Glossary of Terms
Academic Staff
"Academic Staff" means professional and administrative personnel other than faculty, classified staff, limited staff, student employees, or employees in training, with duties and types of appointments that are primarily associated with higher education institutions or their administration (UWS 1.01) Academic staff titles are identified in the UW Unclassified Title Guideline
Alternate Plan
Health Maintenance Organization (HMO)
Appointment
The action of an appointing authority to place a person in a position within the agency in accordance with the law and the Rules of the Administrator, Division of Merit Recruitment and Selection (DMRS). An appointment is effective when the employee reports for work or is in paid leave status on the agreed starting date and time
Benefit
The rights of the participant or beneficiary to either cash or services after meeting the eligibility requirements of the benefit plan
COBRA
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Requires Employer to provide each participant and qualified beneficiary under the Group Plan the option to pay for continued coverage for a specified period of time under the Plan in the event coverage would otherwise have ceased as a result of one of a number of "qualifying events"
- Medicare coverage is extended to state and local government employees
- Employer-provided medical plans can no longer require Medicare to be the primary payer for participants age 70 and over
Continuation Coverage
Coverage under a health insurance plan paid for by a qualified beneficiary following the occurrence of a qualifying event under COBRA
Conversion Coverage
Privilege given to participant to convert to individual policies on termination of group coverage without evidence of insurability. Usually done after exhausting COBRA rights
Coordination of Benefits (COB)
A group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts
Copayment
A specified dollar amount that participant must pay each time covered services are provided, subject to any maximums provided in Schedule of Benefits
Craftworkers
Classified, hourly employees represented by the Building Trades (BU 04)
Deductible
The portion of eligible medical expenses that the participant must pay before the Plan will make any benefit payments
Dismissal for Cause
The termination of an academic staff member’s employment for just cause using Academic Staff policies and procedures
Drug Formulary
A list of prescription drugs approved for coverage by a given health insurance plan A listing of prescription medications that will be covered by a plan or insurance contract that often fosters substitution of generic or therapeutic equivalents on a cost-effective basis
Dual-Choice
"Dual-Choice" refers to an annual enrollment period when currently insured eligible employees may change Health Insurance plans without restriction. The annual Dual-Choice period normally occurs in each October. Changes normally take effect on January 1 of the following year. The name Dual-Choice was created at a time when State Employees had just two plans from which to choose. There are currently more than 20
Eligible Dependents
Your Spouse; and your children including: natural children; adopted children; pre-adoption placements; legal wards who became wards before age 19; stepchildren; grandchildren born to your dependent child (grandchild is covered until the end of the month in which your child turns 18 or ceases to be an eligible dependent, whichever occurs first)
Employee
Any person who receives remuneration for services rendered to the state under an employer-employee relationship in the classified civil service, except where otherwise stated or modified by rule
Employee-in-training
Persons holding titles in this category usually are not enrolled students and are acquiring additional training or experience in their fields of specialization, typically after receiving an advanced degree
Employee Reimbursement Account
An optional benefit that allows eligible State employees to pay for eligible expenses from pre-tax income rather than after-tax income. The program is authorized under Section 125 of the Internal Revenue Service Code
Employer
Any person acting directly as an employer, or indirectly in the interest of an employer, in relation to an employee benefit plan. The term also includes a group or association of employers acting for an employer in such capacity
Faculty
The faculty consists of all persons with instructional, research and service responsibilities who hold the rank of professor, associate professor, assistant professor, or instructor with at least a one-half time appointment with the UW, or a full- time appointment held jointly between the UW and UW-Extension
Family Coverage
Covers employee and eligible dependents
Fee for Service
Fee-for-service plans allow providers of medical services to bill for services as they are rendered
A traditional health benefits plan that pays benefits directly to physicians, hospitals, or other health care providers, or that reimburses the patient for covered medical services. Examples are Blue Cross & Blue Shield and Medicare. Standard Plan and, Standard Plan II and State Maintenance Plan are fee-for-service plans
All three are managed by Blue Cross Blue Shield United of Wisconsin (BWBSUW)(Standard Plan and Standard Plan II differ only in the amount of deductible and copay required)
Full Time Student
Student means a person who is enrolled in an institution which provides a schedule of courses or classes and whose principal activity is the procurement of an education. Full-time status is defined by the institution in which the student is enrolled. A student is considered to be enrolled on the date that person is recognized as a full-time student by the institution (usually first day of classes)
Grievance
Any written statement of dissatisfaction with a managed care plan or limited service health organization submitted by or on behalf of a plan enrollee
Health Maintenance Organization (HMO)
An association of hospitals, physicians and other health professionals that receive a pre-paid fee per participant to provide all medically necessary covered services to HMO participants; provides health care services for enrollees in a particular geographic area; requires the use of specific plan providers
HIPAA
Health Insurance Portability and Accountability Act
A special enrollment when an employee or dependent is eligible but not enrolled and there is a marriage or birth, adoption or placement for adoption, if coverage is elected within 30 days of the event
Layoff
- The termination of an academic staff member’s employment because of funding loss or a budget or program decision either prior to the end of the appointment or when proper notice of nonrenewal under ASPP 3.04 cannot be given
- Permanent and probationary [classified] employees may be laid off if the classified work force is reduced because of work stoppage, lack of work or funds, or material changes in duties or organization. The UW follows policies and procedures that comply with the Rules of the Department of Employment Relations, Division of Merit Recruitment and Selection (DER-MRS) and collective bargaining agreements where applicable
Leave of Absence
Absence from employment with the approval of the appointing authority with or without loss of pay in accordance with the appropriate statutory provision or rule
Limited Term Employee (LTE)
Employment in which the nature and conditions do not permit attainment of permanent status in class and for which the use of normal procedures for recruitment and examination are not practicable
Managed Care
A health insurance plan that makes available to its members health care services performed by providers selected by the plan and which seeks to manage the cost, accessibility, and quality of care
Medically Necessary
A service, treatment, procedure, equipment, drug, device or supply provided by a Hospital, physician or other health care provider that is required to identify or treat a Participant's illness or injury and which is, as determined by the Plan: (1) consistent with the symptom(s) or diagnosis and treatment of the Participant's illness or injury; (2) appropriate under the standards of acceptable medical practice to treat that illness or injury; (3) not solely for the convenience of the Participant, physician, Hospital or other health care provider; (4) the most appropriate service, treatment, procedure, equipment, drug, device or supply which can be safely provided to the Participant and accomplishes the desired end result in the most economical manner
Medicare
Medicare is a Federal health insurance program for people 65 years or older, certain people with disabilities, and people with permanent kidney failure treated with dialysis or a transplant. Medicare has two parts - Part A (hospital insurance) and Part B (medical insurance.)
Non-Plan Provider Means any services provided to Participants outside the Plan Service Area
Means a provider who does not have a signed Participating Provider agreement and is not listed on the most current edition of the Plan's professional directory of plan providers
Non-Renewal of Appointment
The termination of an academic staff member’s employment at the end of the appointment because of funding loss, a budget or program decision, or unsatisfactory performance, when proper notice of nonrenewal under ASPP 3.04 is given
Out-of-Area Service
Means any services provided to Participants outside the Plan Service Area
Participant
The Subscriber or any of his/her Dependents who have been specified for enrollment and are entitled to benefits
Plan
The HMO or other provider providing health insurance services under the Group Insurance Board's program
Plan Service Area
Specific zip codes in those counties in which the affiliated physicians are approved by the Plan to provide professional services to Participants covered by the Plan
Preauthorization/precertification
A provision in insurance policies that requires prior approval by a managed care plan or limited service health organization in order for services to be covered by the plan
Pre-existing condition
A condition for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the (Standard Plan) enrollment date, except pregnancy
Primary Care Provider
Means a Plan Provider who is a physician named as a Participant's primary health care contact. He/She provides entry into the Plan's health care system. He/She also (a) evaluates the Participant's total health needs; and (b) provides personal medical care in one or more medical fields. When medically needed, he/she then preserves continuity of care. He/She is also in charge of coordinating other provider health services and refers the Participant to other Providers of Health Care Must be selected when enrolling in an HMO.
Provider
Doctors, Hospitals, and clinics; and any other person or entity licensed by the State of Wisconsin, or other applicable jurisdiction, to provide one or more Plan Benefits
Qualified Plan
"Qualified" simply means that the Group Insurance Board has determined that a plan meets its requirements for providers in a particular service area, based on availability of primary providers, hospital, pharmacy, chiropractor and dentists, if dental coverage is offered by the plan
Qualifying Event
An occurrence entitling a person to a special enrollment opportunity under HIPAA, such as marriage or the birth, adoption or placement for adoption of a child; or to elect continuation coverage under COBRA, such as termination of employment (or a reduction in hours), death of a covered employee, divorce or legal separation, a covered employee's eligibility for Medicare, a dependent child's loss of dependent status, or loss of coverage due to the employer's filing of a bankruptcy proceeding
Referral
When a Participant's Primary Care Provider sends him/her to another provider for covered services
SHIP
SHIP is the acronym for Student Health Insurance Plan. Each UW campus offers an insurance plan to domestic and international students who are not covered by any other health insurance.
Single Coverage
Covers only Subscriber
Standard Plan and Standard Plan II
Self-Insured Fee for Service Plans which allows you your eligible dependents the most freedom in choosing health care provider(s). The primary goal is to provide cost-effective health care without sacrificing quality of care or access
State Maintenance Plan (SMP)
Self-Insured Fee for Service Plan available to Wisconsin counties that lack a qualified HMO
State
The State of Wisconsin as the policyholder
Subscriber
An eligible employee who is enrolled for (a) single coverage; or (b) family coverage and whose Dependents are thus eligible for benefits
Support and Maintenance
Support tests as a dependent for federal income tax purposes (whether or not the dependent is claimed). For more information, see Tax Rules for Children and Dependents, IRS Publication 929; and Exemptions for Dependents, IRS Publication 501.
Uniform Benefits
A uniform medical benefits package for alternate health plans adopted by the Group Insurance Board. Its stated purpose is to help contain the rising cost of health insurance and simplify the selection of a health plan for employees whose employers participate in the Department of Employee Trust Funds health insurance programs, including State of Wisconsin employees and annuitants
Usual and Customary
An amount for a treatment, service or supply provided by a health care provider that is reasonable, as determined by the Plan, when taking into consideration, among other factors determined by the Plan, amounts charged by health care providers for similar treatment, services and supplies when provided in the same general area under similar or comparable circumstances and amounts accepted by the health care provider as full payment for similar treatment, services and supplies In some cases, the amount the Plan determines as reasonable may be less than the amount billed. In these situations the Participant is held harmless for the difference between the billed and paid charge(s), other than the Copayments or Coinsurance specified on the Schedule of Benefits, unless he/she accepted financial responsibility in writing, prior to receiving services. Charges for Hospital or other institutional Confinements are incurred on the date of admission. All others are incurred on the date a Participant receives the service or item. The benefit levels that apply on the Hospital admission date apply to the charges for the covered expenses incurred for the entire Confinement regardless of changes in benefit levels during the Confinement
You/Your
The Subscriber
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