Employers Glossary
Learn the Language of Healthcare
Click on a letter below to begin searching for terms.
Annual Deductible Combined
Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.
Aggregate Family Deductible Method
All deductibles paid count toward the family deductible amount. One or all can meet it.
Affordable Coverage
Employer coverage is considered affordable – as it relates to the premium tax credit – if the employee’s share of the annual premium for the lowest priced self-only plan is no greater than 9.56% of annual household income. People offered employer-sponsored coverage that’s affordable and provides minimum value aren’t eligible for a premium tax credit.
Appeal
A request for your health insurer or plan to review a decision or a grievance again.
Allowed Amount
Maximum amount on which payment is based for covered healthcare services. This may be called an “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
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.
Blue Cross Blue Shield
Health insurance company
Benefits
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
Benefit Year
A year of benefits coverage under an individual health insurance plan. The benefit year for individual and family plans bought inside or outside HealthSource RI begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year. The timeline for employer insurance can follow a different schedule, depending on when the business originally bought its health coverage.
Balance Billing
Refers to instances when a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Composite Rate
A unique rate calculation used by HealthSource RI that configures the rate for an employer group. To calculate the composite rate, HealthSource RI adds the premium amount for each person in the group (see 2015 Rate Sheet for Premiums by Age). Premium amounts are based on age. Once added, the amounts are averaged across the group to develop composite rates for each family type.
The employer and employee contribution amount for each employee equals the total composite rate for each employee; this is the amount billed to the employer.
COBRA
A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee. You may also choose to enroll as an individual on HelathSource RI and may qualify for assistance.
Claim
A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
Complications of Pregnancy
Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.
Co-Insurance
Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Co-Payment
A fixed amount (for example, $15) you pay for a covered healthcare service, usually when you receive the service. The amount can vary by the type of covered health care service.
Drug List/Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.
Dependent Coverage
Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
Dental Coverage
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan, or by itself through a “stand-alone” dental plan.
Delta Dental
Dental insurance provider
Durable Medical Equipment (DME)
Equipment and supplies ordered by a healthcare provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.
Deductible
The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 for covered services. Some plans pay for certain health care services before you’ve met your deductible.
Exclusive Provider Organization (EPO) Plan
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Essential Health Benefits
The Affordable Care Act requires that health plans on HealthSource RI offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Employer Contribution Amount
The amount that the employer chooses to contribute to an employee’s plan, based on tier. Employers can choose how much to contribute towards a HealthSource RI plan, and for Full Choice groups, employees can apply that contribution amount towards any plan. For medical, the minimum contribution amount is half (50%) of the employee-only reference plan rate. Employers are not required to contribute towards dental; however the employer is required to offer dental coverage by either going through the exchange, or electing off-exchange dental coverage.
Excluded Services
Healthcare services that your health insurance or plan doesn’t pay for or cover.
Emergency Services
Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Emergency Room Care
Emergency services you get in an emergency room.
Emergency Medical Transportation
Ambulance services for an emergency medical condition.
Emergency Medical Condition
An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Formulary/Drug list
A list of prescription drugs that a health plan covers that is organized into price tiers or categories.
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 of your paycheck and put into an FSA. You don’t have to pay taxes on this money. Your employer’s plan sets a limit on the amount you can put into an FSA each year.
Group Health Plan
In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
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) rates these drugs to be as safe and effective as brand-name drugs.
Guardian
Dental insurance provider
Hybrid family deductible method
All deductibles paid count toward the family deductible amount, but, an individual will never pay more than their individual deductible.
High Deductible Health Plan (HDHP)
A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
Health Savings Account (HSA)
A Health Savings Account-qualified plan allows customers to contribute to a separate tax-exempt account which can be used for qualified health care expenses. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses, such as deductibles and copayments. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don’t spend them.
Health Reimbursement Account (HRA)
Health Reimbursement Accounts (HRAs) are employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the account. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.
Health Plan Metal Levels/Categories
Plans in the Marketplace are primarily separated into 4 health plan categories — Bronze, Silver, Gold, or Platinum — based on the percentage the plan pays of the average overall cost of providing essential health benefits to members. The plan category you choose affects the total amount you’ll likely spend for essential health benefits during the year. The percentages the plans will spend, on average, are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn’t the same as coinsurance, in which you pay a specific percentage of the cost of a specific service.
Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Home Health Care
Healthcare services a person receives at home.
Inpatient Care
Health care that you get when you’re admitted as an inpatient to a health care facility, such as a hospital or skilled nursing facility.
In-network services
Services that are provided by doctors, hospitals, and other healthcare providers who have a contract with an insurer. These services are provided at negotiated rates that are typically less than what an individual would pay on their own.
In-Network Co-Payment
A fixed amount (for example, $15) you pay for covered healthcare services to providers who contract with your health insurance or plan. In-network co-payments are usually less than out-of-network co-payments.
In-Network Co-Insurance
The percent (for example, 20%) you pay of the allowed amount for covered healthcare services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
List Bill Rate
The rate for an employee or household member calculated by HealthSource RI, and based on age. The list bill rate is provided on the invoice for informational purposes, as it is the amount paid by HealthSource RI to the medical and dental carriers for each employee. Composite rates quoted to employees are an average of the total list bill rates. – See Composite Rate
Large Group Health Plan
In general, a group health plan that covers employees of an employer that has 51 or more employees.
Minimum value
A health plan meets this standard if it is designed to pay at least 60% of the total cost of medical services for a standard population, and if its benefits include substantial coverage of inpatient hospital and physician services. Individuals offered job-based coverage that provides minimum value and is considered affordable aren’t eligible for a premium tax credit.
Minimum Essential Coverage (MEC)
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
Medically Necessary
Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms—and that meet accepted standards of medicine.
Medicaid/Medical Assistance
A joint federal-state health insurance program that is run at the state level and covers certain low-income people (especially children and pregnant women) and disabled people.
Maximum Out-of-Pocket Payments
The money you spend each year on your medical care (excluding your monthly premium) cannot exceed your health insurance plan’s maximum out-of-pocket cost. Once you reach your maximum, you are protected from additional costs like co-payments and co-insurance.
Managed Care
An organized way to manage the costs, use, and quality of the healthcare system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO).
Non-Preferred 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 a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network that requires you to pay extra to see some providers.
Network
The facilities, providers, and suppliers a health insurer or plan has contracted with to provide healthcare services.
Out-of-Pocket Maximum/ Limit
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 healthcare 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.
Out-of-Pocket Estimate
An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
Out-of-Pocket Costs
Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.
Open Enrollment Period
A designated period of time during which customers can sign up for or renew their health insurance. For individuals and families, the open enrollment period happens once a year. For employer insurance, the open enrollment periodhappens before the renewal dateor coverage start date. Eligible employees may choose plans, or make changes to their enrollment (for renewing employees). Changes include: Enrolling in new coverage, changing plans, changing plan coverage (enrolling or disenrolling dependents), enrolling in a dental plan and other changes.
Out-of-Network Co-Payment
A fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
Out-of-Network Co-Insurance
The percent (for example, 40%) you pay of the allowed amount for covered healthcare services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
Prior Authorization
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
Primary Care Provider (PCP)
A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of healthcare services.
Primary Care
Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.
Preventive Services
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Preventative services are offered at no cost to you.
Point of Service (POS) Plans
A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
Plan Year
A 12-month period of benefits coverage under a group health plan. For employer coverage, this 12-month period may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”).
Provider
A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), healthcare professional, or healthcare facility licensed, certified, or accredited as required by state law.
Primary Care Physician
A doctor (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.
Prescription Drugs
Drugs and medications that legally require a prescription.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Premium
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.
Preferred Provider Organization (PPO)
A network of healthcare providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Healthcare decisions generally remain with the patient as he or she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.
Pre-authorization
A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Pre-authorization isn’t a guarantee that your health insurance or plan will cover the cost.
Plan
A benefit your employer, union, or other group sponsor provides to you to pay for your healthcare services.
Physician Services
Healthcare services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Qualified Health Plan
Rider
A rider is an amendment to an insurance policy. Some riders will add coverage (for example, an acupuncture rider adds coverage for acupuncture to a health plan).
Rescission
The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.
Referral
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Reference Plan
For employer accounts with the Single Plan option, the reference plan is the selected plan for medical coverage to be offered to all employees. For groups with the Full Employee Choice option, employer contribution amounts are calculated based on the selected reference plan. Employees may either choose the reference plan, or top up or down, and apply the employer contribution amount to any HSRI plan.
Rehabilitation Services
Healthcare services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Reconstructive Surgery
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.
Summary of Benefits and Coverage (SBC)
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.
Stand-alone dental plan
A type of dental plan offered through the Marketplace that’s not included as part of a health plan. You may want this if the health coverage you choose doesn’t include dental, or if you want different dental coverage.
Special Enrollment Period
A designated period of time during which Rhode Islanders can enroll in coverage outside of open enrollment. Individuals and families qualify for a special enrollment period if they’ve experienced a life changing event that affects their access to health insurance. For employer coverage, eligible employees and eligible household members may be added for coverage based on a qualifying event. Employers determine whether employees (or their dependents) qualify for a special enrollment period.
Small Group Premiums
Premiums vary by age and family size. The premiums for small employers will depend on the employees who will be covered.
SHOP
SHOP stands for the Small business Health Options Program, otherwise known as HealthSource for Employers.
Service Area
A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may end your coverage if you move out of the plan’s service area.
Specialist
A physician specialist who focuses on a specific area of medicine or a specific group of patients in order to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of healthcare.
Total Cost Estimate (for health coverage)
Tiered Network
Third-Party Payer
UCR (Usual, Customary, and Reasonable)
United Healthcare
Urgent Care
Vision or Vision Coverage
Wellness Programs
Waiting Period (Job-based coverage)
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan.
HealthSource RI for Employers connects you with health and dental insurance from these companies:
