Glossary

A federal statute signed into law in March 2010 as a part of the healthcare reform agenda of the Obama administration. Signed under the title of The Patient Protection and Affordable Care Act, the law included multiple provisions that would take effect over a matter of years, including the expansion of Medicaid eligibility, the establishment of health insurance exchanges and prohibiting health insurers from denying coverage due to pre-existing conditions.

A specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.

A medical coverage source for individuals under age 19 whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage. Children’s Health Insurance Program coverage varies from state to state, but all states’ CHIP plans cover routine check-ups, immunizations, doctor visits, prescriptions, dental care, vision care, hospital care, laboratory services, X-rays and emergency services. Some states also cover parents and pregnant women.

The amount or percentage that 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.

The flat fee that you pay towards the cost of covered medical services.

With the dental PPO plan, you will have the benefit of visiting a provider of your choice, whether it’s a general dentist or specialist. Prior to visiting any provider, however, be sure to completely understand the costs associated with the specific provider. The benefits change within the networks as do the out of pocket costs you will incur.

An EAP is an employer-sponsored service designed for personal or family problems, including mental health, substance abuse, various addictions, marital problems, parenting problems, emotional problems, or financial or legal concerns.

With an HMO plan, you will need to select a primary care physician (PCP). Once elected, the PCP will be directing your level of care. If you ever require services beyond a PCP’s expertise, they will provide the referrals to specialists that can assist. If you ever decide to seek out medical services that are not conducted by your PCP, be sure to consult with him/her first, prior to setting an appointment with the other practitioner. The consultation will help you to understand what the potential out of pocket costs you will incur based on your decision.

Care received from your primary care physician or from a specialist within an outlined list of health care practitioners.

Long term disability insurance (LTD) is an insurance policy that protects an employee from loss of income in the event that he or she is unable to work due to illness, injury, or accident for a long period of time.

A prescription drug benefit program that was created through the U.S. Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The "D" stands for "drugs". The program gives Medicare recipients these basic choices: stay in traditional Medicare without signing up for the prescription drug benefit outlined in the Act, stay in traditional Medicare and enroll in a Medicare drug plan, enroll in other Medicare plans, or enroll in a comprehensive private health plan (which may or may not cover prescription costs). The program began providing coverage for users on Jan 1, 2006.

Open Enrollment is typically offered for one or two months a year by many companies to allow employees to make changes to their health insurance coverage.

Care you receive without a physician referral or services received by a non-network service provider. Out-of-network health care and plan payments are subject to deductibles and copayments.

Amount that you must pay towards the cost of health care services. This includes deductibles, copayments and coinsurance.

The top amount paid for covered services during a benefit period. Both the deductible and the coinsurance apply towards meeting the OOPM, but copayments may not apply. Under some plans, the deductible and OOPM may have the same dollar limit.

With a PPO plan, you will have the benefit of visiting a provider of your choice, whether it’s a physician or specialist through their PPO network. It’s a health plan that offers both in-network and out-of-network benefits. Members must choose one of the in-network providers or facilities to receive the highest level of benefits. Unlike the HMO plan, you will not need to elect a Primary Care Physician (PCP). Prior to visiting any provider however, be sure to completely understand the costs associated with the specific provider. The benefits change within the networks, as do the out of pocket costs you will incur.

Medical care rendered not for a specific complaint but focused on prevention and early-detection of disease. This type of care is best exemplified by routine examinations and immunizations.

The doctor that you select to coordinate your care under your health plan. This generally includes family practice physicians, general practitioners, internists, pediatricians, etc.

With the vision plan, you will be responsible for a small copay per examination and will have allowances for frames, glasses, and contact lenses. Prior to visiting any provider, however, be sure to completely understand the costs associated with the specific provider. The out of pocket costs you will incur can change depending on the provider you select and the frame/lens options you choose.