Case Management - a process that focuses on coordinating a number of services needed by patients with complex medical conditions. It includes an objective assessment of a patient's needs and develops an individualized care plan, within the scope of benefits, that is based on the needs assessment and is goal oriented. Patients' families may be involved as well. The goal is to provide the best possible management of care.
Centered Care - a GIC program that seeks to improve health care coordination and quality while reducing costs. Primary Care Providers play a critical role in helping their patients get the right care at the right place with the right provider. Because health care is so expensive, Centered Care also seeks to engage providers and health plans on managing these dollars more efficiently.
CIC (Catastrophic Illness Coverage) - an optional part of the UniCare State Indemnity Plan/Basic and Medicare Extension (OME) plans. CIC increases the benefits for most covered services to 100%, subject to deductibles and copayments. It is a Commonwealth of Massachusetts enrollee-pay-all benefit. Enrollees without CIC receive only 80% coverage for some services and pay higher deductibles. Over 99% of current Indemnity Plan Basic and Medicare Extension Plan members select CIC.
COBRA (Consolidated Omnibus Budget Reconciliation Act) - a federal law that allows enrollees to continue their health coverage for a limited period of time after their group coverage ends as the result of certain employment or life event changes.
CPI (Clinical Performance Improvement) Initiative – Under this program, which applies to employee/non-Medicare members of Fallon Health, Health New England, Neighborhood Health Plan and the UniCare State Indemnity Plan, claims data from the GIC health carriers are aggregated to identify differences in physician quality and cost efficiency, and this information is given back to the plans to tier specialists. Members who choose to see high-performing doctors pay lower copays
DCAP (Dependent Care Assistance Program) - a pre-tax benefit for state employees that allows participants to set aside a certain amount of their income annually to use to pay certain employment-related dependent care expenses, such as child care or day camp for a dependent child under the age of 13 and/or a disabled adult dependent.
Deductible - a set dollar amount you are responsible for paying to your provider(s) for certain services before the plan will pay for these services. Deductibles reset each year.
Deferred Retirement - allows you to continue your group health insurance after you leave state service with vested pension rights until you begin to collect a pension. Until you receive a retirement allowance, you will be responsible for the entire life and health insurance premium costs, for which you are billed directly. If you withdraw your pension money, you are not eligible for GIC coverage.
EAP (Enrollee Assistance Program) - mental health services that include help for depression, marital issues, family problems, alcohol and drug abuse, and grief. Also includes referral services for legal, financial, family mediation, and elder care assistance.
EGR (Elderly Governmental Retiree) - a state employee who retired from state service prior to January 1, 1956. EGRs also include certain municipal employees who retired prior to the date their city or town elected to provide health insurance benefits to their employees/retirees and whose municipality has elected to participate in the EGR program.
EGWP (Employer Group Waiver Plan): - an employer-sponsored Medicare Part D prescription drug plan. Effective July 1, 2017, members of Harvard Pilgrim Medicare Enhance, Health New England MedPlus, and Tufts Medicare Complement will be enrolled in an EGWP. Members of UniCare State Indemnity/Medicare Extension (OME) Plan are already enrolled in an EGWP. Due to the additional coverage provided by the GIC, benefits are more comprehensive than offered under a standard Medicare prescription drug plan. Under an EGWP Plan, qualified low-income retirees may be eligible for premium subsidies and reduced prescription copayments.
EPO (Exclusive Provider Organization) - a health plan that provides coverage for treatment by a network of doctors, hospitals and other health care providers within a certain geographic area. EPOs do not offer out-of-network benefits, with the exception of emergency care. An EPO encourages the selection of a Primary Care Provider (PCP).
GIC (Group Insurance Commission) - a quasi-independent state agency governed by a 17-member commission appointed by the Governor. The mission of the GIC is to provide high-value health insurance and certain other benefits to state, particular authority, and participating municipality employees, retirees, and their survivors and dependents.
HCSA (Health Care Spending Account) - a pre-tax benefit that allows state employees to contribute a set amount of their income for out-of-pocket health care expenses, such as copayments, deductibles, eyeglasses and orthodontia.
HIPAA (The Health Insurance Portability and Accountability Act of 1996) - the Federal law protects employees' and their families' health insurance coverage when they change or lose their jobs. It also requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. The law also addresses the security and privacy of health data.
HMO (Health Maintenance Organization) - a health plan that provides coverage for treatment by a network of doctors, hospitals and other health care providers within a certain geographic area. HMOs do not offer out-of-network benefits, with the exception of emergency care. An HMO requires the selection of a Primary Care Physician (PCP).
IRMAA (Income-Related Monthly Adjustment Amount) – A monthly additional fee imposed by Social Security on any Medicare beneficiary enrolled in Medicare Part B and/or Part D when it is determined that the member’s adjusted gross income, as reported on the federal tax return, exceeds a certain amount. Contact Medicare.gov for more information. Social Security will notify you if IRMAA applies to you.
Limited Network Plan – a less expensive health plan that offers essentially the same benefits as more expensive, wider network plans, but with fewer physicians, hospitals, and other providers.
LTD - (Long Term Disability) - an income replacement program for active employees providing a tax-free benefit of up to 55% of salary if illness or injury renders them unable to work for longer than 90 days. Employees pay 100% of the premium.
Networks - groups of doctors, hospitals and other health care providers that contract with a benefit plan. If you are in a plan that offers both network and non-network coverage, you will receive maximum higher level of benefits when you are treated by network providers.
PCP (Primary Care Physician) - physicians with specialties in internal medicine, family practice, and pediatrics, as well as nurse practitioners and physician assistants who coordinate their patients' health care.
Portability - allows active employees who end employment with the Commonwealth to continue life insurance coverage at the same level of coverage. The premium for the portable life insurance coverage will be at the same rates you are insured for under the Commonwealth's group plan. Certain coverage and time limits apply.
POS (Point of Service) – a health plan that provides coverage for treatment by a network of doctors, hospitals and other health care providers. Selection of a Primary Care Provider (PCP) is required. To get the lowest out-of-pocket cost, a member must get a referral to a specialist.
PPO (Preferred Provider Organization) - a health insurance plan that offers coverage by network doctors, hospitals, and other health care providers, but also provides a lower level of benefits for treatment by out-of-network providers. A PPO plan encourages the selection of a Primary Care Provider (PCP).
Preventive Services – generally, health care services, such as routine physicals, that do not treat an illness, injury, or a condition.
RMT - a retired teacher from a city, town or school district who is receiving a pension from the Teacher's Retirement Board and whose municipality has elected to participate in the GIC RMT program. Retired teachers who participate in the municipal program for GIC health-only benefits are not RMTs.
Utilization Review - a health plan's process of reviewing the appropriateness and quality of care provided to patients. It may be done before, at the same time, or after the services are rendered.
39-week Layoff Coverage - allows laid-off employees to continue their group health and life insurance for up to 39 weeks (about 9 months) by paying the full cost of the premium.
This information provided by the Group Insurance Commission .