting condition: A preexisting condition refers to an illness or injury for which the employee received medical care, diagnosis, consultation or treatment, or took prescribed drugs or medicines, during the 90-day period immediately preceding the employee’s employment date. The term preexisting condition also includes any condition which is related to such injury or illness.
Proof of claim: Written documentation submitted to EGID and/or the disability claims administrator confirming a claim for benefits. Qualified beneficiary: An employee, their spouse and/or dependent children who were covered under the employee’s group health, dental and/or vision plan on the day before a COBRA qualifying event. This includes any child who is born to, or placed for adoption with, the employee during COBRA coverage.
Qualifying event: A life status change that allows an individual to make midyear changes to insurance benefits.
Reconciliation: The process of making the net difference in credits and debits of a premium bill agree with the balance.
Retiree: An employee who has worked long enough to retire and draw a retirement check.
Section 125 plan: A type of employee benefit plan offered pursuant to Section 125 of the Internal Revenue Code that allows employees to participate pre-tax in different types of benefits.
Social Security disability: An insurance program offered by the federal government that pays benefits to those who are determined to be unable to work.
Term life: A policy that furnishes life insurance for a limited period of time. If death occurs during this period of time, insurance benefits are paid. If death occurs after the policy has expired, no insurance benefits are paid. A term policy has no cash surrender value.
Third-party administrator: An entity or company that an insurance company contracts with to process claims and administer certain business functions; also called claims administrator.
Vested: An employee who has worked long enough to keep benefits and contributed to a retirement system, but is not ready to retire or draw retirement benefits.
Years of service: Time spent as an active employee performing full-time duties with an employer that participates in one of the State of Oklahoma retirement systems.