STOCKTON & ASSOCIATES | Glossary

educate • Yourself

a b c d e f g h I l m n o p q r s t u w 

a

Account Manager:  A designated point of contact who provides customer service for all aspects of insurance including customer inquiries, explaining policy coverages, processing forms, and serving as a liaison between the group and insurance carrier.

Accidental Death and Dismemberment (AD&D):  This is a benefit that is paid out when a death or loss of a limb has occurred due to an accident.

ACA Employer Reporting:  The Affordable Care Act requires employers to file certain information to the Internal Revenue Service (IRS) and in some cases, also provide copies to employees.

Affordable Care Act:  The first part of the comprehensive health care reform law enacted on March 23, 2010 with the intent to improve health care costs and accessibility.  Also known as “ACA, PPACA, and ObamaCare”.  The law created a list of minimum essential coverage requirements for carriers to follow and prevented insurance companies from denying coverage due to pre-existing conditions.

Age Rates:  When an insurance company determines their rates based off individual ages and their estimated health care utilization.

Allowable Charge: This is the maximum that an insurance carrier will reimburse a provider for services rendered.

b

Balance Billing:  When a provider bills the patient the difference between the billed charge amount and what the insurance carrier paid.  This generally occurs when an insured person goes to an out-of- network provider.

Benefits:  The services or items covered by an insurance carrier.

Broker:  A licensed and trained insurance agent who can help you shop multiple carriers and make recommendations that will fit your needs and stay within your premium budget.

c

Catastrophic Insurance:  Catastrophic insurance is a policy designed to have lower premiums in exchange for a higher deductible and is designed to help protect you from major medical expenses. 

COBRA:  The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families the ability to continue their health and dental benefits as a result of voluntary or involuntary job loss or reduction in hours.  Employers with 20 or more employees, who have a group-sponsored health plan, are required to offer COBRA.

Coinsurance:  A percentage of cost that the insured person pays after their deductible has been met, until they reach their out-of-pocket maximum.

Compliance:  Employers who offer employer-sponsored benefit plans are required to comply with federal and state insurance regulations, as well as other governing entities, such as The Department of Labor, The Employee Benefits Security Administration, etc.  Failure to comply with regulations and mandates can result in fines, penalties and even criminal charges.

Composite Rates:  A composite rate is one rate that the insurance carrier applies to a group, based off the average age demographic, at the time the insurance policy goes in-force.  There is one premium rate for employee-only, employee-spouse, employee-child(ren) and family.

Consumer Directed Health Plan (CDHP):  A type of plan that gives employees control over their health care expenses, such as a health savings account, flexible spending account, or health reimbursement account.

Contracted Provider:  A provider that has contracted with a specific insurance carrier, to provide services, at a negotiated fee schedule.

Copayment:  A set dollar amount, determined by the insurance carrier, that a policy holder pays to a provider or facility at the time a service is rendered.

Covid Relief Act:  The Coronavirus Relief and Economic Security Act (CARES Act) was signed into law by Donald J. Trump on March 27, 2020 to help with economic relief due to the Covid-19 pandemic.

Critical Illness Policy:  Critical Illness policies provide a cash benefit upon diagnoses of a heart attack, stroke, cancer, etc. 

d

Deductible:  The amount that an insured person will pay towards covered services to a provider, before the insurance carrier pays towards the claim. 

Dependent:  An eligible person that has insurance benefits under an enrolled member.

Dependent Care FSA:  A pre-tax benefit account used to pay for IRS qualified dependent care expenses, such as preschool, daycare, or adult daycare.

Disability Insurance:  A type of policy that protects against an individual’s loss of earned income.

Drug Formulary:  A list of preferred drugs, chosen by an insurance carrier, that are generally covered at a lower copay than non-formulary drugs.

e

Effective Date:  The date that a policy or plan change becomes effective.

Employee Assistance Program (EAP):  An employee assistance program is a voluntary, work-based program, that employers can elect to provide.  It offers confidential assessments and short-term counseling to employees for personal and work-related challenges.

Employer Contribution: The amount that the employer contributes to an employee’s insurance premium.

ERISA: The Employer Retirement Income Security Act of 1974 is a tax and labor law that establishes minimum standards for most voluntarily established retirement and health plans, in an effort to protect enrolled individuals. 

Evidence of Insurability:  An application process that requires your personal and/or health information to be reviewed by an underwriter, in order to obtain insurance or buy-up in coverage.

Exclusions:  Circumstances or conditions that are not covered under an insurance policy.

Explanation of Benefits (EOB):  An explanation of benefits is created by the insurance carrier after a provider has filed a claim.  It explains the charged amount, how much the carrier will pay, and what the insured person is responsible for, based off contractual agreements. 

f

Federal Poverty Level:  A level of income established by the Department of Health and Human Services, used to determine eligibility for certain programs and benefits, including tax credits.

Flexible Spending Account (FSA):  A type of account that allows employees to contribute funds to pay for certain IRS qualified expenses, on a pre-tax basis. 

FMLA: The Family and Medical Leave Act established in 1993, is a US Labor Law that protects entitled eligible employees to take unpaid, job-protected leave for specified family and medical conditions, with the ability to continue group health coverage through their employer.

Form 1095-B:  Form 1095-B is used to report certain information to the IRS and to taxpayers about individuals who are covered by a minimum essential health plan.

Form 5500:  The Form 5500 Series is a part of ERISA reporting and disclosure guidelines, intended to ensure that employee benefit plans are operated and managed in accordance with government guidelines and mandates.

g

Grandfathered Health Plan:  Grandfathered plans are existing policies that were put into place prior to March 23, 2010, when the Affordable Care Act was signed into law.

Guaranteed Issue:  Where an insurance policy is issued by the carrier with no medical questions asked.

h

Health Maintenance Organization (HMO):  A type of health plan, where the insured person must work with their primary care physician to obtain a referral and/or authorization from the insurance carrier, in order to see a specialist or have certain procedures covered.

High Deductible Health Plan (HDHP):  A health plan policy that has lower premiums and a higher deductible and is most often combined with an HSA or HRA, to maximize tax savings.

Health Reimbursement Account (HRA):  An IRS approved health reimbursement arrangement, that is set up by an employer, to reimburse employees for certain out-of-pocket medical costs, and to provide tax savings. 

Health Savings Account (HSA):  A health savings account, that is pre-taxed and is available to those who have an IRS qualified high deductible health plan.  You can use the funds for any qualified medical expenses.   See IRS.gov for complete details.

HIPAA:  The Health Insurance Portability and Accountability Act of 1996 is a federal statute that is designed to keep patient data safe in three areas: administrative, physical security and technology.

i

In-Network:  Services provided by a physician and/or facility, as part of a contractual agreement with an insurance carrier, for a pre-negotiated rate. 

Insure Oklahoma:  Insure Oklahoma is a program that is provided by the Oklahoma Health Care Authority.  The program subsidizes health insurance premiums for individuals and employer-sponsored health plans, for low to moderate income families.  Participants must be enrolled in a qualified health plan and meet income guidelines, in order to receive premium subsidy.

Individual Coverage HRA (ICHRA): Effective January 1, 2020, employers can offer their employees an individual coverage Health Reimbursement Arrangement (HRA) instead of a traditional group health plan.  This type of account may help reimburse qualifying health expenses. 

Inspire:  To uplift, encourage, motivate or influence in a positive way. 

l

Level-Funded Health Plan:  A level-funded plan is a hybrid of a traditional small group plan and self-funded health insurance. 

Lifetime Maximum:  A cap on the total lifetime benefits you may receive from an insurance carrier for certain conditions.  After the lifetime limit is reached, the insurance company will no longer pay for covered services.

Long-Term Care Insurance:  An insurance policy that covers those fees and expenses, associated with long-term care, that are not typically covered by health insurance.

m

Medicaid:  A joint federal and state-funded program that provides health care coverage for low-income children, families, and disabled individuals.

Medicare:  The federal program that provides health care coverage for eligible senior citizens, and qualified disabled individuals, under the age of 65.

Medicare Part D:  The optional Prescription Drug benefit that is provided through Medicare.

Medical Indemnity Insurance:  A medical indemnity plan is a type of policy that pays out a cash benefit for hospital admissions.  Medical indemnity products are only intended to supplement out of pocket costs and are not intended to be a health insurance replacement.

n

Network:  A group of providers, hospitals, and other health care professionals, that have a contractual agreement with an insurance carrier to deliver services to its members.

Non-Discrimination Testing:  An eligibility test, for health benefits and retirement plans, that prevents favoritism towards highly compensated individuals, employees, and key employees.

o

Off-Exchange Health Plan:  A plan that meets minimum essential coverage requirements under the ACA, but is not offered on the Health Insurance Marketplace, and is not eligible for premium tax credits.

On-Exchange Health Plan: A plan that meets minimum essential coverage under the ACA, is offered on the Health Insurance Marketplace, and is eligible for premium tax credits.

Open Enrollment Period:   A window of time, usually once a year, allocated to allow you to chose from available individual or employer-sponsored benefit plans.

Out-of-Network:  When a provider or facility, whose services you use, is not contracted with your insurance carrier.

Out-of-Pocket Maximum:  The maximum amount you will pay in a plan year.  Once you meet this maximum, your plan will pay 100% of your claims.

p

Pharmacy Benefit Manager (PBM): When your pharmacy benefit is managed by a third party.  This is most commonly contracted with an insurance carrier.

Preferred Provider Organization (PPO): A network of participating providers, contracted under a health plan.

Professional Employer Organization (PEO):  A payroll company that, under contract, assumes the responsibility of administrative functions, such as payroll, taxes, and/or employee benefits for smaller companies.

Premium:  The monthly, quarterly, and/or yearly amount that must be paid to the insurance carrier, in exchange for insurance coverage.

Premium Tax Credit:  Sometimes called an advanced premium tax credit (APTC), this is a tax credit that can be used to lower the cost of your monthly premium.

Premium Only Plan (POP): Is the IRS code Section 125 allowance for employee premium contributions, to be payroll deducted, on a pre-tax basis.

Pre-Existing Condition: Any condition for which you have been treated, prior to applying for healthcare coverage.

Pre-Tax: See premium only plan (POP).

Preventative Services:  These are routine healthcare services, designed to prevent illness, disease, or other health conditions, to include screenings, counseling and regular check-ups, as outlined by the insurance carrier.

Primary Care Provider:  The primary medical practitioner who coordinates your medical care, including admissions to hospitals, outpatient services, and referrals to specialists.

q

Qualifying Event:  A significant event that allows for a special enrollment period, such as changes in household, changes in residence, loss of health coverage and other events, as outlined by the insurance carrier.

Qualified Health Plan:  A health plan that meets the ACA’s minimum essential coverage requirement and is certified by the Health Insurance Marketplace.

r

Referral:  A written authorization from your primary care provider, allowing you to receive services from another contracted doctor, specialist, and/or healthcare facility. 

s

Self-Insured:  When an individual or business does not take out any third-party insurance but rather, chooses to fund claims, up to a certain dollar limit, before reinsurance starts to pay.

Special Enrollment Period (SEP):  The window that is outside the annual open enrollment period, in which you may sign up for benefits.  See qualifying event. 

Specialty Drug:  Usually a high dollar drug that is used to treat complex health conditions.  Most specialty drugs are given through an injection, while some are applied topically, or taken orally.  Specialty drugs usually have certain dispensing requirements, quantity restrictions, and often require prior authorization from the insurance carrier.

State Continuation of Coverage:  The health care coverage continuation program, offered to those living in Oklahoma, is available to employees who are enrolled in an employer-sponsored group plan with less than 20 employees.  If your employment has ended, State Continuation allows individuals and their dependents to stay covered under a state health plan for an extra 63 days. 

t

Tri-Care:  Tri-Care is health care program for uniformed service members, retirees, and their families.

u

Utilization Management:  When an insurance carrier reviews the type and amount of care a member is receiving.  Sometimes this involves a nurse review, prior authorization, case management and proper treatment planning between the provider and/or facility and insurance company.

w

Waiver of Coverage:  If an employee elects to decline employer-sponsored coverage, they will need to complete a waiver form to show coverage was offered to them.

Worksite Benefits:  Worksite benefits are voluntary benefits that are offered as a cost-effective solution to help employees with unexpected out-of-pocket expenses for things such as an accident, cancer, or critical illness.