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<br />Glossarv: Miscellaneous Terms <br /> <br />Adverse Selection: The tendency of an individual to recognize his or her health status in selecting the <br />option under a retirement system or insurance plan that tends to be most favorable to him or her (and more <br />costly to the plan). In insurance usage, a person with an impaired health status or with expected medical <br />care needs applies for insurance coverage financially favorable to himself or herself and detrimental to the <br />insurance company. Also known as antiselection. <br /> <br />Carve-Out: A program separate from the primary plan designed to provide a specialized type of care, such <br />as a mental health carve-out; or for a designated group of employees, such as a management carve-out. <br /> <br />Contributory Plan: A benefit plan under which employees bear part of the cost. <br /> <br />Emplovee Assistance Plan (EAP): Designed to help employees whose job performance is being adversely <br />affected by personal problems. The program may also apply to many types of health education, prevention, <br />counseling and control of specific conditions (e.g. alcoholism, smoking, fitness, etc.). <br /> <br />Emplovee Contribution: Made by an employee into a plan. Mayor may not be required for participation. <br /> <br />Experience: Usually expressed as a ratio or percentage, it is the relationship of premium to claims, <br />coverage or benefits of a plan for a specified period of time. <br /> <br />Experience-Rated Premium: A premium based on the anticipated claims experience of, or utilization of <br />service by, a contract group according to its age, sex and any other attributes expected to affect its health <br />service utilization. Such a premium is subject to periodic adjustment in line with actual claims or utilization <br />experience. <br /> <br />Experience Ratina: The process of determining the premium rate for a group risk, wholly or partially on the <br />basis of that group's experience. <br /> <br />Minimum Participation Reauirement: Minimum number of eligible employees that must elect coverage in <br />order for a carrier to write a policy, normally expressed as a percentage. <br /> <br />Noncontributorv Provision: A term applied to employee benefit plans under which the employer bears the <br />full cost of the benefits for the employees. One hundred percent of eligible employees must be insured. <br /> <br />Preexistina Condition: A physical and/or mental condition of an insured person that existed prior to the <br />issuance of his or her policy. Excluded from coverage under some policies. <br /> <br />Reasonable and Customary (R&C) Charae: The prevailing charge made by providers of similar expertise <br />for a similar procedure in a particular geographic area. See also Usual, Reasonable and Customary Fees. <br /> <br />Trend Factor: The measurement for actuarial purposes of the change in the cost of health care after <br />weighing inflationary changes, changes in utilization and technology. <br /> <br />Usual. Customary and Reasonable (UCR) Fees: Usual is the fee usually charged for a given service by a <br />provider; customary is a fee in the range of usual fees charged by similar providers in area; reasonable is a <br />fee, according to the review committee, that meets the lesser of the two criteria or is justified in the <br />circumstances. <br /> <br />Voluntarv (Emplovee-Pav-AII) Benefits: Specific benefits that the employer administers and the employees <br />pay for. Commonly used for benefits that employees want but which the employer is unable or unwilling to <br />contribute toward. <br /> <br />20 <br />