Definitions for commonly used terms by the GIC.
Additional (Optional) Life Insurance - Commission-sponsored Term Life and Accidental Death and Dismemberment Insurance, based upon a State Employee's annual compensation and age, for which State Employees and State Retirees pay the full premium cost and which is in addition to the Basic Life Insurance.
Annual Enrollment - The period in which eligible insured and uninsured persons may enroll themselves and their Dependents in the Commission's benefit programs or make changes to their status or benefits in those programs that become effective on July 1st.
Basic Life Insurance - Commission-sponsored Term Life and Accidental Death and Dismemberment Insurance, for which eligible Employees and Retirees pay a portion of the premium cost and the Commonwealth pays the premium balance.
Calendar Month - For the purpose of premium payments and Commission coverage, a full month, e.g., March 1st through March 31st.
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.
Child - (a) A son or daughter by birth or legal adoption (including any probationary period);
(b) a minor placed in an adult's custody pursuant to an order from a court of competent jurisdiction, including a guardianship order; or
(c) a person who is dependent upon another person for support and who lives in that other person's household, where there is evidence of a parent-child relationship satisfactory to the Commission, up to age 26 or two years after the child ceases to be an IRS dependent, whichever occurs first.
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.
Commission - The Commonwealth of Massachusetts Group Insurance Commission.
Contributory Insurance - Insurance for which Employees and Retirees pay part of the premium and the Employer or the Commonwealth pays the premium balance.
Continuation Coverage - Federal and state non-group coverage, including COBRA and conversion coverage, available to those who were formerly Insureds but whose eligibility for group insurance coverage through the Commission has ended.
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 Retirees - Former Employees whose employment has terminated and who have vested rights to a retirement allowance, currently deferred, relating to their employment. Persons receiving a pension or retirement allowance whose monies are withdrawn or transferred to a non-participating retirement system are not Deferred Retirees. Otherwise qualified Former Municipal Employees may only be Deferred Retirees for as long as their Municipal Employer continues to offer insurance to Municipal Insureds through the Commission.
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.
Dental and Vision Benefits - Dental benefits for certain preventive and other non-preventive dental care, and vision benefits for certain preventive vision care, products and services, available to eligible Insureds pursuant to 805 CMR 9.22: Dental and Vision Benefits.
Dependent - (a) A Spouse of an insured Employee or Retiree;
(b) A Former Spouse of an insured Employee or Retiree entitled to coverage pursuant to
M.G.L. c. 32A, § 11A or M.G.L. c. 32B, § 9B, 9D, 9D½ and 9D¾;
(c) Up to age 19, or two years after ceasing to be an IRS dependent, but only to age 26, the Child of:
1. an insured Employee or insured Retiree;
2. an Employee's or Retiree's insured Spouse or insured Surviving Spouse; or
3. an Employee’s or Retiree's insured Former Spouse, to the extent the Child was born prior to the date the divorce became final.
(d) Up to age 26, the IRS dependent of an insured Employee, Retiree, or Surviving Spouse; (e) Up to age 26, a person who was previously an IRS dependent of an insured Employee, Retiree, or Surviving Spouse, for two years after ceasing to be an IRS dependent;
(f) The Child of a person who is eligible as a Dependent under 805 CMR 1.02: Dependent(c), (d), or (e);
(g) A Child who is dependent upon an insured Employee, Retiree, or Surviving Spouse for support and who lives in the Employee, Retiree, or Survivor's household, where there is evidence of a parent-child relationship satisfactory to the Commission, up to age 26 or two years after the child ceases to be an IRS dependent, whichever occurs first;
(h) A Student who is the Child of an insured Employee or Retiree, or of an insured Employee's or Retiree's Spouse, Surviving Spouse or Former Spouse, and that Student's Children, if any;
(i) A Handicapped Dependent as defined in 805 CMR 1.02: Handicapped Dependent;
(j) A Child of an insured Employee, Retiree, Spouse, Former Spouse, or Surviving Spouse, up to age 26.
EAP (Employee 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.
Emergency Employment - Employment for an unforeseen Employer emergency, limited to a specified time period, usually not more than 30 days.
Employee - Person whose time is devoted to the service of the Commonwealth or one of its political subdivisions that is authorized to participate in Commission benefit programs by express reference in state law, who works during the Regular Work Week of permanent employees and who contributes to a State pension system, a Housing, Redevelopment or Optional Retirement Plan, or another public sector retirement system; or a person elected by popular vote to state or local government office during the term that he or she holds office. State and municipal board, commission or authority members who do not work a Regular Work Week and its requisite statutory hours are not Employees unless expressly otherwise authorized by law. Contributions to an OBRA Plan do not constitute contributions to a public retirement system.
Employer - The Commonwealth or one of its political subdivisions that participates in certain Commission benefit programs by express statutory authority.
Employer PDP - Employer PDP is the Medicare terminology for an Employer-provided Medicare Part D Prescription Drug Plan.
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).
Family Health Coverage - Commission health coverage that includes a person entitled to and enrolled in Commission coverage and his or her eligible dependents.
Former Spouse - A person who was formerly married to an Employee or Retiree and who has been granted a judgment of divorce or of separate support.
Formulary - A formulary is a list of brand name and generic drugs covered by the plan. You will receive a list from SilverScript of the drugs covered by the Medicare Part D portion of the plan.
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.
Group Insurance Coordinator - The person at each reporting location who acts as a liaison between the reporting location and the Commission on matters involving the employer's and its employees' participation in the Commission's programs.
Half-time, Half-time Employees - Active employees who work at least 18.75 hours in a regular work week of 37.5 hours, or 20 hours in a regular work week of 40 hours.
Handicapped Dependent - A Child of an insured Employee, Retiree or Surviving Spouse, aged 19 or older, who:
(a) upon attaining age 19, was mentally or physically disabled and incapable of earning his or her own living;
(b) earns an annual income of less than 200% of the Federal Poverty Level; and
(c) if enrolling after age 26, other than as the Dependent of a new Enrollee, demonstrates satisfactory proof of involuntary loss of other coverage.
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.
Health Coverage, Health Insurance - Health benefits provided by the Commission to eligible Employees and Retirees and their eligible dependents pursuant to M.G.L. chs. 32A and 32B.
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).
Individual Health Coverage - Health Coverage for a person entitled to and enrolled in a Commission health plan.
Insured - An Employee, Retiree, Survivor, or Dependent eligible for and enrolled in Commission coverage.
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.
Local Governmental Unit - A county, city, town or district that participates in the Commission's Retired Municipal Teacher program.
Long-term Disability Insurance - An income replacement program that qualifies a State Employee to receive a percentage of his or her gross monthly salary, tax-free, after illness or injury renders him or her unable to work for more than 90 consecutive days.
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.
Municipal Employee, Retiree, Survivor, or Dependent - An Employee, Retiree, Survivor, or Dependent whose eligibility for Health Coverage derives from employment or prior employment with a Municipal Employer.
Municipal Employer - A Massachusetts county, city, town or district that is an Employer by virtue of having formally agreed or obtained an order to transfer its Employees, Retirees, Survivors, and Dependents to Commission Coverage pursuant to M.G.L. c. 32B, § 19 or § 23, including the city of Lawrence, to the extent it is deemed to have accepted M.G.L. c. 32B, § 19, per St. 2010, c. 58, § 4(f).
Municipal Insured - A Municipal Employee, Retiree, Survivor, or Dependent eligible for and enrolled in Commission coverage.
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.
Nondiscriminatory Basis - Plans whose coverage does not contain any annual or lifetime dollar or unit of service limitation imposed for care provided by one type of participating provider that is less than any annual or lifetime dollar of unit of service limitation imposed on coverage for the same services by other types of participating providers.
Nurse Practitioner - A Massachusetts licensed registered nurse in good standing who holds authorization in advanced nursing practice as a nurse practitioner under M.G.L. c. 112 § 80B.
OBRA Plan - A deferred compensation plan that serves as an alternative to Social Security as permitted by the federal Omnibus Budget Reconciliation Act of 1990, (PL101-508, 104 Stat. 1388).
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.
Physician Assistant - A registered Massachusetts physician assistant in good standing who is supervised by a registered physician in accordance with M.G.L. c. 112, §§ 9C through 9K.
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.
Regular Work Week - An employee's work, in the service of an Employer of no fewer than 18.75 hours, regularly, in a position for which the established work week is 37.5 hours or no fewer than 20 hours, regularly, in a position for which the established work week is 40 hours, or which meets other statutory requirements. Such hours averaged over any period of time do not constitute a Regular Work Week.
Retiree - A person formerly in the service of the Commonwealth or one of its political subdivisions that is authorized to participate in Commission benefit programs by express reference in state law, whose services ended on or after January 1, 1956 and who are eligible for and are receiving and continue to receive a retirement or pension allowance from a participating retirement system, including from the Board of Higher Education's Optional Retirement Program, but excluding any OBRA Plan.
Retirement - A status that entitles a former Employee to a pension or retirement allowance under any general or special law, either at the time of employment termination or at some future date.
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.
Seasonal Employment - Employment in a single position with recurring duties for a short duration, usually for three months or less.
Separated Spouses - Spouses who are granted a judgment of separate support or other related legal relief.
Spouse - Person joined in marriage, as recognized by state law, to an Employee or Retiree.
State Employee, Retiree, Dependent, or Survivor - An Employee, Retiree, Dependent, or Survivor who is eligible for benefits pursuant to M.G.L. c. 32A. Retired Municipal Teachers and Elderly Governmental Retirees are State Retirees. An Employee, Retiree, Dependent, or Survivor who is eligible for benefits only pursuant to M.G.L. c. 32B, § 19 or § 23, is not a State Employee, Retiree, Dependent, or Survivor.
Student - Child aged 19 years or older but younger than 26 years of age who attends an accredited educational or vocational institution on a full-time basis.
Surviving Dependent - A deceased insured Employee's or a deceased insured Retiree's Child Dependent, who, younger than 26 years old, the Child had no surviving parent.
Surviving Spouse - A widow or widower of an insured Employee or Retiree, until death or remarriage. Persons divorced or legally separated from insured Employees or Retirees are not Surviving Spouses.
Survivor - A Surviving Spouse or Surviving Dependent.
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.