This glossary is intended as a quick reference source of employee benefit plan terms. You should research your Summary Plan Booklet for terms and definitions specific to your Plan.
These are ATPA's Executives who attend regular Trust Meetings and directly communicate with Plan Sponsors [Trustees], Fund
Attorneys and Plan Consultants. They provide direction to ATPA's staff, who carry out the duties assigned by the Client.
Department Managers need to contact Account Executives if there are issues that cannot be resolved or if there is need for
Plan clarification of benefits. They typically will understand the intent of a provision since they attend Trust Meetings
and Appeals Meetings where issues are discussed.
Adverse Benefit Determination:
When a Plan Participant files a claim with the Plan for a disability or for health care, the Plan must send a written response.
Any such response in which the claim is out right denied or leaves the Plan Participant with out of pocket expenses to the
provider, is considered an adverse benefit determination. If a Plan normally pays 80% benefits, for example, for certain
services, the 20% payable by the Plan Participant falls into the adverse benefit determination response category. For such
instances, in their Explanation of Benefits [EOBs], Health Plans must point to the specific Plan provision upon which the
adverse benefit determination is made in order to comply with regulations.
An appeal is a formal request by a Plan Participant to have a benefit denial reviewed by the Board of Trustees. ERISA governs
the timeframes in which appeals may be filed and the Plan's timeframes in which to respond, which range from acknowledgement
of receipt to how to perfect the appeal to the appeal outcome.
Some Trust Funds assign special committees to hear appeals. A Trust Fund with eight Trustees on the Board, may have, for
example, an Appeal Committee of 2 to 4 Trustees, half of whom are Labor Trustees and the other half made up of Management
Trustees. The Appeals Committee reviews the details of each appeal and then makes a recommendation to the full Board of
Trustees who approve or deny the appeal.
Assignment of Benefits:
A method under which a claimant requests that his/her benefits under a claim be paid to some designated person or institution,
usually a physician or hospital. Most claims submitted for benefits [99%] are assigned to the health care provider.
See Business Associate Agreement
Board of Trustees:
BOT refers to the Board of Trustees of a Trust Fund. Comprised of representatives from labor or employee and from management
See Board of Trustees
A business agent is a union official who works at or out of the Local Union office. Union members often forge strong alliances
with Business Agents. It is common for Business Agents to contact the Trust Office on behalf of their members who may be having
issues concerning eligibility, pension benefits or claims payments, etc. Due to federal Privacy Rules, the Trust Office must use
discretion when speaking to Business Agents as without a specific authorization signed by the Plan Participant, our office can
disclose no protected health information [PHI] to the union official.
As defined by HIPAA, Privacy and Security Rules, this is the description given to professionals and vendors hired by each Trust
Fund who provide services in connection with Health Plan administration. Each Business Associate is required to enter into
signed Agreements. See Business Associate Agreement.
Business Associate Agreement:
BAA refers to signed Agreements between a Covered Entity and its vendors or Business Associates. Federal Privacy and Security
Regulations require Covered Entities, such as Health Plans, to enter into such written agreements, in which, the parties agree
to comply with the law governing individuals' protected health information. ATPA, as administrative manager (NOTE - ERISA
identifies the BOT as the "Administrator") for its clients Health Plans, is a Business Associate and has entered into such
agreements with each Trust Fund.
Flexible benefit plan under which an employer provides a range of taxable and nontaxable benefits options from which each eligible
employee can make a limited number of selections. Options that may be available to employees through these plans include life
insurance, health programs, retirement plans, vacation time, and stock options. Nontaxable benefits can include group term life
insurance up to a specified amount of coverage, disability benefits, accident and health benefits, and group legal services to
the extent that such benefits are excludable from gross income. A cafeteria plan that includes taxable and nontaxable benefits
must meet certain requirements under the Internal Revenue Code. The term Cafeteria Plan may also describe a health benefit program
that allows employees to select among various cost, coverage, or provider options.
Accessing coverage for a specific type of service through a contract separate from that established with the primary providers.
Also, a method of integrating Medicare with an employer's retiree health plan (making the employer plan excess or secondary) which
tends to produce the lowest employer cost.
A system for assessing, planning treatment for, referring, and following up on patients in order to ensure the provision of
comprehensive and continuous service and the coordination of payment and reimbursement for care. Health Plans hire Case Management
firms to provide this service, which results in cost savings to the Plan.
See Collective Bargaining Agreement
Centers for Medicare and Medicaid:
CMS refers to the agency of the Department of Health and Human Services that administers Medicare, Medicaid and other federal programs
established by the Social Security Act of 1935. [Formerly, the Health Care Financing Administration (HCFA)]
Certificate of Creditable Coverage:
The amount of a Participant's previous qualified health coverage; required by HIPAA in certain circumstances.
An agency that accepts claims from health care providers and resubmits them to the health plan in the plan's desired format and to
meet the plan's electronic data requirements. Once claims are processed by the health plan, responses are sent electronically
through the Clearinghouse back to the health care provider.
See Centers for Medicare and Medicaid
A group health plan / policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will
apply (primary and secondary) when a person is insured under two contracts.
See Consolidated Omnibus Budget Reconciliation Act
Attorneys hired by a Trust. Co-Counsel indicates that there are multiple law firms involved, one representing the labor interests
and another firm representing management interests.
Collective Bargaining Agreement:
CBA refers to the written agreement that spells out the working conditions, wages and benefit package negotiated between an
employer and its union employees.
A screening method by which a health care provider reviews a procedure performed or hospital admission authorized by a colleague
to assess its necessity for ongoing care or treatment.
Consolidated Omnibus Budget Reconciliation Act:
COBRA is a federal law requiring employers to offer continued health insurance coverage to employees who have had their health
insurance coverage terminated.
Coordination of Benefits:
COB is the provision whereby responsibility for primary payment for health services is allocated among carriers when a person
is covered by more than one employer-sponsored health benefit program. This prevents beneficiaries from being reimbursed for
more than 100% of allowable charges and helps to keep health care costs down.
A type of cost-sharing which requires the Plan Participant to pay a specified flat dollar amount, usually on a per-unit-of-service
basis, with the third-party payer reimbursing some portion of the remaining charges.
Efforts by purchasers and by providers to control health care costs through mechanisms such as benefit design, pre-admission
certification, pre-admission testing, and concurrent review programs; second opinion programs; discharge planning; claims audits,
case management, and employee education.
Under HIPAA's Privacy and Security Rule regulations, a business or professional is a covered entity if they fall into one of these
categories: Health Plan, such as our client health plans. Health Care Provider, such as doctors, hospitals or other health care
practitioners. Health Care Clearinghouse, such as firms that receive and forward electronic claims data between a provider and
See Defined Benefit Plan
See Defined Contribution Plan
Required out-of-pocket expenditure by the Plan Participant before the Plan pays towards the allowable charges for a covered service.
Deductibles may be specified in dollar amounts or units of service.
When data has been removed to the extent that the individual who is the subject of the data cannot be identified. See Protected
Defined Benefit Plan: [DB]
Both ERISA and the Internal Revenue Code define a defined benefit plan as any plan that is not an individual account plan. Under
a defined benefit plan, there is a definite formula by which the employee's benefits will be measured. This formula may provide
that benefits be a particular percentage of the employee's average compensation over his or her entire service or over a particular
number of years; it may provide for a flat monthly payment; or it may provide a definite amount for each year of service, expressed
either as a percentage of his or her compensation for each year of service or as a flat dollar amount for each year of service.
In plans of this type, the employer's contributions are determined actuarially. No individual accounts are maintained as is done
in the defined contribution plans. (Defined benefit plans are subject to regulation by the PBGC and are "pension plans" under the
Internal Revenue Code. That is, they are designed primarily for retirement.)
Defined Contribution Plan:
A DC or individual account plan is defined by the Internal Revenue Code and ERISA as a plan that provides for an individual account
for each participant and for benefits based solely on (1) the amount contributed to the participant's account plus (2) any income,
expenses, gains and losses, and forfeitures of accounts of other participants that may be allocated to the participant's account.
401(k), 403(b) and 457 plans are defined contribution plans.
Dental Health Maintenance Organization:
DHMO means a prepaid dental plan or dental HMO arrangement.
Department of Labor:
The Department issues opinion letters and other pronouncements, and requires certain information forms to be filed on employee
See Dental Health Maintenance Organization
See Department of Labor
A listing of prescribed drugs covered by a Prescription Drug Plan or used within a hospital. A positive formulary lists eligible
products while a negative one lists exclusions. Some Plans do not reimburse for prescribed drugs not listed on the formulary.
Other Plan s may have limited reimbursement for non-formulary drugs.
When both spouses are each Plan Participants within the same Trust Fund. This term is also often used to describe individuals enrolled
in both Medicare and Medicaid.
See Electronic Data Interchange
See Electronic Funds Transfer
Electronic Data Interchange:
EDI refers to the automated exchange of electronic data and documents in a standardized format. In health care, some common uses of
this technology include claims submission and payment, eligibility, and referral authorization.
Electronic Funds Transfer:
EFT refers to transmission of funds between entities and banks by electronic means.
Electronic Protected Health Information:
E-PHI refers to individually identifiable health information that is transmitted by electronic media or maintained in electronic media.
Employee Assistance Program:
EAP refers to workplace programs designed to help identify, educate, rehabilitate, and return physically or emotionally impaired
individuals to the job. These programs may include helping employees gain access to health, legal or social services and to control
specific conditions [Examples: substance abuse, gambling, hypertension, stress, etc.]. Many of the Health Plans we administer provide
Employee Retirement Income Security Act:
ERISA refers to the Federal statute that requires persons engaged in the administration, supervision and management of pension monies
have a fiduciary responsibility to ensure that all investment-related decisions are made (1) with the care, skill, prudence and
diligence that a prudent man familiar with such matters would use and (2) by diversifying the investments so as to minimize risk.
This wording mandates two significant changes in traditional investment practice: (1) the age-old "prudent man" rule has been
replaced by the notion of a prudent "expert"; (2) the notion of a prudent investment has been replaced by the concept of a prudent
portfolio. ERISA also established the Pension Benefit Guaranty Corporation (PBGC), an insurance program designed to guarantee workers
receipt of pension benefits if their defined benefit pension plan should terminate. ERISA includes requirements for funding, bonding,
trusts, claims procedures, reporting and disclosure, and prohibited transactions. It regulates the majority of private pension and
welfare group benefit plans in the United States
EA refers to ATPA's Billing & Eligibility Unit that is responsible for receipt and posting of employer payments to the Health Plans.
The amount an employer contributes toward the benefit plan. Employer contributions are usually set forth in the Collective Bargaining
Agreement and can be based on dollar amounts, percentages, employment status, length of service, single or family status, or other
variables or combinations of the above. These monthly contributions are received by ATPA's Employer Accounting Department and are
the basis of creating eligibility in our system on behalf of the Plan Participants.
The process by which an individual / dependents become subscribers to health plan coverage, 401(k) plans, flexible benefit plans, etc.
Plan Participants generally must complete an enrollment form, listing, for example, their spouse and dependents and in the case of
health care, selecting a health care option. This process is managed by Billing & Eligibility - Participant Assistance.
See Explanation of Benefits
Employee Retirement Income Security Act of 1974. A federal law that exempts self-insured health plans from state laws governing health
insurance, including contribution to risk pools, prohibitions against disease discrimination, and other state health reforms.
Specific conditions or circumstances listed in the policy or employee benefit plan for which the policy or plan will not provide
Exclusive Provider Organization:
EPO refers to a form of PPO, in which patients must visit a caregiver who is on its panel of providers. If a visit to an outside
provider is made, the EPO will offer limited or no coverage for the office or hospital visit. This is a more rigid type of PPO,
closely related to an HMO and provides benefits or levels of benefits only if care is rendered by institutional and professional
providers within a specified network (with some exceptions for emergency and out-of-area services).
Explanation of Benefits:
EOB refers to a statement from the health plan or insurer sent to a group member who files a claim giving specific details about
how and why benefit payments were or were not made. It summarizes the charges submitted and processed, amount allowed, amount paid
and the participant's out of pocket amount, if any.
Explanation of Medicare Benefits:
EOMB refers to the statement of payment from Medicare; it shows the amount charged by the provider, the amount approved by Medicare
and the amount actually paid by Medicare. It is the statement that is submitted to the insurance company for payment under the
Medigap policy. Other insurers sometimes use the term explanation of benefits (EOB) to refer to their own payment statements.
Extension of Benefits:
A provision of many policies which allows medical coverage to be continued past the termination date of the policy for employees
not actively at work and for dependents hospitalized on that date. Such extended coverage usually applies only to the specific
medical condition that has caused the disability and continues only until the employee returns to work or the dependent leave
Family and Medical Leave Act:
FMLA refers to the 1993 federal law requiring employers of 50 or more [and public employers of any size] to allow employees to take
leave to care for ill family members and to return to substantially similar employment conditions following the leave.
Fee For Service:
A method in which physicians and other health care providers receive a fee for services performed.
A comprehensive listing of fees used by a Health Plan to reimburse health care providers on a fee-for-services basis.
Relating to, or found upon, a trust or confidence. A fiduciary relationship exists where an individual or organization has an
explicit or implicit obligation to act on behalf of another person's or organization's interests in matters which affect the other
person or organization. This fiduciary is also obligated to act in the other person's best interest with total disregard for
any interests of the fiduciary. Plan Sponsors are fiduciaries to the Trust Funds on whose Boards they sit. ATPA is also a
fiduciary as TPA to its Trust Fund Clients.
The period during which a claimant may file a claim. Most health plans require claims to be filed within 12 months of the date
services were incurred.
FY refers to a 12-month period in which an organization accounts for the use of its funds. Many Trust Funds have calendar year
fiscal years, January 1 to December 31. Other Trusts establish mid-year Fiscal Years, such as from July 1 through June 30.
Fiscal years are referred to by the calendar year in which they ended.
See Family Medical Leave Act
The panel of drugs chosen by a hospital or managed care organization that is used to treat patients. Drugs outside of the
formulary are not used, unless in rare, specific circumstances.
Non-cash benefits, often including health insurance, provided to a worker by an employer.
Full Time Student:
FTS refers to a dependent child who normally would not be covered by the Plan because he or she exceeds the maximum age for coverage.
Most plans provide for extended coverage up to a limiting age provided they qualify as full time students at a college or other
institution of higher learning.
Used as a verb, fund means to pay over to a funding agency (as, to fund future pension benefits, to fund pension cost). Used as a
noun, fund refers to assets accumulated for the purpose of paying benefits as they become due.
Health and Welfare Fund:
H&W refers to health care benefit funds established under provisions of the Taft-Hartley Act, financed through employer and employee
contributions, and administered by a board composed equally of representatives from labor and management.
Health Maintenance Organization:
HMO refers to an entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific
health care providers using a fixed structure or capitated rates. Plan Participants are typically charged co-pays for services,
such as Physician Visits. HMOs emphasize preventive care, early diagnosis and outpatient treatment.
Federal legislation that improves access to health insurance when changing jobs by restricting certain preexisting condition
limitations, and guarantees availability and renewability of health insurance coverage for all employers regardless of claims
experience or business size. The law also increases the health insurance deduction for the self-employed; provides tax incentives
for purchase of long-term care insurance; and establishes medical saving accounts (MSAs), which provide for tax-deductible
contributions to accounts to cover medical expenses.
See Health Maintenance Organization
Indemnity Health Plan:
Similar to a fee-for-service plan in which the insurer pays for all or part of covered services that the patient chooses to
purchase from health care providers.
An insurance policy in which beneficiaries are allowed total freedom to choose their health care providers. Those providers are
reimbursed a set fee each time they deliver a service. Reimbursement is usually limited to a percentage of customary and reasonable
charges (which may be less than the billed amount). Also see fee for service. The employer pays premiums to the health insurance
company to cover the costs of providing benefits and administering claims. The employee may pay a portion of the monthly insurance
premiums, an annual deductible and/or copayments per medical visit.
Large Health Plan:
A plan with receipts of over $5 million annually.
Leave of Absence:
LOA refers to a granted leave from employment.
Medical Child Support Order:
See Qualified Medical Child Support Order
Medicare Part A:
That portion of Medicare that provides coverage for hospitalizations.
Medicare Part B:
That portion of Medicare that provides coverage for non-hospitalization health care.
Medicare Part C:
That portion of Medicare that provides coverage through advantage care plans.
Medicare Part D:
That portion of Medicare that provides coverage for prescription drugs.
Mental Health Parity Act:
MHPA refers to Plans that offer mental health benefits are prohibited from imposing aggregate lifetime or annual dollar limits
for mental health benefits that are less than those imposed on medical/surgical benefits. Substance abuse treatment is excluded.
See Mental Health Parity Act
Money Purchase Plan - A type of defined contribution plan in which the employer's contributions are determined for, and
allocated with respect to, specific individuals, usually as a percentage of compensation. The benefits for each employee are
the amounts that can be provided by the sums contributed to his or her account.
reference: Employee Benefit Plans: A Glossary of Terms, Tenth Edition
Newborns' and Mothers' Health Protection Act of 1996:
NMHPA refers to federal law that mandates that group health plans (as defined in HIPAA) may not restrict the length of any hospital
stay in connection with childbirth for either the mother or the newborn child to less than 48 hours for a normal vaginal delivery
or 96 hours for a Caesarean delivery. Plans may not offer incentives to mothers to accept less time, nor may they penalize providers
for adherence to the law.
A health care provider who has not contracted with the carrier or health plan to be a participating provider of health care.
Notice of Creditable Coverage:
NOCC refers to the annual notice Health Plans are required to send to their Retirees concerning the status of their prescription
drug coverage. If the prescription drug plan is 'creditable', that means it provides as good or better coverage than the average
Part D prescription drug benefits available.
Notice of Non-Creditable Coverage:
NNCC refers to the annual notice Health Plans are required to send to their Retirees concerning the status of their prescription
drug coverage. If the prescription drug plan is 'not creditable', that means it does not provide as good or better coverage than
the average Part D prescription drug benefits available.
A period during which subscribers in a health benefit plan have an opportunity to select an alternate health plan being offered to
them - such as, an indemnity plan vs. HMO; or a period when uninsured employees and their dependents may obtain coverage without
presenting evidence of insurability.
PA refers to ATPA's Billing & Eligibility Unit that is responsible for direct contact with Plan Participants, from sending initial
enrollment packets to managing open enrollment, distributing Notifications and responding to caller's inquiries concerning Eligibility
for Active and Retiree populations. PA is also responsible for managing the full range of COBRA issues for Participants who lose
employment or require portability of their Health Plan coverage for other reasons.
A health care provider who has a contractual arrangement with a health care service contractor, HMO, PPO, IPA or other managed
An examination of the insured's payroll records by a representative of the insurer to determine the premium due on a policy.
Some insurance, notably workers' compensation, charges its premium on the basis of the policyholder's payroll. The company sends
out "payroll auditors" to determine the accuracy of the policyholder's figures. In the multiemployer plan context, frequently a
part of the collections enforcement procedure, in which the payroll records of a contributing employer are audited by a trust fund
representative or fund employee to ensure that contributions are being made in accordance with the provisions of the collective
The party that establishes and maintains the plan, which is joint board of trustees or other similar group of representatives
of the parties involved, in the case of a plan maintained by one or more employers and one or more employee organizations.
Point of Service Plan:
POS refers to a type of managed care plan that allows members to choose, at the point where care begins, to receive services from
a participating or nonparticipating network provider, usually with a financial disincentive for going outside the network. More of
a product than an organization, POS plans can be offered by HMOs, PPOs or self-insured employers.
An individual changing jobs would be guaranteed health coverage with a new employer, without a waiting period or having to meet
additional deductible requirements. Also, any provision for retaining pension rights / credits when changing from one employer
to another. Vested rights are nonforfeitable. The retention of non-vested (contingent) rights depends upon remaining within the
scope of a multiemployer plan, or its reciprocating plan under a reciprocal agreement. The ability of the consumer to take health
insurance from job to job. The right of an employee to take with him or her, upon separation from the employer, the total
accumulation of monies carried in his or her account.
Power of Attorney:
POA refers to a legal document in which competent individuals can select other individuals to make decisions for them in the event
they become incapacitated.
See Preferred Provider Organization
When a physical or mental condition of a newly insured individual is present prior to the insurance of the new insurance policy.
Normally, these exclusions last from 6 to 12 months, however, more severe conditions may be considered as lifetime exclusions.
Pre-Existing Condition Exclusion:
A physical and/or mental condition of an insured person that existed prior to the issuance of his or her policy. Some plans may
cover these conditions after a waiting period of six months to a year, while others may permanently exclude a person with a
preexisting condition from coverage.
Preferred Provider Organization:
PPO refers to contractual arrangements among hospitals, physicians, employers, insurance companies, or health plans to provide
health care services to subscribers at a negotiated, often discounted, price.
Pregnancy Disability Leave:
PDL refers to a disability that is caused, or contributed to, by pregnancy, childbirth or related medical conditions. Under
Title VII of the Civil Rights Act of 1964, employers must treat such disabilities on a
parity with other, non-pregnancy-related conditions. Also refers to State of California law granting certain leave rights to
employees during who become pregnant.
Prospectively determined rate for insurance coverage for specific health benefits. Generally, a health insurance plan will have
different premium rates for single subscribers, married subscribers and for subscribers with dependants.
See Health Maintenance Organization
Primary Care Physician
PCP refers to a physician designated as responsible to provide specific care to a patient, including evaluation and treatment as
well as referral to specialists
A portion of the federal HIPAA Administrative Simplification Act that requires covered entities to safeguard individually
identifiable protected health information.
Protected Health Information:
PHI refers to information considered protected under federal HIPAA Privacy and Security Rules. Essentially, any identifiers
that could be traced back to an individual are PHI, such as name, Social Security Number, birthdates, etc.
See Qualified Domestic Relations Order
See Qualified Medical Child Support Notice
Qualified Domestic Relations Order:
QDRO refers to a domestic relations order; is a judgment, decree or order (including an approval of property settlement agreement)
that (1) relates to the provision of child support, alimony payments or marital property rights to a spouse, former spouse, child
or other dependent of a participant and (2) is made pursuant to a state domestic relations law (including a community property law).
A domestic relations order is a qualified domestic relations order if it creates or recognizes the existence of an alternate payee's
right, or assigns to an alternate payee the right, to receive all or a portion of the benefits payable to a participant under a plan,
specifies required information and does not alter the amount or form of plan benefits. An alternate payee is a spouse, former
spouse, child or other dependent of a participant who is recognized by a domestic relations order as having a right to receive
all, or a portion of, the benefits under a plan with respect to the participant.
Qualified Medical Child Support Notice:
QMCSO refers to a judgment, decree or order that (1) is issued by a court of competent jurisdiction pursuant to a state domestic
relations law or community property law; (2) creates or recognizes the right of an alternate recipient to receive benefits under
his or her parent's employer's group health plan; and (3) includes certain information relating to the participant and alternate
See Retiree Drug Subsidy
A mechanism to protect against part or all of the financial losses that may be incurred through insuring for risk. Reinsurance may
be used for property and casualty losses as well as for life and health claims. It is a common stop-loss mechanism used by
self-insured and insured entities throughout the economy, including business and industry, labor organizations, hospitals, HMOs,
individual professionals, and even insurance companies. It is commercially available from insurance underwriters. It is also
referred to as risk control insurance. The coverage may be uniquely written for an individual claimant or groups of claimants.
Continuance of coverage under a policy beyond its original term by the acceptance of a premium for a new policy term. The Board of
Trustees for each Trust Fund periodically reviews performance of its vendors and determines whether to renew a contract or send a
request for a bid to other parties.
Retiree Drug Subsidy:
RDS refers to the federal government program implemented January 1, 2006 which provided a means of subsidizing health plans who
continued to make prescription drug coverage available to its retirees and dependents, who are otherwise eligible for Medicare.
A manner of judging medical necessity and appropriate billing practices for services that have already been rendered.
Return to Work:
RTW refers to common abbreviation that means the day the employee returned to work from a leave, such as a disability leave.
Sarbanes-Oxley Act of 2002 [SOA / SOX]:
The act first aims to redress accounting and financial reporting abuses, calling for major changes in corporate governance, internal
financial controls and record managing rules for public traded and companies and public accounting firms. Another significant
provision applies to blackout periods, when plan participants or corporation insiders cannot access their accounts because of
insufficient information. Administrators of individual account plans must now notify participants 30 days in advance of any such
blackout periods; and directors and executive officers (insiders) may not trade in any company stocks during a blackout if they
acquired such stocks in connection with their employment. The act also contains changes to rules pertaining to executive compensation.
[Named for Senator Paul Sarbanes of Maryland and Congressman Mike Oxley of Ohio]
Federal regulations that are part of HIPAA's Administrative Simplification Act. The Security Rule requires that Covered Entities,
including Health Plans, safeguard the confidentiality, integrity and availability of electronic protected health information [e-PHI].
[Directly Invested or Trusteed] A plan funded through a fiduciary, that directly invests the funds accumulated. Retirement payments
are made from the fund as they fall due. This term is used to designate a plan that is not funded through an insurance company.
(Health Care) Some benefits may be insured or subcontracted while others are self-funded.
Often confused with self-insurance, a self-funded health care plan is funded entirely by the Plan Sponsor. A self-funded plan may be
self-administered, or the Plan Sponsor may contract with an outside administrator for an administrative services only arrangement.
Self-funded plans obtain stop-loss insurance to cover catastrophic illnesses.
A fully noninsured or self-insured plan is one in which no insurance company or service plan collects premiums and assumes risk.
In a sense, the Plan Sponsor is acting as an insurance company--paying claims with the money ordinarily earmarked for premiums.
Regardless of the specific self-funding technique a firm chooses, it will need to either buy its administrative services (ASO)
outside the company or develop them in-house. Hence, self-funded arrangements are referenced as ASO or self-administered. There
are two standard self-funding techniques that companies interested in this approach usually evaluate for appropriateness to their
own situation: 501(c)(9) trust and disbursed self-funded plan.
SA refers to the written agreement between ATPA and a Trust Fund, which spells out the duties we have contracted to perform.
Small Health Plan:
An employee welfare plan that covers fewer than 100 participants at the beginning of the plan year.
See Summary Material Modification
See Summary Plan Description
Agreed upon point beyond which a Health Plan is no longer liable for costs. Many Health Plans contract for Stop Loss Coverage
through a Stop Loss Carrier. Once a claimant's benefits reach a certain dollar level, the Health Plan is able to obtain
reimbursement for benefits paid in excess of the attachment point.
The recovery of the cost of services and benefits provided to the enrollee of one Health Plan when other parties are liable,
such as may occur in connection with a motor vehicle accident.
Summary Annual Report:
SAR refers to a summary report on the financial status of an employee benefit plan; must be given to participants.
Summary Material Modification:
SMM refers to a description of important changes to a benefits plan or its summary plan description (SPD), such as plan
administrators, claims procedures and eligibility. ERISA requires the SMM to be provided to each participant and beneficiary.
Summary Plan Description:
SPD refers to the written description or plan booklet of the entire benefits package available to a Plan Participant as required
to be given to persons covered by self-funded plans.
Taft-Hartley Labor Relations Act:
THLRA is an amendment to the National Labor Relations Act of 1935 based on the theory of equalizing the bargaining power of
management with that of labor. Principal provisions: (1) specification of unfair labor practices by labor, (2) granting individual
workers the right to prosecute for unfair labor practices by union or company officials, (3) anti-Communist provisions, (4)
restriction of the closed shop, (5) prohibition of secondary boycott.
Third Party Administrator [TPA]:
TPA refers to administration services provided by firms specializing in management of benefit plans. TPAs collect premiums,
determine eligibility and covered services, pay claims, prepare reports for Plan Sponsors and provide other administrative services.
TPAs administer Plan provisions, which may include reinsurance brokering, cost containment and Participant Notifications.
Insurers may sell administrative services to self-funded groups, but this is described as administrative services only.
Associated Third Party Administrators is a TPA!
Third Party Liability:
TPL refers to provisions in a Health Plan that permit recovery of funds when the loss is caused by the act or omission of a
third party. See Subrogation
See Third Party Administrator
A portion of the federal HIPAA Administrative Simplification Act that requires Covered Entities to process claims electronically
and to use standard data sets or codes to enable all parties to 'converse' in the same language.
A fund whose assets are managed by a trustee or a board of trustees for the benefit of another party or parties. Restrictions as
to what the trustee may invest the assets of the trust fund in are usually found in the trust instrument and in applicable state
and federal laws. In the case of ERISA-controlled employee benefit plan trust funds, there are specific requirements that
should be referred to.
Uniformed Services Employment and Reemployment Rights Act of 1994:
USERRA refers to federal legislation that provides protection of jobs and benefits for employees who take a leave of absence to
serve in the military, National Guard or other uniformed services.
See Uniformed Services Employment and Reemployment Rights Act of 1994
See Utilization Review
Usual, Customary & Reasonable:
UCR refers to charges for health care services in a geographical area that are consistent with the charges of identical or similar
providers in the same geographic area.
UR is the evaluation of the use of hospital services, including appropriateness of the admission, length of stay and ancillary
services. Review may be conducted concurrently, retrospectively, or in combination. The process uses objective clinical criteria
to ensure that the services are medically necessary and provided at the appropriate level of care. UR is conducted by Health Plans
to confirm appropriateness of treatment and length of treatment in an effort to health hold costs down.
A vendor is generally a Service Provider firm with which a Trust Fund or Health Plan contracts, such as PPO Networks, Utilization
Review Firms, HMOs, PBMs, etc. It may also be used in reference to a Trust Fund's or Health Plan's Counsel, Plan Consultant,
Fund Manager, Auditor, Investment Manager, etc., who are sometimes referred to as Plan Professionals.
See Women's Health and Cancer Rights Act of 1998
The liability of a contributing employer to a qualified multiemployer defined benefit plan to make contributions necessary to
fund benefits of employees before it can cease contributions to the plan. The Multiemployer Pension Plan Amendments Act of 1980
(MPPAA) imposes liabilities on contributing employers upon a complete or partial withdrawal of the employer from the plan, rather
than on plan termination as is the case for multiple and single employer plans. MPPAA removed multiemployer plans from the
termination insurance system that governs single and multiple employer plans and substituted a system that imposes liability
for certain unfunded vested benefits when an employer partially or totally withdraws from a multiemployer plan.
Women's Health and Cancer Rights Act of 1998:
WHCRA requires that health plans covering mastectomies must also cover breast reconstruction.
Working Families Tax Relief Act of 2004:
WFTRA provides various tax reform measures, notably a new definition of dependent as "qualifying child" or "qualifying relative."
The new definition may affect hardship withdrawals for medical and tuition plans, QDRO rules and deemed IRAs; it directly impacts
personal income tax filings, health plans, flexible spending accounts and cafeteria plans. Changes are effective for tax and plan
years beginning in 2005.
Year To Date:
YTD is a term often used in accounting and tax-related matters.