Glossary of Terms
The opportunity to enroll or make changes in group heath and dental plans is normally scheduled one time each year--typically in early December. Faculty and staff should take this opportunity to review carefully their current benefit coverage and available options. Any changes made during open enrollment become effective January 1 of the following year.
CIGNA Dental Care Plan
A managed care dental plan (currently grandfathered to Clerical & Technical and Service & Maintenance employees as of 1/1/2007). Services provided by a pre-assigned dentist from CIGNA Dental Care's Network Directory.
Civil Union Partnership
A civil union partnership is defined as two individuals of the same gender who have obtained a legal civil union license.
Delta Dental Assistance Plan (DAP)
One of two dental plans available to Clerical & Technical and Service & Maintenance employees. Covered dental services include diagnostic, preventive, and restorative care. There are no annual deductibles and no annual maximums. No limitations on choice of dentist.
Qualifying dependents include: employee's legal spouse; child up to age 19 or child age 19-25 who is either financially dependent or a full-time student; or civil union partner. (Note: some restrictions apply.)
Dependent Care Center
A place that provides care for more than six persons (other than persons who live there) and receives a fee, payment or grant for providing services for any of those persons, regardless of whether or not the center is run for profit.
Appropriate documentation consists of verifiable receipts, itemized statements or other evidence of covered expenses (identifying the name of the person treated, dates and description of services performed or, in the case of dependent or child care, showing name of child/dependent, date and type of service, provider name and tax ID number. Cancelled checks and credit card receipts are not acceptable forms of documentation.
Eligible dependent care expenses
To be eligible, expenses must meet the following criteria:
- The expenses must be incurred to enable the participant and his/her spouse to be gainfully employed or attend school full time;
- The participant must have one or more "qualifying dependents" in the house-hold while employed; and
- The expenses must be incurred for either household services or for the care of a "qualifying dependent;"
- The child/dependent care reimbursement may not exceed the year-to-date total deducted from the participant's paycheck.
Unless otherwise stated, to be eligible for benefits, you must be a regular employee scheduled to work at least 20 hours per week.
New employees must enroll in one of the health insurance programs during the first 30 days of employment. Existing employees may also enroll, add, or delete dependents, or cancel coverage during the annual open enrollment period each fall, with coverage changes effective on January 1st of the following year. Enrollment changes are also permitted because of a qualifying Family Status Change.
Family Status Change
Any event that results in a change in the makeup of the family (i.e., marriage, birth or adoption of a child, divorce, or death of a family member) or change in work status (i.e., change in benefit eligibility or change in spouse's employment or coverage) resulting in a need to update benefit coverage. Employees have up to thirty (30) days from the date of the qualifying event to make any benefit election changes. For a list of qualifying family status change events, click here.
A Primary Care Physician (PCP) is a physician -- usually specializing in either family practice or pediatrics -- selected from a list of participating providers for the purpose of coordinating health care and providing routine general health care services for you and your dependents. When you need specialized care, your PCP can recommend a network provider -- a specialist or facility -- to deliver the care you need, or you can choose to see an out-of-network provider if you have a POS plan.
A Point of Service plan is an open access plan that provides the opportunity to use either network or non-network health care providers. Care delivered within the network is covered as an HMO plan. Outside the network, care is subject to deductible and co-insurance.
A Policy holder refers to the name of the person who is listed as the subscriber member of the insurance policy.
For dependent/child care, a qualifying dependent is
(a) a dependent of the participant who is under 13 and for whom the participant may claim a personal exemption, or
(b) a dependent (including a person the participant could claim as dependent except that the person has gross income of $2,650.00 or more) who is physically or mentally unable to care for himself or herself, or
(c) a spouse who is physically unable to care for himself or herself.
For health care (medical/dental) reimbursement, qualifying dependents include those individuals (such as the employee's spouse; and/or dependant child) who are listed as dependents on the employee's IRS income tax form.
Use It or Lose It Condition
In the event that reimbursements for non-insured medical and dental expenses paid to a participant in a given year are less than the amount of regular salary or wage reductions designated for this benefit in the same year, the participant will not be entitled to recover the difference, to apply it to another benefit, or to carry it over to the next year. Claims for the current year will only be honored if submitted no later than the end of February of the following year. After that date, no further claims for that year can be accepted.
Yale Health Plan (YHP)
A not-for-profit, physician-led HMO health plan that operates a medical center on the Yale campus. YHP provides coverage for primary, specialty and emergency care, as well as a range of ancillary services (radiology, pharmacy, laboratory, physical therapy) at 55 Lock Street. Upon referral, members also have access to an extensive network of clinicians and services at other area facilities. There is no limitation for pre-existing conditions, and most preventive, diagnostic and treatment services involve no deductibles and no claim forms. Coverage is free for eligible Yale faculty and staff and generously subsidized for dependents.