Glossary

A	AD&D Insurance An insurance plan that pays a benefit to you or your beneficiary if you suffer from loss of a limb, speech, sight, or hearing, or if you have a fatal accident. Allowed Amount The maximum amount your plan will pay for a covered healthcare service. Ambulatory Surgery Center (ASC) A healthcare facility that specializes in same-day surgical procedures such as cataracts, colonoscopies, upper GI endoscopy, orthopedic surgery, and more. Annual Limit A cap on the benefits your plan will pay in a year. Limits may be placed on particular services such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. After an annual limit is reached, you must pay all associated health care costs for the rest of the plan year.
B	Balance Billing In-network providers are not allowed to bill you for more than the plan’s allowable charge, but out-of-network providers are. This is called balance billing. For example, if the provider’s fee is $100 but the plan’s allowable charge is only $70, an out-of-network provider may bill YOU for the $30 difference. Beneficiary The person (or persons) that you name to be paid a benefit should you die. Beneficiaries are requested for life, AD&D, and retirement plan. You must name your beneficiary in advance. Brand Name Drug A drug sold under its trademarked name. For example, Lipitor is the brand name of common cholesterol medicine.
C	COBRA A federal law that may allow you to temporarily continue healthcare coverage after your employment ends, based on certain qualifying events. If you elect COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, you pay 100% of the premiums, including any share your employer used to pay, plus a small administrative fee. Claim A request for payment that you or your health care provider submits to your healthcare plan after you receive services that may be covered. Coinsurance Your share of the cost of a healthcare visit or service. Coinsurance is expressed as a percentage and always adds up to 100%. For example, if the plan pays 70%, your coinsurance responsibility is 30% of the cost. If your plan has a deductible, you pay 100% of the cost until you meet your deductible amount. Copayment A flat fee you pay for some healthcare services, for example, a doctor’s office visit. You pay the copayment (sometimes called a copay) at the time you receive care. In most cases, copays do not count toward the deductible.
D	Deductible The amount of healthcare expenses you have to pay for with your own money before your health plan will pay. The deductible does not apply to preventive care and certain other services. Family coverage may have an aggregate or embedded deductible. Aggregate means your family must meet the entire family deductible before any individual expenses are covered. Embedded means the plan begins to make payments for an individual member as soon as they reach their individual deductible. Dental Basic Services Services such as fillings, routine extractions, and some oral surgery procedures. Dental Diagnostic & Preventive Generally includes routine cleanings, oral exams, x-rays, and fluoride treatments. Most plans limit preventive exams and cleanings to two times a year. Dental Major Services Complex or restorative dental work such as crowns, bridges, dentures, inlays, and onlays. Dependent Care Flexible Spending Account (FSA) An arrangement through your employer that lets you pay for eligible child and elder care expenses with tax-free dollars. Eligible expenses include daycare, before and after-school programs, preschool, and summer day camp for children under age 13. Also included is care for a spouse or other dependent who lives with you and is physically incapable of self-care.
E	Eligible Expense A service or product that is covered by your plan. Your plan will not cover any of the costs if the expense is not eligible. Excluded Service A service that your health plan doesn’t pay for or cover.
F	Formulary A list of prescription drugs covered by your medical plan or prescription drug plan. Also called a drug list.
G	Generic Drug A drug that has the same active ingredients as a brand-name drug, but is sold under a different name. For example, Atorvastatin is the generic name for medicines with the same formula as Lipitor. Grandfathered A medical plan that is exempt from certain provisions of the Affordable Care Act (ACA).
H	Health Reimbursement Account (HRA) An account funded by an employer that reimburses employees, tax-free, for qualified medical expenses up to a maximum amount per year. Sometimes called Health Reimbursement Arrangements. Healthcare Flexible Spending Account (FSA) A health account through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Eligible expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, medical devices, and some over-the-counter items. High Deductible Health Plan (HDHP) A medical plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs (the deductible) before the insurance company starts to pay its share. A high deductible plan (HDHP) may make you eligible for a health savings account (HSA) that allows you to pay for certain medical expenses with money free from federal taxes.
I	In-Network In-network providers and services contract with your healthcare plan and will usually be the lowest cost option. Check your plan’s website to find doctors, hospitals, labs, and pharmacies. Out-of-network services will cost more, or may not be covered.
L	Life Insurance An insurance plan that pays your beneficiary a lump sum if you die. Long Term Disability Insurance Insurance that replaces a portion of your income if you are unable to work due to a debilitating illness, serious injury, or mental disorder. Long-term disability generally starts after a 90-day waiting period.
M	Mail Order A feature of a medical or prescription drug plan where medicines you take routinely can be delivered by mail in a 90-day supply.
O	Open Enrollment The time of year when you can change the benefit plans you are enrolled in and the dependents you cover. Open enrollment is held one time each year. Outside of open enrollment, you can only make changes if you have certain events in your life, like getting married or adding a new baby or child to the family. Out-of-Network Out-of-network providers (doctors, hospitals, labs, etc.) cost you more because they are not contracted with your plan and are not obligated to limit their maximum fees. Some plans, such as HMOs and OAPINs, do not cover out-of-network services at all. Out-of-Pocket Cost A healthcare expense you are responsible for paying with your own money, whether from your bank account, credit card, or from a health account such as an HSA, FSA, or HRA. Out-of-Pocket Maximum Protects you from big medical bills. Once costs “out of your own pocket” reach this amount, the plan pays 100% of most remaining eligible expenses for the rest of the plan year. Family coverage may have an aggregate or embedded maximum. Aggregate means your family must meet the entire family out-of-pocket maximum before the plan pays 100% for any member. Embedded means the plan will cover 100% for an individual member as soon as they reach their individual maximum. Outpatient Care Care from a hospital that doesn’t require you to stay overnight.
P	Participating Pharmacy A pharmacy that contracts with your medical or drug plan and will usually result in the lowest cost for prescription medications. Plan Year A 12-month period of benefits coverage. The 12-month period may or may not be the same as the calendar year. Preferred Drug Each health plan has a preferred drug list that includes prescription medicines based on an evaluation of effectiveness and cost. Another name for this list is a “formulary.” The plan may charge more for non-preferred drugs or brand-name drugs with generic versions. Drugs that are not on the preferred drug list may not be covered. Preventive Care Services Routine healthcare visits that may include screenings, tests, check-ups, immunizations, and patient counseling to prevent illnesses, diseases, or other health problems. Many preventive care services are fully covered. Check with your health plan in advance if you have questions about whether a preventive service is covered. Primary Care Provider (PCP) The main doctor you consult for healthcare issues. Some medical plans require members to name a specific doctor as their PCP and require care and referrals to be directed or approved by that provider.
S	Short Term Disability Insurance Insurance that replaces a portion of your income if you are temporarily unable to work due to surgery and recovery time, a prolonged illness or injury, or pregnancy issues and childbirth recovery.
T	Telehealth / Telemedicine / Teledoc A virtual visit to a doctor using video chat on a computer, tablet, or smartphone. Telehealth visits can be used for many common, non-serious illnesses and injuries and are available 24/7. Many health plans and medical groups provide telehealth services at no cost or for much less than an office visit.
U	UCR (Usual, Customary, and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury, or condition serious enough that care is needed right away, but not so severe it requires emergency room care. Treatment at an urgent care center generally costs much less than an emergency room visit.
V	Vaccinations Treatment to prevent common illnesses such as flu, pneumonia, measles, polio, meningitis, shingles, and other diseases. Also called immunizations. Voluntary Benefit An optional benefit plan offered by your employer for which you pay the entire premium, usually through payroll deduction.