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Employee Benefits Glossary

A

Accidental Death and Dismemberment (AD&D)
AD&D provides coverage for death or dismemberment resulting directly from accidental causes. Provides benefits in the event of loss of life, limbs or eyesight as the result of an accident.

Accidental Death Benefit
A benefit in addition to the face amount of a life insurance policy, payable if the insured dies as the result of an accident. Sometimes referred to as "double indemnity."

Accumulation Period
The period during which funds accumulate for later payment on a deferred annuity. The period during which the insured person must incur eligible medical expenses at least equal to the deductible to establish a benefit period under a major medical expense or comprehensive medical expense policy.

Admitted Carriers
Insurance companies licensed to conduct specific types of business in a given country.

Adoption Assistance Program
Benefit programs created to reimburse employees who legally adopt a child, including such costs as adoption agency fees, legal fees, pregnancy and hospital expenses of the natural mother, and immigration and naturalization expenses.

Amendment
(General) An addition, deletion or change in a legal document. (Employee Benefit Plans) A change in the terms of an existing plan or the initiation of a new plan. A plan amendment may increase benefits, including those attributed to years of service already rendered. (Insurance) A formal document changing the provisions of an insurance policy signed jointly by the insurance company officer and the policyholder or his or her authorized representative. See also Retroactive Benefits.

Annual Benefits Statement
A report containing specific information about the status of a participant’s projected pension income or account balance. Can include a description of the value and cost of health and welfare benefits, and is often distributed to employees to promote awareness and appreciation of benefits.

B
 
Beneficiary
A person named by the participant in an insurance policy or pension plan to receive any benefits provided by the plan if the participant dies. A person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit thereunder.

Benefit
The rights of the participant or beneficiary to either cash or services after meeting the eligibility requirements of the benefit plan.

Benefit Package
A listing of specific benefits provided by an employee benefit plan. The total value of noncash compensation.

Benefits Specialist
An individual in an organization, typically in the human resource management function, whose responsibility it is to administer the employee benefits program.

Brand-Name Drug
A drug protected by a patent issued to the original innovator or marketer. The patent prohibits the manufacture of the drug by other companies as long as the patent remains in effect. See also Generic Equivalent Drugs.

C

Call Centre
A telephone call centre used to provide on-demand tracking, routing and reporting of employee benefit questions. Computer telephony integration can instantly provide relevant information about the caller, and speech recognition allows callers to verbalize their requests. The latest developments in call centres include systems for e-mail management.

Certified Employee Benefit Specialist® (CEBS®)
A designation granted jointly by the International Foundation of Employee Benefit Plans and the Wharton School of the University of Pennsylvania to individuals who complete eight college-level courses and examinations in the areas of compensation and design and operation of employee benefit plans and who pledge to a code of ethical standards and continuing education. In Canada, the program is presented jointly by the International Foundation of Employee Benefit Plans and Dalhousie University of Halifax.

Chronically Ill
A person unable to perform two of six activities of daily living for at least 90 days, or who is severely cognitively impaired is said to be chronically ill. Under this term, qualification for long-term care expenses is determined.

Claim
An itemized statement of services rendered by a healthcare provider for a given patient. The claim is submitted to a health benefits plan for payment. A request for payment under an employee benefit plan or insurer by a plan participant or beneficiary for the payment of certain benefits. The right to any debts, privileges or other things in possession of another; also, the titles to anything which another should concede to, or confer on the claimant.

Claim Administrator
Any entity that reviews and determines whether to pay claims to enrollees or physicians on behalf of the health benefit plan. Claim administrators may be insurance companies or their designated claims review organizations, self-insured employers, management firms, third-party administrators or other private contractors.

Claimant
Plan participant who files a claim for benefits.

Coinsurance
A policy provision, frequently found in major medical insurance, by which the insured person and the insurer share the hospital and medical expenses resulting from an illness or injury in a specified ratio (e.g., 80%: 20%), after the deductible is met. A form of cost sharing.

Consultant
A person or firm offering expert business, professional or technical advice to an organization for a salary or fee.

Coordination of Benefits (COB)
A group health insurance 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.

Copayments
Payments made by consumers, in addition to deductibles and coinsurance, to discourage inappropriate utilization and to help finance health benefits plans.

Critical Illness Insurance
A limited form of health insurance that pays for treatment of specified diseases, such as cancer.

D
 
Death Benefit
The payment made to designated beneficiaries upon the death of a participating employee. This could be the employee’s share in the investment fund, the life insurance purchased for him or her, or both.

Deductible
The amount of out-of-pocket expenses that must be paid for health services by the insured before becoming payable by the carrier.

Dental Care Benefits
Dental insurance plans usually cover preventive care and treatment of teeth, gums and the mouth. Some plans may also cover orthodontia, X-rays and cosmetic work. Dental care benefits are considered a part of healthcare benefits, but insurance plans generally separate the two.

Disability
A condition that renders an insured person incapable of performing one or more duties of his or her regular occupation. Benefits plan definitions of disability vary.

Disability Benefits
Periodic payments, usually monthly, payable to participants under some retirement plans if such participants are eligible for the benefits and become totally and permanently disabled prior to the normal retirement date. Includes short-term and long-term disability benefits.

Disability Management
The proactive employer-centered process of coordinating the activities of labor, management, insurance carriers, healthcare providers and vocational rehabilitation professionals in order to minimize the impact of injury, disability or disease on a worker’s capacity to successfully perform his or her job.

Dismemberment
The loss, or loss of use, of a limb or loss of sight from an injury.

Drug Utilization Management (DUM)
A set of utilization management techniques for determining whether a prescribed drug therapy is the most appropriate form of therapy and also which drug is both medically appropriate and financially cost-effective for the presenting condition.

Drug Utilization Review (DUR)
A review system to monitor usage of prescriptions by enrollees, to identify potential interactions with other medications, or to identify alternative effective or cost-effective therapies.

E

Elder Care
Financial, emotional, physical and referral support to parents and older relatives, including adult day care.

Eligibility Requirements
Conditions that an employee must satisfy to participate in a plan or obtain a benefit.

Employee Assistance Program (EAP)
An employment-based health service program designed to assist in the identification and resolution of a broad range of employee personal concerns that may affect job performance. These programs deal with situations such as substance abuse, marital problems, family troubles, stress and domestic violence, as well as health education and disease prevention. The assistance may be provided within the organization or by referral to outside resources.

Employee Self-Service
Automated benefit systems that allow managers and employees to complete processes such as annual benefit enrollment, managing participant-directed accounts like 401(k) plans, changing personal and beneficiary data, tracking vacation and sick days, and referencing the employee handbook online, using company intranets and other Web-based tools. Employee self-service can also include call centers and integrated voice response (IVR). See also Call Centres.

Enrollment
Any process by which an individual and/or dependents become subscribers to health plan coverage, flexible benefit plans, etc. May be done either through an actual “signing up” of the individual, by virtue of a collective bargaining agreement or by conditions of employment.

F

Flexible Spending Accounts (FSAs)
Many flexible benefit programs include flexible spending accounts, which give employees the opportunity to set aside pretax funds for the reimbursement of eligible tax-favored welfare benefits. FSAs can be funded through salary reduction, employer contributions or a combination of both. Employees can purchase additional benefits, pay health insurance deductibles and copayments, or pay for child-care benefits with the money in their FSAs. See also Debit Cards; Dependent Care Flexible Spending Account; Healthcare Flexible Spending Account.

Full-Time Employees
Employees of an employer who work for 1,000 or more hours in a 12-month period or employees who usually work 40 hours per week.

G

Generation X
Individuals born between 1965 and 1980.

Generic Equivalent Drugs
Prescription drugs that are equal in therapeutic power to the brand-name originals because they contain identical active ingredients at the same doses.

Group Insurance
Any insurance plan under which a number of employees and their dependents are insured under a single policy, issued to their employer, with individual certificates given to each insured employee; the most commonly written lines are life and accident and health.

H

Healthcare Flexible Spending Account
Allows employees to set aside pretax funds for eligible healthcare benefits such as vision care and dental care, including deductibles and copayments.

Healthcare Fraud
A deception or misrepresentation that is intentionally made by an individual entity, knowing that the misrepresentation could result in some unauthorized benefit to the individual or to some other party.

Healthcare Provider
An individual or institution that provides medical services (e.g., a physician, hospital, laboratory, etc.). This term should not be confused with an insurance company which “provides” insurance.

Health Insurance
Protection that provides payment of benefits for covered sickness or injury. Included under this heading are various types of insurance, such as accident insurance, disability income insurance, medical expense insurance, and accidental death and dismemberment insurance.

Health Risk Assessment
A wellness program instrument that can evaluate the health status of an individual and the relative risk of disease, injury or death associated with a specific set of lifestyle behaviors when combined with specific information about the individual involved.

I

Infertility Benefits
Insurance coverage for treatments to enable human reproduction where that capacity is reduced or absent. Can range from diagnostic tests, to treatment of underlying causes of infertility to in vitro procedures.

Inpatient
A person who occupies a hospital bed, crib or bassinet while under observation, care, diagnosis or treatment for at least 24 hours.

Integrated Disability Management (IDM)
Single management systems for occupational (workers’ compensation) and nonoccupational (short-term and long-term) disability. Aspects of an IDM program include a single claims intake and notification process, a single claims management system, a common medical case management process, a common return-to-work program and a single database.

L

Life Expectancy
Length of time a person of a given age is expected to live. The period is a statistical average, based on mortality tables showing rate of death at each age. It does not seek to predict the life span of any particular individual.

Life Insurance
A type of insurance that provides a sum of money if the person who is insured dies while the policy is in effect.

Long-Term Disability (LTD)
A disability that prevents a person from continuing in the occupation for which he or she was trained, lasting two years or more.

Long-Term Disability Income Insurance
Insurance issued to an employer (group) or individual to provide a reasonable replacement of a portion of an employee’s earned income lost through serious and prolonged illness or injury during the normal work career.

M

Major Medical Insurance
Supplementary insurance coverage (beyond basic medical) intended to cover the costs associated with a major illness or injury. Although characterized by large maximum limits, some limitations apply. The term can also refer to the catch-all portion of a medical plan that picks up payment for miscellaneous charges.

Maximum Allowable Cost (MAC) List
A list health plans distribute to their participating pharmacies describing the maximum amount the plan will pay for specific medications.

Maximum Out-of-Pocket Payment
The maximum amount of money a person will pay in addition to premium payments. The out-of-pocket payment is usually the sum of the deductible and coinsurance payments.

O

Outpatient
A person who visits a clinic, emergency room or health facility and receives healthcare without being admitted as an overnight patient.

Outpatient Services
Medical and other services provided by a hospital or other qualified facility or supplier, such as a mental health clinic, rural health clinic, mobile X-ray unit or freestanding dialysis unit. Such services include outpatient physical therapy services, diagnostic X-ray and laboratory tests, X-ray and other radiation therapy.

Outsourcing
The practice of purchasing parts or finished goods from domestic nonunion shops or from foreign companies. Means of eliminating in-house management, administrative and/or clerical duties associated with a particular employee benefits plan by contacting with an external service provider specializing in that particular benefit area.

P

Part-Time Employees
Refers to employees who work less than 1,000 hours for an employer in a year. Such employees may be kept from participating in qualified retirement plans. Employees who usually work between one and 34 hours each week (at all jobs within a company) regardless of the number of hours worked in a given week.

Pharmacy Benefits Manager/Management (PBM)
Refers either to an individual or to a company that manages pharmacy benefits. Company services typically include development of formularies and drug utilization review to help contain costs.

Policy
The contract between the insurance company and the policy owner under which the insurance company agrees to pay the policy benefit when specific losses occur, provided the insurer receives the required premiums.

Prescription Drug Formulary
A listing of prescription medications that will be covered by a plan or insurance contract that often fosters substitution of generic or therapeutic equivalents on a cost-effective basis.

Prescription Drug Plan
Usually a provision under medical coverage plans whereby the beneficiary can obtain prescription drugs without incurring potentially large out-of-pocket expense. Different types of prescription drug plans are available. Examples are discount plan, closed panel drug plan, service-delivered plan, mail-order plan and maintenance drug option with major medical plan.

Preventive Care
Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunization and well-person care.

Primary Care
Basic or general healthcare as opposed to specialist or subspecialist care. Primary care providers often oversee the total care of patients, referring the patient to other professionals as appropriate. Physicians whose practices are predominantly primary care include general or family practitioners, internists and pediatricians. Primary care also may be provided by nurse practitioners, physicians’ assistants or other midlevel practitioners.

R

Reinstatement
The resumption of coverage under a policy that has lapsed.

Return-to-Work Program
An employer-sponsored program of rehabilitation, job modification and monitoring to get disabled employees back to work as soon as possible.

S

Service Provider
Any of the following who provide service to a benefit plan: persons, such as accountants, attorneys, enrolled actuaries, investment managers, trustees or other plan fiduciaries; entities, such as third-party administrators or insurance carriers.

Short-Term Disability (STD)
Often considered to be a disability lasting usually not longer than two years.

Short-Term Disability Income Insurance
A provision to pay benefits to a covered disabled person as long as he or she remains disabled up to a specified period.

Sick Leave
Plans that provide employees protection against short-term disability and typically specify a maximum number of benefit days per year or per disability that an employee may take at full pay before insured short-term or long-term disability benefits are initiated.

Surviving Spouse Benefits
Payments to the spouse of a deceased participant.

T

Therapeutic Substitution
The practice of substituting one drug for another when both are thought to produce the same therapeutic effects.

Third-Party Administrator (TPA)
The party to an employee benefit plan that may collect premiums, pay claims and/or provide administrative services. Usually an out-of-house professional firm providing administrative services for employee benefit plans.

Trauma
A severe, life-threatening injury that requires emergency care and possibly extensive lifesaving measures.

U

Underwriter
(Insurance) Can mean (1) the company that receives the premiums and accepts responsibility for fulfilling the policy contract, (2) the company employee who decides whether or not the company should assume a particular risk or (3) the agent who sells the policy.

W

Wellness (Health Promotion) Programs
A broad range of employer- or union-sponsored facilities and activities designed to promote safety and good health among employees. The purpose is to increase worker morale and reduce the costs of accidents and ill health such as absenteeism, lower productivity and healthcare costs. May include physical fitness programs, smoking cessation, health risk appraisals, diet information and weight loss, stress management and high blood pressure screening.

Work/Life Benefits
A broad range of programs and services designed to improve the balance between work and personal life. Includes work reorganization initiatives such as job sharing, flextime and telecommuting; as well as on-site child care and/or elder care, emergency/sick child care, tuition assistance, concierge services, financial or career counseling, etc. Work/life benefits tend to result in healthier, more productive employees and are seen as a retention tool for employers. 

Glossary terms are from the International Foundation of Employee Benefits. The full Benefits and Compensation Glossary can be accessed here.

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