Glossary of terms

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Allowable Charge – This is the dollar amount typically considered payment-in-full by an insurance company. The Allowable Charge is typically a discounted rate rather than the actual charge. For example: You visit your doctor for the flu. The total charge for the visit is $100. If the doctor is a member of your health insurance company’s network of providers, he or she may be required to accept $80 as payment in full for the visit – this is the Allowable Charge. Your health insurance company will pay all or a portion of the remaining $80, minus any copayment or deductible that you may owe. The remaining $20 is considered provider write-off. But, if the doctor you visit is not a network provider then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100.

Benefit period – The annual cycle in which a health insurance plan operates. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew in late summer or fall.

Bi-weekly contributions – This is the amount deducted per pay period for your benefits.

Coinsurance – An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20 percent).

Copayment – A set amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug.

Declination of Healthcare Coverage/Opt Out Program – Benefit-eligible employees may choose to opt-out of medical insurance coverage during Open Enrollment by meeting with a Benefits Counselor. Employees must provide a completed Declination of Healthcare Coverage Affidavit. Outside of the Open Enrollment period, employees must provide proof of other group employer coverage or proof of government-funded coverage in order to opt out of medical insurance (i.e, for a mid-year Change In Status election). Employees remain eligible for all other benefits.

Deductible – The amount you must pay for healthcare before your insurance begins to pay.

Flex Dollars – Employees receive $250 per year in “Flex Dollars” from DCPS to help pay for their benefits. This is funded bi-weekly in accordance with the payroll deduction schedule. Any left over Flex Dollars not used to offset pretax benefits will be added to your payroll check.

Formulary – A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.

Generic drug – A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.

Health Flexible Spending Account – This benefit lets you use pretax dollars to pay for eligible healthcare expenses for you, your spouse, and your eligible dependents. Money is set aside from your paycheck before taxes are taken out. Money remaining in the account cannot be returned or carried forward to the next year.

Health Savings Account – A type of savings account that allows you to set aside money on a pretax basis to pay for qualified medical expenses. A Health Savings Account can be used only if you have a High Deductible Health Plan (HDHP). HSA funds roll over year to year if you don’t spend them and may earn interest.

High Deductible Health Plan – A type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower.

In-network – Doctors, hospitals, pharmacies, and other healthcare carriers that have agreed to provide members of a certain insurance plan a discounted price if they use an in-network carrier.

Network – The facilities, carriers, and suppliers your health insurer or plan has contracted with to provide healthcare services.

Non-Formulary – Prescription drugs not covered by a prescription drug plan or another insurance plan offering prescription drug benefits.

Out-of-network – Healthcare rendered to a patient outside of the health insurance company’s network of preferred providers. In many cases, the health insurance company will not pay for these services or pay only a portion.

Out-of-pocket costs – Health or prescription drug costs that aren’t covered by insurance and must be paid for by the employee.

Out-of-Pocket Maximum – This is the most you’ll have to pay during a policy period for healthcare services. Once you’ve reached your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount for covered services.