Medical Glossary
To help you better understand your medical benefits, here are definitions of some key words and phrases used to describe the plans.
Annual enrollment — The annual period during which you may choose to change your medical coverage level or switch plans for the next plan year.
Annual out-of-pocket maximum — The maximum amount of coinsurance you pay for covered medical and pharmacy expenses in any single calendar year. For the PPO Plan: once you have paid the out-of-pocket maximum, the PPO pays 100% of expenses (except for plan co-payments, which are still required). Prescription copays do not count toward your out-of-pocket maximum. For the CIGNA Choice Fund: once you have paid the out-of-pocket maximum, the Choice Fund pays 100% of all medical and pharmacy expenses.
Approved charges — Charges for a medical service, including fee schedules and per diems, determined by BCBS and CIGNA to be reasonable, which are used as the standard for payment of benefits. For out-of-network charges, both the PPO plan and Choice Fund benefits apply as a percentage of those established fees.
Brand-name drugs — Prescription drugs that carry a trademark or brand name. Brand-name drugs may be significantly higher in cost than generic drugs, even though, by law, both must have the equivalent active ingredients.
Coinsurance — When both the plan and the member share the costs of expenses, it is considered coinsurance. For the PPO Plan: coinsurance is the portion of medical expenses you must pay in addition to your co-payment. For the CIGNA Choice Fund: coinsurance is the portion of medical and pharmacy expenses that you pay after your have used your HRA fund, and after you have met your deductible and before you have reached your out-of-pocket maximum.
Co-payment (or copay) — In the PPO plan, this is the amount you’re required to pay directly to the provider each time you use medical services (for example, you pay a small co-payment each time you visit a doctor’s office), and it is the amount you pay to the pharmacy for your prescription.
Covered expense — Any expense for medical services or products that is eligible for benefits under your medical plan.
Deductible — A deductible is the amount that you must pay each year before the plan begins paying benefits. For the PPO Plan: a deductible applies only if you go for out-of-network service. For the CIGNA Choice Fund: the deductible applies only after you have used your HRA fund.
Drug maintenance list — A list that identifies medications for disease states that are long term, chronic and stable. If your ongoing medication is on the list, you may be able to purchase several weeks’ supply of it by mail order.
Eligible change in status — Events (such as marriage, divorce, childbirth or change in job status) that qualify you to change your level of medical coverage during the year without waiting until annual enrollment.
Emergency care — Any illness or injury that, without immediate medical attention, could result in loss of life or limb, or cause serious harm to bodily functions (for example, an apparent heart attack, severe bleeding, loss of consciousness, or severe or multiple injuries).
Explanation of benefits (EOB) — The document you receive after you file a claim. The EOB shows how much of the expense the plan paid and how much you are expected to pay. If part or all of the expense is not covered, the EOB should explain why.
Generic drugs — Prescription drugs that meet the standards for safety, purity, strength, and quality as their brand-name counterparts. These drugs, however, bear only a chemical or general-classification name — not a brand name.
In-network services Medical care or treatment you receive from physicians, hospitals, or other health care professionals that participate in the insurance company’s network of providers. You receive the highest level of coverage when you go a provider in the insurance company’s network.
Inpatient hospital care — A hospital stay (usually 24 hours or more) for which a room and board charge is made by the hospital.
Medically necessary — Services and supplies, including tests and examinations that are consistent with generally accepted practices for the diagnosis of an illness or injury, or the medical care of a diagnosed illness or injury. Only medically necessary services and supplies, as determined by the PPO or the Choice Fund, are covered by the plan.
Network — A group of health care providers and facilities that have agreed to provide Metro employees with services at a reduced cost.
Out-of-network services — Care or treatment you receive from physicians, hospitals, or other health care professionals who are not participating in the insurance company’s network.
Outpatient hospital care — A hospital stay (usually less than 24 hours) for which no room and board charge is made by the hospital.
Pre-certification — A requirement under the plan to have all non-emergency hospital admissions approved in advance.
Urgent care — An illness or injury that requires immediate but not emergency care (that is, the condition is neither life- nor limb-threatening). Examples include high fever, flu, earaches, sprains, nausea, and headaches.