Resources: Commonly Used Terms
Knowledge Database around Employee Benefits
Get helpful explanations for typical terms around employee benefits.
When you receive a statement from a provider that claims you owe additional funds after your copay and insurance carrier have paid. If you receive a statement from your provider verify with your insurance carrier if you need to pay the amount due.
The percentage paid for AFTER you have met the deductible. Can refer to the percentage you pay or the percentage the insurance carrier pays.
The amount you pay when visiting doctors or having services performed.
The amount you must pay before the insurance carrier starts payment. Even after you reach the deductible, you still are responsible for your portion of the coinsurance not paid by the insurance carrier. Could be any amount, usually between 40-100%.
Care provided in an emergency siting, inside a hospital or free standing Emergency facility. If the facility has the words “Emergency” or “Emergency Room” in their title participants will be billed like they visited an emergency room in a hospital.
Very similar to HMO. You can go to anyone in their network for the usual copays and/or coinsurance. Usually lower premium because of less choice in the network.
Flexible Savings Accounts can be used for medical, dependent care and in some areas transportation expenses. Participants contribute with pre-tax money from their paycheck to use for the appropriate type of account. Use it or lose it rules apply to these accounts.
Technically named “no label” drugs. Produced after the patents run out, costs are much less expensive. Ask your doctor to prescribe generics if the effect will be the same.
Guarantee Issue means the insurance carrier has to issue the policy, regardless of your health. The policy may not cover pre-existing conditions for a period of time.
There are NO out of network benefits, ONLY IN-Network benefits. Narrow Network and Primary Care doctor must refer you to specialists. Usually lower premium because of less choice in the network.
This is a pre-tax account that a participant in a high deductible health plan can open. The participant has money deducted from his paycheck pre-tax and deposited into this account. These funds are then used to pay for medical, dental, and vision expenses the participant incurs when they need services. Funds are able to be carried from one year to the next. There is a limit on the amount a participant can contribute each year but not a limit on the balance of the account.
The IRS sets minimum and maximum limits on these plans, because of the high deductible participants can have a pre-tax savings account if they want. Participants/Enrollees in an HDHP can have money deducted from their paycheck pre-tax and then save the funds in a Health Savings Account to help cover their costs when they use services.
The limit on how much you pay in a calendar or plan year for medical services. Does not include the premium amount.
The prescribing doctor must provide additional information to the insurance carrier before the prescription will be filled.
The insurance carrier has the right to say they will not cover expenses associated with a condition you already have and have had treatment for. Pre-existing conditions will usually be covered after a certain length of time. Plans covered under Affordable Care Act do not have a pre-existing limitation.
Preferred Brands are those named drugs manufactured that have a preferred contracted rate with an insurance carrier.
Broad network usually available with nationwide coverage. Traditionally accepted plans with a large choice of in and out of network providers. Usually have less benefits available with an out of network provider, but benefits are still available.
A participant can have deductions for certain types of benefits made before the calculation of payroll taxes. This process allows for both the employee and employer to save on taxes. This is legitimate savings based on IRS guidelines and proper documentation.
A provider that is your primary care physician, can be a Internist, Family Practice, Pediatrician, General Practice, OB/GYN or other primary care provider as designated by the insurance carrier.
All the doctors, specialists, hospitals, clinics, drug stores, and medical providers who have agreed to accept the rates negotiated by the insurance company. Each insurance provider has their own network of providers. Be sure to check for changes to your network when you change insurance carriers.
Very expensive drugs that have limited markets. Insurance carriers usually have specific limits and limited quantity on these drugs.
A process insurance carriers use to ensure that the doctor has tried other medications before prescribing a stronger or more potent dose.
The multiple page summary description of your insurance plan. This is a quick reference. You can find out a lot including a telephone number to the insurer.
Use medical services via smart device or computer for simple diagnostic procedures. Personnel are state certified and able to prescribe most medications as needed. It is advised to setup participant in the Telehealth system before the actual first use. Check your health plan for coverage details.
Services provided in a standalone facility, billed as “Urgent Care.” Usually less expensive than Emergency Room care. Urgent Care can perform many services later in the evening and on weekends. Services include x-rays, casting, immunizations, sick visits, strains and sprains, and school physicals .
Usually employee paid benefits that are payroll deducted. Plans usually reimburse participant for costs incurred in health plans, such as copays, deductibles, and coinsurance amounts. Can be pre-tax or post-tax arrangements. Policies may include accident, medical bridge, cancer, critical illness, or intensive care or specified illness.