Open enrollment is the time of year reserved for your employees to makes changes to their benefit selections. Unfamiliar terms can make the process more difficult and confusing. So, we’ve created this benefits glossary to help your employees navigate through their benefits options.
Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
Broker: That’s us! An agent or broker is a person or business who assists you as apply for coverage and enroll in a Qualified Health Plan (QHP). They can make specific recommendations about which plan you should enroll in.
COBRA: A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Coinsurance: The amount or percentage you pay for certain covered health care services under your health plan. This is typically the amount paid after a deductible is met, and can vary based on the plan design.
Copayment: A fixed amount you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
Deductible: The amount you owe for covered health care services before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible. The deductible may not apply to all services.
Dependent: A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction.
Flexible Spending Account (FSA): An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices.
Full-time Employee: An employee who works an average of at least 30 hours per week.
Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency.
Health Reimbursement Account (HRA): Employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year.
Health Savings Account (H S A): A medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
High Deductible Health Plan (HDHP): A qualified health plan that gives you more control over your health care spending by offering lower monthly premiums in exchange for higher deductibles and out-of-pocket limits. These plans are often coupled with and HSA or HRA.
In-Network: Healthcare received from your primary care physician or from a specialist within your health plan.
Inpatient: A patient checked into a hospital or other health care facility. This person accrues room and board charges.
Medically Necessary: Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Medicare: A Federal health insurance program for people who are age 65 or older and certain younger people with disabilities.
Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Out-of-Network: Healthcare received from providers who don’t contract with your health insurance or plan.
Out-of-Pocket Costs: Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
Out-of-Pocket Maximum: The most you pay during a policy period before your health insurance or plan starts to pay 100% for covered essential health benefits.
Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network.
Primary Care Provider: A physician who coordinates or helps a patient access a range of health care services. This generally includes family practice physicians, general practitioners, internists, pediatricians, etc.
Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, changes in your family size, and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
Usual, Customary, and Reasonable (UCR): 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.