Key Benefits Terms

The amount you pay for coverage, usually taken from each paycheck. You pay it whether or not you use care.

Watch for The premium is only part of your cost. A low premium can come with a high deductible.

Your share of the premium, after your employer pays its share. This is the amount you see on your pay stub.

The part of the premium your employer pays for you. It is real compensation even though it never reaches your paycheck.

The amount you usually pay for covered care before the plan starts paying more of the cost. Some services, such as preventive care or copay visits, may be covered before you meet it.

Watch for Check which services skip the deductible. It changes how a plan feels day to day.

The deductible for coverage that includes dependents. Plans handle it in one of two ways: embedded or aggregate.

Watch for Ask which one your plan uses. With a family, it can matter as much as the dollar amount.

A family deductible with an individual deductible built in. Once one person meets their individual amount, the plan starts paying more for that person, even if the family total isn't met yet.

A family deductible with no individual amount inside it. The whole family amount must be met before the plan pays more for anyone.

A fixed amount you pay for a covered service, like a doctor visit or a prescription.

Your share of the cost after the deductible, shown as a percentage. If coinsurance is 20%, you pay 20% of the allowed amount and the plan pays 80%.

The most you generally pay in a plan year for covered in-network care. Deductibles, copays and coinsurance count toward it. Premiums, non-covered services and most out-of-network costs do not.

Watch for This is the number to look at when you ask, "What's the worst year I could have?"

The most a plan will pay for a covered service. For in-network care it is the rate the plan negotiated with the provider. Your coinsurance is a percentage of this number, not of the provider's full charge.

When an out-of-network provider bills you for the difference between their charge and the plan's allowed amount. Federal law now protects you from many surprise bills, such as most emergency care, but not every situation.

A statement from your plan after you get care, showing what was charged, what the plan paid and what you may owe. It is not a bill. Compare it with any bill you receive.

A plan that usually covers care only from its network, except in emergencies. You typically choose a primary care provider and need a referral to see a specialist.

A plan that lets you see in-network and out-of-network providers, usually without referrals. Out-of-network care costs more.

A plan that covers care only from its network, except in emergencies, but usually without requiring referrals.

A mix of HMO and PPO rules. You usually need a primary care provider and referrals, but some out-of-network care is covered at a higher cost.

A plan with a higher deductible and, usually, a lower premium. An HDHP that meets IRS rules lets you contribute to a Health Savings Account.

The doctor, nurse practitioner or physician assistant you see for routine care. Some plans require you to choose one.

A written approval from your primary care provider to see a specialist. Some plans, often HMOs and POS plans, won't cover specialist visits without one.

Routine care to keep you healthy, such as checkups, screenings and many vaccines. Most plans cover listed preventive services in-network at no cost to you.

Watch for A visit that starts as preventive can include a diagnostic service that is billed separately.

The doctors, hospitals, pharmacies and other providers that have contracts with your plan.

Providers that have contracted rates with your plan. They usually cost you less.

Providers that do not have contracted rates with your plan. They may cost more or may not be covered at all.

Watch for Check your doctors, hospital and pharmacy against the plan's directory before you enroll, not after.

Approval your plan may require before it covers certain services, medications or procedures. Without it, the plan can deny the claim.

The list of prescription drugs a plan covers. Drugs not on it may not be covered, or may cost much more.

Groups the formulary sorts drugs into, often generic, preferred brand, non-preferred brand and specialty. Higher tiers usually cost you more.

Watch for Look up each medication you take. Its tier sets what you'll pay.

A high-cost medication, often for complex or chronic conditions, that may need special handling or a specific pharmacy.

A rule that you try a lower-cost drug first and move to the prescribed drug only if the first one doesn't work.

The company that runs a plan's prescription coverage: the formulary, pharmacy network and drug pricing.

A savings account you can use with a qualifying high-deductible health plan. Contributions are pre-tax, the money is yours to keep, and it rolls over from year to year, including if you change jobs.

Watch for You can only contribute while you're covered by a qualifying HDHP.

An employer account for eligible health expenses, funded with pre-tax pay. Money you don't use by the deadline may be lost, unless your plan allows a carryover or a grace period.

A separate pre-tax account for eligible child or adult day-care costs so you can work. It does not cover medical expenses.

An account funded only by your employer that reimburses eligible expenses. Your employer sets the rules, and the money usually stays with the employer if you leave.

The yearly window when you can choose or change your benefits. Outside it, most changes need a qualifying life event.

The 12-month period your benefits run for. Deductibles and out-of-pocket maximums usually reset when it starts. It isn't always January to December.

A change such as marriage, a birth or adoption, or losing other coverage that lets you change benefits outside open enrollment. You usually have 30 days to act, sometimes 60.

Watch for The deadline is short and easy to miss. Tell HR as soon as the event happens.

The time between starting a job and when coverage begins. Federal rules cap it at 90 days for most employer health plans.

A family member you can cover on your plan, such as a spouse or child. Plans that cover children must allow them to stay on until age 26.

A federal law that lets you keep your employer's group health coverage for a limited time after you lose it, for example when you leave a job. You usually pay the full premium plus a small administrative fee.

A standard summary every health plan must provide, in the same format, so plans can be compared side by side. It is a summary; the plan documents govern.

The detailed document explaining how an employer plan works: who is eligible, what is covered, and how to file claims and appeals.

Insurance that replaces part of your income for a limited time if illness, injury or childbirth keeps you from working.

Insurance that replaces part of your income for a longer period if you can't work, usually starting after short-term disability ends.

The waiting time between when a disability starts and when benefits begin.

Life insurance your employer provides, often at no cost to you. Employer-paid coverage above $50,000 is taxable to you as imputed income.

Extra life insurance you can buy through work, usually paid through payroll. It may require health questions above certain amounts.

Optional coverage you pay for, such as accident, critical illness or hospital indemnity insurance. These usually pay you a set cash amount when a covered event happens. They don't replace health insurance.

A confidential employer-provided service offering short-term counseling and referrals for personal, family or work issues, usually at no cost.