Glossary of Terms

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Active full-time employee
Person that works a normal workweek for an employer at a minimum number of required hours.

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Coinsurance
Requires payment of a percentage of the cost of the medical services. Most plans require either a coinsurance or copay: usually not both.
Copayment  (copay)
A flat fee charged each time you visit the doctor or use certain medical services regardless of the cost of the procedure. Doctor visits and pharmaceutical purchases are often subject to copays.

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Deductible
Money paid out-of-pocket each year before medical plan coverage begins.  Each family member usually has a separate deductible to meet.
Dependent
A person who is covered by another person’s plan.  It can be a child, spouse or domestic partner.

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Emergency
A serious illness or condition that comes on suddenly and needs immediate medical care.
Explanation of Benefits (EOB)
A detailed document provided by an insurance carrier outlining the charges, payments and balances of processed claims.

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Health Savings Account (HSA)
An account that can be used to pay for covered health care costs or can be saved for future health care costs.  Plan members must be covered by a high deductible health plan to qualify for an HSA.
High-Deductible Health Plan (HDHP)
A plan that meets Federal regulations and has a higher deductible than standard health plans allowing participants to utilize a health savings account (HSA).

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Mail Order Pharmacy
Service available through Aetna Rx Home Delivery® that allows members to save time and money with a three-month supply of certain prescriptions delivered directly to their home.

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Network
A group of health care providers including doctors and hospitals that are contracted with the carrier.  For Aetna health plans, choose the Open Choice PPO Network.

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Out-of-pocket maximum mandate
The maximum amount you’ll have to spend before all of your medical bills are covered by the medical plan.  All cost sharing must apply toward the out-of-pocket maximum including in-network medical, behavioral health and pharmacy cost sharing. Does not include premiums, balance billing amount of non-network providers or spending for non-covered services.
Over-the-counter drugs (OTC)
Drugs that can be purchased without a prescription and are not covered under the Rx benefits of the plan..

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Precertification
Approval required for certain care, admission or procedures that must be completed prior to event taking place.  Precertification can also be called:

  • Preauthorization
  • Authorization
  • Certification
  • Prior Authorization
Premiums
The amount you pay for your insurance policy. Premiums are often deducted from your paycheck.
Preventive or Preventative Care
Services that can help prevent certain diseases and illnesses.  Generally includes annual exams, immunizations and testing for certain diseases.

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Qualifying Event
An event that allows a member to change his or her health benefits.  Some examples include death, job loss, divorce, marriage and the birth of a child.

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Renewal
The beginning of a new plan contract year, where open enrollment begins and updated rates and plans are available.
Rx
The common symbol describing prescription or pharmacy.

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Specialist
A provider that is trained in a specific medical area such as a dermatologist or cardiologist.
Step Therapy
A provision requiring members to try certain drugs prior to a particular brand name drug being paid for under the plan.

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Urgent Care
The delivery of ambulatory medical care, outside of a hospital emergency department, on a walk-in basis without a scheduled appointment.