Health Insurance Terms

Coinsurance – The portion of a medical expense that the employee pays, usually 20-50%, for certain services after the annual deductible has been met.

Copay – A fixed amount employees and their dependents pay for prescriptions, doctor appointments, and urgent care visits before and after they meet their deductible.

Deductible – The amount an employee and their dependents pay out of pocket for medical expenses before coinsurance kicks in. (Deductible is waived for preventive care and frequently for primary and specialist visits as well as for generic prescriptions.)

HDHP – A High Deductible Health Plan (HDHP) is, like it sounds, one with a high annual deductible ($3500+) and out-of-pocket maximum. It allows the use of pre-tax dollars for health expenses through a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA). HDHPs protect against catastrophic out-of-pocket expenses. If annual out-of-pocket expenses, including deductible, copays and coinsurance, pass the out-of-pocket maximum, the plan pays 100% of covered expenses above that maximum for the remainder of the plan year.

No-network plan – A health plan that allows employees to seek care from any provider without any network restrictions. (Exceptions for prescriptions and certain exempt medical expenses).

Out of pocket max – The maximum a plan member will pay in a plan year on deductible, copays, and coinsurance.

Prescription coverage – A benefit that sets copays for prescriptions within a prescription network, typically $10-$20 for Tier 1(preferred generics), $15-$50 for Tier 2 (generics), higher for Tiers 3 (preferred brand) and 4 (brand). See information on prescription tiers here.

Preventive care – Medical services covered at 100% as mandated by the Affordable Care Act. Including well-checks, immunizations, many screenings, contraception, etc. See full list here.