Glossary - Key Terms and Definitions | UNOFFICIAL MS State & School Employees’ Insurance Plan Help Center

Accidental Injury

A sudden and unforeseen event from an external agent or trauma, resulting in injuries to the physical structure of the body. It is definite as to time and place and it happened involuntarily or, if the result of a voluntary act, entails unforeseen consequences.

Acute Care

Short-term diagnostic and therapeutic services provided in a hospital for a patient who is ill from a disease or injury of an acute nature. The period of acute care continues until the patient is stable enough to be transferred to a long-term care facility or bed for rehabilitation or maintenance care, or until the patient can be discharged to home care.

Allowable Charge

The lesser of the submitted charge or the amount established by the Plan as the maximum amount allowed for covered expenses.

Ambulatory Surgical Facility

An institution licensed as such by the appropriate state agency or certified by Medicare as an Ambulatory Surgical Facility whose primary purpose is performing elective or nonemergency surgical procedures on an outpatient basis.

Brand Name Drug

A drug with a trademark name protected by a patent issued to the original innovator or marketer. The patent prohibits the manufacture of the drug by other companies without consent of the innovator, as long as the patent remains in effect.

Calendar Year

A 12-month period beginning each January 1.

Certification

A review by the Plan's Utilization Review Vendor to determine if an admission or health care service is medically necessary as well as meets the notification requirements of the Plan.

Child

Any natural child, stepchild, child placed in anticipation of adoption, child placed in foster care, legally adopted child, child for whom the enrollee is legal guardian, child for whom the enrollee has legal custody, or child of the enrollee who is required to be covered by reason of a Qualified Medical Child Support Order.

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986)

Federal regulations that provide participants the option to pay for continued coverage under the Plan in the event that the participant no longer meets the Plan eligibility requirements.

COBRA Participant

A qualified beneficiary who elects to continue coverage under the Plan due to a qualifying event.

Coinsurance

The amount (usually a percentage of costs) of a covered health care service that a participant will pay after the deductible has been applied.

Coinsurance Maximum

The maximum amount of coinsurance a participant is responsible for before benefits are paid at 100 percent of the allowable charge for the remainder of the calendar year. Certain expenses cannot be used to meet the coinsurance maximum.

Convalescent Facility

An institution (or distinct part thereof) that meets each of the following tests

- It is primarily engaged in and licensed to provide, for compensation, skilled nursing services or intermediate care services and physical restoration services to convalescing patients on an inpatient basis.

- It provides these services on a 24-hour daily basis and under the full-time supervision of a provider or a registered nurse, with licensed nursing personnel on duty at all times.

- It maintains a complete medical record on each patient and has a utilization review plan for all of its patients.

- It is not, other than incidentally, a place for rest, custodial care, educational care, the care of mental disorders, or a place for the aged. Mental disorders include, but are not limited to, drug addiction, alcoholism, chronic brain syndrome and mental retardation.

Skilled nursing services and intermediate care services means services rendered by a registered nurse or by a licensed practical nurse under the direction of a registered nurse; physical restoration services means services which assist the patient to achieve a sufficient degree of body functioning to permit self-care in the essential activities of daily living; custodial care means care primarily to aid the patient with bathing, dressing, eating, and other activities of daily living; and, chronic brain syndrome means a condition of mental deterioration involving some irreversible brain damage due to a variety of causes ranging from alcohol abuse to senile dementia of unknown cause.

Coordination of Benefits (COB)

The process that determines the order of benefits payable when an enrollee and/or his eligible dependent(s) are covered under more than one insurance plan.

Copayment

A fixed amount you pay for covered health care services that can vary depending on the type of services. A deductible may or may not apply depending on the services provided.

Covered Expense

The expense incurred for eligible services, supplies, and prescription drugs subject to the allowable charge, received on or after the effective date of the participant's coverage. The expense incurred, or portion of such expense, for medical care, services, supplies, or prescription drugs that are prescribed by a health care professional and are necessary in conjunction with the therapeutic treatment of the injury or illness involved, are not excluded from payment of benefits by the provisions of a particular coverage or by the exclusions and limitations, and are not in excess of the allowable charges for the same or similar medical care, services, supplies or prescription drugs.

Covered Provider or Provider

Health care professionals or facilities (as defined in this Plan Document) providing services within the scope of their license under state law. No other practitioners are considered covered providers.

Custodial Care

Services and supplies furnished primarily to assist an individual in the activities of daily living, including room and board, with or without routine nursing care, training in personal hygiene and other forms of self-care, or supervisory care by a provider for a participant who is mentally or physically disabled. Such services and supplies are custodial care without regard to whom they are prescribed, by whom they are recommended, or by whom or by which they are performed. This term also includes convalescent or domiciliary care.

Deductibles (Base Coverage)

- Individual Calendar Year Deductible

A specific dollar amount that a participant must meet for covered expenses before the Plan will pay benefits in a calendar year.

- Family Calendar Year Deductible

A cumulative dollar amount that, when met, satisfies the calendar year deductible for covered expenses for all family members.

- Individual Calendar Year Preventive Medications Deductible

A specific dollar amount that a participant must meet before the Plan will pay benefits for certain preventive medications in a calendar year. Once either the calendar year deductible or the calendar year preventive medications deductible is met, participants will pay the standard prescription drug copayments for certain preventive medications.

Deductibles (Select Coverage)

Calendar Year Deductible

A specific dollar amount that a participant must meet for covered medical expenses before the Plan will pay benefits in a calendar year.

Family Deductible

A cumulative dollar amount that, when met, satisfies the calendar year deductible for covered medical expenses for all family members.

Prescription Drug Deductible

A specific dollar amount that a participant must meet for covered prescription drugs before the copayment amount is applied in a calendar year.

Disabled dependent

A child who is

Permanently mentally or physically disabled or incapacitated.
So incapacitated as to be incapable of self-sustaining employment.
Dependent upon the enrollee for 50 percent or more support.
Otherwise eligible for coverage as a dependent except for age.

The disabling condition must have occurred before the dependent's 26th birthday.

Durable Medical Equipment

Equipment prescribed by the attending provider and determined by the medical claims administrator to be medically necessary for treatment of an illness or injury, or to prevent the participant's further deterioration. The equipment must be made to withstand repeated use. DMEs are primarily used to serve a medical purpose rather than for comfort or convenience and generally not useful to a person in the absence of illness, injury or disease. DMEs are appropriate for use in the home care setting.

Emergency Care

Care as the result of the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical care could reasonably severe injury or even death.

Determination of emergency care is based on presenting symptoms rather than final diagnosis. This means the treatment given in a hospital's or urgent care's emergency room to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in

Permanently placing the participant's health in jeopardy.
Serious impairment of bodily functions.
Serious and/or permanent dysfunction of any bodily organ, or part or other serious medical consequences.
Serious jeopardy to the health of the mother and/or fetus, in the case of a pregnant woman.

Employee

An active full-time employee who has satisfied the specifications in the Health Insurance Eligibility and Enrollment section of this Plan Document.

Employer Unit

Any of the following Mississippi public employers whose employees are eligible to participate in the Plan

State Agency
Institution of Higher Learning
Public School District
Community College
Public Library

Enrollee

An employee, a retired employee, a COBRA participant, or a surviving spouse who is enrolled in the Plan.

Explanation of Benefits (EOB)

An itemized statement from Plan's medical claims administrator or pharmacy benefit manager that lists charges made and the benefits allowed or denied as the result of a claim.

Facility

A hospital or other entity licensed or certified by the appropriate state or federal agency and approved by the Plan and BCBSMS as a specific type of institution to provide a specific level of care.

Formulary

A specific list of covered drugs maintained by pharmacy benefit manager (PBM), which can assist practitioners and pharmacies in selecting clinically appropriate and cost-effective drugs. The formulary represents the clinical judgment of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and promotion of health.

Generic Drug

A drug that is therapeutically equivalent (identical in strength, concentration and dosage form) to a brand name drug and that generally is made available after the expiration of the brand name patent.

Health Care Provider

A physician or other medical practitioner who is licensed to perform specified health services consistent with State law.

Health Savings Account (HSA)

Portable, interest-bearing, funded accounts that provide for tax-free savings for medical expenses as provided by Section 1201 of the Medicare Prescription Drug Improvement and Modernization Act of 2003.

HIPAA

The Health Insurance Portability and Accountability Act of 1996, including all amendments.

Home Infusion Therapy

Services and supplies required for the administration of home infusion therapy regimen.

Horizon Employee

An employee initially hired on or after January 1, 2006, who, before January 1, 2006, was never a full-time employee of a Mississippi State agency, public school district, public community college, public library or State institution of higher learning.

Hospice Care

A program in which emphasis is placed upon palliative and supportive care, either on an inpatient or outpatient basis, to meet the special needs of patients and their families during the final stages of illness. Full scope health services are provided by an organized interdisciplinary team, available on a 24/7 basis.

Hospital

An institution which, for compensation from its patients, is primarily engaged in providing diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment, and care of injured and sick persons by or under the supervision of a staff of providers who are duly licensed to practice medicine in the state where the institution is located; which continuously provides 24-hour a day nursing service by a Registered Nurse (RN); and which is duly licensed as a hospital in such state.

The term hospital may also include an institution that primarily provides psychiatric or chemical dependency care, if licensed as such by the state in which the hospital is located.

Benefits are not provided for treatment in a facility that is primarily a place for rest, rehabilitation or the aged, including custodial and convalescent, except as otherwise provided by the Plan.

Illness

An accidental injury, a bodily or mental disorder, a pregnancy, or any birth defect of a newborn child. Conditions that exist and are treated at the same time or are due to the same or related causes are considered to be one illness.

Intensified Outpatient Program

As provided for the treatment of substance abuse, intensified outpatient program refers to a program provided as a continuation of inpatient substance abuse treatment prescribed by a provider, under the management of a substance abuse provider, which is licensed or certified by the appropriate state or federal agency and is approved by the Plan.

Investigative or Experimental

Use of a procedure, facility, equipment, drug, device, or supply not recognized at the time of treatment as accepted medical practice within the United States for the condition being treated. A drug, device, medical treatment, or procedure will be determined to be experimental or investigational if

There are insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved.
It cannot be lawfully marketed without the approval of the FDA or other governmental agency and such approval has not been granted at the time of its use or proposed use.
It is the subject of a current investigational new drug or new device application on file with the FDA.
A recognized national medical or dental society or regulatory agency has determined, in writing that it is experimental, investigational or for research purposes.
A written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment, or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure, or treatment states that it is experimental, investigational or for research purposes.

It is being provided pursuant to

A Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial.
A written protocol which describes among its objectives, determinations of safety, toxicity, effectiveness, or effectiveness in comparison to conventional alternatives.
Is being delivered, or should be delivered, subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations particularly those of the FDA or the Department of Health and Human Services (HHS).

In the predominant opinion among experts

As expressed in the published, authoritative literature, is substantially confined to use in research setting; or
Is subject to further research in order to define safety, toxicity, effectiveness, or effectiveness compared with conventional alternatives.
Is experimental, investigational, unproven, or is not a generally acceptable medical practice.
Is not a covered service under Medicare because it is considered investigational or experimental as determined by the Centers for Medicare and Medicaid (CMS) of HHS.
Is provided concomitantly to a treatment, procedure, device or drug which is experimental, investigational or unproven treatment.

The Plan may, at its discretion, determine that a drug, device, medical treatment or procedure, which is deemed experimental or investigational under the above criteria, should nonetheless not be deemed experimental or investigational.

Legacy Employee

An employee who is an active employee as of January 1, 2006, or an employee hired on or after January 1, 2006, who was ever a full-time employee with a Mississippi State agency, public school district, public community college, public library, or State institution of higher learning before January 1, 2006.

Legal Custody

The permanent legal status created by a court order which gives the legal custodian the responsibilities of physical possession of the child and the duty to provide him with food, shelter, education and reasonable medical care.

Legal Custodian

A court appointed custodian of a child.

Legal Guardian

A court appointed guardian of a child.

Legal Guardianship

The permanent legal status created by a court order which gives the guardian of a child the same responsibilities as though he was the child's natural parent. This includes the duty to feed, clothe, house the child, and make decisions concerning the child's education and health care.

Long Term Acute Care Facility

A facility specializing in treating patients with serious and often complex medical conditions requiring a longer length of stay than is usually provided by traditional acute care hospitals.

Maintenance Drug

A prescription drug taken for an extended period of time for a chronic health condition.

Maintenance or Exercise Therapy

Consists of activities that preserve the Participant's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.