Human Resources: Benefits

  Claim

A form you complete for reimbursement of medical or dental expenses which you have incurred.

Cobra

"COBRA" is the acronym for the Consolidated Omnibus Budget Reconciliation Act. This Act requires BGSU to offer health care benefits for you to purchase if you should leave your job. Complete information on COBRA can be found in Section VI.

Coinsurance

Coinsurance amounts are the percentages of a covered health care service expense that BGSU and you pay. You pay the coinsurance percentage after you meet the deductible requirements.

Contributions

The employee contribution paid for health care coverage. Employee contributions are determined on a Plan Year basis.

Coordination of Benefits (COB)

Describes how the BGSU Plans coordinate payments with other plans (such as your spouse's coverage with another employer). See Section VI for additional information.

Co-payment

An up-front payment which the covered person must pay at the time the service is provided. The co-payment is paid in lieu of any deductible which might otherwise apply.

Cost Containment

The practice you or BGSU may use to help hold down health care costs and to reduce the rate of out-of-pocket increases. The utilization review program, second opinions and the use of generic rather than brand drugs are examples of cost containment.

Coverage

When you have health care "coverage," you have benefits available through participation in BGSU's Medical, Dental, and Prescription Drug Plans.

  Deductible

A specific dollar amount the Health Care Program requires you to pay before it reimburses you for medical charges. For example, if your deductible is $100, you must pay this amount toward covered medical expenses before the Plan pays for any charges above $100.

Dependent

Your legally married spouse and eligible children. See complete definition in  Section I

  Eligibility

Full time contract or classified employees are considered "eligible" employees.

Eligible Expenses

Charges made for services, treatment or supplies which are covered under the Health Care Program.

Eligible Providers

The Plan will only pay for covered services provided by the following persons or entities which are licensed as required:

• Licensed practical nurse (L.P.N.)
• Licensed vocational nurse(L.V.N.)
• Nurse-midwife
• Physician (as defined below)
• Psychologist
• Registered nurse (R.N.)

Exclusions

Specific services or treatments that are not covered by the Health Care Program. You should be aware of the exclusions of your Plan so that you do not accrue financial obligations for medical expenses for which a benefit is not provided.

Experimental/ Investigative Treatment

The Health Care Program does not cover experimental or investigative treatment, procedures, facilities, equipment, drugs, devices or supplies which are not recognized as acceptable medical practice.

  Health Care ProgramHospice

Refers to the combined optional Medical Plans, Dental Care Benefits, and Prescription Drug Card Plan.An agency which provides counseling, medical services, and room and board for terminally ill patients.

  Inpatient

If you receive care as a registered bed patient in a hospital or other approved facility and are charged room and board, you are considered to be a hospital inpatient.

  Medicaid

A medical care program paid for by the federal government, but administered by the states. Medicaid provides medical benefits to persons who are disabled, blind or have low incomes.

Medical Necessity

Treatment for a medical stay or illness must be consistent with the symptoms or diagnosis and must be appropriate with regard to the standards of good medical practice. To determine the medical necessity of a treatment from a Non-Network or non-contracting provider, you must call MMO to precertify.

Mental Health

The Medical Plans provide coverage for treatments which have a substantial likelihood of benefit. Psychotherapy, family counseling and psychological testing are examples of covered mental health services.

  Outpatient Treatment

When you receive treatment in a hospital's dispensary, clinic, physician's office or outpatient department and are not admitted or charged for room and board, you are considered to be treated as an outpatient.

  Participant Physician

A "participant" of the Plan could be you and/or your dependents as long as you/they have met the eligibility requirements of the Plan and have been properly enrolled.Any legally qualified and licensed doctor, psychiatrist, osteopath, dentist, chiropractor, podiatrist, or ophthalmologist practicing within the scope of his/her license. A licensed nurse midwife performing obstetrical procedures also qualifies as a "physician."

Plan

Wherever "Plan" is referred to in this booklet, it describes one of the optional Medical Plans, Dental Care Benefits, or Prescription Drug Plans in the Health Care Program

Plan Administrator

Bowling Green State University

Plan Document

The Plan Document details the provisions of the Health Care Program, and supersedes this information. The Plan Document is available for review in the Benefits Office.

Plan Year

The Plan year commences on January 1 of each year and ends on December 31 of each year. Deductibles, coinsurance, and annual out-of-pocket maximums are also determined on a calendar year basis (January 1 - December 31).

Preferred Provider Organization (PPO)

A group of physicians, hospitals, and other health care providers which agrees to offer services at favorable rates. This group is referred to as a "network."

  Re-certification

Physical therapy and chiropractic treatments require a physicians's certification after the tenth visit for continued coverage.

  Substance Abuse

The Medical Plans provide coverage for substance abuse services such as detoxification and rehabilitation. Refer to Section II for the specific coverage under the Plan which you have selected.