Definitions

annual deductible   The amount you pay for covered expenses first, before an insurance plan begins to pay benefits. Some plans require deductibles for all services, some for just certain types of services; other require no deductible at all.

co-pay/co-insurance   The flat amount or percentage you pay for covered service after you satisfy the annual deductible, if any.

covered expenses   Charges for services which are medically necessary and eligible for payment under the plan. A covered expense can be no more than the maximum amount stated in the plan.

deductible   (see annual deductible)

drugs, formulary   Drugs which the medical literature indicates are clinically effective, safe and of reasonable cost. The goal of the formulary list of prescription drugs, as established for the Pharmacy Plan, is to identify and promote prescription drugs which are therapeutically appropriate and cost-effective.

drugs, non-formulary   Prescription drugs not on the formulary list.

emergency  A sudden, serious or unexpected acute illness, injury or condition which could permanently endanger your health if medical treatment is not received immediately.

group insurance   A single policy issued to an employer under which employees and their eligible family members may be covered.  Each employee receives a certificate of coverage outlining his/her health plan benefits.

hospitals, non-contracting   Hospitals that are not part of the plan's network and that have not signed a standard contract with the plan are considered non-contracting hospitals. The plan does not pay benefits for services provided by non-contracting hospitals except in the case of a medical emergency.

individual insurance Health care coverage for individuals or single family units.

limited fee schedule   A list of maximum amounts the plan will pay for certain services provided by non-network providers. You are responsible for paying your co-insurance and any amount over the limited fee schedule.

negotiated fee   The discounted rates that the plan network doctors and hospitals agree to charge for covered expenses.

network/in-network  The term used for services received from doctors, hospitals and other providers contracting with the plan to provide care at the negotiated fee and to handle the paperwork.

out-of-network/non-network   The term used for services received from doctors, hospitals or to the providers that are not part of the plan's network. You pay substantially more for out-of-network services.

out-of-pocket maximum  The most you pay for covered expenses during the year before the plan begins paying 100% of covered expenses for the rest of the year. Only covered expenses count toward the maximum. For example, any charges above the limited fee schedule for out-of-network doctor's services do not count.

PCP (Primary Care Physician)   The doctor who serves as your health care manager and coordinates virtually all of the health care services you receive. Your PCP provides you with routine medical care and refers you to a specialist if necessary.

PPO (Preferred Provider Organization)   Health care providers who are under contract to provide care at discounted or fixed fees. Unlike HMOs, health plans with a PPO allow you to choose any doctor at any time. However, if you select a non-PPO provider you will pay more out of pocket for services than you would if you selected a PPO "network" provider.

Pre-existing condition or pre-existing waiting period  If you receive medical advice, or treatment was recommended or received for any accident, illness, or other medical condition during six months before you enroll in a plan, you won't be covered for the care you receive as a result of that condition until you've been enrolled in the plan for six months. If you satisfied the six-month waiting period while enrolled in another medical plan, and enrolled with the plan within 30 days of completing that waiting period, you won't need to complete another pre-existing waiting period. You will receive partial credit if you were insured under another plan for less than six months.

Qualifying prior coverage  Any individual or group plan that provides medical, hospital, and surgical coverage, including continuation or conversion coverage or coverage under a publicly sponsored program such as Medicare or Medicaid.  It does not include accident only, credit, disability income, Medicare supplement, long term care insurance, dental, vision, workers' compensation insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans.

stop loss  Stop loss is an insurance product that provides protection against catastrophic or unpredictable losses. It is purchased by employers who have decided to self-fund their employee benefit plans, but do not want to assume 100% of the liability for losses arising from the plans. Under a Stop Loss policy, the insurance company (reinsurer) becomes liable for losses that exceed certain limits called deductibles. The stoploss deductible represents the amount a group is able to cover on an individual before receiving reimbursement from a reinsurance carrier for claims paid on an individual for the remainder of the plan year. The terms of the stoploss arrangement are established between the group and the reinsurance carrier.