TRS Member Handbook - Glossary
Glossary
Anniversary Date - The beginning of the benefit year.
Behavioral Health Care - The assessment and treatment of mental and/or psychoactive substance abuse disorders.
Benefit Package - The services a plan offers to a group or an individual.
Centers for Medicare & Medicaid Services (CMS) - The branch of the government that manages the Medicare program.
Coordination of Benefits - A provision in a contract that applies when a person is covered under more than one group medical program. It requires the payment of benefits to be coordinated by all programs to eliminate over-insurance or duplication of benefits.
Co-payment - A cost sharing arrangement in which the HMO enrollee pays a specified flat amount for a specific service. Typical co-payments are fixed amounts for physician office visits, prescriptions, or hospital services.
Disenrollment - Enrollees who do not renew their contract with the alternative delivery system either because they chose not to renew during open enrollment, have left the company, are no longer qualified, are terminated, or are deceased.
Drug Formulary - A listing of prescription medications, which are preferred for use by SWHP and are dispensed through participating pharmacies. The list is subject to periodic review and modification by SWHP.
Effective Date - The date on which a policy's coverage goes into effect.
Enrollee - Any person eligible for service as either a subscriber or a dependent in accordance with a contract.
HMO (Health Maintenance Organization) - SWHP is a HMO. A HMO is an entity that provides
Medically Underwritten Health Plans - Refers to policies that are issued only after medical questions are answered or a physical is performed to make sure the applicant qualifies for the product.
PCP (Primary Care Physician) - A physician selected within the panel of contracted or salaried providers who will provide and coordinate your health care.
Service Area - The geographical area within certain boundaries where SWHP provides services to enrollees. An enrollee should not have to drive longer than 30 miles to obtain emergency care.
Spring Enrollment - A period during which subscribers in a dual choice benefit program have an opportunity to select the alternative health plan being offered to them. Most frequently, spring enrollment periods are held one month every year. Enrollees are allowed to add/delete changes in the plan during spring enrollment.
Summer Enrollment - A period during which subscribers in a dual choice benefit program have an opportunity to select the alternative health plan being offered to them. Most frequently, summer enrollment periods are held one month every year. Enrollees are allowed to add/delete changes in the plan during summer enrollment.
TDI (Texas Department of Insurance) - In Texas, the agency that insurance laws and regulations are administered by.
TRS-ActiveCare - Established in 2001 by articles 3.50-8 and 3.50-9, Texas Insurance Code, TRSActiveCare is a statewide health care program administered by the Teacher Retirement System of Texas (TRS) and designed to address the health care needs of Texas public education employees.
Utilization - The extent to which a given group uses services during a specified period of time.
For more definitions of terms, visit the main glossary section.