ASO (Administrative Services Only) contract
An arrangement in which a plan sponsor hires a third party to deliver plan administration services such as claims, processing and billing while the plan still bears the risk and costs of claims.
Under stop-loss insurance contracts, the threshold at which medical claims become payable by the stop-loss carrier for the remainder of the policy year, the portion that would otherwise be the self-insured retention for the plan sponsor.
A change in the terms of an existing plan or the initiation of a new plan.
Benefit Review Conference (BRC)
This is the earliest and least formal hearing officiated by the State to resolve disputes in a Workers’ Compensation injury case.
The Employee Retirement Income Security Act(ERISA) requires trustees of welfare benefit plans (unless they are unfunded) to be covered by a fidelity bond to protect plan assets from fraud and dishonesty.
A utilization management technique that focuses on coordinating a number of health care and disability services. Case management includes a standardized, objective assessment of client needs to develop and provide service or a care plan based on these needs.
Certified Network (1305)
An employer that elects to provide workers’ compensation insurance cover under the Texas Workers’ Compensation Act may receive workers’ compensation health care services for the employer’s injured employees through a workers’ compensation health care network. The term network means an organization that is formed as a health care provider network to provide health care services to injured employees, is certified in accordance with Chapter 1305 and commissioner rules and established by, or operates under contract with, an insurance carrier. A political subdivision can also utilize the services of a Certified Health Care Network.
Contested Case Hearing (CCH)
This is the most formal hearing officiated by the State with strict rules of evidence on contested issues.
Designated Doctor (DD)
This refers to the system established by the State of Texas to resolve disputes between the injured workers and the insurance Carrier. The Designated Doctor is random selected by the State to examine injured workers and their opinions serve as the definitive opinion like an umpire’s call at a baseball game.
Division of Workers’ Compensation (DWC)
This is the name of the State agency that holds the hearings and makes the rules for the State Workers’ Compensation system.
Durable Medical Equipment (DME)
This refers to Crutches, Walkers, Wheelchairs – any physical aid needed to help establish temporary relief for an injured worker.
Employee Retirement Income Security Act of 1974 (ERISA)
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. ERISA requires plans to provide participants with plan information such as plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.
The federal "wage and tax statement" that must be filed with the IRS by an employer for payments made to each employee during a calendar year. Employers also must provide a copy to employees by January 31 of the following reporting year.
Impairment Income Benefits (IIBS)
This is the name for benefits employees receive AFTER being declared at MMI (Maximum Medical Improvement). It is the State’s means of compensating employees for loss of use of bodily functions related to the accident. The impairment benefit is shown as a percentage of impairment to the body overall and employees receive 3 weeks of payments at 70% of their TIBS benefit for each 1% of impairment.
A form of payment to Claiments for loss of wages in a work related injury or for loss of use by impairment to the body overall.
Independent Medical Exam (IME) or Required Medical Exam (RME)
Every six months the insurance carrier may elect to send the employee to a doctor for a physical examination to obtain an opinion on the medical condition of the employee outside that of the treating physician. If an employee refuses an invitation to attend an Independent Medical Exam (IME), then the carrier may ask for an order for a Required Medical Exam (RME).
Person who is indemnified against loss, damage or liability arising from an event that is contingent or unknown.
A person, organization, insurance company or other entity that assumes risk and undertakes to indemnify another person against loss, damage or liability arising from an event that is contingent or unknown.
An approach to controlling utilization, quality and cost of medical care using a variety of cost-containment methods, with an emphasis on creating incentives for employees to choose less expensive treatments and disincentives for employees to choose more expensive ones.
Maximum Medical Improvement (MMI)
This is the point at which a doctor indicates that an injured worker has recovered to the fullest extent. At this point, the doctor is supposed to provide an opinion on the effect this injury has had on the impaired function as a percentage of to the body as a whole.
Medical Only (MO)
A Workers’ Compensation claim that involves only medical service and no indemnity payments.
Program sponsored by the federal government to pay for various medical expenses for qualified individuals—specifically those age 65 or older, those with end-stage renal disease or with disabilities. Medicare includes two separate but coordinated programs: Hospitals insurance (Part A) and supplementary medical insurance (Part B).
Medicare Secondary Plans
Under Medicare secondary payer rules, employer-provided and other health plans generally are primary to Medicare. Medicare is on a secondary basis if a retiree or the retiree's spouse works.
Benefit whose value may be excluded from an employee's gross income for income tax purposes.
Nurse Case Manager (NCM)
This is a nurse hired by the insurance carrier to meet with the doctor and the employee in order to clarify issues and cut red tape to get the injured worker well.
This is a reference to having the medical records for an injury reviewed by another doctor to ask specific questions about the treatment plan or medications, but does not involve the employee seeing the peer review doctor reviewing the records.
Physician Panel (504)
A political subdivision that self-insures individually or collectively can directly contract with health care providers to provide medical services to their injured employees through Section 504 of the Texas Labor Code. They must ensure that workers’ compensation medical benefits are reasonably available to all injured workers’ of the political subdivision and that health care services are provided in a manner that will ensure the availability of and accessibility to adequate health care providers, specialty care and facilities.
Plain Language Notice (PLN)
Mandated by the State for communication to claimants.
Plain Language Notice of a carrier dispute on the compensability of the claims or certain body parts.
"Prudent Man" Rule
Under ERISA, fiduciaries are required to carry out their duties with skill and good judgment in the use of resources.
Reasonable and Customary (R&C) Charges
Also called UCR or Usual, Reasonable and Customary. The price at or below the majority of health care professionals charge for similar procedures within a specific geographic area.
The time immediately proceeding a stop-loss contract’s effective date that is configured to cover claims.
Length of time subject, to negotiation between the plan sponsor and the stop loss carrier, that a stop-loss contract can be configured to remain responsible for claims that are incurred during plan year, but not paid during the plan year.
Self-Insured Retention (SIR)
The amount of dollars retained by the District on each occurrence of loss in the Excess Insurance Policy. For JISD this amount is currently $350K.
Stop Loss Insurance, Aggregate Coverage
Coverage under which payments are made when the sum of all claims paid within the year exceeds a predetermined limit or aggregate attachment point. The stop-loss carrier sets the loss limit after evaluation of claims experience during the last three to five years and a projection of expected claims for the next year.
Provision that gives an employer or plan the right to recover benefits paid to a participant who later recovers the same expense for a third party.
Summary Plan Description (SPD)
A description of the provisions in an employee benefit plan that is provided to plan participants (regardless of employer size) and the Labor Department.
Supplemental Income Benefits (SIBS)
This benefit applies only to those employees who have received a 15% impairment rating by the doctor once they have reached Maximum Medical Improvement (MMI). Those employees with impairments to the body overall at 15% or better AND do not go back to work or earn 80% of the regular pay prior to the injury – are eligible for this form of compensation.
Temporary Income Benefits (TIBS)
This is the name for the benefits employees receive in replacement for their regular wages prior to being at MMI (Maximum Medical Improvement). This is usually figured as 70% of the average weekly wage over the 13 weeks immediately preceding the date of injury. Employees only receive this benefit if they are taken off work by the doctor.
Third Party Administrator (TPA)
Company that accepts responsibility for administering some or all of an employer's benefits program.
Legal agreement between a plan sponsor and a trustee that fixes the rights and liabilities with respect to managing and controlling the fund for the purposes of the plan.
A benefit plan where the employer assumes all risk and pays claims out of general assets.
Benefit in which an employer provides cash payments or medical care to an employee who is injured on the job. These benefits are mandated by state law and include partial wage replacement benefits and rehabilitation benefits.