The annual period of time during which Subscribers and other Eligible Individuals may elect and/or change Plans for the following plan year for themselves and their Eligible Dependents. 

The amount a plan will pay in actual medical claims for the plan year.

BlueCross and BlueShield

Manufacturers patent “brand-name” drugs, so that only they can produce and sell them—often at a high price. When the patent expires, other manufacturers are permitted to produce these same drugs as generics, and often sell them at a much lower price.

A process of identifying plan members with special healthcare needs, developing a healthcare strategy that meets those needs, and coordinating and monitoring care.

Cigna Behavioral Health

A health plan that has an annual deductible, which cannot be less than a certain amount as determined by the IRS for self-coverage and family coverage. Your coverage consists of two components under this type of plan: a traditional plan with a high deductible (except for preventive care) and a tax-advantaged savings account. The High Deductible Health Plan works much like a PPO plan. You and/or your employer can fund the Health Savings Account (HSA), which you may use to pay for medical expenses. If you do not use the money in your HSA, it remains yours and continues to grow with tax-free earnings to use for your future medical expenses.

Center for Medicare and Medicaid Services (see “Medicare”)

Cost-sharing under a health insurance plan. The covered individual is responsible for a portion (usually a percentage) of the costs of covered services, after his or her deductible has been paid. For example, the covered individual pays 20 percent toward the charges for a service and the insurance plan pays 80 percent. PPO, EPO, and POS plans typically require that you pay coinsurance, while HMOs do not.

The amount a member or employer pays in exchange for healthcare coverage.

A set, per-visit fee paid by the patient (covered individual).

The amount that must be paid by the covered individual before the plan begins to make any payments. For example, if a covered individual has a $100 annual deductible, the plan makes no payments until at least $101 in eligible claims are processed. Deductibles usually apply per plan year.
Copayments typically do not apply toward the deductible, while coinsurance payments usually do. Generally, HMOs do not have deductibles.

Denominational Health Plan. A Church-wide program of healthcare benefit plans authorized by General Convention and administered by The Church Pension Fund (CPF), with benefits provided through the Medical Trust.

Cigna Dental and Orthodontia Plan

The Employee Assistance Program through Cigna

Explanation of Benefits. An Explanation of Benefits (commonly referred to as an EOB form) is a statement sent to covered individuals explaining what medical treatment and/or services were paid for on their behalf.

Extension of Benefits. A provision that allows employees to voluntarily continue their healthcare coverage, at their own expense, after terminating their employment.

Under an EPO plan, you agree to use the healthcare providers and facilities associated with the EPO. As with health maintenance organizations (HMOs), the EPO does not cover the cost of services you receive from doctors or other providers outside the network, except in emergencies. There are no claim forms. You are not required to select a primary care physician (PCP) to coordinate your care.

Some plans, especially HMOs, require a gatekeeper —usually the designated Primary Care Physician (PCP)—to oversee the administration of the patient’s treatment by coordinating and authorizing all medical services, laboratory studies, specialty referrals, and hospitalizations.

A prescription drug that is chemically equivalent to a brand-name drug that is no longer protected by a patent. Generic drugs are typically sold at a lower price than the brand-name equivalent, but have the same active ingredients and are manufactured according to the same strict federal regulations.

A program of medical and dental Plans through which Eligible Individuals and Eligible Dependents of The Episcopal Church are provided health benefits on or after enrolling in Medicare Parts A and B. A Group Medicare Advantage plan provides coverage for medical expenses not covered or partially covered by the Original Medicare Plan (Part A and B). It may also provide benefits for expenses not covered by the Original Medicare Plan such as pharmacy benefits and vision care. A Group Medicare Advantage plan is another way to get Medicare Part A and Part B coverage. Medicare Advantage plans, sometimes called “Part C,” are offered by Medicare-approved private companies that must follow rules set by Medicare.

HIPAA is a federal law that, among other things, provides rights and protections for participants and beneficiaries in group health plans by regulating the portability and continuity of group health coverage. HIPAA limits exclusions based on preexisting conditions, prohibits discrimination based on health status factors, and gives individuals a special opportunity to enroll in a group health plan in certain circumstances. The Administrative Simplification Provisions of HIPAA address the privacy and security of certain health information.

A person who occupies a hospital bed, crib or bassinet while under observation, care, diagnosis or treatment for at least 24 hours.

See Case Management

Medicare is a federal health insurance program for those aged 65 and older, certain disabled persons, and those with end-stage renal disease (ESRD). It is administered by the Center for Medicare and Medicaid Services (CMS) and is made up of several “parts.” (See Medicare Parts A, B, C and D)

Medicare Part A is usually available at no cost to people who have paid into the social security system for a minimum of 40 quarters when they reach age 65 or have certain disabilities. (Refer to Medicare.gov or Medicare & You for details and limitations.) Part A usually covers:

• Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
• Inpatient care in a skilled nursing facility (not custodial or long-term care)
• Hospice care services
• Home healthcare services
• Inpatient care in a Religious Nonmedical Healthcare Institution

Episcopal Church retirees or surviving spouses who want to enroll in the Medical Trust’s Medicare Supplement Health Plans must have Medicare Parts A & B coverage.

Medicare Part B helps cover medically necessary services like doctors’ services, outpatient care, home health services, and other medical services. (Refer to Medicare.gov or Medicare & You for details and limitations.) Episcopal Church retirees or surviving spouses who want to enroll in the Medical Trust’s Medicare Supplement Health Plans must have Medicare Parts A & B coverage.

Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are health plans offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan provides all your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage, and may include other services such as vision or prescription coverage. (Refer to Medicare.gov or Medicare & You for details and limitations.)

Medicare Part D is optional prescription drug coverage offered to anyone with Medicare through plans approved by Medicare. These may be stand-alone Prescription Drug Plans or may be included under a Part C Medicare Advantage plan. (Refer to Medicare.gov or Medicare & You for details and limitations.) Episcopal Church retirees who are members of the Medical Trust’s Medicare Supplement Health Plans do not need Medicare Part D coverage.

A Medicare supplement health plan provides coverage for medical expenses not covered or partially covered by the Original Medicare Plan (Part A and B). It may also provide benefits for expenses not covered by the Original Medicare Plan such as pharmacy benefits and vision care. A Medicare supplement health plan only works with the Original Medicare Plan, where Medicare pays first (primary) for a medical claim, and the Medicare supplement health plan pays for the medical claim after the Original Medicare Plan (secondary). The Original Medicare Plan and the MSHP only pay claims for services that are provided in the United States.

Network providers and facilities agree to provide services to participants of a vendor’s plans at negotiated rates. When you receive care from a network provider or in a network facility, you will pay these lower network rates for services. In certain plans, network services require only a copayment.

Notice of Creditable Coverage

A brand-name medication that is not included on a plan’s Formulary list, and so is normally more costly than a Generic and Formulary/Preferred medications. Non-Formulary medications may or may not have generic equivalents.

If you receive care from a physician or in a facility that is not part of your medical plan's network, you will be responsible for more of the costs of that care.

The maximum amount of money a person will pay in addition to premium payments and copayments in one plan year for covered expenses. The out-of-pocket maximum is usually the sum of the deductible and coinsurance, and typically excludes copayments.

A person who visits a clinic, emergency room or health facility and receives healthcare without being admitted as an overnight patient.

The period on which a plan’s annual benefits and costs are based. For the Medical Trust plans this is January 1 – December 31.

A list of prescription medications preferred by a health plan. The medications are selected based on clinical effectiveness and opportunities to help contain a health plan's costs. Preferred drug lists are usually subject to periodic review and modification by the health plan. The term “formulary” may refer to the list itself, or to a medication included in the list (also sometimes called a “preferred” medication). Formulary medications may or may not have generic equivalents.

A form of managed care in which employees choose to use network or out-of-network providers when care is needed. No designated primary care physician or gatekeeper is required and members can self-refer to specialists. However, if the employee chooses to receive care within the plan's network, he/she will generally receive a higher level of benefits coverage.

An approach to healthcare emphasizing preventive measures and health screenings such as routine physicals, well-baby care, immunizations, Pap smears, mammograms and other early detection testing (recommended screenings). Its purpose is to diagnose a health problem early, when it is less costly to treat and outcomes tend to be more favorable.

The physician, chosen by the member from among the plan’s network physicians, to be responsible for coordinating care with specialists and provide referrals. A PCP is usually required under most managed care medical plan options.

Any person (doctor, nurse, etc.) or institution (hospital, clinic, laboratory, urgent care facility, etc.) that provides medical care.

An event as described in the Plan Election and Enrollment Guidelines section, where as a result of the event, the Subscriber is eligible to make certain mid-year election changes.

A written order from a patient’s PCP/Gatekeeper to see a specialist or get certain services. These are required under some types of plans, such as HMOs, for the service to be covered.

Skilled Nursing Facility

Typically high cost drugs that are injected or infused in the treatment of acute or chronic diseases. Specialty Drugs often require special handling such as temperature-controlled packaging and expedited delivery. Most Specialty Drugs require preauthorization to be considered Medically Necessary.

See Reasonable and Customary

Healthcare provided in situations where the patient’s medical needs have not reached the level of emergency. Claim costs for urgent care services are typically much less than for services delivered in emergency rooms.

A classification under section 501(c)(9) of the Internal Revenue Code, a VEBA is a tax-exempt trust whose funds are used to pay eligible medical expenses.