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Glossary of Benefits Terms

Glossary of Terms
Below are definitions of some of the most commonly used insurance terms to help you understand your health benefits.
A
Annual Deductible
The amount you pay for covered services in a calendar year before the plan begins to pay benefits. Since the deductible is on a calendar-year basis, it starts over every January 1, not July 1 when the new plan year begins.
B
Brand-Name Drug
A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand-name drugs may be available by prescription or over the counter.
C
Coinsurance
Your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance after you've met your deductible.
 
For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your 20% coinsurance payment would be $20. The health insurance plan pays the rest.
 
 
Co-Payment
A fixed amount (for example, $15) you py for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
 
 
Covered Services
The health care services that a plan will cover in part or in full based on plan documents.
F
Flexible Spending Account (FSA)
An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices.
 
You decide how much of your pre-tax wages you want taken out from your paycheck and put into an FSA. You don't have to pay any taxes on this money. Your employer's plan sets a limit ($2,600 for SAUSD) on the amount you can put into an FSA each year.
G
Generic Drugs
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rate these drugs to be safe and effective as brand-name drugs.
N
Network Provider
Any licensed doctor, hospital, lab, or other health care provider that has contracted to provide members with wide-ranging services at discounted rates.
O
Out-of-Network Provider
A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see an out-of-network provider.
 
 
Out-of-Pocket Maximum
The most you'll pay for covered services in a policy period (usually one year). After you reach this amount, your health plan will pay 100% for covered essential health benefits.
 
Since the out-of-pocket maximum is on a calendar-year basis, it starts over every January 1, not July 1 when the new plan year begins.
P
Plan Year
A 12-month period of benefits coverage under a group health plan (July 1 through June 30 of each year for SAUSD). The plan period is not the same as the calendar year.
 
 
Pretax Basis
Not included in your W-2 income or subject to income taxes.
 
 
Primary Care Dentist (PCD)
A dentist within an HMO network whom you have selected to handle your dental care. They will treat you directly or refer you to a specialist, as necessary.
 
 
Primary Care Physician (PCP)
A doctor within an HMO network whom you have selected to handle your medical care. He/she will treat you directly or refer you to a specialist, as necessary.
 
 
Primary Care Provider
A physician, nurse, practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Q
Qualifying Life Event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage.
 
Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).
S
Special Enrollment Period
A time outside of the open enrollment period during which you and your family have a right to sign up for health coverage.
 
With SAUSD, you qualify for a special enrollment period 30 days following certain life events that involve a change in family status (for example, a marriage or birth of a child) or loss of other health coverage.
U
UCR (Usual, Customary and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same of similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Visit HealthCare.gov for more terms.