ISCEBS Fellow flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Medical Loss Ratio

Percentage of premium revenue spent on clinical services and quality improvement. Minimums are 80% for individual and small-group markets and 85% for large-group markets, with rebates if not met.

Out-of-Pocket Maximum

The annual limit on cost-sharing a member pays for covered in-network essential benefits, excluding premiums. After reaching it, the plan pays 100% of covered benefits.

COBRA Qualifying Event

An event such as termination, divorce, death, or Medicare entitlement that allows qualified beneficiaries to continue group health coverage for a defined period, typically 18 to 36 months.

Preventive Care Mandate

Requirement that non-grandfathered plans cover specified preventive services without cost-sharing when delivered in-network, including screenings, immunizations, and well-child visits.

Health Savings Account Rules

Tax-advantaged account paired with a qualifying high-deductible health plan. Contributions are deductible, growth is tax-deferred, and qualified medical withdrawals are tax-free; funds roll over.

Flexible Spending Account

Employer-sponsored account funded with pre-tax salary reductions for qualified medical expenses. Funds are generally use-it-or-lose-it, with limited carryover or grace period options.

Step Therapy

Utilization management requiring a trial of a preferred, lower-cost drug before covering a more expensive alternative, unless a clinical exception applies.

Wellness Program Incentive Cap

Outcome-based rewards tied to a health factor are limited to 30% of the cost of coverage, or 50% for tobacco cessation, with reasonable alternatives required.

Funding Target

Present value of all accrued benefits under a defined benefit plan, generally targeted at 100% funding. Shortfalls are amortized over seven years through minimum required contributions.

Final Average Pay Formula

Benefit equals years of service multiplied by an accrual rate and average compensation over a specified period, commonly the highest three or five consecutive years.

ADP Test

Nondiscrimination test comparing average deferral percentages of highly compensated and non-highly compensated employees, limiting deferrals when the gap is too large.

Top-Heavy Plan

Plan where key employees hold more than 60% of account balances or accrued benefits, triggering minimum contribution or benefit requirements for non-key employees.

Required Minimum Distribution

Minimum annual withdrawal from tax-deferred retirement accounts beginning at the applicable age, with excise tax penalties for shortfalls.

Cash Balance Plan

A defined benefit plan expressing benefits as a hypothetical account with pay credits and interest credits, often converted to a lump sum at termination.

PBGC Guarantee Limits

Statutory maximum monthly benefit the Pension Benefit Guaranty Corporation pays to participants in terminated single-employer plans, adjusted for age at termination.

ERISA Fiduciary Duty

Obligation to act solely in the interest of participants with the care, skill, and prudence of a knowledgeable expert, including diversification and plan-document compliance.

Vesting Schedule

Rules determining when an employee gains nonforfeitable rights to employer contributions. Common schedules are three-year cliff or two-to-six-year graded vesting.

Compensation Limit

Annual indexed cap on compensation that may be counted for plan purposes, set under Internal Revenue Code Section 401(a)(17).

ERISA Preemption

Doctrine under which ERISA supersedes state laws relating to employee benefit plans, though state insurance laws continue to regulate insured arrangements.

Summary Plan Description

Plain-language document describing plan terms, eligibility, benefits, and claims procedures, required to be furnished to participants within set deadlines.

Form 5500

Annual report filed with the Department of Labor disclosing plan financial condition, operations, and compliance information for employee benefit plans.

FMLA Eligibility

Employee must have worked 12 months, 1,250 hours, and be at a worksite with 50 or more employees within 75 miles to receive 12 weeks of job-protected leave.

Own Occupation Definition

Disability standard that pays benefits when the insured cannot perform the material duties of their own occupation, typically used in short-term or early long-term disability periods.

Section 409A

Internal Revenue Code provision governing timing of deferred compensation elections and distributions, imposing penalties for noncompliant arrangements.

Qualifying Life Event

Event such as marriage, birth, divorce, or loss of other coverage that permits mid-year enrollment changes outside the annual open enrollment window.

Canada Health Act

Federal law setting criteria provinces must meet for health transfer payments: public administration, comprehensiveness, universality, portability, and accessibility of insured services.

OAS and GIS

Old Age Security provides a universal pension; the Guaranteed Income Supplement adds income-tested benefits for low-income seniors. Both are federally administered and indexed.

CPP Enhancement

Phased increase in Canada Pension Plan replacement earnings and contribution rates, raising benefits for contributors and requiring higher payroll contributions.

RRSP Versus TFSA

RRSP contributions are deductible and withdrawals taxable; TFSA contributions are after-tax and withdrawals tax-free. Both allow tax-sheltered growth.

RRIF Minimum Withdrawal

Annual minimum amount that must be withdrawn from a Registered Retirement Income Fund after conversion from an RRSP, based on age and prescribed factors.

Quebec Drug Insurance Plan

Provincial requirement that Quebec residents have prescription drug coverage through an employer plan or the public plan, with premium and deductible rules.

Employment Insurance Benefits

Federal program providing temporary income for maternity, parental, sickness, and compassionate leave, subject to eligibility hours and benefit maximums.