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 remaining percentage is paid by the health plan.

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 Organization) 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.

EOI (Evidence of Insurability): Proof of good health that is required to purchase certain types and/or levels of insurance.

EPO (Exclusive Provider Organization): 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).

Formulary: Insurance carriers each have their own list of prescription drugs. Drugs are divided into tiers 1 (generic), 2 (brand name) & 3 (specialty). The formulary will also indicate if pre-authorization, step therapy or quantity limits are required.

FSA (Flexible Spending Account): is a special account you put money into that you use to pay for certain out-of-pocket healthcare or child care costs. You don’t pay taxes on this money. This means you’ll save an amount equal to the taxes you would have paid on the money you set aside.

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.

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: An easy to under-stand description of the benefits available to you under the plan. The Summary is divided into categories and is known by the standard blue and white color.