Glossary

The amount the employee will pay to enroll in a OUSD-sponsored UnitedHealthcare plan.

The buy-up is calculated based on the cost difference of the enrolled medical plan's premium and the District's maximum contribution for the same coverage tier-level.

A person who meets the IRS Section 125 requirements to be covered under an OUSD employee's insurance benefits.

An individual (typically age 65+ or less than 65 with permanent disability) must enroll with the Social Security Administration in Medicare Part A (Hospitals) and Part B (Doctors) when they are no longer an active OUSD employee enrolled in a District-sponsored medical plan.

The California Family Rights Act (CFRA) authorizes eligible employees to take up a total of 12 weeks of paid or unpaid job-protected leave during a 12-month period. While on leave, employees keep the same employer-paid health benefits they had while working. Eligible employees can take the leave for one or more of the following reasons:

• The birth of a child or adoption or foster care placement of a child.

• To care for an immediate family member (spouse, child or parent) with a serious health condition.

• When the employee is unable to work because of a serious health condition (SHC).

For more information, visit the State of California website.

Diagnostic care includes tests/procedures ordered by a physician and office visits needed to help diagnose or monitor a member's condition or disease.  

Individuals enrolled in a MediGap (Supplement) plan must also obtain a Medicare Part D, prescription drug plan, to avoid financial penalties.

A system of integrative medicine based on the diagnosis and manipulative treatment of misalignments of the joints, especially those of the spinal column, which are held to cause other disorders by affecting the nerves, muscles, and organs. 

Per California law, a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the member, as a prudent layperson, could reasonably expect the absence of immediate medical attention to result in any of the following:

• Placing the member's health in serious jeopardy;

• Serious impairment to the member's bodily functions;

• A serious dysfunction of any bodily organ or part; OR

• Active labor, meaning labor at a time that either of the following would occur:

  • There is inadequate time to effect a safe transfer to another hospital prior to delivery; or

  • A transfer poses a threat to the health and safety of the member or unborn child.

Orthodontics is a specialty of dentistry that deals with the diagnosis, prevention and correction of malpositioned teeth and jaws, misaligned bite patterns. 

CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

Under the Family Medical Leave Act, eligible employees may take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. Eligible employees are entitled to:

• Twelve workweeks of leave in a 12-month period for:

  • the birth of a child and to care for the newborn child within one year of birth;

  • the placement with the employee of a child for adoption or foster care and to care for the newly placed child within one year of placement;

  • to care for the employee’s spouse, child, or parent who has a serious health condition;

  • a serious health condition that makes the employee unable to perform the essential functions of his or her job;

  • any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter, or parent is a covered military member on “covered active duty;” or

• Twenty-six workweeks of leave during a single 12-month period to care for a covered servicemember with a serious injury or illness if the eligible employee is the servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave).

For more information, visit the Department of Labor website.

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. 

The Consolidated Omnibus Budget Reconciliation Act of 1985 allows for the continuation of medical, dental, and vision plans & Section 125 medical reimbursement benefits for employees and qualified dependents at the employees/dependents own expense.  Coverage can continue for up to 18 months for the employee and up to 36 months for dependents.

An account where an employee elects an annual amount to use for qualified medical expenses incurred by the employee and covered dependents. The annual election is divided into equal installments, deducted from the employee's paycheck on a pretax basis, thus, saving approximately 15 - 22% in payroll taxes on the elected amount.

The full cost of the insurance plan. This does not include any out-of-pocket expenses when using health care services.

A percentage of the total cost of services provided that a member is responsible to pay.

An employer pays a premium amount, typically monthly, to a health insurance company or plan administrator in return for insurance coverage for its employees.

Preventive care is the care you receive to prevent illnesses or diseases.

A specified amount that a subscriber is required to pay as part of the cost to be enrolled on the health plan.

The Health Insurance Portability & Accountability Act requires the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data for individuals, portability, creditable coverage certificates, and nondiscrimination.

The employer runs and funds its own health plan instead of purchasing coverage through an insurance carrier. 

Specified dollar amount that a member must pay at the time services are rendered.

A employer or administrator-funded account that helps employees pay for qualified medical expenses incurred by the employee and covered dependents.

The main person enrolled in the insurance coverage and is responsible for enrollment costs.

A specified amount for which a member is responsible before the insurance company will make payment.

Free or no cost government health coverage for low-income individuals and their families.

The health plans' configuration of coverage based on family size for premium cost designation.

Artificial tooth roots that provide a permanent base for fixed, replacement teeth.  

Insurance coverage offered by private companies that are approved by Medicare, to fill the in the gaps of Medicare Parts A and B, and is considered the most comprehensive option, similar to an HMO.

Services that are medically necessary health services required to prevent the serious deterioration of the member's health, resulting from an unforeseen illness or injury for which treatment cannot be delayed until the member can be seen by their Primary Care Physician.