Glossary
In addition, under the Affordable Care Act, the Department of Health and Human Services (HHS) and Labor has posted a uniform Glossary of Terms on their website.
Please click here for important terms to know for the No Surprises Act (NSA).
A
-
Accidental Bodily Injury
Physical damage to the body, i.e., an injury, a wound, a trauma, resulting from a sudden and unexpected event, injury or external force occurring without forewarning. -
Accidental Death
Any death directly and solely resulting from external means or an external cause, as opposed to a death caused by or contributed to by a disease or existing infirmity. Accidental Death and Dismemberment Benefits are not payable if death occurs in a manner excluded by the Plan Document.
-
Active Employee
A person who is actively working for a contributing employer. Employees currently laid off or otherwise unable to actively work are not considered active employees. Employees receiving Short-Term Disability Benefits are considered Active Employees. -
Affordable Care Act (ACA)
The Patient Protection and Affordable Care Act (ACA) is a complex piece of legislation designed to reform the healthcare system by providing more Americans with quality and affordable insurance. -
Allowed Amount
Benefit amount determined by Plan Section 11.09.
-
Alternate Payee
A member, spouse, adult child, or custodial parent can request that an alternate address added that will be used for all correspondence, Explanation of Benefits statements, and claim payments relating to the covered individual. Examples of possible alternate payees include an adult child or spouse residing at a different address than the member, a former spouse with custody of the minor child(ren) covered by the plan, or the estate of a deceased member.
-
Annual Major Medical Out-of-Pocket Expense Limit
An Annual Major Medical Out-of-Pocket Expense Limit is your portion of eligible covered medical expenses that you must pay after TeamCare has paid its required percentage. -
Annual Plan Deductible
The Plan deductible is the amount of covered medical expenses that you or your dependents must pay each calendar year before the Plan begins paying benefits. -
Annual Plan Maximum
Certain Retiree Plans have an annual limit on the maximum amount which may be paid as a benefit that is determined per person, per calendar year. All medical benefits paid by TeamCare are applied to the Plan Maximum. Once you reach the annual plan maximum, you are responsible for all costs for the remainder of the year.
B
-
Bariatric Surgery
A surgical procedure to induce weight loss.
-
Benefit Rate
The percentage under your benefit plan that the Plan pays for these services.
(Related to No Surprises Act) -
Billed Amount
Total amount the provider billed TeamCare for the services.
(Related to No Surprises Act)
C
-
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that allows you to make self-payments to continue your health coverage if you have a qualifying event which causes loss of health coverage under TeamCare for you or a covered family member such as: layoff, termination, reduction of work hours, sickness, divorce, change in dependent status, etc.
-
Coinsurance You Owe
The Eligible Amount multiplied by the Member's Coinsurance Rates.
(Related to No Surprises Act) -
Collective Bargaining Agreement
An agreement reached by bargaining as to wages and conditions of work, and to which the Union and an Employer are parties. -
Coordination of Benefits
Coordination of Benefits is a practice used by health plans to determine the order in which plans pay benefits when more than one plan provides coverage. -
Co-Pay
A fixed fee you pay for a covered healthcare service or prescription, negotiated by TeamCare. The amount may vary based on the type of service or drug.
-
Copay You Owe
-
Cosmetic
Care, treatment, services or supplies the primary effect of which is to improve the physical appearance of a Covered Individual. The fact that there may be an incidental medical benefit does not prevent a determination that the care, treatment, services, or supplies are cosmetic. -
Coverage
Full entitlement to all benefits of this Plan by a Participant or Dependent, unless limited or excluded by any provision of this Plan.
D
-
Deductible You Owe
Amount of medical expenses that you or your covered dependents pay each calendar year before TeamCare pays certain benefits.
(Related to No Surprises Act) -
Dependent
A member's spouse or child (under age 26) who has TeamCare coverage.
E
-
Eligible Amount
Amount after reduction for your Deductible (if any) from the Qualifying Payment Amount (QPA).
(Related to No Surprises Act) -
Employee
An employee can be defined as:
- All persons who are accepted by the Trustees for participation in the Fund, under the terms and conditions stated by the Trustees for participation, and who are Active Employees of an Employer under the terms and conditions of a Collective Bargaining Agreement which requires Employer contributions be made to the Fund, and such other employees of the Employer as are proposed and accepted by the Trustees for participation, on whose behalf payments are required by the agreement of the Employer or applicable law to be made to the Fund;
- All persons employed by the Union upon being proposed by the Union and accepted by the Trustees; as to such Union personnel, the Union shall be considered an Employer solely for the purpose of contributions within the meaning of the Trust Agreement, as herein defined, and shall, on behalf of such personnel, make payments to the Trust Fund at the same times and at the rate of payment equal to that made by any other Employer who is a party to the Trust Agreement;
- All persons employed by Central States, Southeast and Southwest Areas Health and Welfare Fund or Central States, Southeast and Southwest Areas Pension Fund upon acceptance by the Trustees; as to such Trust Fund personnel, the Trustees shall be deemed an Employer solely for the purpose of contributions within the meaning of the Trust Agreement, on behalf of such personnel, make payments to the Trust Fund at the times and at the rate of payment equal to that made by any other Employer who is a party to the Trust Agreement; or All persons who are Trustees of Central States, Southeast and Southwest Areas Health and Welfare Fund or Central States, Southeast and Southwest Areas Pension Fund upon acceptance by the Trustees; on behalf of such persons who are Trustees, their Employers shall make contributions to the Trust Fund at the times and at the rate of payment equal to that required by any other Employer who is a party to the Trust Agreement.
- In all instances the common-law test for, or the applicable statutory definition of, master-servant relationship shall control Employee status. The continuation of employee status shall be subject to such rules as the Trustees may adopt.
-
Employer
Any Employer (including an Association of Employers) who is or becomes a party to a Collective Bargaining Agreement and who, with the acceptance of the Trustees, agrees to be bound by the Trust Agreement and this Plan and is accepted for participation in TeamCare by the Trustees, subject to such rules as the Trustees may in their discretion adopt. The Union, the Health Fund and the Pension Fund shall be deemed to be Employers of those persons employed and proposed by such organizations and accepted by the Trustees. -
Employer Contributions
Contributions made by Employers to TeamCare; contributions made by the Union or TeamCare on behalf of their Employees; and, amounts set aside by TeamCare on behalf of its Employees. -
ERISA
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. As a member, you are entitled to certain rights and protections under the ERISA. These rights include being allowed to examine all documents governing your health plan, receive copies of these documents, and receive a summary of your TeamCare plan's annual financial report. For a full explanation of your ERISA rights, see your Summary Plan Description.
-
Explanation of Benefits
After your claim is processed, you will receive an Explanation of Benefits (EOB), which explains the amounts paid on your claim. The EOB will also indicate a reason if your claim was denied either in full or in part. You can also review your EOBs on your My Claims page once you log in. If you disagree with how the claim was processed, you can file an appeal. Appeal forms can be downloaded from the Claims Appeals page.
F
-
Family Medical Leave
A voluntary absence from work taken by an Employee pursuant to the provisions of the federal Family Medical Leave Act. -
Family Protection Benefit
After your death, your family may be entitled to up to five years of continued coverage. For details, please refer to your Plan Document. -
Form 1095-B
Form 1095-B is a tax form which reports the type of coverage you and your dependents have from TeamCare, and the period of coverage during the prior year. -
Formulary
A formulary is a list of prescription drugs that are covered by your plan. Drugs may be removed from your list from time to time; in that case you may be given a generic drug or may have other options. If you choose to continue to use a drug once it's been removed from your formulary you may be required to pay full cost. -
Fund
The Central States, Southeast and Southwest Areas Health and Welfare Fund.
H
-
HMO
A Health Maintenance Organization plan requires members to visit an in-network provider and designate a primary care physician. -
Hospital Confinement
A hospital stay of at least overnight duration. An emergency room visit is not part of a Hospital Confinement unless it leads directly to a stay in a hospital room.
I
-
Initial Contribution Period
Also referred to as an establishing period. A period during which an employer is obligated to make contributions to TeamCare in order for an employee to become eligible for healthcare coverage. -
In-Network
If a provider is in-network, that means that TeamCare or its network administrators have a contractual relationship with the provider to reduce costs. By using an in-network provider, you get access to TeamCare’s extensive network of doctors, healthcare facilities, and hospitals at the lowest possible costs. Using an out-of-network provider could result in higher fees, as well as losing eligibility for the TeamCare Family Protection Benefit.
L
-
Lay-Off
An involuntary separation from employment caused by an Employer suspending Employees. Individuals shall not be deemed on lay-off if they engage in gainful employment for any other employer, nor shall lay-off status continue when an individual retires or otherwise terminates the employment relationship.
-
Leave of Absence
An employee’s voluntary temporary absence from employment, approved by the employer. Individuals on Leave of Absence shall not engage in gainful employment for any other employer, nor shall Leave of Absence status continue when an individual retires. -
Local Union
Those Local Unions affiliated with the International Brotherhood of Teamsters who have executed Collective Bargaining Agreements that require contributions to be made to Team Care on behalf of the covered employees, and such other Unions the Trustees may agree upon.
M
-
Maintenance Care
Maintenance Care is care provided to a person who needs assistance or support for the essence of daily living but who is not under a course of treatment which will improve his condition to the extent necessary to enable him to function without such assistance or support, except for care which is necessary to treat a curable illness. A Maintenance Care determination is not precluded by the fact that a patient is under the care of a Physician and that the services are provided at the Physician’s request. -
Maintenance Medications
Prescription medications used to treat chronic or long-term conditions, such as high blood pressure or asthma. -
Major Medical Expense Benefit
The Major Medical Expense Benefit covers certain medical expenses for illness, injury or pregnancy that are not covered by other benefits under the Plan. -
Maximum
The limit that TeamCare will pay for certain covered services, typically per calendar year. -
Member
The covered employee is referred to as a member, participant, or a subscriber.
N
-
Network
The doctors, healthcare providers, and facilities that TeamCare has contracted with to deliver members high-quality services at the lowest possible cost.
O
-
Out-of-Network
A provider or healthcare facility that TeamCare does not have a contractual relationship with. -
Out-of-Pocket
The portion of eligible medical expenses you must pay after TeamCare has paid the covered amount.
P
-
Participant
An employee who is eligible for coverage under this Plan through required employer contributions, or an employee who is entitled to make self-payments to TeamCare. -
Payable By Plan
Is the Allowed Amount minus the Total You May Owe.
(Related to No Surprises Act) -
Plan
A set of medical benefits an employer, union, or other group sponsor provides to employees to pay for their healthcare services.
-
Plan Document
The legal document by which the Fund administers TeamCare. -
Plan Payment
-
PPO
A Preferred Provider Organization allows members to receive service from a provider who is in-network and who has a contractual relationship with the Fund. -
Predetermination
A written request by a provider to inquire if a proposed treatment or service is covered under a patient’s TeamCare plan. Predetermination approvals and denials are based on medical necessity and the network’s medical policies — in accordance with their Plan Document.
-
Premises Injury
An injury that occurred due to a condition or incident on a residential, business, or municipal property. -
Prescription Drug
A drug or medicine prescribed by a physician or dentist, dispensed by a pharmacist, not available over the counter (except for insulin and insulin syringes) and bearing the Federal or State Legend. -
Psychiatric Treatment Facility
A facility that is:- Primarily engaged in providing, under the supervision of a Physician, psychiatric services for the diagnosis and treatment of mentally ill persons; and
- Licensed, certified or approved as a Psychiatric Treatment Facility, and not as a Hospital, by the state or jurisdiction in which it is located.
Q
-
Qualified Medical Child Support Order
Any order entered by a court of competent jurisdiction that complies with requirements of the federal Qualified Medical Child Support Act and which requires that a parent provide coverage for one or more dependent children. -
Qualifying Payment Amount (QPA)
Amount used to calculate any coinsurance you may owe for certain out-of-network services. The QPA is calculated in accordance with the No Surprises Act.
(Related to No Surprises Act) -
Quit
A permanent termination of employment initiated by the Employee.
R
-
Reasonable and Customary
The usual, Reasonable and Customary charge for the treatment, supply or service, determined by comparison with the charges customarily made for similar treatments, supplies or services to individuals with similar medical conditions within a given geographical area. -
Referral
A written order from your physician for you to visit a specialist or receive certain healthcare services. In most cases, TeamCare does not require a referral unless the member is covered by an HMO. -
Reimbursement
The process to recover benefits paid by TeamCare for a member’s physical or mental condition or injury that was or may have been caused by any person.
S
-
Self-Payments
Contributions to TeamCare by a member on his or her own behalf. -
Short-Term Disability Benefit
If you become disabled due to a non-work-related illness or injury, or pregnancy that is covered by the Plan, and cannot work, most TeamCare plans offer Short Term Disability benefits that provide you with some income. To qualify for Short-Term Disability, you must be following a treatment plan prescribed by a physician, be actively employed and covered by TeamCare when you become disabled, and submit a claim form. Find out more about how to file for Short-Term Disability here.
-
Sick Leave
A temporary absence from work caused by an employee’s illness, injury, or pregnancy. -
Spouse
An individual who is married to a participant in a legally recognized civil or religious ceremony. A Participant’s common-law spouse shall be considered a spouse for purposes of TeamCare, if: the participant’s state of domicile recognizes common-law marriage; and the member furnishes the Fund with appropriate documentation that the couple has fulfilled all conditions which their state of domicile requires for such a marriage. -
Standard Medical Care, Treatment, Services, or Supplies
Care, treatment, services or supplies which are uniformly and professionally endorsed by the general medical community as Standard Medical Care, Treatment Services or Supplies. -
Subrogation
Subrogation refers to TeamCare’s right to recover 100% of benefit payments made by us for any physical or mental condition or injury that was or may have been caused by any person.
T
-
TEA Number
The TEA number is commonly referred to as your Identification Number or UMI (unique medical identification number) on your Blue Cross Blue Shield medical ID card. The TEA Number or Identification Number will begin with "TEA" followed by a series of 9 numbers, typically beginning with “806.” -
Teamsters
The International Brotherhood of Teamsters, and its affiliated Local Unions. -
Temporary Work Stoppage
A strike by Participants which is sanctioned by the Teamsters. -
Terminated Employee
An individual who is separated from his employment by reason of Quit or Discharge. -
Total and Permanent Disability
A disease or bodily injury which will permanently, continuously, and wholly prevent a person from engaging in any occupation or employment for wage or profit for the duration of his life. Additionally, the complete and irrecoverable loss of the sight of both eyes, or the use of both hands, or of both feet, or of one hand and one foot. -
Total You May Owe
Total of Copay You Owe, Deductible You Owe, Coinsurance You Owe, and out-of-network reduction (if any).
(Related to No Surprises Act) -
Trust Agreement
The Agreement and Declaration of Trust made and entered into on the fourteenth (14th) day of March, 1950, by and between Central Conference of Teamsters, Southern Conference of Teamsters and their affiliated Local Unions, and the Southeastern Area Motor Carriers Labor Relations Association; Southwest Operators Association; and Motor Carriers Employers Conference – Central States, and as amended from time to time thereafter by the Trustees.
We’re here to help make sense of all TeamCare has to offer. Members, Providers, Partners and Local Unions are encouraged to contact us for help understanding their plans and benefits. Visit our Contact Us page to learn more about how to call by phone, or log in to your Message Center to send a TeamCare Benefits Specialist a secure message.