Annual Benefits Salary: Used to determine employees' medical contributions, Child Care Benefit eligibility, Life Insurance coverage and Long-Term Disability (LTD) coverage amount. Annual Benefits Salary is calculated as of July 1 each year and is the greater of a) the base salary in effect on each July 1 or b) the prior 12 months' gross compensation, plus additional and private practice compensation, to June 30.
Appeal of Claim: If you have a claim for a benefit which is denied in whole or in part, you must receive a written explanation of the reason for the denial. Under ERISA, you have the right to appeal the denial of a claim and have the denial decision reconsidered.
Coinsurance: Cost-Sharing between you and the healthcare Plan for Eligible Expenses for certain Covered Health Services, where you are required to pay a percentage of the cost. For example, a 90/10 coinsurance plan with a $200 deductible requires you to pay 10% of the covered costs after the Annual Deductible has been met, while the Plan will be responsible for paying the remaining 90%.
Copay: A fixed amount you pay when you receive a healthcare service. The amount can vary by the type of Covered Health Service. Typically you pay a copay for a visit to an in-network provider's office.
Cost of Living Adjustment (COLA): An adjustment made to income in order to adjust benefits to reflect the effects of inflation.
Cost Sharing: The share of plan costs that you pay out of your own pocket. This generally includes Annual Deductibles, Coinsurance and Copays, but does not include premiums or the cost of non-covered services.
Covered Health Services: Health services, including supplies, which are determined by the Plan to be provided for the purpose of preventing, diagnosing or treating sickness, injury, mental illness, substance use disorders, or their symptoms. Covered services are listed in the Summary Plan Descriptions at http://hr.columbia.edu/benefits/spds.
Deductible: The amount you pay for Covered Health Services each year before the healthcare Plan begins to pay for expenses.
Eligible Expenses: Charges for Covered Health Services rendered, or supplies furnished by a certified health professional under the Plan. Eligible Expenses may be subject to Cost Sharing and/or annual or lifetime maximums as specified by the terms of the Plan. Eligible Expenses for services rendered by In-Network providers are limited to the network negotiated charge. For Out-of-Network providers, Eligible Expenses are limited to 190% of the Medicare Maximum Allowable Charge.
Evidence of Insurability/Evidence of Good Health: Documentation of good health by an applicant for insurance. Usually this takes the form of a medical examination. Enrollment in Optional Term Life and Optional Long-Term Disability benefits require such evidence if the employee has not elected the plans within 31 days of their eligibility date and, for Long-Term Care, if elected 60 days after date of hire.
Exclusion(s): A health condition or service not eligible for coverage under the healthcare Plan.
Explanation of Benefits (EOB): A statement provided by a health insurer to the plan participant that explains how their claim was paid. The EOB typically includes the date of service, type of service rendered, eligible expense, amount paid by the Plan and the balance to be paid by the plan participant. If applicable, it will also provide any reason(s) the service or supply was not covered by the Plan.
Guaranteed Issue: A feature of certain insured benefits that permits you to enroll regardless of health status, age, gender, or other factors that might predict the use of the benefit.
Imputed Income: The value of an employer-sponsored benefit or service that is considered by the IRS as compensation and added to an employee's taxable wages in order to properly withhold income and employment taxes from the wages.
Examples of Imputed Income include:
- Educational assistance above the excluded amount.
- Employer contributions to the coverage of same-sex domestic partners & their children.
Network: The group of physicians, hospitals and other providers who are contracted with the health plan carrier to provide services to health plan participants at lower-priced, negotiated rates.
Non-Duplication: A provision in healthcare plans specifying that benefits will not be paid for amounts reimbursed by other plans. This typically applies to a plan participant who is eligible for benefits under more than one plan (for example, being covered under a spouse's plan).
Non-Preventive Drugs: Prescription medications that are designed and intended to treat a specific condition. If either a therapeutic class or specific drug is not defined as a Preventive Drug, then it is considered a Non-Preventive drug.
Open Enrollment: The annual period in which employees can select from a choice of benefits options with an effective date of January 1 of the following year.
Out-Of-Network Benefits: Covered Health Services provided by non-network Providers. Individuals usually are responsible for additional Out-of-Pocket Costs if they use an out-of-network provider. Eligible Expenses for out-of-network services are indexed to 190% of the Medicare Maximum Allowable Charges (PDF).
Out-of-Pocket Costs: Expenses for medical services that are not reimbursed by the plan. Out-of-Pocket Costs include deductibles, coinsurance, copayments for Covered Health Services, costs above the Eligible Expense, and costs for services that are not covered under the Plan.
Out-of-Pocket (OOP) Maximum: The maximum amount a patient must pay for Covered Health Services during a plan year.
The in-network Out-of-Pocket Maximum includes the Annual Deductible, Medical (but not prescription drug) Copays and Coinsurance. The OOP maximum does not include premiums, payments made for non-covered services, or charges above Eligible Expenses.
Point Of Service (POS) Plan: Typically, this type of plan offers in and out-of network options.
Precertification: A process where the health plan carrier is contacted before certain services are provided, to determine if it is a Covered Health Service. Precertification is not a guarantee your health plan will cover the cost of the services. Also called prior authorization, preauthorization or prior approval.
Pre-Tax Contribution: A contribution which is made from the employee's paycheck before federal and/or state taxes are withheld.
Preventive Care: Medical care that focuses on health maintenance such as annual physicals, certain screening tests, and child immunization programs.
Preventive Drugs: Prescription medications that are designed to prevent individuals from developing a health condition.
Qualified Life Status Change: A change to benefits eligibility that is recognized by the IRS and allows an employee 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, employees are only able to change benefits for the remainder of the calendar year if they experience a Qualified Life Status Change.
Self-Insured Plan: Columbia University's medical and prescription benefits are "self-insured." Columbia University does not pay "premiums" to each of the insurance carriers. Columbia University pays employee healthcare claims plus an administrative fee to the healthcare plan carriers.
Single-Source Brand: Prescription drugs that do not have a generic equivalent.
Summary Plan Description (SPD): A document that explains the fundamental features of an employer's retirement or medical plan including eligibility requirements and the schedule of benefits.
Vesting: a term that means a permanent right of ownership. You are always 100% vested in your Voluntary Retirement Savings Plan (VRSP) contributions.
Fringe Pool: The collection of benefits provided to employees by Columbia University. The cost of these benefits is 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.