Glossary

Need to find out what something means? Try finding it in our glossary.

The following does not replace the terms and definitions found in your school-sponsored Aetna health insurance plan policy. Please make sure to consult your school-specific web site on the Student Connection for specific terminology as it relates to your school health insurance plan benefits.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Accelerated Death Benefit (ADB)
A group life insurance feature that lets a member or spouse who is diagnosed with a terminal illness or life-limiting medical condition get a percentage of the life benefits as an early payment.

Accidental Death and Dismemberment (AD&D)
A benefit that is payable to a beneficiary for loss of life or to a member for an accidental injury, as specified in a policy.

Accidental Death and Personal Loss Coverage (AD&PL) or AD&D Ultra®
Covers the same losses as AD&D, but also pays a benefit for unexpected events that result in the loss of sight, speech and hearing; paralysis; coma; and third-degree burns. In case of loss of life, benefits may also be available for education, child care and return of remains. An additional benefit may be available if the member dies while properly using a passenger restraint system.

Active Full-Time Employee
An employee who works on a regular basis in the usual course of the employer's business. An employee must work at least the number of hours in the employer's normal workweek or the number of hours as shown in the plan's Schedule of Insurance.

Adjudication
The determination by an insurer or health plan of the availability of health insurance or health benefits for a claim and the level of benefit to be paid.

Aexcel®
A designation by Aetna for certain specialists who have met certain levels of clinical performance and efficiency.

Age Discrimination Employment Act (ADEA)
A federal law that bans unfair and discriminatory treatment in employment on the basis of age.

Aggergate Maxium
The maximum benefit that will be paid under the Policy for all Covered Medical Expenses incurred by a Covered Person that accumulate from one year to the next.

Alcohol & Drug Restriction
Any limit on length of benefits for disabilities related to alcoholism and/or drug addiction.

Allowable Expense(s) (also known as Covered Expense(s))
Any medically necessary and reasonable health expense, part or all of which is covered under any of the health benefits or health insurance plans of the member for whom the claim is made.

Amalgam
A type of filling made up of a mixture of several metallic materials. Amalgams are silver in color and usually used on posterior, or back, teeth.

Ambulatory Surgery
Procedures that do not require an overnight stay in the hospital or ambulatory surgery facility. These procedures can be performed in the hospital, a surgery center or physician office.

Americans with Disabilities Act (ADA)
A federal antidiscrimination law that entitles qualified people with disabilities to the same employment consideration as anyone else.

Any Occupation
A job for which a person is qualified by education, training or experience.

Appeals
A process available to a member to ask that the health plan reconsider a benefit denial or claim decision.

Authorization
The process of receiving approval for some health care, such as hospitalization, outpatient surgery or prescription drugs, before it can be covered. Through this process, eligibility and determination of coverage can be confirmed and communicated before a member receives treatment or services.

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B

Balance Billing
The process of billing a member the difference between the fee amount that the participating doctor or hospital negotiated with the insurer and that doctor's or hospital's usual fee for a service or supply. Participating doctors and hospitals agree not to bill the member for the difference between these two amounts.

Beneficiary
The person(s) or entity that is named by the member to receive the amount of his/her life insurance and/or AD&D insurance, in the event of his/her death.

Benefit
Payment received for covered services under the terms of a health insurance/health benefits plan or policy. Or the amount payable by an insurer to a person making a claim, assignee or beneficiary under each coverage in a group contract.

Benefit Duration
The maximum length of time for which benefits are paid while an employee is out on short-term disability (STD) and long-term disability (LTD), after the employee meets the plan's qualification period. Called "commencement period" for STD and "elimination period" for LTD.

Benefit Period
The maximum length of time for which benefits will be paid.

Brand-Name Drug
A drug that is sold under a specific trade name by a pharmaceutical manufacturer. These drugs are under patent protection. A patent gives the company that developed the drug exclusive rights to make and sell that drug for a time period - usually 20 years. When these rights run out, other drug companies can make and sell generic versions of the drug.

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C

Calculus (Also known as Tartar)
If left untreated, plaque can begin to mineralize and harden into calculus or tartar.

Capitation
A fixed, prepaid amount a doctor or hospital receives for each person served.

Caries
A term that means cavities or tooth decay.

Case Management
A process of: identifying people at high risk for problems related to complex health care needs and; reviewing ways to coordinate care.

Certification
The process of receiving approval for some health care, such as hospitalization, outpatient surgery or prescription drugs, before it can be covered. Through this process, eligibility and determination of coverage can be confirmed and communicated before a member receives treatment or services.

Certification of a Period of Disability
A process used to determine and communicate whether an employee meets the definition of disabled under a disability policy.

Chemotherapy
Treatment of cancer by chemical or biological drugs.

Chiropractic Care
Therapy provided by a licensed professional - a chiropractor - who adjusts the spine and joints to treat pain and improve general health.

Claim
A request for benefits payment to an insured employee or beneficiary (the claimant).

Closed Formulary
Refers to pharmacy plans covering eligible prescription drugs listed on a Preferred Drug List. It does not include drugs on the Formulary Exclusions List. A medical exception is needed to cover prescription drugs on the Formulary Exclusions List.

Combined Life Insurance Maximum
The highest total amount of basic employer-paid and supplemental employee-paid life insurance that may be issued to applicants who have provided satisfactory Evidence of Insurability.

Common Law Marriage
A marriage that is not made official by ceremony, but is created by an agreement to marry, followed by living together. It is only recognized in some states.

Complication of Pregnancy
An event or process that occurs during pregnancy that is not associated with a normal pregnancy.

Composite
A type of filling that matches the natural tooth color. Composites are white and usually used on anterior, or front, teeth.

Congenitally Missing Teeth
Teeth that never existed. This should not be confused with impacted teeth (teeth that never erupted). This is a condition existing at or dating from birth.

Consolidated Omnibus Budget Reconciliation Act (COBRA)
A 1986 federal law for group health plans covering 20 or more employees. The law requires these plans to continue offering coverage to individuals who would otherwise lose it. COBRA does not require continuation of life or disability insurance coverage.

Contract (also known as a Benefit Certificate or Policy)
A legal agreement between an individual subscriber or an employer group (contract-holder) and a health insurance or health benefits plan that describes the benefits and limitations of the coverage.

Contributory
Indicates that the cost of a group insurance plan is made in part by the employer and in part by employees.

Conversion Charge
The amount charged to the policyholder when a covered member chooses to convert group policy coverage to an individual policy.

Conversion Option
An option that allows a member to buy individual life insurance coverage if he/she: loses group coverage because of employment termination or retirement; has less existing group coverage because of a reduced amount due to age.

Coordination of Benefits (COB)
A provision to help avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. One plan becomes the "primary" plan and the other becomes the "secondary" plan. This establishes an order in which the plans pay their benefits.

Copay
The specific dollar amount or percentage that the member must pay, or that must be paid on behalf of a member, when covered services are provided.

Cost of Living Adjustment (COLA)
Optional long-term disability benefit that provides a yearly percentage increase to the monthly benefit received after deductions, usually for a defined period.

Covered Benefits (also known as Covered Services)
Necessary services and supplies that are covered under the plan. They must follow all the terms and conditions of the group agreement or group insurance policy.

Covered Monthly Payroll (also known as Covered Monthly Salary)
The amount of monthly earnings used to calculate the long-term disability premium and disability benefit, taking into account the maximum monthly benefit in the plan.

Covered Weekly Benefit
The amount used to calculate the short-term disability premium and disability benefit, taking into account the maximum weekly benefit in the plan.

Credentialing
A process to evaluate a doctor's qualifications and record of professional competence and conduct. The process includes a review of related training, academic background, experience, licensing, certification and/or registration to practice in a health care field.

Crown Lengthening
The removal of gum tissue (gingiva) and bone, to expose more of the tooth's structure. A dentist will usually perform crown lengthening when a tooth needs to be restored, but there is not enough tooth above the gum line to support the crown or filling.

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D

Date Claim Incurred (DCI)
Under a disability contract, the day the doctor who is responsible for the claimant considers him/her to be disabled.

Date Claim Received
The date the claim is received.

Date Last Worked (DLW)
For long-term disability, the last day a claimant worked any part of the day. For short-term disability, if a claimant worked less than half of a normal scheduled day, the DLW is changed to previous day worked. If a claimant worked a half day or more, then the DLW is that day.

Date of Disability (also known as Date of Claim or Incurred Date)
The date the claimant became disabled according to the policy or plan definition.

Day Treatment Center
A psychiatric facility that is licensed to provide outpatient care and treatment of mental and nervous conditions and/or substance abuse under a doctor's supervision.

Death Benefit (also known as Face Amount or Specified Amount)
The amount of money paid to the beneficiary if the insured dies.

Debridement
The removal of excessive amounts of plaque and tartar, which impair the dentist's ability to examine the teeth. This is performed in rare instances when the patient has not had a dental cleaning in a very long time and a gross amount of debris has built up.

Deductible
An amount of money that a member must pay for covered services, including prescription drugs, in a specified time period, before the plan will pay benefits.

Dependent
A person who is eligible to receive life and/or health insurance/health benefits coverage under a plan's provisions. Examples would be the plan subscriber's spouse, child or domestic partner, if offered.

Diagnostic Tests
Tests and procedures ordered by a health care professional to determine if a person has a specific condition or disease based on signs or symptoms. These may include radiology, ultrasound, nuclear medicine, and laboratory and pathology services or tests.

Direct Access (also known as Open Access)
Refers to health benefits/health insurance plans that let a member visit a participating health care professional without a referral.

Disability
See Long-Term Disability and Short-Term Disability

Disability - Extended Life
A provision that allows the member's life insurance to remain in effect if he/she is unable to work at his/her own job for pay or profit. The disability must also prevent the employee from working at any reasonable job that he/she may be suitable for by education, training or experience.

Disability - Life
When the employee is unable to work at his/her own job for pay or profit. The disability must also prevent the employee from working at any reasonable job that he/she may be suitable for by education, training or experience.

Disability and Absence Management
An inclusive term for the family of disability and absence management products and services.

Disability Extension
A provision that allows for continued life insurance while an employee is disabled. Certain conditions must be met for coverage to be continued. Premiums for continued coverage will be required. The disability extension applies only to employee basic and supplemental life insurance.

Disability Payment
A payment received by an insured person because of a disability.

Disability Provision
A common provision that continues life insurance for an employee who becomes permanently and totally disabled.

Disability Waiting Period - Extended Life
The period an employee must continuously be absent from work, because of disease or injury, in order to be eligible for extended life insurance.

Disease Management Program
A program available under some health insurance/health benefits plans that supports members with chronic - or long term - conditions such as diabetes, asthma and heart disease. The program may include educational materials and member support for monitoring the condition and treatment.

DocFind®
A directory of health care professionals that is available on the website. Used to help members find information about participating doctors, hospitals, dentists, pharmacists and other providers in an area.

Domestic Partners
Generally refers to unmarried, unrelated individuals who live together and are responsible for each other's welfare and financial obligations. May or may not be same-sex couples.

Durable Medical Equipment (DME)
Equipment that is: made for and mainly used in the treatment of a disease or injury; made to be used over a long period of time; suited for use by someone who is not an inpatient in the hospital; not normally of use to people who do not have a disease or injury; not for use in altering air quality or temperature; not for exercise or training.

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E

Earnings Definition
Refers to the base weekly (short-term disability) or monthly (long-term disability) payments that exclude a person's bonuses, overtime or other extra compensation. Some types of compensation, such as commissions, are included or excluded depending on the policy.

Effective Date
The date on which the coverage under a member's plan goes into effect at 12:01 a.m.

Eligibility
Insurance policy terms that define who is eligible to get coverage and the requirements for receiving coverage. These may include length of employment with the plan sponsor, job status and other provisions.

Elimination Period
A period of time that an employee must be continuously disabled before disability benefits are payable.

Emergency (also known as Medical Emergency)
An emergency medical condition having symptoms that are severe enough (including sharp pain) that it causes a careful person, who has an average knowledge of health and medicine, to reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with a pregnant woman, the health of the woman and her unborn child) in serious jeopardy; serious harm to bodily functions; serious dysfunction of any body organ or part.

Emergency Facility
A health facility that provides short-term care for medical situations or procedures needing immediate treatment. Includes urgent care centers, hospitals and walk-in clinics.

Endodontist
A dental specialist who treats diseases of the tooth's nerves or pulp, which is located in the center of the tooth and in canals (called root canals) within each tooth root.

Enrollee
A subscriber or subscriber's dependent who is enrolled in and covered by a health benefits/health insurance plan.

Evidence of Insurability (EOI) (also known as Medical Underwriting)
The process of doing an individual and/or group risk analysis for someone applying for new or increased coverage, where good health must be shown. The EOI process might include: EOI statement - questions about health and medical conditions answered by an applicant; Medical exam - done by a paramedical professional; Tests, such as an EKG; Report from the applicant's doctor; Additional information if required.

Exclusions
Specific conditions or circumstances that are not covered for benefits under a plan.

Experimental Services or Procedures (also known as Investigational)
Health care services, supplies, treatments or drug therapies that have not yet been determined to be effective and safe in treating the illness or injury for which their use is proposed.

Explanation of Benefits (EOB)
A form that explains how the payment amount for a health benefit/health insurance claim was calculated. It also may explain the claims appeal process and provide other information.

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F

Face Amount
The amount of money paid to the beneficiary if the insured dies.

Facility-of-Payment Provision
Allows an insurer to deduct an amount from the life insurance benefit and pay it to a beneficiary, friend or relative before the final settlement of the claim.

Family Medical Leave Act (FMLA)
A federal law for employers with 50 or more employees that entitles eligible employees to a total of 12 workweeks of unpaid leave during any 12-month period for: care of a newborn child within the first 12 months of life; adoption of or foster care for a child within the first 12 months of placement; care of a spouse, child or parent of the employee if afflicted with a serious health condition; medical leave for the employee who has a serious health condition and cannot perform duties of the job.

Formulary (also known as Preferred Drug List)*
A list of the prescription drugs that are approved for coverage by many of the pharmacy benefits plans. It includes many brand-name and generic drugs approved by the U.S. Food and Drug Administration (FDA). Based on a member's plan, preferred drugs on the formulary may have lower copay than nonpreferred drugs.

Formulary Exclusion List
A list of prescription drugs that a pharmacy benefits plan does not cover if a member belongs to a closed-formulary plan. If it is medically necessary for a member in this type of plan to use a drug on the Exclusion List, the member's doctor must contact the Pharmacy Management Precertification Unit to request coverage as a medical exception.

Functional Capacity Evaluation
An assessment of someone's ability and willingness to perform a full range of activities, mostly relating to a job. It might evaluate how well the person can lift, bend, stand, climb or make fine-hand motions, and is usually done by an occupational or physical therapist. *Many drugs on it are subject to rebate arrangements between Aetna and the manufacturer. The Preferred Drug List is subject to change.

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G

Generic Drug
A prescription drug that contains the same active ingredients in the same amounts as its brand-name counterpart. The U.S. Food and Drug Administration (FDA) considers generic drugs to be as effective as brand-name drugs. A generic drug can usually be sold when the patent on a brand-name drug expires.

Gingivitis
Swelling of the gum - or gingival -- tissue caused by plaque. Gums may appear red, swollen, and bleed easily during brushing. This is the beginning stage of periodontal disease.

Group Insurance
Insurance coverage that is available to members through a plan sponsor - usually an employer. The available benefits are defined by the plan sponsor's policy with the insurer. Policies contain detailed plan descriptions, limitations and exclusions for each type of coverage.

Group Universal Life (GUL)
A product that provides ongoing life insurance coverage while allowing the member to build up a fund that has tax advantages.

GSHIP
Graduate Student Health Insurance Plan

Guarantee Issue Maximum
The amount of life insurance coverage up to which an applicant is guaranteed coverage under the group plan without needing to provide Evidence of Insurability.

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H

Hardwaiver
An insurance enrollment process that requires showing or demonostrating proof in hard copy that a student is properly insured. It is the process followed for an insurance requirement policy given by a university or state regulation.

Health Benefits Plan
The health insurance or health maintenance organization (HMO) product offered by a licensed health benefits/health insurance company. The plan is based on a contract and includes a set of covered services or expenses that are obtained through: a network of doctors and other health care professionals or; direct access to licensed health care providers - like doctors - and facilities

Health Insurance Portability and Accountability Act (HIPAA)
A federal law that was created to improve availability and portability - or transferability - of health coverage by: limiting exclusions for pre-existing conditions; giving credit for prior health coverage; allowing transfer of coverage information (such as covered family members and coverage period) to a new insurer; ensuring that people can sign up for health coverage when they lose existing coverage or have a new dependent; banning discrimination in sign-up and payment costs; guaranteeing availability of health insurance coverage for small employers. HIPAA rules also improve the efficiency of the health care system, by: providing a standard way to electronically send health information and; protecting the security and privacy of information that can identify a member.

Health Maintenance Organization (HMO)
A form of health benefits plan that arranges for health services that its members need. In a traditional HMO plan, non-emergency services must be received from a network of health care professionals, although some HMO plans may offer reduced benefits for care received outside of the network. In most HMO plans, members must choose a primary care physician (PCP) from the network to provide routine care and make referrals for specialty and hospital services when appropriate.

Home Health Care
Skilled nursing and other therapy provided by a home health care agency in the home instead of in a hospital or skilled nursing facility.

Home Infusion Therapy
Treating someone at home with drug therapy that is given through a vein.

Hospice Care
Care to support and reduce pain for a terminally ill person, either on an inpatient or outpatient basis, and to support his or her family. The goal is to let terminally ill patients remain in familiar surroundings for as long as possible.

Hospital
An organization providing inpatient and outpatient medical services, which is accredited as a hospital by the appropriate industry organizations, or otherwise determined as meeting reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.

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I

ID Card
A card given out by a health insurance company that provides information about the coverage. It includes a unique member identification number and a toll-free phone number to contact member services.

In-Network
Refers to the use of health care professionals who participate in the health plan's provider and hospital network.

Indemnity Plan
A traditional plan that gives members flexibility in their choice of health care professionals for covered expenses. Members are responsible for finding care, getting precertification, paying for services provided, and sending in claims for repayment of covered services. Indemnity plans usually have out-of-pocket expenses such as deductibles and copayments. The member must pay these before any expenses are paid under the plan. Benefit and lifetime maximums also apply.

Independent Medical Exam (IME)
A medical examination, by an unbiased doctor, that is required to help determine disability.

Independent Practice Association (IPA)
A legal entity or group of doctors that contracts with managed care plans while maintaining a separate practice. A member who selects an IPA as a primary care office generally will be referred to specialists and hospitals connected with the IPA, unless the member's medical needs go beyond the capability of those doctors.

Indexed Pre-disability Earnings
Basic monthly earnings in effect just before the date that disability started, adjusted on January 1 following the first anniversary of benefit payments and each following anniversary. Each adjustment is based on the lesser of 10% or the current annual percentage increase in the Consumer Price Index, which is published by the U.S. Department of Labor. Applies to long-term disability only.

Infusion Therapy
A treatment that gives therapeutic agents through the vein. This includes intravenous feeding and enteral nutrition, which is the delivery of nutrients into the stomach by tube.

Injectable Drug
A liquid medicine that is put into the body with a needle or a tool called a syringe. The medicine may start as a powder that is mixed with water. The medicine is put under the skin, into a muscle, or into a vein.

Inpatient Care
Service provided after a patient is admitted to the hospital. Inpatient care lasts 24 hours or more.

Integrated Health and Disability (IHD)
For members who have medical and disability coverage, refers to the service that combines focused case management with individual contact.

InteliHealth®
An online health website for finding valuable information about current health issues, fitness tips and health-related products.

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J

Job Analysis
A detailed breakdown of a person's job requirements. It is conducted by interviewing the worker and supervisor or observing the work place and the job being performed.

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K

No term available for this letter.

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L

Lapse
Termination - or ending - of a policy because premiums were not paid to the insurer or health plan.

LASIK (also known as laser-assisted in situ keratomileusis)
A vision correction procedure that is performed using a laser.

Late Entrant (also known as Late Enrollee)
An employee who: does not choose coverage within 31 days of first being eligible to do so, whether under the current policy or any prior group policy the person was eligible to elect coverage under, and who enrolls for coverage after the end of the yearly enrollment period or open enrollment period, or; does not choose coverage within 31 days of obtaining a dependent, but chooses coverage at a later date.

Length of Disability (LOD)
The period for which disability is certified.

Level Amount Schedule (also known as Flat Amount)
A benefits schedule under which all employees receive the same amount of benefit. This might differ based on the employee's title.

Life Insurance
A benefit that pays a specific dollar amount to a member's beneficiary upon the death of the member. It is offered through plan sponsors as a group product or sold to individuals. There are many types, including term life, whole life, group universal life and others. The policy defines eligibility, elimination periods, and terms and conditions.

Limitation
Restriction.

Long-Term Disability (LTD)
A benefit that pays an employee a percentage of his/her income if the employee is unable to work for an extended period of time because of a non-work-related illness or injury. The policy defines eligibility, elimination period, and terms and conditions.

LTD Pension Accrual
Benefit that provides pension fund payments at the same time that an insured person is collecting disability benefits (for the period of the disability). It lets the insured collect a regular pension at retirement, without penalty for the period of disability.

LTD Pension Supplement
Benefit that provides for an annuity, or a series of payments made to the insured person on a regular basis, after retirement. It replaces pension benefits that were unearned because of a disability period.

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M

Mail-Order Drugs (also known Rx Home Delivery)
Prescription drug service for pharmacy members, who receive medications by mail. These are prescription drugs used to treat chronic - or long-term - conditions, such as arthritis, asthma, diabetes, high cholesterol, heart conditions and hypertension.

Managed Care
Any form of health plan in which members have access to a network of contracted health care professionals and hospitals, and that requires approval of some services.

Master Policy

Maximum Benefit Amount
The highest benefit amount payable under the plan design. It can be a weekly amount (short-term disability), monthly amount (long-term disability) or annual amount (life).

Maximum Benefit Period
The longest time period for which disability benefits are payable, once all plan conditions are met.

Maximum Drug Benefit
The highest amount a health benefits/health insurance plan will pay to cover the costs of prescription drugs for a member and a member's family during a time period. These periods may be a quarter year, a calendar year or contract year.

Medical Emergency
An emergency medical condition having symptoms that are severe enough (including sharp pain) that it causes a careful person, who has an average knowledge of health and medicine, to reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with a pregnant woman, the health of the woman and her unborn child) in serious jeopardy; serious harm to bodily functions; serious dysfunction of any body organ or part.

Medical Evacuation
When a member is evacuated to an appropriate medical facility due to an emergency medical situation.

Medical Underwriting
The process of doing an individual and/or group risk analysis for someone applying for new or increased coverage, where good health must be shown. The EOI process might include: EOI statement - questions about health and medical conditions answered by an applicant; Medical exam - done by a paramedical professional; Tests, such as an EKG; Report from the applicant's doctor; Additional information if required.

Medically Necessary
Services or supplies that are appropriate for or consistent with the diagnosis according to accepted medical standards as described in the Covered Benefits section of the plan. The term applies only to the determination by the plan whether health care services are covered benefits. All services are subject to the exclusions and limitations described in the plan documents.

Medicare
The federal health insurance program for people 65 years of age or older, certain people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). For more information go to http://www.aetna.com/members/individuals/medicare/medicare_resources/glossary.html

Member (also known as Enrollee)
A subscriber or subscriber's dependent who is enrolled in and covered by a health benefits/health insurance plan.

Member Services
A department in a health insurance/health benefits company that helps members with questions about plan benefits and exclusions and, if part of a plan, choosing or changing a primary care physician (PCP). It is reached by calling the toll-free phone number on the member ID card.

Mental Disorder
A condition that shows itself through poor or unusual physical, psychological or behavioral functioning. Treatment is generally provided by a mental health professional such as a psychiatrist, psychologist or psychiatric social worker.

Minimum Benefit
The least benefit amount payable under a disability period regardless of income from other sources.

Monthly Benefit
A monthly sum payable to a claimant while he/she is disabled.

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N

National Advantage Program (NAP)*
Offers agreed-on rates for: many medical claims that would otherwise be paid as billed under many indemnity plans; the out-of-network portion of managed care plans; emergency/medically necessary services not provided within the standard network.

National Committee for Quality Assurance (NCQA)
An independent, not-for-profit organization that evaluates how well a health insurance/health benefits plan manages all parts of its medical delivery system and continues to improve health care for members.

National Medical Excellence Program®
Helps eligible members get covered treatment for solid organ transplants, bone marrow transplants, and some other rare or complicated conditions at participating facilities experienced in performing these services.

Necessary, Medically Necessary, Medically Necessary Services or Medical Necessity
Services or supplies that are appropriate for or consistent with the diagnosis according to accepted medical standards as described in the Covered Benefits section of the plan. The term applies only to the determination by the plan whether health care services are covered benefits. All services are subject to the exclusions and limitations described in the plan documents.

Network (also known as Provider Network)
Doctors, hospitals and other health care providers who have a contract with a health insurance/health benefits company to provide services at a negotiated rate of repayment.

Non-Occupational Disease
A disease that is not, in any way, connected with employment or self-employment, or does not result, in any way, from a disease or injury that occurs from such an activity.

Non-Occupational Injury
An accidental injury that does not occur from or during any act connected with employment or self-employment, whether or not on a full-time basis.

Noncontributory
The part of the cost of a group insurance plan that is paid by the employer (may be a part of or the entire cost).

Nonparticipating Provider (also known as Out-of-Network or Nonpreferred Care Provider)
Generally used to mean health care professionals - like doctors - and hospitals that have not contracted with a health plan to provide services at reduced fees. *Aetna does not credential, monitor or oversee those providers who participate through third-party contracts. Since there are a number of factors that determine whether a discount will be given, Aetna is unable to guarantee any level of discount under this program.

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O

Occupational Injury/Disease
An injury or disease resulting from performing a job. In most states, an occupational injury or disease is covered by workers' compensation.

Occupational Therapy
Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing.

Open Formulary
Refers to specific pharmacy benefits plans that cover all eligible prescription drugs. In these plans, prescription drugs may be covered at lower copays if they are preferred and higher copays if they are nonpreferred.

Oral and Maxillofacial Surgeon
A dental specialist whose practice is limited to surgical treatment in and around the oral cavity and jaws.

Orthodontist
A dental specialist whose practice is limited to the detection, prevention, and correction of abnormalities in the positioning of the teeth in their relationship to the jaws.

Other Income Benefits (also known as Offsets or Reductions)
Income provided to an employee (and family members) because of the disability period for which the employee is claiming benefits under the plan. Other income benefits, such as Social Security disability, workers' compensation and pensions, may reduce benefits payments and reserves.

Out-of-Pocket Maximum
The highest amount a health plan member is required to pay for covered services outside of his/her benefits plan. Once the member reaches the out-of-pocket maximum(s), the plan pays 100% of expenses for covered services.

Outpatient Care
Care provided in a clinic, emergency room, hospital or non-hospital surgical center, without admitting the patient.

Outpatient Surgery (also known as Ambulatory Surgery)
Procedures that do not require an overnight stay in the hospital or ambulatory surgery facility. These procedures can be performed in the hospital, a surgery center or physician office.

Over-the-Counter (OTC) Drugs
Drugs that can be bought without a prescription. They are not covered under most standard prescription benefits plans.

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P

Palliative
Treatments that are used for the immediate (temporary) relief of pain, not as a final treatment for the patient's condition.

Partial Day Treatment
An outpatient program offered by licensed psychiatric facilities that includes a day or evening treatment program for mental health or substance abuse issues.

Partial Disability
An illness or injury that prevents an insured employee from performing one or more functions of his/her regular job and causes the employee to earn 80% or less of pre-disability earnings.

Participating Pharmacy
A pharmacy that has a contract with a health plan to fill covered prescriptions for its customers.

Participating Provider (also known as Preferred Care Provider)
Any doctor, hospital, skilled nursing facility, other individual or entity involved in the delivery of health care or related services that contracts to provide covered services to members for a negotiated charge.

PCP
Primary care physician who often acts as the primary gatekeeper in health plans. That is,often the PCP must approval referrals to specialists. Particularly in HMOs and somePPOs, all members must choose or are assigned a PCP.

Pediatric Dentist (also known as a Pedodontist)
A dental specialist who treats only children.

Pending Claim
A claim that has not yet been approved or denied.

Periapical
The tissues surrounding the end of the tooth root.

Periodontal Disease (also known as Periodontitis)
A condition that affects the gums and other structures supporting the teeth. Periodontal disease is a chronic bacterial infection combined with inflammation. Bacteria grow in dental plaque, which sticks to the tooth or root surface next to the gums, causing swelling. If left untreated, the bacteria and inflammation will spread and destroy the gums and supporting bone around the teeth.

Periodontist
A dental specialist whose practice is limited to the prevention, diagnosis, and treatment of diseases of the surrounding and supporting structures of the teeth.

Permanent and Total Disability
An insurance contract provision that provides installment or lump-sum payments if a person becomes permanently and totally disabled.

Permanent Partial Disability
Type of workers' compensation disability benefit that repays an employee a percentage or a flat dollar amount of the income he/she lost because of an occupational injury or disease.

Pharmacy Copay (also known as Pharmacy Copayment)
The amount of money a member pays to a participating pharmacy for prescription drugs covered by a pharmacy benefits plan.

Physical Therapy
Treatment that uses exercise and physical movement to relieve pain, restore use, promote healing and prevent disability in a part of the body. The treatment can be a part of care after a disease, illness, injury or operation.

Plan

Plan Documents
The contractual plan documents, describing the terms and conditions of coverage, that are provided to the plan sponsor. They may include the Group Agreement, Group Policy, and Certificate or Evidence of Coverage (or Certificate of Insurance) or Summary of Coverage or Benefits.

Plan Exclusions and Limitations
Binding terms and conditions that are applied to insurance plans. They may refer to services, specific types of coverage, pre-existing conditions and/or other limitations.

Plan Maximum
The greatest amount of benefits that will be paid under an insurance plan.

Plan Sponsor
The organization, usually an employer, to which a health benefits/health insurance or group insurance policy is issued.

Point-of-Service (POS)
A health benefits plan that provides coverage for care received from both participating providers - such as doctors and hospitals - and non-participating providers. In many POS plans, patients whose care is directed through referrals from their primary care physician (PCP) receive a higher level of benefits, while patients who go directly to other physicians or facilities receive a lower level of benefits.

Policy (also known as a Group Plan or Contract)
A contract between an insurer and a group (usually an employer) or an individual subscriber, which describes the provisions, benefits and limitations of coverage.

Portability
The process of receiving approval for some health care, such as hospitalization, outpatient surgery or prescription drugs, before it can be covered. Through this process, eligibility and determination of coverage can be confirmed and communicated before a member receives treatment or services.

Pre-Disability Earnings (PDE)
The weekly or monthly rate of basic earnings in effect on the day before becoming disabled.

Pre-Existing Condition
A health condition (other than pregnancy) or medical problem that was diagnosed or treated during a specified time before enrollment in a new insurance plan. Some pre-existing conditions may be excluded from coverage during a specified time after the effective date of coverage in a new plan.

Preauthorization/Precertification (a.k.a. Authorization, Certification, or Prior Authorization)
The process of receiving approval for some health care, such as hospitalization, outpatient surgery or prescription drugs, before it can be covered. Through this process, eligibility and determination of coverage can be confirmed and communicated before a member receives treatment or services.

Preferred Care Provider
Any doctor, hospital, skilled nursing facility, other individual or entity involved in the delivery of health care or related services that contracts to provide covered services to members for a negotiated charge.

Preferred Drug List
A list of the prescription drugs that are approved for coverage by many of the pharmacy benefits plans. It includes many brand-name and generic drugs approved by the U.S. Food and Drug Administration (FDA). Based on a member's plan, preferred drugs on the formulary may have lower copay than nonpreferred drugs.

Preferred Provider Organization (PPO)
A health benefits plan that lets members choose any doctor or hospital without naming a primary care doctor. It offers incentives, usually in the form of lower payments for services, to members who choose preferred, or in-network, doctors or hospitals.

Premium
The fee or charges incurred to receive coverage by an insurance company or carrier.

Premium Waiver (PW)
A contract feature in which the insurer agrees to continue life insurance coverage for a disabled employee without premium payments, based on the policy terms and conditions.

Prescription
A doctor's order for a prescription drug. If it is a verbal order, it must promptly be put in writing by the pharmacy.

Prescription Drug
A drug that, by law, is sold only with a doctor's written or verbal order.

Preventive Care
Programs or services that can help maintain good health, such as annual physical exams, or are meant to detect early signs of health problems or disease, such as mammograms and colon cancer screenings.

Primary Care Physician (PCP)
A participating doctor who coordinates and provides care to members, and also gives referrals for specialist care. A PCP can be a general or family care doctor, an internist or pediatrician.

Prophylaxis
A routine service performed for the prevention of dental problems such as periodontal disease and caries. It includes a thorough scaling (removal of tartar above the gum line) and polishing of the teeth to remove plaque and stains.

Prosthetic Devices
Something that replaces all or a portion of a human body part. These devices are necessary because the body part is permanently damaged, missing or not working properly.

Prosthodontist
A dental specialist whose practice is limited to the restoration or maintenance of function by replacement of natural teeth.

Provider
A licensed health care facility, program, agency, doctor or health professional that delivers health care services.

Provider Network
Doctors, hospitals and other health care providers who have a contract with a health insurance/health benefits company to provide services at a negotiated rate of repayment.

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Q

Quadrant
One of the four equal sections into which the dental arches can be divided. A quadrant begins at the midline of the arch and extends to the last tooth located at the back of the mouth.

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R

Radiation Therapy
Treatment of a disease by X-ray, radium, cobalt or high-energy particle sources.

Rate
The charges to receive coverage from an insurance company or carrier sometimes categorized by subscriber and additional dependents.

Reasonable Occupation or Job
Any paid job for which a disabled employee is, or may reasonably become, suited by training, education or experience.

Rebase
The replacement of the entire base of a denture without changing the teeth. This is usually done to balance changes in the supporting tissues.

Recurrent Disability
Occurs after a person has met the benefit Elimination Period and qualified for disability benefits under the plan. It is followed by a recovery period and a second period of "total disability." The second period of disability may not be separated from the first period of disability for longer than a specified period of time and must be caused by the same or related condition. In most cases, the policy must remain in force for the provision to apply.

Referral
Specific directions or instructions from a member's PCP that direct a member to a participating health care professional for medically necessary care. A referral may be written or electronic.

Rehabilitation Engineering
Using knowledge, skills, techniques or technology to help a disabled person fully participate in his/her job, community and activities of daily living. It can be as complex as a voice-activated computer or as simple as a block of wood under a desk to make it more accessible to a person in a wheelchair. It can also involve restructuring job duties.

Rehabilitation Program
Involves physical, mental or vocational services and supplies that help improve or restore an employee's health and well-being so he/she can return to work. The program is based on medical evidence and the potential for return to "own occupation" or a reasonable occupation on a full-time basis or for the greatest amount of time possible.

Related Absences
Two or more periods of absence from work that are related in diagnosis and separated by a time period defined by the contract. However, the return to work/nondisabled period falls within the qualifying period.

Reline
A procedure performed to resurface the part of the denture that fits against the gum tissue.

Respiratory Therapy
Treatment of illness or disease done by bringing dry or moist gases into the lungs.

Retiree
A former employee who meets minimum age and years-of-service requirements, which are determined by the employer.

Retirement Rule
Rule that determines the benefit amounts available to retired employees.

Return-To-Work Incentive (RTW)
Lets employees return to work part-time as long as the sum of disability benefits and current income is less than 100% of adjusted pre-disability earnings.

Root Canal
The removal of inflamed, infected or damaged pulp (connective tissue, nerves and blood vessels that nourish the tooth) from either the center of the tooth or from the canals within each tooth root. Once the infection is treated the empty canals are filled with an inert, or inactive, material, with the goal of eliminating the need for extraction.

Root Planing and Scaling
The removal of plaque and calculus from the area below the gum line, along the root. This smoothing of the root surface is performed to help remove the uneven surface that would allow bacteria to attach easily.

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S

Salary Continuation
A formal benefits program in which an employer continues all or a percentage of an employee's salary while the employee is disabled on a short-term basis.

Second Opinion
The choice or requirement to visit another doctor or surgeon for an opinion about a diagnosis, treatment or type of optional surgery to be performed.

Service Area
The geographic area the HMO or PPO is licensed to operate in or, when licensing is not required, the area where an adequate network exists to provide covered services.

SHIP
Student Health Insurance Program

Short-Term Disability (STD)
A benefit that pays an employee a percentage of his/her income if the employee is unable to work for a limited period of time because of a non-work-related illness or injury. The STD policy defines eligibility requirements, elimination periods, and terms and conditions.

Skilled Nursing Facility (SNF)
An institution or a part of an institution that is licensed or approved under state or local law to provide skilled nursing care and related services as a Skilled Nursing Facility, extended care facility or nursing care facility. It must be approved by the appropriate industry organizations.

Specialist
A doctor who provides medical care in any generally accepted medical or surgical specialty area.

Speech Therapy
Treatment to correct a speech problem present from birth, or caused by disease, injury or earlier medical treatment.

Subscriber
The employee covered under an employer's group agreement or group insurance policy. The subscriber can sign up eligible dependents, as determined by the policy, under family coverage.

Successive Disabilities
Two or more periods of disability that are related in diagnosis and separated by a period of time defined by the contract.

Supplemental Life Insurance
Additional life insurance which members buy beyond the amount of basic coverage paid for by the employer.

Survivor Benefit
Provides benefits payment to an eligible survivor after a disabled insured person has died.

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T

Temporary Partial Disability
Type of a workers' compensation benefit that provides for a loss of income to an employee who has a temporary partial disability.

Temporary Total Disability
Type of a workers' compensation benefit that provides for a loss of income to an employee who has a temporary total disability.

Temporomandibular Joint Dysfunction (TMJ)
A group of conditions that affect the jaw joint, and/or the muscles that control chewing and moving the jaw.

Term Insurance
Life insurance that remains in force only during the period - or term - for which premiums are paid. It does not build up cash value.

Tertiary Care
Specialized medical care, usually over a long time period, that involves complex procedures done by medical specialists in state-of-the-art facilities.

Total Disability - Any Occupation
The inability to perform the functions of any job because of an illness or injury. It is determined by factors such work experience, job history or the job market.

Total Disability - Own Occupation
The inability to perform the functions of one's own job because of illness or injury.

Transferable Skills Analysis
A detailed examination of specific skills a person can perform in spite of any disabling conditions. It includes a review of past jobs and education, as well as hobbies and household activities, in order to create a list of skills that might be transferred to other types of employment.

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U

Urgent Care
Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care. An urgent situation requires prompt medical attention to avoid problems and unnecessary or severe pain, such as a high fever.

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V

Voluntary Plans
Indicates that the entire cost of a group insurance plan is the responsibility of the employee, with no contributions by the employer.

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W

W-2
A form that is used to report a person's income to the Internal Revenue Service.

Weekly Benefit
A weekly sum payable to a claimant while he/she is disabled. It is subject to the terms of the group short-term disability insurance policy (fully insured) or short-term disability plan document (ASC).

Well Baby/Well Child Care
The routine care, testing, checkups and shots for a generally healthy child from birth through the age of eight.

Wellness Program
A health management program that includes disease prevention, medical self-care and health promotion. It focuses on preventing illness and disability.

Work Adjustment
A technique to help a worker improve work skills and attitudes so that he/she functions at a competitive level on the job. This can take the form of one-on-one counseling or a trial period of closely supervised work in a rehabilitation center. It is often used when employees have been out of the workforce for a long period of time, and with individuals who have learning or psychiatric impairments.

Workers' Compensation
Legally protected benefits, including medical and disability income, for injuries related to the job. It is available in all 50 states, American Samoa, Guam, Puerto Rico and the U.S. Virgin Islands.

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X

No term available for this letter.

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Y

No term available for this letter.

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Z

No term available for this letter.

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