Benefit Terms and Definitions
Coinsurance
The percentage paid for a covered service, shared by you and the plan. Coinsurance can vary by plan and provider network. Review the plans carefully to understand your responsibility. You are responsible for coinsurance until you reach your plan’s out-of-pocket maximum.
Co-pay
A fixed dollar amount you pay the provider at the time of service; for example, a $20 co-pay for an office visit or a $15 co-pay for a generic prescription.
Deductible
The amount you pay each calendar year before the plan begins paying benefits. Not all covered services are subject to the deductible; for example, the deductible does not apply to preventive care services.
Emergency Room Care
Care received at a hospital emergency room for life-threatening conditions.
Evidence of Insurability
The process of providing health information to qualify for certain types of insurance coverage.
In-Network Care
Care provided by contracted doctors within the plan’s network of providers. This enables participants to receive care at a reduced rate compared to care received by out-of-network providers.
Out-of-Network Care
Care provided by a doctor or at a facility outside of the plan’s network. Your out-of-pocket costs may increase, and services may be subject to balance billing—when the provider bills you for the difference between their charge and pays.
Out-of-Pocket Maximum
The maximum amount you pay per year before the plan begins paying for covered expenses at 100%. This limit helps protect you from unexpected catastrophic expenses.
Premium
The complete cost of your plans. You share this cost with your employer and pay your portion through regular paycheck deductions.
Preventive Care
Routine healthcare including annual physicals and screenings to prevent disease, illness, and other health complications. In-network preventive care is covered at 100%.
Urgent Care
Care provided at an urgent care center for sudden illnesses or injuries that are not life-threatening. Urgent care centers are helpful when care is needed quickly to avoid developing more serious pain or problems.
Benefit Acronyms
| Acronym | Definition |
|---|---|
|
AD&D
|
Accidental Death & Dismemberment
|
|
DHMO |
Dental Health Maintenance Organization
|
|
EAP
|
Employee Assistance Program
|
|
EOB
|
Explanation of Benefits
|
|
EOI
|
Evidence of Insurability
|
|
EPO |
Exclusive Provider Organization
|
|
FSA
|
Flexible Spending Account
|
|
HSA
|
Health Savings Account
|
|
LSA
|
Lifestyle Spending Account |
|
OOPM
|
Out-of-Pocket Maximum
|
|
PCP
|
Primary Care Provider
|
|
PPO
|
Preferred Provider Organization
|
|
QLE
|
Qualifying Life Event
|
|
STD
|
Short-Term Disability
|
|
VLTD
|
Voluntary Long-Term Disability
|