Helpful Terms
Insurance that pays fractional amounts of the policy to a covered employee who loses a bodily appendage or sight because of an accident or pays benefits to the beneficiary if the cause of death is due to an accident.
Pays specific benefit amounts for expenses resulting from non-work related injuries or accidents and is designed to supplement employer-sponsored health coverage. Benefits are paid lump-sum, tax-free to employees and generally increase with the severity of the accident. The option of electing spouse and/or dependent coverage is also available.
Contributions for benefits deducted from your paycheck after Social Security, Medicare, and federal state and local income taxes have been assessed.
Balance billing is the practice of charging full fees in excess of covered amounts and billing the patient for the portion of the bill that the insurance company or medical plan does not pay. In-network providers do not balance bill for covered services. They must accept the amount paid by the plan (plus any member copayment and/or coinsurance) as stipulated in his or her contract. Non-network providers, however, are not under contract so they can balance bill.
A person designated to receive the income or other benefits from a will, insurance policy, annuity contract, trust, etc.
Coverage for healthcare services available in accordance with the terms of your healthcare coverage.
A series of tests conducted by a nurse measuring an individual’s overall health, including blood pressure, cholesterol, body mass index, etc.
The original manufacturer’s version of a particular drug. Because the research and development costs that went into developing these drugs are reflected in the price, brand name drugs cost more than generic drugs.
Employees 55 and older enrolled in the Health Savings Account (HSA) may contribute an additional money to the maximum yearly contribution. These contributions must end when the individual enrolls in Medicare.
A program that coordinates your health benefits when you have coverage under more than one group health plan (e.g., a spouse’s plan).
Coinsurance is your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. Your coinsurance will begin after you have met your deductible. For example, if the health plans allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health plan pays the rest of the allowed amount.
A copay is a fixed dollar amount you pay for a healthcare service. The amount can vary by the type of service. Your copays will not count toward your deductible but will count toward your out-of-pocket maximum.
Services, treatments, or supplies identified as payable in the Summary Plan Documents (SPD). Covered services must be medically necessary to be payable, unless otherwise specified.
This supplements major medical coverage by helping employees pay the direct and indirect costs associated with a critical illness or event. This coverage also includes an annual health screening benefit. Benefits are paid tax-free in a lump-sum to be used at the claimant’s discretion. Employees select the amount of coverage purchased. The option of electing spouse and/or dependent coverage is also available.
The deductible is the amount you owe for covered healthcare services before your plan begins to pay benefits. For example, if your deductible is $2,800, your plan won’t pay anything until you’ve met your $2,800 deductible for covered healthcare services subject to the deductible. Preventive care is not subject to the deductible as it is covered 100% by any medical plan option.
Medical plan—children under age 26 (naturally born or lawfully adopted by you or your legal spouse) or disabled children age 26 or older who are incapable of self-support, provided the disability began before age 26. Dental and vision plans—dependent, unmarried, natural born or lawfully adopted children under age 26; or disabled, dependent children age 26 or older who are incapable of self-support, provided the disability began before age 26.
Validly wed legal spouse of the same or opposite sex.
Two people in an established relationship who meet all of the following requirements: intend to remain in a committed relationship as each other’s domestic partner indefinitely; reside together in the same permanent residence; are financially interdependent, having agreed to be responsible for each other’s basic living expenses during their domestic partnership and that anyone who is owed these expenses can collect from either of them, and have provided proof of shared financial interests; are not legally married to anyone else and are not the domestic partner of anyone else; have not been in such a relationship in the past six months prior to the current domestic partnership; are not related by blood closer than would bar marriage under acceptable law; are both at least 18 years of age and mentally competent to enter into a legal contract; and have not entered into the relationship with the primary purpose of obtaining medical coverage or any other staff-member benefit.
If you are on a family medical plan with an embedded deductible, your plan contains two components: an individual deductible and a family deductible. Having two components to the deductible allows each member of your family to have your insurance policy cover their medical bills prior to the entire dollar amount of the family deductible being met. The individual deductible is embedded in the family deductible.
An EOB is a statement from the insurance company showing how claims were processed. The EOB tells you what portion of the claim was paid to the healthcare provider and what portion of the payment, if any, you are responsible for.
The application process in which you provide information on the condition of your health or your dependents’ health in order to be approved for coverage.
The amount of covered expenses an entire family (a subscriber and all dependents) must pay before benefits are paid by Carrier. See also deductible and individual deductible.
FSAs are voluntary accounts that allow you to use your pre-tax earnings to pay for IRS eligible health care expenses and dependent day care expenses. There are two types of FSAs – the Health Care FSA for eligible health care expenses and the Dependent Care FSA for qualified dependent care expenses. These are separate accounts.
Lower-cost alternative to a brand name drug that has the same active ingredients and works the same way.
A series of online questions an individual must answer with regard to lifestyle, fitness, eating habits, and overall life satisfaction.
An HSA is a portable savings account that allows you to set aside money for health care expenses on a tax-free basis. You must be enrolled in an HDHP in order to open an HSA. An HSA rolls over from year to year, pays interest, can be invested, and is owned by you – even if you leave the company.
HDHPs are health insurance plans with lower premiums and higher deductibles than traditional health plans. Only those enrolled in a HDHP are eligible to open and contribute tax-free to a health savings account (HSA).
Designed to help provide financial protection for covered individuals by paying a benefit due to hospitalization. Employees can use the benefit to meet the out-of-pocket expenses and extra bills that can occur. Indemnity lump-sum benefits are paid directly to the employee based on the amount of coverage listed, regardless of the actual cost of treatment. The option of electing spouse and/or dependent coverage is also available.
The amount of covered expenses an individual must pay before benefits are paid by a carrier. See also family deductible.
Federal health reform mandates most U.S. citizens have health insurance for themselves and their dependents. Your company helps you stay insured by offering affordable healthcare for all employees who work at least 30 hours each week. Coverage is effective the first of the month following 60 days of full-time employment and allows you to cover your spouse and children.
In-network providers are doctors that are contracted with the insurance company. In-network providers do not balance bill for covered services. They must accept the amount paid by the plan (plus any member copayment and/or coinsurance) as stipulated in their contracts. Non-network providers, however, are not under contracts so they can balance bill.
A network is composed of all contracted providers. Networks request providers to participate in their network, and in return, providers agree to offer discounted services to their patients. If you pick an out-of-network provider, your claims will be higher because you will not receive the discounts the in-network providers offer.
A hospital, pharmacy, physician, or other medical service provider that does not have a contract with an insurance carrier or another insurance carrier plan to provide healthcare services to members. Depending on the member’s plan, services from a nonparticipating provider may or may not be covered. A nonparticipating provider is also referred to as an out-of-network provider. Preferred provider organization members who visit a nonparticipating provider will receive limited benefits.
Doctors or services that are not partnered with your plan and might cost you more money.
The most you pay each year “out-of-pocket” for covered expenses. Once you’ve reached the out-of-pocket maximum, the health plan pays 100% for covered expenses.
A medical home is a healthcare setting that fosters partnerships between patients and their healthcare team, led by a primary care provider. Through technology and shared information, care is facilitated when and where you need and want it and coordinated between all of your healthcare providers.
Designed to provide permanent coverage in addition to the existing term option. While also available to the executive class, this program is generally designed to allow non-executive employees to fund a life-long insurance policy during their working years. Employee, spouse, child, and grandchild coverage is available independent of employee purchase.
The year for which the benefits you choose during open enrollment remain in effect. If you’re a new employee, your benefits remain in effect for the remainder of the plan year in which you enroll, and you enroll for the next plan year during the next open enrollment.
Allow you to “self-refer” to any provider in- or out-of-network; however, you receive greater discounts when you use in-network providers.
Contributions for benefits deducted from your paycheck before Social Security, Medicare, federal, state, and local income taxes have been assessed.
The amount a member or group pays on a periodic basis for coverage as defined in the member’s health insurance certificate or contract.
Routine healthcare services can minimize the risk of certain illnesses or chronic conditions. Examples of preventive care services include but are not limited to physical exams, mammograms, flu vaccines, prostate tests and smoking cessation.
A QLE allows you to make changes to your benefits during the year ONLY if you have a qualified event resulting in a “change in family status.”
The amount of money a health plan determines is the normal or acceptable range of charges for a specific health-related service or medical procedure. If your healthcare provider submits higher charges than what the health plan considers normal or acceptable, you may have to pay the difference.
A modified individual retirement account in which a person can set aside after-tax income up to a specified amount each year.
An income protection policy that can help replace a portion of an employee’s salary should he or she experience a disability. The plan pays monthly benefits in the event of sickness and off-the-job accidents. Most short term disability plans have a 12-month pre-existing condition limitation. Premiums are based on income, attained age and amount of coverage purchased.
A monthly spousal surcharge will apply to the following scenarios: you have a spouse or domestic partner who has access to group coverage elsewhere, or your spouse or domestic partner does NOT have group coverage elsewhere and you fail to fill out the Spousal Attestation form.
Benefit that pays for most copays, deductibles, and coinsurance for covered insurance carrier services provided by your company or one of its affiliated providers. This is not a separate medical plan or coverage.
Life insurance that covers the employee during the period of employment.
A participant’s right of ownership to the money in his or her plan account. A participant’s contributions and their earnings are always 100% vested; however, company contributions and employer matching contributions may become vested over a period of time.
Life insurance policy that the employee can continue outside of employment; builds cash value.