Benefits Glossary

Columbia University Fringe Pool Financial Terms
General Benefits Terms
Medical, Dental and Prescription Plan Terms
Retirement Plan Terms

Columbia University Fringe Pool Financial Terms

Fringe Pool: The collection of benefits provided to employees by Columbia University. The costs of these benefits are accounted for in a central pool as fringe expenses. The fringe pool is funded by schools and departments which are charged a tax in proportion to wages paid to employees.

Fringe Rate: The rate(s) assessed against wages to cover the cost of benefits provided to employees.

Fringe Recoveries: The funding received by the fringe pool through a charge to schools and departments. Eligible wages multiplied by the applicable fringe rate yields the fringe recovery to the fringe pool and an expense to each school or department.

Fund Balance: The cumulative sum of all annual operating surpluses or deficits of the fringe pool.

Surplus/Deficit: The annual operating performance of the fringe pool. A surplus exists when recoveries exceed expenses in any given year; a deficit exists if expenses are greater than recoveries.

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General Benefits Terms

Dependent: An individual other than the employee who meets the eligibility requirements specified in the Plan. For purposes of benefits administration, the definition of a dependent generally includes any eligible immediate family member (such as a spouse, same-sex domestic partner or child).

Self-Insured: The Columbia University medical and prescription benefits are “self-insured” (except for HIP HMO). That is, Columbia University does not pay “premiums” to each of the insurance carriers. Columbia University pays employee healthcare claims plus an administrative fee to the insurance carriers.

Qualified Life Status Change: A change to benefits eligibility that is recognized by the Internal Revenue Service which allows one to make a change in certain benefits during the calendar year. After the initial enrollment as a new hire, or after annual Benefits Open Enrollment, you are only allowed to change benefits for the remainder of the calendar year if you experience a qualified life status change.

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Medical, Dental and Prescription Plans

Annual Deductible (or Deductible): The amount you must pay for Covered Health Services in a calendar year before the Plan will begin paying benefits that are subject to deductible in that calendar year.

Coinsurance: The percentage of Eligible Expenses a Plan participant is required to pay for certain Covered Health Services. Similar to copays, except copays require the insured to pay a set dollar amount at the time the service is rendered. For example, a 90/10 coinsurance plan with a $400 deductible requires the insured to pay 10% of the covered costs after the deductible has been paid, while the insurance company will be liable for the remaining 90%.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA): A federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance has been terminated.

Copay (or Copayment): The fixed dollar amount a covered individual is required to pay for certain Covered Health Services.

Cost-Effective: The least expensive equipment that performs the necessary function. For healthcare purposes, this term typically applies to Durable Medical Equipment and prosthetic devices.

Covered Health Services: Those health services and supplies that are provided for the purpose of preventing, diagnosing or treating acute sickness, injury, mental illness, substance abuse, or their symptoms; provided to a Covered Person who meets the Plan’s eligibility requirements.

Covered Person: Either the Employee or an enrolled Dependent only while enrolled and eligible for Benefits under the Plan.

Deductible: The dollar amount of covered expenses the individual is responsible to pay before the Plan will pay any benefits.

Eligible Expenses: These are expenses for healthcare services that represent Covered Health Services under the Plan. Participants may be required to pay a percentage of Eligible Expenses in the form of a Copay and/or Coinsurance. Eligible Expenses are subject to the Claims Administrator’s reimbursement policy guidelines. Participants may request a copy of the guidelines related to claim adjudication from the Claims Administrator.

Exclusion(s): A health condition or service not eligible for coverage under the health care plan.

Explanation of Benefits(EOB): A statement provided by a health insurer to the health plan member, the member’s Physician, or another health care professional that explains:

• the Benefits provided (if any);
• the allowable reimbursement amounts;
• deductibles;
• coinsurance;
• any other reductions taken;
• the net amount paid by the Plan; and
• any reason(s) the service or supply was not covered by the Plan.

Lifetime Maximum Benefit: The most the Plan will pay for Benefits during the entire period a participant is enrolled in a specific Plan.

Medicaid: A federal program administered and operated individually by participating state and territorial governments that provides medical benefits to eligible low-income people needing health care. The federal and state governments share the program’s costs.

Medicare: Parts A, B, C and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.

Network: When used to describe a Provider of healthcare services, this means a Provider that has a participation agreement in effect (either directly or indirectly) with the Claims Administrator or with its affiliate to participate in the Network. A Provider may enter into an agreement to provide only certain Covered Health Services, but not all Covered Health Services, or to be a Network Provider for only some products. The participation status of Providers will change from time to time.

Network Benefits (also referred to as “In-Network”): Description of how benefits are paid for Covered Health Services provided by a Network Provider.

Non-Network Benefits(also referred to as “Out-of-Network”): Description of how benefits are paid for Covered Health Services provided by non-Network Providers.

Out-of-Pocket Maximum: The maximum amount of money a patient is responsible to pay for covered services during a plan year. The “maximum” calculation may or may not include deductibles, it does not include copayments or any payments made for non-covered services or charges above reasonable and customary.

Plan Sponsor: Columbia University.

Provider: A healthcare professional or facility operating as required by law.

Reasonable and Customary: The amount normally charged by a Provider for similar services and supplies; this amount does not exceed the amount ordinarily charged by most providers of comparable services and supplies in the locality where the services or supplies are received.

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Retirement Plans

Employee Retirement Income Security Act of 1974 (ERISA): The federal legislation that regulates retirement and employee-welfare benefit programs maintained by employers and unions.

Vested: This means one is eligible to receive a retirement benefit from the University Retirement Plan or the VRSP. Vesting is sometimes figured as a percentage, based on employee status.

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