Glossary
Brand-name drug: A drug that is patented and produced only by one manufacturer.
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 Segal used to pay, plus a small administrative fee.
Coinsurance: Money that you are required to pay for services, generally after you have met your deductible. Coinsurance is often specified by a percentage.
Contribution: The net out-of-pocket amount you pay each pay period for healthcare coverage.
Copay: Copay is a predetermined (flat) fee that you pay for healthcare services, in addition to what the plan covers.
Coverage tier: The level of coverage that indicates who is covered under your medical, dental, and vision options. Tiers include Employee Only, Employee Plus One and Employee Plus Family.
Deductible: The amount you must pay for healthcare expenses before the plan starts to cover the costs.
Dependent: A person covered by your benefit elections and may include your legal spouse, spousal equivalent or domestic partner, and/or children through the end of the month in which they attain age 26.
Dependent Care Flexible Spending Account (DCFSA): A plan that allows you to set aside pre-tax contributions from your paychecks to pay the cost of daycare for eligible dependents.
Employee Assistance Program (EAP): An employment-based plan designed to help you manage (or navigate) issues, such as work-life balance, stress and grief. The plan offers counseling assistance by telephone and may also cover follow-up visits with counselors if needed.
Exclusive Provider Organization (EPO): A type of health plan that offers a local network of doctors and hospitals for you to choose from. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency).
Flexible Spending Account (FSA): A plan that allows you to set aside pre-tax dollars for common healthcare and/or dependent daycare expenses. You must use Dependent Care FSA funds by the end of the plan year, or they will be lost. For your Healthcare FSA, you may roll over up to 20% of unused funds from one year to the next.
Formulary: A list of covered drugs, which may also include how much you pay for each drug. Formularies can include both generic drugs and brand-name drugs.
Generic drug: A drug that does not have the trademark of the original manufacturer but is chemically identical and generally costs less than its brand-name counterpart.
Health Assessment: A health questionnaire that asks about your health habits to help identify possible health needs.
Healthcare Flexible Spending Account (HCFSA): An account you may establish to set aside pre-tax contributions from your paychecks to pay eligible healthcare expenses.
Health Insurance Portability and Accountability Act of 1996 (HIPAA): A federal law regulating health coverage portability, data privacy and data security by:
- Providing additional opportunities for individuals to enroll in group health plan coverage when they lose other health coverage, get married or add a new dependent
- Establishing federal standards protecting sensitive health information from disclosure without the patient’s consent
- Requiring healthcare providers and organizations to implement strict physical, network and process security measures
Health Reimbursement Account (HRA): An employer-funded arrangement from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year.
Health Savings Account (HSA): A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed HSA dollars to pay for deductibles, copayments, coinsurance and some other eligible expenses, you may be able to lower your overall healthcare costs. HSA funds roll over year to year if you don’t spend them, so they also allow you to save for future healthcare expenses. You may contribute to an HSA only if you are enrolled in an HSA-eligible high-deductible health plan.
High-deductible health plan (HDHP): A plan that features higher deductibles than traditional insurance plans. HDHPs that meet the federal government minimum deductible and maximum out-of-pocket cost limits can be combined with a Health Savings Account (HSA).
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. An HMO may require you to live or work in its service area to be eligible for coverage.
In-network: Providers or healthcare facilities that are part of a health plan’s network of providers through which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider.
Long-term disability (LTD): Insurance that pays you a percentage of your monthly earnings if you are unable to work due to a non-work-related illness or injury for an extended length of time.
No Surprises Act: Signed into law December 27, 2020 as part of the Consolidated Appropriations Act of 2021 to protect participants in health benefit plans from surprise medical bills for emergency and non-emergency medical care. It prevents surprise billing of patients who receive emergency services in the emergency department of a hospital, at an independent freestanding emergency department and from air ambulances. In addition, the law protects patients who receive certain non-emergency services from an out-of-network provider at an in-network facility.
Out-of-network: Physicians, hospitals or other healthcare providers who do not participate in an insurer’s provider network. This means that the provider has not signed a contract agreeing to accept the insurer’s negotiated prices. Expenses incurred for services provided by out-of-network health professionals may not be covered or may only be partially covered by an individual’s insurance plan.
Out-of-pocket maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments and coinsurance for covered services, your health plan pays 100% of the cost of covered benefits for the remainder of the plan year.
Patient Protection and Affordable Care Act (PPACA): A law that was enacted on March 23, 2010 and amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” refers to the final, amended version of the law. The law provides numerous rights and protections that make health coverage fairer and easier to understand, along with subsidies (through the “premium tax credit” and “cost-sharing reductions”) to make it more affordable. The law also expands Medicaid to cover more people with low incomes.
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, but you can use doctors, hospitals, and providers outside of the network for an additional cost.
Preventive drug: Drugs used to help avoid disease and maintain health. The U.S. Preventive Services Task Force defines the list of preventive prescription drugs covered at no cost for eligible members.
Short-term disability (STD): Insurance that pays a percentage of your weekly earnings if you are unable to work for a short-term period due to non-work-related illness or injury.
Telehealth: The use of digital information and communication technologies, such as computers and mobile devices, to access healthcare services remotely and manage your healthcare.
Transparency Rule: Signed into law November 12, 2020 and requires plans and insurance issuers to disclose cost-sharing information, negotiated rates for in-network providers, and allowed amounts for out-of-network providers.
Urgent care provider: A provider that performs services for health problems that require immediate medical attention but are not life-threatening emergencies.