Below is a glossary of common health insurance terms and definitions. It’s designed to make unfamiliar terminology easier to understand and to help you make more informed, cost-conscious health care decisions.
An additional life insurance benefit. This covers death due to a sudden, unexpected accident. You may also get a percentage of the benefit amount if you lose the ability to use a part of your body in an accident.
The Patient Protection and Affordable Care Act, commonly called the Affordable Care Act is a United States federal statute signed into law by President Barack Obama in March 2010. The law puts in place comprehensive health insurance reforms.
The maximum amount that a carrier will consider paying for a service, including any amount that the patient will be responsible for paying.
Total dollar amount a plan pays during a calendar year toward the covered expenses of each person enrolled.
When a provider bills you the difference between the provider’s charge and the carrier’s allowed amount.
A deductible beginning on January 1 and ends on December 31. Calendar-year deductibles reset every January 1.
You or your spouse’s or eligible domestic partner’s child who resides within the U.S. and is under age 26 (regardless of student status, marital status, residence or financial dependence). Children will be covered on the medical, Rx and life plans until the end of the year in which they turn 26, or day before their 30th birthday for dental and vision. Such children include:
A percentage of the medical costs, based on the allowed amount, you must pay for certain services after you meet your annual deductible.
A team member changes or “converts” her/his Group Life coverage to an Individual Life Insurance policy without having to answer any medical questions. Conversion is for a team member who is leaving her/his job, reducing hours or has reached the age when coverage may be reduced or eliminated and still wants to maintain the protection that life insurance provides.
A set dollar amount you pay for network doctors’ office visits, emergency room services and prescription drugs.
Total dollar amount, based on the allowed amount, you must pay out of pocket for covered medical expenses each calendar year before the plan pays for certain services. The deductible does not apply to network preventative care and any services where you pay a co- payment rather than coinsurance. Your dental plans also have an annual deductible and generally applied to covered basic and major dental services.
A benefits-eligible dependent is a spouse, domestic partner or a child.
Equipment and/or supplies ordered by for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches, and blood testing strips.
An embedded deductible means that each person covered under a family plan has their own individual deductible amount within the larger family deductible. Once an individual meets their personal deductible, the plan begins paying for covered services that are subject to that deductible—even if the family deductible hasn’t been met. When the family deductible is met, the plan begins paying covered services for all family members, even for those who haven’t met their individual deductible.
An illness or injury so serious that one must seek care right away to avoid severe harm.
The day in which you become injured, sick, or give birth. The event date marks the beginning of your disability claim regardless of whether it is for short-term or long-term disability.
Requirement under the insurer for the covered person to provide a completed application that details the condition of your health or your dependent’s health in order to be considered for coverage.
A form of insurance where you can use the doctors and hospitals within a network but cannot go outside the network for care. There are no out-of-network benefits, except in cases considered an emergency.
Healthcare services that your insurance doesn’t cover.
Account offering tax savings by allowing you to contribute pre-tax dollars from your salary for eligible medical and wellness expenses. Restrictions apply based on the medical plan elected. A portion of your funds can be rolled over each year and the amount allowed is based on IRS guidelines.
Your prescription drug formulary is an approved list of medications covered by your health plan.
These drugs are usually the most cost effective. Generic drugs are chemically identical to their brand name counterparts. Purchasing generic drugs allows you to pay a lower out-of-pocket cost than if you purchase formulary or nonformulary brand name drugs.
The amount of life insurance available to you without having to complete an Evidence of Insurability.
A portable savings account that allows you to set aside tax-free money for healthcare expenses. You must be enrolled in a High-Deductible Health Plan (HDHP) to open an HSA. An HSA rolls over from year to year, pays interest, can be invested, and is owned by you even if you leave the company.
A High-Deductible Health Plan (HDHP) is a health plan with typically a higher deductible than traditional health plans. Except for approved routine care, individuals on a HDHP will need to satisfy the annual deductible before the health plan will contribute towards the cost of care. Being covered by a qualified HDHP allows contributions to a Health Savings Account.
Services to comfort and support individuals in the last stages of a terminal illness.
Doctors or services that have a negotiated partnership with your plan. Using in-network doctors and facilities saves you money.
The percent you pay for covered health care services to providers who contract with your health insurance. In-network co-insurance typically costs less than out-of-network co-insurance.
A set amount that you pay for covered services to providers who contract with your health insurance. In-network co-payments typically cost less than out-of-network co-payments.
Insurance that protects your income if you are unable to work due to a long illness or injury. This insurance goes into effect after you have been out of work for a specific period of time.
A service that lets you order prescription drugs in bulk—typically a 90-day supply—and have them delivered directly to your home through the mail, instead of picking them up at a local pharmacy. It’s often used for maintenance medications you take regularly, offering convenience and sometimes lower costs.
Prescriptions commonly used to treat conditions that are considered chronic or long term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.
A group of health care providers, including dentists, physicians, hospitals and other health care providers, that agrees to accept predetermined rates when serving members.
These drugs are not on the recommended formulary list. These drugs are usually more expensive than drugs found on the formulary. You may purchase brand name medications that do not appear on the recommended list, but at a significantly higher out-of-pocket cost.
A provider without a contract with your insurance plan. You’ll generally pay more to see a non-preferred provider.
Doctors or services that do NOT have a negotiated partnership with your plan and might cost you more money.
The percent you pay for covered health care services to providers who do not contract with your health insurance. In-network co-insurance typically costs more than out-of-network co-insurance.
The most you’ll pay before your insurance begins to pay 100% of the allowed amount. The limit never includes your premium or services that your plan doesn’t cover.
The maximum amount of covered expenses a plan member must pay toward covered medical expenses in a calendar year for both network and non-network services. Once you meet this out-of- pocket maximum, the plan pays the entire coinsurance amount for covered services for the remainder of the calendar year. Deductibles and copays apply to the annual out-of-pocket maximum.
Services provided by a licensed medical physical (M.D. or D.O.)
A team member carries or “ports” their current Group Life coverage after employment ends, without having to answer any medical questions. Portability is for an employee who is leaving her/his job and still wants to maintain the protection that life insurance provides.
Preferred Provider Organization (PPO) plans allow members to use any healthcare professional without a referral. Staying in-network means smaller copays and more coverage. If you go out-of-network, you’ll have higher out-of-pocket costs, and not all services may be covered.
The amount that must be paid for your health insurance by you and your employer. Typically paid monthly.
A plan for active team members that is paid for with pre-tax money. The IRS allows for certain expenses to be paid for with tax-free dollars. The state takes premiums out of your check before taxes are calculated, increasing your spendable income and reducing the amount you owe in income taxes. Consequently, the IRS has tax laws that require you to stay in the plans you select for a full plan year (January through December). You can only make changes during Open Enrollment or if you have a Qualifying Event.
Healthcare services that you get when you are not sick or injured. These are designed to keep you healthy. They include annual checkups, gender- and age-appropriate health screenings, well-baby care, and immunizations recommended by the American Medical Association.
Getting approval from your provider for the recommended medicine, services or supplies prior to receiving them. Without this prior approval, your health plan may not provide coverage, or pay for the medication, services or supplies. Not all covered health services require prior authorization.
A physician (M.D or D.O.) who provides or coordinates a variety of healthcare services.
A physician (M.D. or D.O.), health care professional or facility that is licensed and certified as required by state law.
A major change in your personal or work situation—such as marriage, divorce, birth or adoption of a child, loss of other coverage, or a change in employment status—that allows you to make changes to your benefits outside of the annual open enrollment period.
R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of: (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services, as determined by MetLife.
Services that help a person keep or reclaim skills and functioning for daily living lost due to an illness or injury. Examples include occupational therapy, speech therapy, and select psychiatric services.
Medications that you get from a physical pharmacy, such as Walgreens, CVS, or Target. Generally, retail medications are offered only as a 30-day supply.
An income replacement benefit that provides a percentage of pre-disability earnings on a weekly basis when employees are unable to work due to an illness or injury that’s unrelated to their job. It typically covers off-the-job accidents and illnesses that workers’ compensation would not cover.
Services for licensed nurses in a nursing home or your own home.
A physician that focuses on a specific area medicine or group of patients to diagnose, prevent, or treat certain conditions.
Prescription medications that require special handling, administration or monitoring. These drugs may be used to treat complex, chronic and often costly conditions.
A straightforward summary that allows you to compare costs and coverage between different health plans.
The amount paid for a service in a geographic area based on what local providers typically charge.
Care for a condition or injury serious enough that one would seek care right away, but not one severe enough to require emergency room care.
In addition to group life insurance your employer provides additional voluntary life insurance. You can enroll in this coverage for yourself, your spouse or child(ren). Your dependents are eligible to enroll only if you are also enrolled yourself. You are responsible for the full premium.
The time that must pass before coverage becomes effective for an employee and his or her dependents.
A program offered by an employer or insurance carrier to incentivize employee health and fitness through discounted gym memberships, gift certificates for preventive care, and more.