Terms to Know

Benefit plans, programs and policies often seem like they have their own language! Here are definitions of some of the most common and important terms that can help you better understand your benefits.

Coinsurance

The percentage amount the health plan pays on a claim once the deductible has been satisfied. You are responsible for the balance.

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Copay, copayment

A fixed, up-front cost you pay to see a doctor or specialist or to get a prescription at the time of service.

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Deductible

The amount of money you pay before certain benefits are paid from the health care plan. Does not apply to physician office visits, prescriptions and other services subject to a copay.

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Dependent eligibility

Eligible dependents include:

• Your legal spouse for federal income tax purposes.

• Your same- or opposite-sex domestic partner. Check out the requirements for covering a domestic partner.

• Children to age 26, including stepchildren, children of your domestic partner (if you are covering your domestic partner), adopted children and children legally with you awaiting adoption.

• Children over age 26 who are not able to support themselves due to a physical or mental disability.

To be eligible for dependent coverage, proof that dependents meet the above criteria will be required.

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Employee and Family Assistance Plan (EFAP)

A Company-paid program providing confidential phone counseling on personal matters to you or a covered dependent at no cost to you.

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Employment status change

Any change in employment (such as going from hourly to salaried status) that impacts your benefit coverage or your ability to pay for it. If you have a qualifying employment status change, you can change your benefit coverage. Any change in benefits must be consistent with the type of status change event.

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Evidence of insurability (EOI)/proof of good health

Documentation that you are in good health; required when you increase life insurance coverage over a certain level.

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Formulary

A list of preferred, brand-name drugs chosen by the pharmacy benefits provider. Brand-name drugs on the formulary are covered at a higher level than those that aren't.

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Life event change/qualifying life event

Any change in your life (such as marriage, divorce, birth of a child, etc.) that impacts your benefit coverage or your ability to pay for it. If you have a qualifying life event, you can change your benefit coverage. Any change in benefits must be consistent with the type of life event.

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Network provider

Doctors, specialists, hospitals and other facilities that have agreed to charge fixed rates for procedures when patients are members of a medical plan, like the PPO.

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Out-of-pocket (OOP) maximum

The most money you will pay out of your own pocket toward eligible medical expenses in a calendar year. The OOP maximum includes your deductible, copays and your portion of the coinsurance. The OOP maximum protects you in the event of a large or catastrophic claim. Once met, the plan pays 100% of eligible expenses for the remainder of the calendar year.

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Preferred provider organization (PPO)

A medical plan that provides coverage through a network of participating health care providers. Enrollees may receive services outside the network, but at higher costs. The additional costs may be in the form of higher deductibles, higher coinsurance rates or both, or non-discounted charges from providers.

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Rollover

A rollover is a direct payment of plan benefits from a defined contribution plan into an IRA or another employer's plan. In a direct rollover, the teammate is not taxed on the payment until it is withdrawn or distributed later.

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“Use it or lose it.”

An expression of an IRS rule governing Flexible Spending Accounts that states any money left in your accounts on December 31 can't be carried over into the next plan year or returned to you. There is a grace period of 2½ months during which qualified health care expenses can be reimbursed with funds left in your accounts from the previous year, but that money cannot be refunded to you.