Employee Benefits
Frequently Asked Questions
For a Glossary of Health Care Terms And definitions: Click Here
For a link to the Medicare web site: Click Here
For an Explanation of COBRA terms and definitions: Click Here
For an Explanation of HIPAA terms and definitions: Click Here
For CHIP information (Childrens Health Insurance Plan): Click Here
Q. What is an HMO?
A. An HMO is a Health Maintenance Organization and is typically the most affordable plan offered.
Health services are accessed through the Primary Care Physician chosen from the physician listed in the Provider Directory.
For each office visit, you usually pay only your copayment.
Q. What is a PPO?
A. A Preferred Provider Organization is a network of physicians that have agreed, by contract, to discount their rates to carriers.
These "preferred providers" may be Primary Care Physicians or Specialists, and PPO members are free to see any of them. PPO members may also access non-contracted providers, but usually at a higher out- of -pocket- cost .
Q. What is a POS?
A. A Point of Service plan combines the cost savings of a HMO with the flexibility of a PPO. Most plans offer both Dual Option and Triple Option POS plans.
Dual Option: If you are looking for affordability, use the "In-Network" option of you plan.
Just like an HMO, make an Appointment with the Primary Care Physician you have chosen from the Provider Directory.
You will be charged only your copayment.
If you want flexibility, choose to go "Out-of-Network." Like a PPO, you can see any of the preferred providers."
Triple Option: This adds the option of seeing non-participating providers at a higher out-of-pocket-cost.
Q. What is the difference between Emergency Services and Urgent Care?
A. Emergency services is typically defined as those services required as a result of an unforeseen injury or acute illness for which a delay in treatment would result in a permanent physical impairment or loss of life.
Urgent Care, on the other hand, is defined as those services required as a result of unforeseen injuries and acute illness that require immediate attention.
A broken arm may be an example of an urgent care situation. If possible, insurance companies ask that you try to contact your primary care physician in an urgent care situation and arrange your care.
Q. What are "Medical Networks" and "IPA's"?
A. Most contracted physicians belong to either a Medical Group or and IPA.
A Medical Group is a partnership of Primary Care Physicians and Specialists.
These physicians share the same medical offices and are employed by the Medical Group.
An Independent Practice Association (IPA) is just that -a group of independent physicians that have joined together to work with health care companies.
Physicians belonging to an IPA usually have their own offices, separate from other physicians in the IPA.
Q. An employee is laid off and he elects COBRA Health Continuation Coverage. After one year, the Employer rehires the Employee. Must this Employee satisfy any new waiting periods or be subject to pre-existing condition limitations, like any other new Employee?
A. No, this is because the Employee was continuously covered under the plan as a COBRA beneficiary during the period he was unemployed.
However, if the Employer offered medical and dental benefits and the Employee had elected only medical coverage under COBRA, then he will be required to satisfy the waiting period and be subject to the late applicant provisions and limitations that apply to dental coverage.
Q. If an employee terminates employment due to a work related disability, is he eligible to elect COBRA Health Continuation Coverage even though he is eligible to receive benefits under Workers' Compensation?
A. Yes, because the benefits will only be payable for the disabling condition under the Workers' Compensation coverage.
Under COBRA, the Employee will be able to elect coverage for himself and his dependents and coverage will be for all conditions except Employee's disabling condition.
Q. What are some of the more common Acronyms and Abbreviations used in the health care industry today?
A. Acronyms and Abbreviations
AB-Allowed Benefit
AHA-American Hospital Association
AMA-American Medical Association
ASC-Administrative Service Contract
C & S-Claims and Service
CARE-Consolidated Adjudication and Reimbursement System
COB-Coordination of Benefits
COBRA-Consolidated Omnibus Budget Reconciliation Act of 1986
COMP-Comprehensive Insurance
CPT-Current Procedural Terminology
DHMH-Department of Health and Mental Hygiene
DHP-Delmarva Health Plan
DMO-Dental Maintenance Organization
ER-Emergency Room
ECF-Extended Care Facility
EOHB-Explanation of Healthcare Benefits
EOMB-Explanation of Medicare Benefits
FDA-Food and Drug Administration
FEP/FEHP-Federal Employee Program/Federal Employee
Health Plan
HCACC-Health Care Access and Cost Commission
HCFA-Health Care Financing Administration (Medicare)
HIAA-Health Insurance Association of America
HMO-Health Maintenance Organization
HSCRC-Health Services Cost Review Commission
ICM-Individual Case Management
IHM-Integrated Health Management
IMD-Individual Market Division
IP-Inpatient
JCAH-Joint Commission on the Accreditation of Hospitals
LPN-Licensed Practical Nurse
LPT-Licensed Physical Therapist
MB-Medical Benefits
MCO-Managed Care Organization
MEOB-Medicare Explanation of Benefits
MM-Major Medical
NAIC-National Association n of Insurance Commissioners
OCL-Outstanding Claims Liability
OOP-Out- of- Pocket
OP-Outpatient
OPL-Other Party Liability
PAR-Participating (plan, hospital, physician, etc.)
PCP-Primary Care Physician
PDR-Physician Desk Reference
PPA-Preferred Provider Arrangement
PPN-Preferred Provider Network
PPO-Preferred Provider Organization
PT-Physical Therapist
QA-Quality Assurance
RFP-Request for Proposal
RPT-Registered Physical Therapist
RX-Prescription Drug
SRO-Self Referral Option
SSA-Social Security Administration
SSOP-Second Surgical Opinion
TPA-Third Party Administrator
UR-Utilization Review
For an Explanation of 401-K plans: Click Here
For a Glossary of Retirement Plan Terms And Definitions: Click Here
For FAQ regarding Employees who have been called up for Military Active Duty: Click Here
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If you have questions regarding Human Resources or employment regulations
contact your legal counsel or Jennifer McBennett of Seay Management Consultants
at (407) 426.9484
