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In order to get the best value from your benefits, it’s important to understand the terms used when describing the ASEA Health Benefits Trust (the Health Trust). |
- Allowable Expenses - Are the actual costs (billed amount) charged for services to the extent that such charges are Usual, Customary and Reasonable (UCR) for the area and the type of service, or Usual and Reasonable Charge for outpatient dialysis treatment. For non-PPO services in Anchorage, the Allowable Expense for inpatient hospital services will be limited to the contracted rate at Alaska Regional Hospital. The Allowable Expense for outpatient facility at a non-PPO provider in Anchorage will be the case rate at Alaska Regional Hospital or 50% of the billed charges, if no case rate is available. The Allowable Expense for non-PPO physical therapy services in Anchorage will be the contracted rate at Chugach Physical Therapy. Charges in excess of the Allowable Expense as determined by the Plan will not be paid by the Plan, and will not apply to your Annual Out-of-Pocket Maximum.
- Allowable Expenses for Multiple Surgical Procedures - When two or more surgical procedures are performed during the same operative session, the Health Trust Administrator will determine which procedure is primary and the Allowable Expense will be the lesser of the billed charge or:
- 100% of the UCR for the primary procedure, and
- 50% of the UCR for all other procedures
- Allowable Expenses for Assistant Surgeon - When an assistant surgeon bills for services, the Allowable Expense will be the lesser of the billed charge or 25% of the UCR for the procedure performed.
- Annual Deductible - the amount you pay for covered expenses each benefit year before the Plan starts to pay benefits. Plan C has no annual medical deductible. Plans A, B and C have separate dental deductibles.
- Annual Out-of-Pocket Limit - the maximum amount you pay for covered medical expenses in a year if you are in Plan A or Plan B. For example, if under the current Plan A, you pay a $250 deductible, you'll then pay 20% of the first $5,000 in covered expenses to reach the Out-of-Pocket Limit. After that, the Plan pays 100% for that person for the remainder of the benefit year. The Out-of-Pocket Limit is increased and applied to non-PPO services in the Municipality of Anchorage, for Plans A and B.
- Benefit Year - the period beginning July 1 and ending June 30. All benefits limited in a benefit year are reset on July 1 each year.
- COBRA - the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. COBRA allows you and your dependents, under certain circumstances, to continue paying for health care benefits at your own expense, if you lose benefit eligibility.
- Copay - your portion of prescription drug costs.
- Coinsurance - the percentage of the charges you are responsible for paying for certain services (i.e., the Plan pays 80% and you pay 20%)
- Coinsurance Maximum - the maximum amount of coinsurance you pay in a year for eligible medical expenses (not including copays, deductibles, penalties or non-eligible charges). Once you've reached this maximum, the Plan will pay 100% for the rest of the year. This is the same as the Annual Out-of-Pocket Limit.
- Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or with respect to a pregnant woman, the health of the woman and/or her unborn child) in serious jeopardy,
- Serious impairment to bodily functions, or
- Serious dysfunction of any bodily organ or part,
- As determined by the Health Trust Administrator.
- Employee - a person actively working and receiving earnings.
- Full-Time - employees scheduled to work 30 or more hours a week on a regular basis.
- Health Coverage - hospital, surgical, medical, dental, vision, audio, or prescription drug coverage provided under a health plan, such as the ASEA Health Benefits Trust. Health Coverage is subject to change as a result of open enrollments or plan modifications.
- HIPAA - The Health Insurance Portability and Accountability Act, which includes Federal regulations designed to protect the privacy of individually identifiable health information.
- In-network - the doctors, hospitals, laboratories, pharmacies, etc. that are members of a Preferred Provider Organization. When you see a provider "in the network," you benefit from negotiated discounts and the Plan may pay a higher benefit.
- Medically Necessary - a service that is:
- Expected to improve or maintain your health or to relieve pain and suffering without aggravating the condition or causing additional health problems; or
- Expected to provide information to determine the course of treatment; and is no more costly than another service or supply which could fulfill these requirements.
- Open Enrollment - the annual period in which all participants may make a new Plan election.
- Out-of-Pocket Limit - the maximum amount you pay for covered medical expenses in a year, not including your deductible. Plans A and B have an Annual Out-of-Pocket Maximum.
- Part-time - employees scheduled to work at least 15 but less than 30 hours a week on a regular basis.
- Precertification or Precertify - is a request for the determination of medical necessity for a particular procedure, treatment or hospital stay.
- Preauthorization for Travel - a request for coverage for travel expenses. In order to be considered for coverage, preauthorization must be requested before you travel.
- Preferred Provider Organization (PPO) - a network of doctors, hospitals and other health care providers that furnish medical services at discounted fees. You may pay less out-of-pocket when you see a provider in the PPO network. The benefits provided for treatment at preferred provider facilities may be greater than the benefits provided at non-preferred facilities.
- Prior Authorization for Some Medications - is a request for the determination of Medical Necessity for a prescription drug.
- Reimbursement Percentage - the percentage of Allowable Expenses the Plan pays, after the deductible is met.
- Usual Customary & Reasonable (UCR) - the charge the ASEA Health Trust Administrator determines to be the prevailing rate charged in the geographic area where the service is provided or the provider's usual charge, whichever is less. Some types of procedures, such as surgery, are based on claims data statewide or from a larger area to ensure sufficient information to establish UCR. A multiplier may be applied to reflect differences in the cost of services in a particular region.
- Usual and Reasonable Charge for Outpatient Dialysis Treatment means with respect to dialysis-related claims, the Dialysis Claims Administrator shall determine the Usual and Reasonable Charge based upon the average payment actually made for reasonably comparable services and/or supplies to all providers of the same services and/or supplies by all types of plans in the applicable market during the preceding calendar year, based upon reasonably available data, adjusted for the national Consumer Price Index medical care rate of inflation. The Dialysis Claims Administrator may increase or decrease the payment based upon factors concerning the nature and severity of the condition being treated.
