Terms to Know

Coinsurance

The percentage of a covered expense you must pay after you meet your deductible but before you reach the annual out-of-pocket maximum. The health plan pays the remaining approved medical expenses for the remaining plan year.

Copayment

The per-service fixed fee you pay for certain covered medical expenses.

Deductible

The amount you must pay each year for medical expenses before the medical plan begins to pay benefits.

DHMO (Dental Health Maintenance Org.)

Participant must elect a dentist to provide all services. Services are provided for no cost or a copay. There is no annual maximum.

Domestic Partnership

Two people of the same or opposite sex whose relationship has been recognized as legally binding by a state or local government.

EOB (Explanation of Benefits)

Statement sent by the medical carrier to explain the medical services that were covered on your behalf and any responsibility the member has.

EOI (Evidence of Insurability)

Proof of good health that is required to purchase certain types or levels of insurance.

EPO (Exclusive Provider Organization)

An EPO is a managed care plan which only covers medical care via in-network healthcare providers, unless in an emergency. You do not need a referral from your Primary Care Physician (PCP) to see a specialist. You cannot go out of the plan’s network, except for an emergency (sudden and serious illness).

Drug Formulary

Drugs are divided into tiers 1, 2, & 3. The formulary will also indicate if pre-authorization, step therapy, or quantity limits are required.

FSA Healthcare Spending Account and Dependent Care

A Flexible Spending Account or “FSA” is an opportunity to set aside pre-tax dollars, which can be used to pay for out-of-pocket medical & prescription, dental, and vision expenses.

Click here for an FSA and HSA comparison.

HDHP (High Deductible Health Plan)

With the high deductible health plan, you contribute the lowest premium. However, all benefits, including Rx, are subject to the medical deductible. You can enroll in a Health Savings Account with an HDHP and deposit pre-tax dollars to cover qualified medical expenses.

HSA (Health Savings Account)

A tax-free account you can use to pay for current and future medical expenses.

Out-of-Pocket Maximum: The limit the medical plan puts on the amount of money you must pay each year out of your pocket for eligible medical expenses. Once you reach the limit, the plan will pay 100% of your eligible expenses for the rest of the year.

Click here for an FSA and HSA comparison.

Preventive Care

Services available to you, such as screenings and vaccinations, that can help you avoid illness and improve your health at no cost to you.

PPO (Preferred Provider Organization)

A PPO provides the flexibility to go in or out of network without a referral from your PCP, although you will save money by staying in-network.

Summary of Benefits and Coverage (SBC's)

An easy-to-understand description of the benefits available to you under the plan you have chosen.