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Glossary of Terms

Use these definitions of common terms to help you navigate your benefits options.

Coinsurance – The amount of percentage that you pay for certain covered health care services under your health plan. This is typically the amount paid after a deductible is met, and can vary based on the plan design.

Co-payment – A flat fee that you pay toward the cost of covered medical services.

Deductible – A specific dollar amount you pay out-of-pocket before benefits are available through a health plan. Under some plans, the deductible is waived for certain services.

Dependent- Individuals who meet eligibility requirements under a health plan and are enrolled in the plan as a qualified dependent.

In-Network – Health care received from your primary care physician or from a specialist within an outlined list of health care practitioners.

Member – You and those covered become members when you enroll in a health plan. This includes eligible employees, their dependents, COBRA beneficiaries and surviving spouses.

Out-of-Network – Health care you receive without a physician referral, or services received by a non-network service provider. Out-of-Network health care and plan payments are subject to deductibles and co-payments.

Out-of-Pocket Expense – Amount that you must pay toward the cost of health care services. This includes deductibles, copayments and coinsurance.

Out-of-Pocket Maximum (OOPM) – The highest out-of-pocket amount paid for covered services during a benefit period.

Premium – The amount you pay for a health plan in exchange for coverage. Health plans with higher deductibles typically have lower premiums.

Primary Care Physician (PCP) – A doctor who is selected to coordinate treatment under your health plan. This generally includes family practice physicians, general practitioners, internists, pediatricians, etc.

Usual, Customary and Reasonable (UCR) Allowance – The fee paid for covered services that is: (1) a similar amount to the fee charged from a health care provider to the majority of patients for the same procedure; (2) the customary fee paid to providers with similar training and expertise in a similar geographic area, and (3) reasonable in light of any unusual clinical circumstances.

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