INSURANCE DEFINITIONS
The following are definitions of specific terms and words as used in the Public Employees’ Benefit Program (PEBP) Plan Document, or that would be helpful in understanding covered or excluded health care services. These definitions do not, and should not be interpreted to, extend coverage under the Plan. Additional definitions and the complete plan documents can be found at www.pebp.state.nv.us.
Coinsurance: That portion of Eligible Medical Expenses for which the covered person has financial responsibility. In most instances, the Covered Individual is responsible for paying a percentage of covered medical expenses in excess of the Plan’s deductible. The coinsurance varies depending on whether in-network or out of network providers are used.
Co-payment, Copay: The fixed dollar amount you are responsible for paying when you incur an Eligible Medical Expense for certain services, generally those provided by network Health Care Practitioners, Hospitals (or Emergency Rooms of Hospitals), or Health Care Facilities.
Non-network: See Out of Network.
Non-Participating Provider: A Health Care Provider who does not participate in the Plan’s Preferred Provider Organization (PPO).
Office Visit: A direct personal contact between a Physician or other Health Care Practitioner and a patient in the Health Care Practitioner’s office for diagnosis or treatment associated with the use of the appropriate office visit code
Open Enrollment Period: The period during which participants in the Plan may select among the alternate health benefit programs that are offered by the Plan or eligible individuals not currently enrolled in the Plan may enroll for coverage. The Plan’s Open Enrollment Period is described in the Eligibility chapter of the Plan Document.
Out-of-Network Services (Non-network): Services provided by a Health Care Provider that is not a member of the Plan’s Preferred Provider Organization (PPO), as distinguished from In-Network Services that are provided by a Health Care Provider that is a member of the PPO.
Out-of-Pocket Maximum: The maximum amount of coinsurance each covered person or family is responsible for paying during a Plan Year before the coinsurance required by the Plan ceases to apply. When the Out-of-Pocket Maximum is reached, the Plan will pay 100% of any additional covered expenses for the remainder of the Plan Year. See the section on Out of Pocket Maximum in the Medical Expense Coverage chapter for details about what expenses do not count toward the Out-of-Pocket Maximum.
Outpatient Services: Services provided either outside of a hospital or Health Care Facility setting or at a hospital or Health Care Facility when room and board charges are not incurred.
Participating Provider: A Health Care Provider who participates in the Plan’s Preferred Provider Organization (PPO).
Pharmacy: A licensed establishment where covered prescription drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices.
Urgent Care Facility: A public or private Hospital-based or free-standing facility, that includes x-ray and laboratory equipment and a life support system, licensed or legally operating as an Urgent Care Facility, primarily providing minor Emergency and episodic medical care with one or more Physicians, Nurses, and x-ray technicians in attendance at all times when the facility is open.
Usual and Customary Charge (U&C): The charge for Medically Necessary services or supplies will be determined by the Plan Administrator or its designee to be the lowest of:
Medical Benefits
1. For medical benefits, no more than the 70th percentile of Ingenix (MDR), a national schedule of prevailing health care charges, updated twice per year; or for dental benefits no more than the 70th percentile of the Ingenix (MDR) updated twice per year; or
2. With respect to a PPO or Participating Health Care or Dental Provider, the fee set forth in the agreement between the PPO or Participating Health Care or Dental Care Provider and the PPO or the Plan; or
3. The Health Care or Dental Care Provider’s actual charge; or
4. The usual charge by the Health Care or Dental Care Provider for the same or similar service or supply.
The “Prevailing Charge” of most other Health Care or Dental Care Providers in the same or similar geographic area for the same or similar health care service or supply will be determined by the Claims Administrator using proprietary data that is provided by a reputable company or entity and is updated no less frequently than annually. The Plan will not always pay benefits equal to or based on the Health Care or Dental Care Provider’s actual charge for health care services or supplies, even after you have paid the applicable Deductible and Coinsurance. This is because the Plan covers only the Usual and Customary charge for health care services or supplies. Any amount in excess of the Usual and Customary Charge does not count toward the Plan Year’s Out-of-Pocket Maximum. The Usual and Customary Charge is sometimes referred to as the U & C Charge, the reasonable and customary charge, the R & C charge, the usual, customary and reasonable charge, or the UCR charge.
Dental Benefits
1. For dental benefits, no more than the 70th percentile of the Ingenix (MDR) Usual and Customary prevailing dental care charges, updated twice per year; or
2. When dental benefits are available under a PPO, the fee set forth in the agreement between the PPO or Participating Dental Provider and the PPO or the Plan; or
3. The Dental Care Provider’s actual charge; or
4. The usual charge by the Dental Care Provider for the same or similar service or supply. The “Prevailing Charge” of most other Dental Care Providers in the same or similar geographic area for the same or similar
health care service or supply will be determined by the Claims Administrator using proprietary data that is provided by a reputable company or entity and is updated no less frequently than annually. The Plan will not always pay benefits equal to or based on the Dental Care Provider’s actual charge for health care services or supplies, even after you have paid the applicable Deductible and Coinsurance. This is because the Plan covers only the Usual and Customary charge for dental care services or supplies. Any amount in excess of the Usual and Customary Charge does not count toward the Plan Year’s Out-of-Pocket Maximums. The Usual and Customary Charge is sometimes referred to as the U & C Charge, and may sometimes be called the reasonable and customary charge, the R & C charge, the usual, customary and reasonable charge, or the UCR charge.
Utilization Management (UM): A Managed Care procedure to determine the Medical Necessity, appropriateness, location, and cost-effectiveness of health care services. This review can occur before, during or after the services are rendered and may include (but is not limited to) Precertification and/or preauthorization; Concurrent and/or continued stay review; Discharge planning; Retrospective review; Case Management; Hospital or other Health Care Provider bill audits; and Health Care Provider
fee negotiation. Utilization Management services (sometimes referred to as UM services, UM program, Utilization Review services, UR services, Utilization Management and Review services, or UMR services) are provided by licensed health care professionals employed by the Utilization Management Company operating under a contract with the Plan.
Utilization Management Company: The independent utilization management organization, staffed with licensed health care professionals, who utilize nationally recognized health care screening criteria along with the medical judgment of their licensed health care professional, operating under a contract with the Plan to administer the Plan’s Utilization Management services.
Well Baby Care; Well Child Care: Health care services provided to a healthy newborn or child that are determined by the Plan to be Medically Necessary, even though they are not provided as a result of Illness, Injury or congenital defect. The Plan’s coverage of Well Baby Care is described under Wellness/Preventive Care in the Schedule of Medical Benefits.
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