|
Adopted Child |
A child who is
adopted or placed for adoption, as defined by the state in which the
adoption takes place. |
|
Affiliation Period |
A period of time
that must pass before health insurance coverage provided by an
HMO (Health Maintenance Organization becomes effective.
If a
group health plan provides coverage to you through an HMO with an
affiliation period, the affiliation period cannot be longer than 2 months (3
months for a
late enrollee) from your
enrollment date, and the plan cannot impose a
pre-existing condition exclusion.
During the affiliation period, the
plan cannot charge you premiums, and the HMO is not required to provide
benefits.
The affiliation period must run concurrently with any waiting period for
coverage under the plan. |
|
Certificate of Creditable Coverage |
A written
certificate issued by a
group health plan or health insurance issuer (including an
HMO) that shows your prior health coverage (creditable
coverage). A certificate must be issued automatically and free of charge
when you lose coverage under a plan, when you are entitled to elect
COBRA continuation coverage or when you lose COBRA continuation
coverage. A certificate must also be provided free of charge upon request
while you have health coverage or within 24 months after your coverage ends.
For more information, see
Questions and Answers: Recent Changes in Health Care Law.
|
|
COBRA (Consolidated Omnibus Budget
Reconciliation Act of 1985) |
COBRA is a federal
law that provides rights to temporary continuation of
group health plan coverage for certain employees, retirees and family
members at group rates when coverage is lost due to certain
qualifying events. |
|
COBRA Continuation Coverage |
The temporary
continuation of
group health plan coverage available after a
qualifying event
to certain employees, retirees and family members who
are
qualified beneficiaries.
Those who are eligible may be required to pay for COBRA continuation
coverage and are generally entitled to coverage for a limited period of time
(from 18 months to 36 months), depending on certain circumstances. |
|
Covered Employee |
An individual who
is (or was) provided coverage under a
group health plan that is subject to COBRA because that individual was
employed by one or more persons maintaining the group health plan. |
|
Creditable Coverage |
Health coverage you
have had in the past, such as coverage under a
group health plan (including
COBRA continuation coverage), an
HMO, an individual health insurance policy, Medicare or Medicaid, and
this prior coverage was not interrupted by a
significant break in
coverage. The time period of this prior coverage
must be applied toward any
pre-existing condition exclusion imposed by a new health plan. Proof of
your creditable coverage may be shown by a
certificate of creditable coverage or by other documents showing you had
health coverage, such as a health insurance ID card. For more information,
see
Questions and Answers: Recent Changes in Health Care Law. |
|
Drug Formulary |
A list of all the
medicines that will be covered by your
group health plan. |
|
Elect |
When referring to
health coverage, this means to choose, generally in writing, to participate
in a
group health plan. |
|
Election Notice |
Written
notification that you are eligible for
COBRA continuation coverage. This notice should explain how long you
will have to decide whether or not to elect COBRA continuation coverage. The
group health plan must give you at least 60 days from the date the
notice is provided to you, or from the date your coverage ended, whichever
is later, to elect COBRA continuation coverage. The election notice should
explain, among many other things, how much you must pay for coverage and
when and to whom the payments are due. |
|
Employee
Organization |
Any labor union or
organization of any kind in which employees participate and which exists for
the purpose of dealing with employers concerning an employee benefit plan
(including
group health plan) or other matters involving employment relationships.
An employee organization can also be an employee beneficiary association.
|
|
ERISA (Employee Retirement Income
Security Act of 1974) |
ERISA is a federal
law that regulates employee benefit plans, such as
group health plans, that private sector employers, employee
organizations (such as unions), or both, offer to employees and their
families. |
|
Enrollment Date |
The first day of
coverage or, if there is a
waiting period, the first day of the waiting period. If you enroll when
first eligible for coverage, your enrollment date is generally the first day
of employment. If you enroll as a late enrollee, your enrollment date is the
first day of coverage. |
|
Exhausted COBRA
Coverage |
The end of your
COBRA continuation coverage because the period of time that this
coverage was available to you has lapsed, or for any reason other than your
failure to pay premiums on time or for cause (such as making a fraudulent
claim or an intentional misrepresentation of a material fact in connection
with your plan). Additional reasons for exhaustion of COBRA coverage are
possible besides the time being up. You have exhausted your
COBRA
continuation coverage if the coverage ends because your employer failed to
pay the premiums on time or you no longer live or work in an
HMO service area and there is no similar COBRA coverage available to
you. You need not accept a conversion policy at the end of your COBRA
coverage in order to exhaust your COBRA coverage. |
|
Genetic Information |
Information about
genes, gene products and inherited characteristics that may derive from you
or a family member. This includes information regarding carrier status and
information derived from laboratory tests that identify mutations in
specific genes or chromosomes, physical medical examinations, family
histories and direct analysis of genes or chromosomes. |
|
Gross Misconduct |
The term "gross
misconduct" is not specifically defined in COBRA or in regulations under
COBRA. Therefore, whether a terminated employee has engaged in "gross
misconduct" that will justify a plan in not offering COBRA to that former
employee and his or her family members will depend on the specific facts and
circumstances. Generally, it can be assumed that being fired for most
ordinary reasons, such as excessive absences or generally poor performance,
does not amount to "gross misconduct." |
|
Group Health Plan |
An employee benefit
plan established or maintained by an employer or by an
employee
organization (such as a union), or both, that provides medical
care to employees and their dependents directly or through insurance
(including an
HMO), reimbursement or otherwise. |
|
HMO (Health Maintenance Organization) |
Legal entity
consisting of participating medical providers that provide or arrange for
care to be furnished to a given population group for a fixed fee per person.
HMOs
are used as alternatives to traditional indemnity plans. |
|
HIPAA (Health Insurance Portability
and Accountability Act) |
HIPAA is a federal
law that limits
pre-existing condition exclusions, permits
special enrollment when certain life or work events occur, prohibits
discrimination against employees and dependents based on their health
status, and guarantees availability and renewability of health coverage to
certain employees and individuals. |
|
Late Enrollee |
An individual who
enrolls in a
group health plan on a date other than either the earliest date on which
coverage can begin under the plan terms or on a
special enrollment date. Under HIPAA, a late enrollee may be subject to
a maximum pre-existing condition exclusion of up to 18 months. |
|
Mental Health Parity Act (MHPA) |
MHPA is a federal
law that requires annual or lifetime dollar limits on mental health benefits
provided by a group health plan to be no lower than the annual or lifetime dollar
limits for medical and surgical benefits offered by that plan. MHPA applies
to employers with more than 50 employees. |
|
Newborns' and Mothers' Health
Protection Act (Newborns' Act) |
The Newborns' Act
is a federal law that prohibits
group health plan and insurance companies (including
HMO's) that cover hospitalization in connection with childbirth from
restricting a mother's or newborn's benefits for such hospital stays to less
than 48 hours following a vaginal delivery or 96 hours following delivery by
cesarean section, unless the attending doctor, nurse midwife or other
licensed health care provider, in consultation with the mother, discharges
earlier. |
|
Plan Administrator |
The person who is
responsible for the management of the plan. The plan administrator is a
person specifically designated by the terms of the plan. If the plan does
not make such a designation, then the
Plan sponsor is generally the plan administrator. |
|
Plan Sponsor |
Generally, the
employer, the
employee organization (such as a union), or both, that establishes or
maintains an employee benefit plan, including a
group health plan.
|
|
Pre-existing
Condition |
An illness or
condition that was present before an individual's first day of coverage
under a
group health plan. For more information, see
Questions and Answers: Recent Changes in Health Care Law.
|
|
Pre-existing Condition Exclusion |
A limitation or
exclusion of benefits for a condition based on the fact that you had the
condition before your
enrollment date in the
group health plan. A pre-existing condition exclusion may be applied to
your condition only if the condition is one for which medical advice,
diagnosis, care or treatment was recommended or received within the 6 months
before your
enrollment date in the plan. A pre-existing condition exclusion cannot
be applied to pregnancy (regardless of whether the woman had previous
coverage), or to
genetic information in the absence of a diagnosis. A pre-existing
condition exclusion also cannot be applied to a newborn or
a child who is adopted or placed for adoption if the child has health
coverage within 30 days of birth, adoption or placement for adoption and
does not later have a
significant break in coverage. If a plan provides coverage to you
through an
HMO that has an
affiliation period, the plan cannot apply a pre-existing condition
exclusion. A pre-existing condition exclusion can not be longer than 12
months from your enrollment date (18 months for a
late enrollee). A pre-existing condition exclusion that is applied to
you must be reduced by the prior
creditable coverage you have that was not interrupted by a significant
break in coverage. You may show creditable coverage through a
certificate
of
creditable
coverage given to you by your prior plan or
insurer (including an HMO) or by other proof. The plan can apply a
pre-existing condition exclusion to you only if it has first given you
written notice. If your plan has both a
waiting period and a pre-existing condition exclusion, the exclusion
begins when the waiting period begins. In some states, if plan coverage is
provided through an insurance policy or HMO, you may have more protections
with respect to pre-existing condition exclusions. |
|
Pre-existing Condition Exclusion Period |
The period of time
that a
group health plan can legally limit your access to the health benefits
offered by that plan because of a
pre-existing condition. Under HIPAA, the maximum pre-existing condition exclusion period that can be
applied to an individual is 12 months (18 months for
late enrollees). |
|
Qualified
Beneficiary |
Generally,
qualified beneficiaries include
covered
employees, their spouses and their dependent children who are
covered under the
group health plan on the day before the qualifying event. In certain
cases, retired employees, their spouses and dependent children may be
qualified beneficiaries. In addition, any child born to, or
placed for adoption with, a covered employee during a period of
COBRA continuation coverage is a qualified beneficiary. |
|
Qualifying Event |
Certain events that
would ordinarily cause an individual to lose health coverage. The type of
qualifying event will determine who the qualified beneficiaries for the
qualifying event are and the length of time COBRA continuation coverage is
available. For more information, see
Questions and Answers: Recent Changes in Health Care Law. |
|
Significant
Break in Coverage |
Generally, a
significant break in coverage is a period of 63 consecutive days during
which you have no
creditable
coverage. In some states, the period is longer if your plan
coverage is provided through an insurance policy or HMO. Days in a
waiting period during which you had no other health coverage cannot be
counted toward determining a significant break in coverage. For more
information, see
Questions and Answers: Recent Changes in Health Care Law. |
|
Similarly Situated Non-COBRA Beneficiaries |
The group of
covered employees, their spouses or dependent children who are covered
under a
group health plan
maintained by the employer or
employee organization. This group is receiving their benefits under the
group plan and not through
COBRA continuation coverage. They are most similarly situated to the
circumstances of the qualified beneficiary immediately before the
qualifying event. |
|
SPD (Summary Plan
Description) |
An important
document that the
plan administrator must provide to participants and beneficiaries that
explains what coverage the plan offers, how the plan operates and the rights
and responsibilities of participants and beneficiaries. Each SPD is
different. If you need a copy of the SPD, contact your plan administrator.
|
|
Special Enrollment |
The opportunity to
enroll in a
group health plan when certain work or life events occur, regardless of
the plan’s regular enrollment dates. Generally, if certain conditions are
met, special enrollment is available when you, your spouse or your
dependents lose other coverage (including
exhaustion of COBRA continuation coverage), when you marry or when you
have a new child by birth,
adoption or placement for adoption. The plan must give you at least 30
days--from the loss of coverage or from the date of the marriage, birth,
adoption or placement for adoption--to request special enrollment. The
maximum
pre-existing condition exclusion that may be applied to a person upon
special enrollment is 12 months (reduced by the person's prior
creditable coverage). However, if enrolled within 30 days of birth,
adoption or placement for adoption, children may be exempt from any
pre-existing condition exclusion. A description of a plan's special
enrollment rules must be given to the employee on or before the time the
employee is offered the opportunity to enroll in the plan. For more
information, see
Questions and Answers: Recent Changes in Health Care Law |
|
Waiting Period |
The period that
must pass before an employee or dependent is eligible to enroll (becomes
covered) under the terms of the
group health plan. If the employee or dependent enrolls as a
late enrollee or on a
special enrollment date, any period before the late or special
enrollment is not a waiting period. If a plan has a waiting period and a
pre-existing condition exclusion, the pre-existing condition exclusion
period begins when the waiting period begins. Days in a waiting period are
not counted toward
creditable coverage unless there is other creditable coverage during
that time. You should try to maintain creditable coverage during a waiting
period to reduce any pre-existing condition exclusion that may apply. Days
in a waiting period are also not counted when determining a
significant break in coverage. |
|
Women's Health and Cancer Rights Act (WHCRA) |
WHCRA is a federal
law that provides important protections for individuals who have undergone a
mastectomy. For more information, see
Your Rights After a Mastectomy: The Women's Health and Cancer Rights Act. |
