Coinsurance
The percentage the plan or you pay for a covered service or supply. For example, the plan may pay 80 percent while you pay 20 percent.
Consumer-Driven Health Plan (CDHP)
A plan that provides competitive health insurance along with a tax-advantaged health savings account (HSA) that lets you decide how to spend your health care dollars. Essentially, you pay a lower premium in exchange for a higher deductible, much like car insurance.
Copayment (Copay)
A copay is a flat-dollar amount you pay for specific covered services upon each visit to the provider. It is not impacted by the plan deductible, coinsurance or out-of-pocket maximum.
Deductible
The amount you pay each year before the plan begins to pay coinsurance.
Evidence of Insurability (EOI)
The documentation of the good health condition of the insurance beneficiary and his/her dependent’s health in order to be approved for coverage. It is only required in certain circumstances.
Explanation of Benefits (EOB)
After you receive medical services, your insurance will provide you with an EOB. It will outline details regarding how your insurance processed your medical claim, including what portion of the charges your insurance paid and what portion, if any, you are responsible for paying.
Flexible Spending Accounts (FSAs)
An FSA is a tax-advantaged account that lets you put money aside on a pre-tax basis to pay for a wide range of health and/or dependent care expenses (as defined by the IRS) not covered by your plan that you incur during the plan year. Unlike the HSA, any unused funds remaining after the plan year ends will be forfeited.
Formulary
A formulary is a list of medications covered by your prescription plan. If you use a medication that is not on your plan’s formulary, you may be required to pay the full cost. To view the formulary for your plan, visit the plan’s website.
Health Savings Account (HSA)
An HSA is a tax-advantaged savings account for consumer driven health plan (CDHP) participants that lets you put money aside on a pre-tax basis to pay for a wide range of health care expenses (as defined by the IRS) not covered by your plan. Unused money remaining in the account at the end of the plan year rolls over to be used the next year. Please refer to IRS Publications 502 and 969 for complete details on eligible expenses.
HSA Contribution
This refers to a contribution, or “deposit,” an employee may make to his/her HSA, or a deposit made by the company to the HSA of an employee participating in the CDHP.
In-network & Out-of-network Providers
Benefit plans develop networks by contracting with doctors, hospitals, labs, etc., who have agreed to provide health care services to members at negotiated rates. You generally pay less out of pocket when you use in-network providers.
Out-of-pocket Maximum
The maximum amount you will pay out of pocket for covered medical expenses per calendar year, including your deductible. After your share of covered expenses reaches this annual limit, the plan pays 100 percent for eligible network services and supplies for the remainder of the calendar year.
Preferred Provider Organization (PPO) Plan
A type of health plan that contracts with doctors, hospitals, labs and other health care providers to create a network of participating providers. You generally pay less when you use providers that belong to the PPO network. You may use providers that fall outside of the plan’s network at an additional cost. This type of plan typically has higher premiums and a lower deductible than a consumer driven health plan (CDHP).
Prescription Drug Out-of-pocket Maximum
The maximum amount you will pay out of pocket for covered prescription drug expenses per calendar year. After your share of covered prescription drug expenses reaches this annual limit, the plan pays 100 percent for eligible prescription drugs for the remainder of the calendar year. The prescription drug out-of-pocket maximum is separate from the medical out-of-pocket maximum.
Reasonable & Customary (R&C) Charges
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 R&C amount sometimes is used to determine the allowed amount.
Summary Plan Description (SPD)
An important document that tells plan participants what the plan provides and how it works.
Questions?
- For questions about your benefits, contact Health Advocate at 866-799-2728.
- For questions on the enrollment process, contact HRLink.