Administrative Services Only A contract in which a THIRD PARTY ADMINISTRATOR or insurance company process claims for a self funded health plan.
Aggregate Advancement Optional stoploss coverage which protects against monthly claims fluctuations. The stoploss carrier advances the health plan amounts in excess of the accumulated monhtly attachment point.
Aggregate Report A monthly claims report that shows total paid claims and claims that are subject to the stoploss reimbursement.
Aggregate Stoploss Protects the employer against excessive claim expenditures for the entire group. Stoploss carriers usually set the threshold at 125% of expected claims.
Attachment Point The point at which the stoploss carrier begins to reimburse the employer based upon the cumulative total of claims paid within a policy year.
Deficit Carryforward The amount of claims in excess of the aggregate insurance amount during the plan year that will carryforward into the next plan year.
ERISA (Employee Retirement Income Security Act) A Federal law that applies to retirement programs and to employee welfare benefit programs established or maintained by employers and unions.
Expected Claims Cost An amount in dollars which represents the predictable claims a self-funded medical plan will have in any given plan year.
Fixed Costs Refers to those costs which are payable monthly which do not include claims dollars. Generally fixed costs include all administration and stoploss premiums.
Form 5500 The annual filing form for ERISA for all plans with 100 or more participants.
Health Reimbursement Account (HRA) An arrangement where the employer reimburses an employee for health expenses not covered by the group health insurance plan.
Health Savings Account (HSA) An account owned by an individual designed to help pay for current medical expenses or save for future qualified medical and retiree health expenses on a tax-free basis.
Incurred Eligible claims are those for which services are provided within the plan year regardless of when the claim is actually paid.
Incurred but Not Reported (IBNR) Claims where the service has been provided by the health care professional but has not yet been processed and paid. This amount is also referred to as the RESERVE.
Maximum Liability The toal combined dollar figure for FIXED COSTS, ATTACHMENT POINT and TERMINAL LIABILITY.
Multiple Employer Welfare Arrangement (MEWA) An arrangement that allows a group of employers collectively to offer health insurance coverage to their employees. MEWAs are generally found among employer groups belonging to a common trade or industry.
Paid Eligible claims are those paid within the plan year regardless of when the claim was INCURRED.
Pharmacy Benefit Manager (PBM) A contractor that supplies a network of member pharmacies to a health plan and is responsible for processing and paying prescription drug claims.
Reserve A specific amount of claims established to cover RUN OUT in the event an employer should terminate its self funded contract for any reason. Also referred to IBNR.
Run In Claims that are incurred prior to the plan year but are paid within the plan year.
Run Out Claims that are incurred during the plan year but are paid after the plan year ends.
Specific Deductible The amount for which the plan is responsible on each indvidual employee or dependent claim in the policy year.
Specific Stoploss Protects the employer against catastrophic claims on an individual in excess of the SPECIFIC DEDUCTIBLE.
Stoploss Insurance A product designed to protect self-funded employers against catastrophic loses. Stoploss insurace has two types of coverage; SPECIFIC and AGGREGATE.
Summary Plan Description (SPD) A document supplied by the plan administer, explaining to participants what the plan provides and how it operates. The document typically provides information on when an employee can begin to participate in the plan, how service and benefits are calculated, when benefits become vested, when and in what form benefits are paid, and how to file a claim for benefits.
Terminal Liability Stoploss insurance which covers the RUN OUT.
Third Party Administrator (TPA) An organization that contracts to process claims and provide other administrative services for self funded health plans.
Uniformed Services Employment and Reemployment Rights (USERRA) USERRA prohibits discrimination against persons because of their service in the Armed Forces Reserve, the National Guard, or other uniformed services. USERRA prohibits an employer from denying any benefit of employment on the basis of an individual’s membership, application for membership, performance of service, application for service, or obligation for service in the uniformed services. USERRA also protects the right of veterans, reservists, National Guard members, and certain other members of the unifor
Usual, Customary or Reasonable (UCR) The amount reimbursed to providers based on teh prevailing fees in a specific area.