Glossary

The term "eligibility" refers to conditions an employee must meet in order to qualify for coverage under a plan, such as length of service, employment status, or attainment of a certain minimum age.

An employee is a common-law worker of an employer.

An employee benefits plan is a plan an employer or employee organization creates or maintains in order to provide welfare and pension benefits to employees.

ERISA is a federal law that sets minimum standards for most voluntarily established, private industry pension and health plans within the United States to provide protection for individuals covered under these plans.

Participants must be provided with information about plan features and funding, and they have the right under ERISA to sue for benefits and breaches of fiduciary duty.  Individuals who manage and control plan assets must follow fiduciary responsibilities that are established under ERISA, and they must establish grievance and appeals procedures for participants to receive plan benefits that are owed to them.

ERISA generally does not cover group health plans for governmental entities or church employees, or plans that are maintained solely to comply with applicable workers compensation, unemployment, or disability laws.  ERISA also preempts state statutes, which means an ERISA mandate will rule over a conflicting law within the state that governs the plan.

An employee welfare benefits plan is a plan, fund, or program that an employer or an employee organization (or both) maintains for the purpose of providing benefits, other than pension benefits, to its participants or their beneficiaries through the purchase of insurance.  The following are plans that provide non-pension benefits: medical, surgical, or hospital care; benefits in the event of sickness, disability, accident, death, or unemployment; vacation benefits; apprenticeship or other training programs; day-care centers; scholarship funds, prepaid legal services; or any benefit described in Section 302(c) of the Labor-Management Relations Act of 1947.

An employer is any person who acts directly as an employer or indirectly in the interest of an employer in relation to an employee benefits plan.

An EPO is a type of health plan that features financial incentives to seek health care services from in-network providers, and patients are responsible for considerable out-of-pocket expenses if they receive care from out-of-network providers.

The term "enrollment" means any process by which individuals or their dependents become subscribers to a benefits plan.  Enrollment may be carried out by completing a written application, by virtue of a collective bargaining agreement, or by conditions of employment.

An enrollment date is either the effective date of coverage under a plan or the first day of the waiting period (typically the date employment begins) if there is a waiting period.

An enrollment form is a document that the employer provides to employees who are eligible to participate in a group benefits plan.  Employees complete and submit forms as a notice of their request to participate in the employer's group benefits plan.  These forms may include health questions or questions relating to an employee's dependent(s).

The term "EOB" means explanation of benefits.

The term "EPO" means enhanced provider option.

The term "ERISA" means the Employee Retirement Income Security Act of 1974 .  An ERISA mandate will rule over a conflicting law within the state that governs the plan.

The term "evidence of insurability" means any statement or proof of a person's physical condition, occupation, or other factor affecting his or her eligibility for insurance.  Evidence of insurability is usually not required for enrollment in group plans, and it is prohibited under COBRA continuation coverage.

Excess-loss coverage is stop-loss coverage.

The term "expected paid claims" refers to an estimate of the anticipated dollar amount of claims to be paid during a policy or contract year.

The term "experimental" or "investigational" refers to a drug, device, or medical treatment or procedure that meets any of the following criteria:

1. The U.S. Food and Drug Administration (FDA) must approve the lawful marketing of the drug, device, or medical treatment or procedure, and the FDA has not given such approval when the drug, device, or medical treatment or procedure is initially received.
2. A patient informed consent document utilized with the drug, device, or medical treatment or procedure was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or federal law requires such a review or approval.
3. The drug, device, or medical treatment or procedure is shown by Reliable Evidence to be any of the following:
1. The subject of ongoing Phase I or II clinical trials.
2. The research, experimental, study, or investigational arm of ongoing Phase III clinical trials.
3. Otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis.
4. Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device, or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis.

Reliable Evidence means only published reports or articles in authoritative medical and scientific literature; the written protocol(s) used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or medical treatment or procedure; or the written informed consent used by the facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

An EOB is a statement that a claim administrator sends to a plan participant or a provider of services that summarizes how the claim administrator adjudicated a claim.

Extra-contractual benefits are benefits that are paid at the request or approval of the employer for services or products not covered under the plan.