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| OBRA |
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See Omnibus Budget Reconciliation Act (OBRA) Of 1990.
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| Occupational Disease |
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Impairment of health caused by continued exposure to conditions inherent in a person's occupation or a disease caused by an employment or resulting from the nature of an employment.
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| Occupational Therapy |
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The treatment of Sickness or Injury, by a Health Care Practitioner who is an occupational therapist, using purposeful activities or assistive devices that focus on all of the following:
1. Developing daily living skills.
2. Strengthening and enhancing function.
3. Coordination of fine motor skills.
4. Muscle and sensory stimulation.
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| OEP or "Open Enrollment Period" |
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Running from January 1 until March 31, A Medicare Beneficiary can make additional choices regarding Medicare Advantage Plans. A Medicare Beneficiary who has both Medicare Part A and Medicare Part B, and who has enrolled in a Medicare Part D plan (PDP) can switch to a Medicare Advantage Plans (MA-PD) - Please note however, in the OEP, you may not move to another stand alone PDP. A Medicare Beneficiary who already has a MA-PD can switch to another MA-PD or they can switch back to Original Medicare and a stand-alone PDP. MA-PD members are not allowed to switch to a MA plan without a prescription drug plan. If a Medicare Beneficiary is in a MA plan without prescription drug coverage, they are not able to switch to a MA-PD (Medicare Advantage Plans with prescription drug coverage). Related to this word are AEP, IEP, and SEP.
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| Office Visit |
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An in-person meeting between a Covered Person and a Health Care Practitioner in the Health Care Practitioner's office. During this meeting, the Health Care Practitioner evaluates and manages the Covered Person's Sickness or Injury as defined in the most recent edition of Current Procedural Terminology (CPT) or provides preventive medicine services.
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| Omnibus Budget Reconciliation Act (OBRA) Of 1990 |
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A federal act which established theMedicare SELECT program, a Medicare Supplement that uses a Preferred Provider Organization (PPO) to supplement Medicare Part B Coverage.
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| Open Access |
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A provision that specifies that plan Members may self-refer to a specialist, either In-network or Out-Of-Network, at full Benefit or at a reduced Benefit, without first obtaining a Referral from a Primary Care Provider (PCP).
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| Open Debit |
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A Life and Health Insurance (HI) debit (territory) currently without an Agent.
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| Open Enrollment |
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A period each year during which employees have an opportunity to change their employer-provided health care Coverage. They usually can choose among various plans from different Health Insurance (HI) Providers.
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| Open Enrollment Period |
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A period during which Members can elect to come under an alternate plan, usually without providing Evidence of Insurability.
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| Open Formulary |
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The provision that drugs on the preferred list and those not on the preferred list will both be covered by a PBM or MCO.
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| Open Panel |
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See Open Access.
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| Open PHO |
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A type of Physician-Hospital Organization (PHO) that is available to all of a hospital's eligible medical staff.
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| Open-Panel HMO |
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An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a Provider. These physicians typically operate out of their own offices and see other patients as well as HMO members.
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| Operational Integration |
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The Consolidation into a single operation of operations that were previously carried out separately by different Providers.
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| Operations Director |
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Individual who typically oversees Claims, management information services, Enrollment, Underwriting, Member Services, and office management.
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| Optional Benefits |
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See Elective Benefits.
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| Optionally Renewable |
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A contract of Health Insurance (HI) in which an insurer reserves the unrestricted right to terminate Coverage at any anniversary or, in some cases, at any Premium due date. It may not do so in between.
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| Original Medicare |
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The term "OriginalMedicare" is often used to describe your normalMedicare A and B Benefits. If you have Medicare Part A and/or Medicare Part B Coverage you can purchase a Medicare Part D (PDP) plan. If you haveMedicare A and B you can also purchase a Medicare Supplement to cover a portion of the costs not covered by Original Medicare or you can enroll in aMedicare Advantage Plan (with or without Prescription Drug Coverage).
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| Orthognathic Treatment |
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Malocclusion, Mandibular Protrusion or Recession, Maxillary or Mandibular Hyperplasia or Maxillary or Mandibular Hypoplasia. Refer to the Definitions of these conditions in this section of the plan.
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| Osteoporosis High-Risk Individual |
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Includes, but is not limited to, a Covered Person who:
1. Is estrogen-deficient and at clinical risk for osteoporosis;
2. Has vertebral abnormalities;
3. Is receiving long-term glucocorticoid (steroid) therapy;
4. Has primary hyperparathyroidism; or
5. Has a family history of osteoporosis.
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| Outcomes Measurement |
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A method of keeping track of a patient's treatment and the responses to that treatment.
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| Outcomes Measures |
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Healthcare Quality indicators that gauge the extent to which healthcare services succeed in improving patient health.
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| Out-of-Area (OOA) |
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Treatment given to a Member outside of the normal area.
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| Out-Of-Network |
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Health care services received outside the HMO or PPO Network
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| Out-Of-Network Benefit |
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Generally provides a Beneficiary with the option to Access plan services outside of the contracted Provider Network. In some cases, a Beneficiary's Out-of-Pocket Costs may be higher for an Out-Of-Network Benefit.
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| Out-Of-Plan |
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This phrase usually refers to physicians, Hospitals or other Health Care Providers who are considered non-Participants in an insurance plan (usually an HMO or PPO). Depending on an individual's Health Insurance (HI) plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered at a reduced Benefit level.
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| Out-of-Pocket Costs |
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Insured health care costs for which one is responsible, because of the application of Deductibles, Coinsurance and Copayments.
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| Out-of-Pocket Costs - Medicare Part D |
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The amounts the Beneficiary pays as their share of prescription drug costs in a Part D plan. Deductible, Coinsurance, and the amounts paid during the Doughnut (Donut) Hole or "Coverage Gap" make up the total Out-of-Pocket Costs. The Out-of-Pocket Costs are called TrOOP - True Out-of-Pocket. When each Beneficiary "true Out-of-Pocket Costs" exceed $4550, they are eligible for the Catastrophic Coverage plan phase.
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| Out-of-Pocket Limit |
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The Out-of-Pocket Limit is the sum of the Covered Charges for which the Insurance Carrier does not pay benefits. When Covered Charges equal to the Out-of-Pocket Limit have been Incurred and processed by the Insurance Carrier, the Out-of-Pocket Limit will be satisfied for the remainder of the Calendar Year. The Out-of-Pocket Limit applies separately to each Covered Person, except as otherwise provided by the plan.
The following do not count toward satisfying any Out-of-Pocket Limit:
1. All Access Fees.
2. All Penalties applied under the Utilization Review (UR) Provisions section.
3. Amounts in excess of the Maximum Allowable Amount.
4. Charges Incurred after the maximum amount has been paid for a Benefit under the plan.
5. All Outpatient Rx - Ancillary Charge, Ancillary Pharmacy Network Charges.
An Out-of-Pocket Limit only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what the applicable Out-of-Pocket Limits are along with the Covered Charge to which they apply.
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| Out-of-Pocket Limit - Family |
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The total dollar amount of Covered Charges that must be paid by You and Your Covered Dependents before the Insurance Carrier will consider the Out-of-Pocket Limit for all Covered Persons under the same Family Plan to be satisfied.
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| Out-of-Pocket Limit - Individual |
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The dollar amount of Covered Charges that must be paid by each Covered Person before the Insurance Carrier will consider the Out-of-Pocket Limit for that Covered Person.
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| Out-of-Pocket Limit - Non-Participating Provider |
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The dollar amount of Covered Charges for services received from Nonparticipating Providers that must be paid by each Covered Person before the Non-Participating Provider Out-of-Pocket Limit is satisfied for that Covered Person.
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| Out-of-Pocket Limit - Participating Provider |
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The dollar amount of Covered Charges for services received from Providers in the Participating Provider Network that must be paid by each Covered Person before the Participating Provider Out-of-Pocket Limit for that Covered Person.
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| Out-of-pocket maximum |
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Total dollar amount an Insured will be required to pay for covered medical services during a specified period, such as one year. The out-of-pocket maximum may also be called the Stop-Loss limit or catastrophic expense limit.
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| Outpatient |
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Treatment, services or supplies received at a licensed medical facility, Health Care Practitioner's office or dispensary on other than an Inpatient basis for a stay of less than 24 hours.
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| Outpatient Care |
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Treatment that is provided to a patient who is able to return home After Care without an overnight stay in a Hospital or other Inpatient facility.
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| Outpatient Rx - Ancillary Charge |
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The difference in cost between a Outpatient Rx - Brand Name Drug and what the Insurance Carrier will pay for a Outpatient Rx - Generic Drug when a Outpatient Rx - Generic Drug substitute exists but the Outpatient Rx - Brand Name Drug is dispensed. A Covered Person must pay any applicable Outpatient Rx - Ancillary Charge directly to the Outpatient Rx - Participating Pharmacy.
The Outpatient Rx - Ancillary Charge does not count toward satisfying any Coinsurance, Copayment, Deductible or Out-of-Pocket Limit under the Outpatient Prescription Drug Benefits section or any other section in the plan.
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| Outpatient Rx - Ancillary Pharmacy Network Charge |
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The difference in cost between the actual charge and the maximum amount that a Outpatient Rx - Participating Pharmacy has agreed to accept as total payment for the cost of a Prescription Drug. The Covered Person must pay any applicable Outpatient Rx - Ancillary Pharmacy Network Charge directly to the Outpatient Rx - Pharmacy. An Outpatient Rx - Ancillary Pharmacy Network Charge may apply if the Covered Person does not use his or her identification (ID) card to obtain Prescription Drugs at a Outpatient Rx - Participating Pharmacy or if Prescription Drugs are purchased at a Outpatient Rx - Non-Participating Pharmacy.
The Outpatient Rx - Ancillary Pharmacy Network Charge does not count toward satisfying any Coinsurance, Copayment, Deductible or Out-of-Pocket Limit under the Outpatient Prescription Drug Benefits section or the Medical Benefits section.
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| Outpatient Rx - Average Sales Price |
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A published cost of a Prescription Drug as listed by the Insurance Carrier's national drug data bank or by a federal or other national source on the date the Prescription Drug is purchased.
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| Outpatient Rx - Average Wholesale Price |
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A published cost of a Prescription Drug that is paid by a Outpatient Rx - Pharmacy to a wholesaler as listed by the Insurance Carrier's national drug data bank on the date the Prescription Drug is purchased.
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| Outpatient Rx - Brand Name Drug |
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"A Prescription Drug for which a pharmaceutical company has received a patent or trade name."
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| Outpatient Rx - Compounded Medication |
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A drug product make up of two or more active parts or ingredients which must be specially prepared by a licensed pharmacist pursuant to a Outpatient Rx - Prescription Order. If covered, Outpatient Rx - Compounded Medication will be considered to be Non-Preferred Brand-Name Drugs.
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| Outpatient Rx - Drug List |
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A list of Prescription Drugs that the Insurance Carrier designates as eligible for reimbursement. A Outpatient Rx - Drug List is subject to change at any time without notice.
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| Outpatient Rx - Generic Drug |
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A Prescription Drug that:
1. Has the same active ingredients as an equivalent Outpatient Rx - Brand Name Drug or that can be used to treat the same condition as a Outpatient Rx - Brand Name Drug; and
2. Does not carry any drug manufacturer's Brand name on the label; and
3. Is not protected by a patent.
it must be listed as a Outpatient Rx - Generic Drug by the Insurance Carrier's national drug data bank on the date it is purchased. Outpatient Rx - Compounded Medication are not Outpatient Rx - Generic Drugs. Medications that are commercially manufactured together and/or packaged together are not considered to be Outpatient Rx - Generic Drugs, unless the entire combination product is specifically listed as a Outpatient Rx - Generic Drug product by the Insurance Carrier's national drug data bank on the date it is purchased and it must be approved by the Insurance Carrier.
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| Outpatient Rx - Mail Service Prescription Drug Vendor |
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A Outpatient Rx - Participating Pharmacy that is under contract with the Insurance Carrier or it's Network Manager through the Insurance Carrier's Outpatient Rx - Participating Pharmacy Network. The Outpatient Rx - Mail Service Prescription Drug Vendor dispenses selected Outpatient Rx - Prescription Maintenance Drugs to Covered Persons through the mail.
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| Outpatient Rx - Maximum Allowable Cost (MAC) List |
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A list of Prescription Drugs that are considered for reimbursement at a Outpatient Rx - Generic Drug product level that is established by the Insurance Carrier. This list is subject to change at any time without notice.
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| Outpatient Rx - Non-Participating Pharmacy |
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A Outpatient Rx - Pharmacy that is not under contract with the Insurance Carrier or it's Network Manager to provide Prescription Drugs to the Covered Person through the Insurance Carrier's Outpatient Rx - Participating Pharmacy Network.
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| Outpatient Rx - Participating Pharmacy |
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A Outpatient Rx - Pharmacy that is under contract with the Insurance Carrier or it's Network Manager to provide Prescription Drugs to the Covered Person through the Insurance Carrier's Outpatient Rx - Participating Pharmacy Network.
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| Outpatient Rx - Participating Pharmacy Network |
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A Prescription Drug delivery system established by the Insurance Carrier or the Network Manager in which Participating Provider Pharmacies are under contract with the Insurance Carrier or it's Network Manager. The Outpatient Rx - Participating Pharmacy List is subject to change at any time without notice.
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| Outpatient Rx - Pharmacy |
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A licensed establishment where Prescription Drugs are dispensed by a licensed pharmacists in accordance with all applicable state and federal laws.
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| Outpatient Rx - Prescription Card Service Administrator (PCSA) |
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An organization or entity that administers the processing of Claims under the Outpatient Prescription Drug Benefits section. This organization or entity may be changed at any time without notice.
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| Outpatient Rx - Prescription Drug Coinsurance |
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The Outpatient Rx - Prescription Drug Coinsurance is the dollar amount or percentage of Covered Charges for Prescription Drugs that must be paid by a Covered Person after any Outpatient Rx - Ancillary Charge, Outpatient Rx - Ancillary Pharmacy Network Charge, Outpatient Rx - Prescription Drug Copayment or Outpatient Rx - Prescription Drug Deductible are satisfied. The Covered Person must pay any applicable Outpatient Rx - Prescription Drug Coinsurance directly to the Outpatient Rx - Participating Pharmacy.
The Outpatient Rx - Prescription Drug Coinsurance only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what any applicable Outpatient Rx - Prescription Drug Coinsurance percentage is. The Outpatient Rx - Prescription Drug Coinsurance does not count toward satisfying any Out-of-Pocket Limit under the Medical Benefits section.
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| Outpatient Rx - Prescription Drug Condition Specific Deductible |
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The dollar amount of Covered Charges for Prescription Drugs that must be satisfied by a Covered Person because of a named condition, shown in a Condition Specific Deductible endorsement that is included with the plan, and for any complications related to that named condition. When Covered Charges for Prescription Drugs equal to the Prescription Drug Condition Specific Deductible for the named condition have been Incurred and processed by the Insurance Carrier, the Prescription Drug Condition Specific Deductible for that Covered Person will be satisfied for the remainder of the time period shown in the Condition Specific Deductible endorsement. After the Prescription Drug Condition Specific Deductible is satisfied, additional Covered Charges for Prescription Drugs for the named condition will be paid subject to all the terms, limits and conditions in the plan, including satisfaction of any other applicable Outpatient Rx - Prescription Drug Coinsurance, Outpatient Rx - Prescription Drug Deductible, Deductible under any other section of the plan, or other fee.
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| Outpatient Rx - Prescription Drug Copayment |
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A Outpatient Rx - Prescription Drug Copayment is the dollar amount of Covered Charges that a Covered Person pays each time a Outpatient Rx - Prescription Order is received that is covered under the Outpatient Prescription Drug Benefits section after any applicable Outpatient Rx - Prescription Drug Deductible is satisfied. The Covered Person must pay any applicable Outpatient Rx - Prescription Drug Copayment directly to the Outpatient Rx - Participating Pharmacy.
A Outpatient Rx - Prescription Drug Copayment only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what the applicable Outpatient Rx - Prescription Drug Copayments are. A Outpatient Rx - Prescription Drug Copayment does not count toward satisfying any Out-of-Pocket Limit under the Outpatient Prescription Drugg Benefits section or the Medical Benefits section.
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| Outpatient Rx - Prescription Drug Deductible |
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A Outpatient Rx - Prescription Drug Deductible is the dollar amount of Covered Charges for Prescription Drugs that each Covered Person pays before Benefits are paid by the Insurance Carrier. The Covered Person must pay any applicable Outpatient Rx - Prescription Drug Deductible directly to the Outpatient Rx - Participating Pharmacy. When Covered Charges equal to the Outpatient Rx - Prescription Drug Deductible have been Incurred and processed by the Insurance Carrier, the Outpatient Rx - Prescription Drug Deductible for that Covered Person will be satisfied for the remainder of the Calendar Year. Charges applied to the Outpatient Rx - Prescription Drug Deductible do not count toward satisfying any Outpatient Rx - Prescription Drug Condition Specific Deductible that would apply.
A Outpatient Rx - Prescription Drug Deductible only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what any applicable Outpatient Rx - Prescription Drug Deductibles are. Charges applied to the Outpatient Rx - Prescription Drug Deductible do not count toward satisfying any Out-of-Pocket Limit under the Medical Benefits section.
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| Outpatient Rx - Prescription Drug Family Deductible |
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The dollar amount that must be satisfied by all Covered Persons before Benefits are payable by the Insurance Carrier. The Outpatient Rx - Prescription Drug Deductibles that all Covered Persons may have to pay are limited to the Prescription Drug Family Deductible amount. When the Outpatient Rx - Prescription Drug Family Deductible amount is reached, the Insurance Carrier considers the Outpatient Rx - Prescription Drug Family Deductible requirements for all Covered Persons in the family to be satisfied for the remainder of the Calendar Year, except for any Outpatient Rx - Prescription Drug Condition Specific Deductible that a Covered Person may have.
The Outpatient Rx - Prescription Drug Family Deductible only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what the applicable Outpatient Rx - Prescription Drug Family Deductible amount is. Charges applied to the Outpatient Rx - Prescription Drug Family Deductible do not count toward satisfying any Out-of-Pocket Limit under the Medical Benefits section.
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| Outpatient Rx - Prescription Maintenance Drugs |
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Prescription Drugs that are:
1. Drugs that are taken regularly to treat a chronic health condition; and
2. Covered under the Outpatient Prescription Drug Benefits section; and
3. Approved by the Insurance Carrier for Coverage under the Outpatient Rx - Mail Service Prescription Drug Vendor provision in the Outpatient Prescription Drug section.
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| Outpatient Rx - Prescription Order |
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The request by a Health Care Practitioner for:
1. Each separate Prescription Drug and each authorized refill; or
2. Insulin only by prescription; or
3. Any one of the following supplies used in the self-management of diabetes and purchased during the same transaction only by prescription:
a. Disposable insulin syringes and needles; or
b. Disposable blood/urine/glucose/acetone testing agents or lancets.
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| Outpatient Services |
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Services that do not take place as an Inpatient in the Hospital. They may be provided in clinics or Provider officers, ambulatory surgical centers, Hospices, Home Health Services, and so forth.
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| Outpatient Services Maximum |
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The annual maximum amount the plan pays toward Outpatient Services.
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| Overage Insurance |
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Health Insurance (HI) issued at ages above the usual limit, which is generally 65.
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| Overhead Expense Insurance |
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Insurance which covers such things as rent, utilities, and employee salaries when a business owner becomes disabled. The insurance Benefit is generally not a fixed amount, but pays the amount of expenses actually incurred.
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| Over-The-Counter Drugs (OTC) |
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A drug that can be purchased without a prescription.
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| Owner - ADD |
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means the Insured unless an Owner other than the Insured is shown on the application. The Owner may be changed by written notice to Us at any time while the Insured is living. The Owner has all the rights and privileges under this certificate, including the right to name a Loss Payee, subject to Our prior agreement.
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