Preferred Provider Organization (PPO) – A network of providers that has agreed to contracted rates with the insurance carrier. A PPO plan pays claims from In-Network and Out-of-Network providers. Members may see reduced out of pocket costs when utilizing In-Network providers.
Health Reimbursement Arrangement (HRA) – A plan used to administer reimbursements on qualified medical expenses that apply towards the deductible. The reimbursements are funded by the employer.
Health Savings Account (HSA) – A tax-free savings account that is owned by the employee. It can be used to pay for insurance deductibles and qualified out-of-pocket medical expenses. Deposits into the HSA can be made by the employee and employer. If adult children (non-tax dependent) are enrolled on the HSA plan, they may need to set up their own HSA.
Calendar Year Deductible (CYD) – The amount you pay before co-insurance is paid. You only need to meet your deductible once per calendar year.
Out-of-Pocket-Maximum – The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Co-Insurance – The percentage of cost-sharing between what you and the insurance company must pay, after any applicable deductible has been met.
Co-pay – The set dollar amount that you must pay to a provider when services are rendered.
Outpatient – A patient who receives treatment at a hospital or outpatient facility without being admitted overnight.
Provider – Any facility, person, or entity recognized for payment by the insurance company.
Usual, Customary and Reasonable (UCR) – The determined going rate for like services in the same area. The insurance companies co-insurance percentage that they pay is taken from the UCR amount for that service. You are responsible for your co-insurance percentage plus all of the amount that exceedsUCR. UCR is used only when services are provided by an Out-ofNetwork provider.