AD&D: Accidental Death & Dismemberment (AD&D) insurance is coverage that would only be paid to your beneficiary(ies) as a result of an accidental death (car accident, etc.) or dismemberment (losing a hand, etc.).
Affiliate: A person or organization officially attached to a larger body. For example, Highland Hospital is an affiliate of the University of Rochester, however, Highland employees receive their pay and benefits directly from Highland Hospital.
AHP: Accountable Health Partners (AHP) is a network of hospitals and physicians that make up the Tier 1 network for the UR Health Plans.
Claim: A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
COBRA Coverage: A federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Coinsurance: The percentage of the fee that the Plan pays for a certain covered expense once you have met your deductible.
Copay: A fixed dollar amount you must pay to a provider at the time services are received.
Covered Service/Coverage: A health care provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.
Deductible: The amount of out-of-pocket expenses that you must pay for health services before the Plan begins to pay benefits for many covered services.
Dependent Child: An employee’s son, stepson, daughter, stepdaughter, adopted child, child placed with the employee for adoption by an authorized placement agency, or eligible foster child placed with the employee by an authorized placement agency or by judgment, decree, or other order of a court, who the employee can claim as a dependent on his or her federal tax return under Code §152. Generally, a child of divorced or separated parents can be treated as a dependent of both parents provided that the child receives more than 50% of his or her support from either or both parents combined and the child has the same principle residence as is in the custody of either or both parents for more than one-half of the year (temporary absences to attend school do not affect the child’s primary residence). It also includes a son, stepson, daughter, stepdaughter, adopted child, child placed with the individual for adoption by an authorized placement agency, or eligible foster child placed with the individual by an authorized placement agency or by judgment, decree, or other order of a court, of a domestic partner/same-sex spouse who the domestic partner/same-sex spouse can claim as a dependent on his or her federal tax return under Code §152.
Domestic Partner: Means the same or opposite gender partner of an employee, who, together with the employee, satisfies all of the following criteria:
- Have an exclusive mutual commitment, similar to that of marriage;
- Are each other’s sole domestic partner and intend to remain so indefinitely;
- Are not legally married to each other or to anyone else in a marriage recognized by state or federal law;
- Are not related by blood to a degree of closeness which would prohibit legal marriage in the state in which the partners legally reside;
- Are at least 18 years of age and are legally competent to contract;
- Are currently residing together and have resided together in a common household for at least six consecutive months and intend to reside together indefinitely;
- At least six months have elapsed since the Office of Total Rewards has received a Statement of Termination of Domestic Partnership from either partner; and
- Share joint responsibility for the partners’ common welfare and financial obligations demonstrated by: (a) the existence of a domestic partner agreement (a qualifying domestic partnership agreement is a legally binding agreement between two individuals creating personal and financial interdependence, i.e., joint and several liability for each other’s debts and expenses, responsibility for mutual care, etc.); and (b) at least two other items showing joint responsibility, such as joint bank accounts, joint deed, mortgage agreement or lease, joint credit account or other liability, joint ownership of a motor vehicle, designation of domestic partner as primary beneficiary for life insurance or retirement contract(s), designation of domestic partner as primary beneficiary of will, durable property or health care power of attorney, co-parenting agreement, or an adoption agreement.
Full-Time: For nonexempt job classifications (excluding those in PAS job classifications paid hourly): a regular weekly work schedule of at least 35 hours; for all professional, administrative, and supervisory (PAS) job classifications (including PAS paid on an hourly basis): a weekly work schedule of 40 hours or more; for faculty: a normal full teaching and research load as defined for the faculty by the college or school concerned.
Gross Wages: The total remuneration in Box 1 of Form W-2 that is paid to a Participant for personal services actually rendered, plus the Participant’s pre-tax elective deferrals under the University’s 403(b) and cafeteria plans, but excluding wellness incentives, tuition assistance, taxable relocation assistance, sign-on bonuses, severance benefits, and forms of extra remuneration not related to actual services.
In-Network: Doctors, hospitals, or other health care facilities that are affiliated with the TPA you have selected. When you use a doctor, hospital, or other healthcare facility that is in-network, your out-of-pocket costs are lower because these providers have agreed to accept a discounted rate in return for your use of their services and because the benefit coinsurance is higher.
Open Enrollment: An annual time frame in which people can enroll or change benefit elections for the coming year.
Out-of-Network: Doctors, hospitals, or other health care facilities that are not affiliated with the TPA you have selected. When you use a doctor, hospital, or other healthcare facility that does not participate in the network, your out-of-pocket costs are higher because these providers have not agreed to accept discounted rates and because the benefit coverage is generally lower.
Out-of-Pocket Cost: The maximum amount you pay each Plan Year to receive covered services after you meet your deductible. Once you meet your out-of-pocket maximum, the Plan pays 100% of covered services you receive. In-network and out-of-network services are subject to separate out-of-pocket maximums.
Part-Time: A regular weekly or monthly schedule which is less than that required for full-time status but generally not less than 17.5 hours per week in the case of those in nonexempt and/or professional, administrative, and supervisory (PAS) job classifications. For faculty, it indicates that the individual carries at least half the normal (full) teaching and research load as defined for faculty by the college or school concerned.
PAS Staff: Professional/Administrative/Supervisory (PAS) job classifications include those in salary grades 50 and above.
Premium: The amount you pay for your health and/or dental insurance every month. In addition to your premium, you usually have to pay other costs, including a deductible, copayments, and coinsurance.
Primary Care Physician (PCP): A physician who directly provides or coordinates a range of health care services for a patient.
Prorate: An amount or benefit is adjusted so that you may owe a partial amount or receive a partial benefit.
Qualifying Event: A qualifying event allows you to change your elections for certain benefits outside of the annual Open Enrollment period. A few common qualifying events include family status changes (such as marriage, divorce, birth, etc.), death, retirement, approved leave (such as FMLA), loss of coverage, etc.
Quarters: Typically fall, winter, spring, summer.
Regular: A period of appointment in nonexempt and/or professional, administrative, and supervisory (PAS) job classifications that is expected to exceed four months, unless otherwise defined in collective bargaining agreements; period of appointment for faculty- instructional staff that is at least one year (or one academic year) or, if shorter, is expected to be renewed. Appointments primarily for furthering education (for example, graduate assistant) are not considered “regular” appointments.
Semesters: Typically fall, winter, spring, summer.
Spouse: Means the employee’s current spouse, if the marriage was valid in the state or country where it was performed.
TAR: Time-as-reported (TAR) is a staff appointment with (1) no regular schedule or (2) in which the individual is generally expected to work fewer than 17.5 hours per week in the case of those in nonexempt and/or professional, administrative, and supervisory (PAS) job classifications, unless otherwise defined in collective bargaining agreements. For faculty, it indicates that the individual carries less than half the normal (full) teaching and research load as defined for faculty by the college or school concerned.
Tax Exempt: This reduces or entirely eliminates your obligation to pay tax. For non-taxable tuition benefits, you must complete the tax exemption form, as needed.
TPA: A third-party administrator (TPA) is responsible for processing medical insurance claims from doctors, hospitals, and pharmacies, in addition to helping your health plan stay in compliance with federal regulations and additional services for members.