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San Joaquin Health Care 2004 JPA Handbook

Glossary of Terms
BENEFIT ALLOWANCE
    The amount allowed to be charged for a specific benefit. This amount is contractually agreed to by the provider of care and the plan. The negotiated rate is based on provider fees and what is considered customary and reasonable.

COBRA
    The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA) requires that the group health plan offer the covered employee and their family members the opportunity for a temporary extension of health coverage (continuation coverage) at group rates in instances where coverage under the plan would otherwise end (that is, upon a qualifying event)

DEDUCTIBLES
    A deductible is a dollar amount. The accumulated amount of eligible expenses incurred throughout the calendar year that must be paid by the member prior to any medical insurance benefits being paid by the plan.

ELIGIBLE EXPENSE
    Charges for medical services or supplies that are covered under the Medical, Dental, Vision and Section 125 FSA plans.
    Amounts eligible for reimbursement from the Dependent Care and/or Health Care Reimbursement Account are as defined by IRC regulations.

FAMILY COVERAGE CATEGORY
    The structure of your coverage type is determined by your district or employer: composite (one premium rate for employee only or family coverage) and tiered (a different premium rate for employee only, employee plus spouse and employee plus family coverage).

HMO-HEALTH MAINTENANCE ORGANIZATION
    A qualified plan that requires you to use a
    pre-defined list of doctors, hospitals and other
    health care providers. You must select a
    primary care physician (PCP) at the time of
    enrollment. This doctor will direct all of your
    medical care.

IPA-INDEPENDENT PRACTICE ASSOCIATION
    A partnership, association or other legal entity that
    has a Service arrangement with individual private
    physicians or other health care providers and who has
    a written agreement in effect with a qualified HMO.

MEDICAL GROUP
    A legal entity or corporation owning medical assets
    and providing care through physicians who are
    employees of the organization.

PCP-PRIMARY CARE PHYSICIAN
    The physician you select to provide your primary care
    a general or family doctor, an internist, a pediatrician
    and in some cases an Obstetrics-Gynecological (Ob-
    Gyn) doctor. Initial referrals to a specialist listed within
    the PCP’s medical group or IPA will be directed by this
    physician.

PPO-PREFERRED PROVIDER ORGANIZATION
    A group of doctors, hospitals and other health care
    providers -a network- providing services for an agreed
    uponcharge. This charge is at a discounted fee. You
    may choose to use providers within or outside of the
    PPO network. If you select a provider who is not part
    of thenetwork, you will pay a higher percentage of the
    costs.A PPO plan is a plan that contracts with a
    Preferred Provider Organization for access to their
    network of providers.

PRE-TAX CONTRIBUTIONS
    Money you elect to contribute to purchase additional
    benefits beyond the dollar amount that your employer
    contributes on your behalf. This includes additional
    money you contribute to a reimbursement or spending
    account. Pre-tax contributions are deducted from your
    pay check before payroll withholding taxes are taken,
    reducing your taxable income.

QUALIFYING EVENT
    A change in family status that is the result of: marriage,
    divorce, the death of a spouse or child or the birth or
    adoption of a child.

REIMBURSEMENT ACCOUNTS
    The Dependent Care and the Un-reimbursed Medical
    Account are both considered reimbursement or flex-
    ible spending accounts (FSA). At the beginning of the
    year, you elect to fund these accounts with pre-tax
    contributions. During the year, you are refunded from
    these accounts for eligible expenses incurred in the plan
    year.

SPECIALIST
    A physician who specializes in a specific type of health
    care. Your primary care physician may refer you to a
    specialty provider if he/she determines you require
    specialty care. In a HMO, services provided by a
    participating specialist are covered only if you receive
    a referral prior to your visit from your PCP, IPA or
    medical group.

TPA-THIRD PARTY ADMINISTRATOR
    A firm selected by the SJJPA to administer the plan
    and process medical claims. The SJJPA has contracted
    with Capitol Administrators to process PPO claims
    for the Morada and Pacific plans and to process the
    San Joaquin Dental Premier & Preferred plans.

CO-PAY
    A co-pay is a flat dollar amount that is the patient’s
    responsibility.

CO-INSURANCE
    A co-insurance is a percentage of the claim that is the
    patient’s responsibility.


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Phone: (209) 546-0402 ~ Fax: (209)546-0824
San Joaquin JPA Handbook 2004