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Glossary

Board of Trustees

Under the Taft-Hartley Act (1947), a health and welfare trust fund must be administered by an equal number of union and employer representatives. These individuals are known as “trustees.” It is their job to manage and administer the plan. They make decisions about the plan’s assets, establish eligibility rules, determine the plan’s benefit levels, and determine the processes and procedures for paying benefits.

Calendar Year Deductible

A calendar year deductible is the amount a participant pays each year before the plan pays benefits. It applies to services that require co-insurance. Co-pays for services, such as a visit to your primary care physician, or for prescription drugs, do not apply to the deductible.

Case Management

Case management is a process in which a patient’s health care providers identify plan participants with special health care needs, and together with the patient and insurance company, develop a plan for coordinating and monitoring care.

Chronic Disease Management

Chronic disease management is a program for coordinating preventive, diagnostic, and therapeutic measures for participants who are at risk for or have specific chronic illnesses or medical conditions (e.g., diabetes, asthma, COPD).

Claim

A claim is a request by a plan provider or participant made to the participant’s insurance company or plan administrator to pay for health care services rendered.

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)

COBRA refers to the law that requires employers or plan sponsors to offer extended benefit plan coverage under certain circumstances when coverage otherwise would end (such as at termination of employment or when a dependent child is no longer eligible).

Co-insurance

Co-insurance is the percentage of a dollar amount that a participant and the plan pay for certain services. After you meet your annual deductible, you pay a share and your medical plan pays a share of co-insurance.

Copay

A copay is a flat dollar amount that you pay for certain health care services (e.g., a $20 copay for a doctor’s office visit). A copay is not the full cost of the service—only the portion of its cost contributed by you.

Dental Table of Allowances

The Dental Table of Allowances is a description of dental procedures and the amounts payable for each. This table may be amended from time-to-time.

Drug List/Forumlary

A drug list (also known as a “formulary”) is a list of the drugs covered by an insurance provider. It includes generic and preferred brand-name drugs.

Emergency

In general, an emergency is a life-threatening situation that if left untreated could result in significant impairment or death.

Explanation of Benefits

An explanation of benefits is the plan administrator’s written explanation to a claim, showing the cost of the service, what the plan paid and what the participant must pay.

Full-Time Students

Under current plan rules, a dependent child loses coverage upon attaining age 19 unless enrolled in an accredited school or college as a full-time student. Students are covered while attending school. Students are also covered during the summer if they attended the previous spring and are registered for the following fall. The extension of coverage to students ends when your child reaches age 25.

To cover your child over age 19, submit the JBT Student Status Form (67 KB PDF) and proof of full-time student status to the JBT Administrative Office. Proof of the student's full-time status can usually be obtained from the school's registrar's office.

Generic Drug

A generic drug is a Food and Drug Administration (FDA) approved copy of a brand-name drug. A generic medicine is equal to the brand-name product in safety, effectiveness, quality and performance. Generic drugs are typically included on a drug plan's drug list/formulary.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA) is legislation passed in 1996 that protects health insurance coverage for individuals who lose or change jobs and establishes a privacy rule and national standards for protecting personal health information.

Health Maintenance Organization (HMO)

A health maintenance organization (HMO) delivers care through hospitals, doctors, and other providers with which the HMO has a contract. An HMO typically covers only care provided by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions.

Health Risk Questionnaire

A health risk questionnaire is a series of questions asked during your annual myhealthIQ screening regarding your current health, your age, what you eat, how much you exercise and whether you use tobacco or alcohol.

Lifetime Maximum Benefit

The lifetime maximum benefit is the maximum amount a medical plan will pay in benefits to a participant during his/her lifetime.

Maintenance Drugs

Maintenance drugs are used to treat conditions on an ongoing or long-term basis.

Multiemployer Trust Fund

A multiemployer trust fund is established to provide health and welfare or retirement benefits to employees. Employers typically contribute toward these benefits on the employee's behalf. A trust fund operates under the terms established by the National Labor Relations Act (1935), as amended by the Labor-Management Relations (Taft-Hartley) Act (1947), which permits a group of employers to contribute money into a trust fund established for the exclusive benefit of employees and their eligible dependents. Contributions are held in trust to pay insurance benefits for participants.

myhealthIQ

myhealthIQ is an annual health screening program that can alert a participant to his/her health risks and the possibility for developing a chronic condition like diabetes or heart disease.

myhealthIQ Score

Your myhealthIQ Score represents the risk that existing and modifiable risk factors (i.e., those that you can do something about) place on your health. The score is calculated using several physical measurements (e.g., height and weight) and blood test results obtained during your worksite health screening.

Network

A network is a group of doctors, hospitals and other health care providers contracted with a health insurance plan to provide services to participants at pre-negotiated (and usually discounted) fees.

Non-Preferred Drug

A non-preferred drug belongs to the most expensive group of drugs. These are not typically included on a drug plan's drug list/formulary. You will pay the most if your prescription is filled with a non-preferred drug.

Non-Preferred Provider

A non-preferred provider is a doctor, hospital or other facility that does not participate in an insurance plan’s network. Benefits for services received through a non-preferred provider are usually provided at lower levels than for in-network care, resulting in higher costs for participants and the plan. In addition, the benefits paid are typically based on the “reasonable and customary” charges allowed by the plan. These charges may be substantially higher than the fees negotiated with and charged by in-network providers.

Out-of-Pocket Maximum

The out-of-pocket maximum is the most you will pay for your deductible and co-insurance each year. It does not include your copays. Once you reach your out-of-pocket maximum, the plan pays 100% of covered medical expenses for the remainder of the calendar year.

Preferred Brand-Name Drug

A preferred brand-name drug is a prescription drug marketed under a specific brand name by the company that manufactures it. A preferred brand-name drug is included on the drug plan's drug list/formulary when a generic is not available. Your cost will be higher than for a generic but less than for a non-preferred drug.

Preferred Provider

A preferred provider is a doctor, hospital or other facility that contracts with an insurance plan’s network. Benefits for services received through a preferred provider (also known as “in-network” care) are usually provided at higher levels than for out-of-network care, resulting in lower costs for participants and the plan.

Preferred Provider Organization (PPO)

A PPO plan gives participants direct access to a network of doctors and facilities that charge pre-negotiated (and typically discounted) fees for the services they provide to members. Plan participants may self-refer to any physician or specialist in the network. The benefit level covered through the plan typically depends on whether the participant visits a preferred network provider or non-preferred provider when seeking care.

Prescription Drug Copay

Typically, participants are required to pay a prescription drug copay when filling a prescription. This is the fixed dollar amount you pay, such as $10 per prescription. The copay is lowest for a generic, higher for a preferred brand-name drug and highest for a non-preferred drug. A copay is not the full cost of the drug—only the portion of its cost contributed by you.

Preventive Care

Preventive care refers to services or tests that help identify health risks and health conditions. For example, preventive care includes mammograms, PAP smears and colonoscopies as well as regular blood pressure checks. In many cases, preventive care can help a patient avoid a serious or even life-threatening disease.

Primary Care Physician

Primary Care Physician (also known as PCP) refers to a participant’s regular medical doctor. This is the physician you see most often. A PCP can be a general practitioner, a doctor who practices family medicine, internal medicine, OB/GYN or pediatrics or a nurse practitioner.

Qualified Medical Child Support Order (QMCSCO)

You may be required to provide coverage for your child(ren) under a Qualified Medical Child Support Order (QMSCO) or through a National Medical Child Support Notice (NMCSN). If the JBT Administrative Office receives a QMSCO or NMCSN requiring you to provide coverage for your child, the JBT is obligated to provide benefits for your child in accordance with the terms of the QMSCO or NMCSN.

Contact the JBT’s Administrative Office at 1-800-JBT-HELP (1-800-528-4357) for detailed information regarding the procedures governing QMCSO and NMCSN determinations. This information is provided at no cost to you.

Reasonable and Customary Charges

Reasonable and customary charges are the amounts a plan will consider for payment of services provided by a non-preferred provider. If a non-preferred provider’s charges are higher than the plan’s reasonable and customary limits, the plan pays co-insurance based on that limit. The participant pays his/her share of co-insurance plus 100% of the amount that exceeds the limit. For example, assume that you have met your deductible and are charged $100 for a service that has a reasonable and customary limit of $80. The plan pays 70% as co-insurance and you pay 30%. In this case, the plan would pay $56 (70% of $80) and you would pay $44 (30% of $80, or $24, plus the $20 that exceeds the limit).

Registered Domestic Partner (and His/Her Eligible Dependents)

You can cover your domestic partner and his or her eligible children if your partnership is registered with the State of California.

For purposes of plan coverage, a domestic partner is a person with whom you have established a domestic partnership under California law. Once you establish a registered domestic partnership with the State of California, you will receive a Certificate of Registration of Domestic Partnership from the Office of the California Secretary of State. For more information, visit the State of California Domestic Partners Registry website.

Generally, you can register your domestic partner if you:

  • Share a common residence
  • Are jointly responsible for each other’s basic living expenses
  • Are not married to another person (unless you and your domestic partner are of the same gender and married to each other in a jurisdiction recognizing same-sex marriage)
  • Are not related by blood in a way that would prevent you from being married in California
  • Are both over 18 years of age
  • Are of the same sex: however, if one or both of you are age 62 or older and eligible for Social Security benefits, you can be members of the opposite sex yet still qualify as Domestic Partners under California law.

To cover your registered domestic partner, you need to provide the JBT Administrative Office with a notarized copy of your Declaration of Domestic Partnership and proof of its filing with the State of California or your Certirficate of Registration of Domestic Partnership.

In addition, each quarter, JBT will bill you for the federal employer payroll taxes on thei fair market value of domestic partner coverage.

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The information on this website is intended only to provide highlights of the benefits available under the Joint Benefit Trust. Complete information about the Plan is contained in the governing Plan documents and any applicable insurance contracts. In the event of any inconsistency between the information on this website and the official Plan documents, the terms of the official Plan documents will govern. The Joint Benefit Trust reserves the right to amend, modify, or terminate all or part of the Plan at any time.

Page modified on 7/12/11 11:55 AM