Coinsurance: Your share of a covered health care service, calculated as a percentage of the total allowed amount. For example, the plan may pay 80% of the cost of a service and you would pay the remaining 20%. Coinsurance does not include deductibles or copays.
Copayment (or Copay): A fixed amount you pay when you receive covered health care services. Amounts vary depending on your plan and the type of provider you use or service you receive.
Deductible: A flat dollar amount you pay each year before the plan begins paying benefits. The deductible varies based on the number of individuals for whom you are providing coverage and generally does not apply for those services subject to a copayment.
Eligibility: Conditions that you must meet to participate in a plan or obtain a benefit.
Employee Contribution: The amount you pay for your benefits through payroll deductions.
Enrollment Period: The period of time you have to sign up for insurance.
Formulary: A list containing the names of certain prescription drugs that a medical plan covers when dispensed to its members who have drug coverage.
Guaranteed Issue: The amount of life insurance coverage you are guaranteed to receive without the requirement of medical history or examination.
Health Reimbursement Account (HRA): Employer-funded plans that reimburse employees for incurred medical expenses that are not covered by the company’s standard insurance plan. Reimbursement dollars received by the employee are generally tax free.
Health Savings Account (HSA): A personal savings account that allows you to pay for qualified medical expenses with tax-advantaged dollars. You and/or your employer contribute money to an HSA through pre-tax contributions. The money contributed to the account is not subject to federal income tax at the time of deposit.
In-Network: Medical, dental and vision providers or facilities who have agreed to discounted fees with insurance carriers to participate within their provider networks.
Inpatient: A person who occupies a hospital bed, crib or bassinet while under observation, care, diagnosis or treatment for at least 24 hours.
Mail Order Prescription: A method of dispensing medication directly to the patient through the mail by means of a mail-order drug distribution company. Offers greatly reduced costs for prescriptions, especially for long term drug therapy.
Medical Group (network): An organization of physicians who are generally located in the same facility or participate in a group network and provide services to covered individuals.
Member: A person eligible to receive, or receiving, benefits from an insurance policy. Includes both those who have enrolled or subscribed and their eligible dependents.
Non-Formulary: A drug or medication not listed and approved on a health insurance plan coverage schedule.
Out-of-Network: A health care provider with whom an insurance carrier does not have a contract to provide services. A member may pay higher copays, and/or deductibles to see an out-of-network provider or have no coverage at all.
Out-of-Pocket Maximum: The maximum amount you need to pay toward your health care for the plan year. Once you reach your out-of-pocket maximum, the plan pays at 100 percent for eligible expenses. Depending on the plan you choose, deductibles and copayments may or may not be included in the out-of-pocket maximum.
Outpatient: A person who visits a clinic, emergency room or health facility and receives health care without being admitted as an overnight patient.
PCP: Primary Care Physician (PCP) provides treatments for routine illness and injuries. For members enrolled in an HMO Plan, a PCP will need to refer the member to a specialist.
PPO: Preferred Provider Organizations (PPO) have a network of providers whose services are available to members at lower cost that services of out-of-network providers. PPOs allow members to self-refer to any network provider at any time.
Premium: The amount of money an insurance company charges for insurance coverage.
Reasonable & Customary: The prevailing charge made by physicians of similar expertise for a similar procedure in a particular geographic area.
Wellness: A healthy balance of the mind, body and spirit that results in an overall feeling of well-being and leads to a high quality of life.