Alphabet Soup of Benefits Abbreviations
Here is a quick review of some frequently used benefits abbreviations:
I’m choosing a health plan. What’s the difference between an HMO and a POS?
Health Maintenance Organizations (HMOs) and Point-of-Service Plans (POS) have a lot of similarities. Both place emphasis on preventive services, such as an annual routine physical, to promote good health. Both are also managed care plans that require you to select a Primary Care Physician (PCP) to direct your care.
If you choose a Health Maintenance Organization (HMO), you can only receive coverage for care provided by physicians and providers within your HMO network. If you receive anything other than emergency care outside of the network, it will not be covered. Partners offers HMO coverage through Harvard Pilgrim Health Care, Neighborhood Health Plan and Tufts Total Health Plan.
A point-of-service (POS) plan is similar to an HMO in that preventive care must be provided by network providers to be covered, with the highest reimbursement being for care provided by in-network providers under the direction of your PCP. However, with a POS plan such as Partners Plus and Partners Value, you have the freedom of choice to receive care from a non-network provider, without your PCP’s referral, at reduced benefit levels. A special provision of Partners Plus and Partners Value allows your PCP to refer you to BWH or MGH for specialty care with a participating provider, regardless of where your PCP practices, at in-network benefit levels.
I keep hearing about COBRA and HIPAA. What are they?
While they may sound like exotic animals, they’re actually two laws that protect employees’ rights to health benefits.
COBRA stands for the Consolidated Omnibus Reconciliation Act of 1985. This federal law allows employees in group health plans and their covered family members to temporarily extend health coverage when it would otherwise end. For example, if you stop working at Partners, your health coverage ends on your last day at work. COBRA gives you the right to continue group coverage for an additional amount of time (usually up to 18 months). You pay the full amount of the plan’s monthly insurance premium. Proof of good health is not required.
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. You may have heard of the regulations associated with HIPAA that protect patient privacy. In addition, the federal HIPAA statute limits coverage exclusions for preexisting conditions in group health plans and prohibits discrimination against employees and their dependents based on health status. It also permits employees to enroll in a new health plan under certain circumstances, even if it is not open enrollment. For example, if you decline Partners medical coverage because you have coverage elsewhere but then lose that coverage, you may be eligible to enroll in a Partners health plan within 30 days.
What is the difference between LTD and LTC insurance?
LTD refers to Long-Term Disability insurance. This type of insurance replaces a percentage of your pay when a disability makes you unable to work for 90 days (12 weeks) or longer. Partners Corporate employees receive core LTD coverage of 50% of their base pay at no cost, and have the option to buy increased LTD coverage up to 60% or 75% of their base pay.
By contrast, LTC – or Long-Term Care insurance – pays for long-term nursing home care or skilled nursing care at home when you or a family member can no longer care for yourself. This benefit is provided through the John Hancock Life Insurance Company, so you cannot enroll through eBenefits. You may be asked to provide proof of good health.
How is LTD different from AD&D?
LTD (Long-Term Disability) covers any type of injury or illness that keeps you from working, whether the injury occurs on the job or outside of it. It is meant to be an ongoing income replacement system that continues part of your pay while you are unable to earn a paycheck.
This differs from AD&D (Accidental Death and Dismemberment insurance), a one-time payment amount that only covers very specific accidental injuries, such as loss of a limb. AD&D also provides a one-time benefit to your named beneficiaries if you die in an accident.
What is an RMSA?
RMSA is short for Retirement Medical Savings Account. Eligible Partners Corporate employees age 50 or older can use an RMSA to save for post-retirement medical expenses while receiving matching funds from Partners and tax-free interest on their savings. An RMSA also qualifies Partners retirees, their spouses and dependents for Partners group medical coverage after retirement. In addition, once you retire you can draw on your RMSA for certain expenses such as hearing aids, eyeglasses, prescription drugs, and insurance deductibles and co-payments.
More Information
If you have questions about the above topics or any of your other benefits, please contact the Benefits Office at “Benefits, Information” on the Outlook Global Address Directory, via email at ibenefits@partners.org, or call (617) 726-8133.
More Terms to Know
Health Maintenance Organizations (HMOs)
Managed Care plans require that you select a Primary Care Physician (PCP) to help direct your care. They place emphasis on preventive services, such as an annual routine physical, to promote good health.
Indemnity Plans
Traditional indemnity insurance plans permit self-directed referrals to specialty care but, generally, insure fewer preventive services.
Point-of-Service Plans (POS) plans
With Partners Plus and Partners Value, you enjoy the benefits of a managed care plan — access to cost-effective, high-quality care — with the freedom of choice of an indemnity plan. You may use a POS plan just as you would an HMO, receiving care from network providers under the direction of your PCP. Or, you have the freedom of choice to receive care from a non-network provider, without your PCP’s referral, at reduced benefit levels.
A special provision of Partners Plus and Partners Value allows your PCP to refer you to BWH or MGH at full benefit levels for specialty care with a participating provider, regardless of where your PCP practices, at full benefit levels.
Primary Care Physician (PCP)
The doctor you select to provide your medical care and/or refer you to a specialist. Each covered family member may select his or her own PCP.
Co-pay
The amount you pay per service received, such as office visits, emergency care, prescription drugs, etc. Co-pays typically range from $15 to $70.
Deductible
The amount you pay before a plan pays any benefits. For example, if you receive out-of network care under Partners Plus, you would have to pay $200 for individual coverage.
Co-insurance
The plan’s share of the charges that are paid after you have met any deductibles. If a plan pays 80%, for example, you would pay the remaining 20%, up to the plan’s annual out-of-pocket maximum.
Out-of-Pocket Maximum
The most you would have to pay in deductibles and coinsurance in a calendar year before a plan pays 100% of covered services. Under Partners Value, for example, your out-of pocket maximum is $2,000 per individual and $4,000 per family when you
receive care in the network. After you reach your maximum, including your deductible and co-payments, the plan would pay 100% of all remaining covered expenses you incur during the year.
Calendar-Year Maximum
The most a plan will pay in a calendar year for a certain benefit for each covered person.
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