• Benefit Percentage
• Carrier
• Coinsurance
• Contribution
• Contribution Percentage
• Copay
• Copayment
• Deductible
• Eligible Employee
• Employer Contribution
• Exclusion
• Formulary
• HMO (HMO plan)

• Limitation
• Maximum Benefit
• MSA
• Network
• Out-of-Pocket Maximum
• PAR (PAR plan)
• Participation Percentage
• PCP (Primary Care Physician)
• Plan Name
• Plan Type
• POS (POS plan)
• PPO (PPO plan)

• Pre-existing Condition
• Premium
• Prescription Drug Formulary
• Preventive Care
• Primary Care Physician (PCP)
• Probationary Period
• Provider
• Provider Network
• Rate
• Traditional Plan
• Waiting Period

Benefit Percentage
The benefit amount paid by the carrier for your medical, dental or other covered expenses. This is expressed as a percentage, for example, an 80% benefit or a 100% benefit, etc.

Carrier
The name of the insurance company (insurance carrier) or health plan that is providing medical, dental, life or disability coverage. Click here to see the carriers we represent.

Coinsurance
The amount shared by the carrier and you to pay for your medical, dental or other health care expenses. For example, in an "80%/20%" coinsurance plan, the carrier pays 80% and you pay 20% of your expenses. In a "70%/30%" plan, the carrier pays 70% and you pay 30%. The 80% or 70% paid by the carrier is also sometimes called the "benefit percentage."

Contribution (Employer Contribution)
Refers to a group insurance plan in which the employer and employee "contribute" to pay for the plan. The amount contributed, i.e., paid by the employer and employee can be a fixed dollar amount, or it may be a percentage of the cost (i.e., premium or rate) charged by the carrier.

Often this is referred to as the "employer contribution." For example, when someone says the "employer contribution" is 100% for employees only, it means the employer pays the entire cost for employees, but nothing for employees' dependents (spouse and/or children). In this example, if an employee has dependents enrolled, the employee would "contribute" (pay for) all of the dependents' cost through payroll deduction.

Many carriers require the employer to contribute at least 50% to 75% of the cost for employees; there is usually no requirement to pay for dependents.

Copay (Copayment)
An amount that is paid by you each time you receive a health care service. The most common copays apply to office visits, emergency room visits and prescription drugs. Copays are usually a fixed dollar amount but may also be expressed as a percentage (similar to coinsurance described above). For example, if a plan includes a $20 office visit copay, you'll pay $20 each time you have an office visit. If a plan includes a 20% copay for prescription drugs, you'll pay 20% of the cost for each prescription.

Deductible
An amount you must pay for health care services before a carrier starts to pay benefits. A deductible usually applies per calendar year for all covered services you have in that year (as opposed to a copay, described above, which applies each time you receive treatment). Some medical plans have a separate deductible just for prescription drugs. If a medical plan has a $500 deductible per calendar year, it means you will pay for the first $500 of covered medical expenses each calendar year. Some plans limit the deductible per family to 2 X or 3 X the individual deductible amount. For example, if the individual deductible is $500 and the family limit is 3 X, the maximum deductible is $1,500 for the family. This could help if 4 or more family members are enrolled.

Here's an example. Let's assume you have a $500 deductible plan and a $2,000 hospital bill on January 1. You'll pay the first $500 to the hospital. The carrier will then pay benefits for the remaining $1,500 according to the plan's coinsurance (benefit percentage). If the coinsurance is 80%/20%, the carrier will pay $1,200 (80% of $1,500) and you'll pay $300 (20% of $1,500). The total you'll pay for the $2,000 bill is $800 ($500 deductible plus $300 coinsurance). Now that you've exceeded your deductible amount for the year, the next time you need treatment, no additional deductible will be required. If you have another $1,000 hospital bill later that year, the carrier will pay $800 (80% of $1,000) and you'll pay $200 (20% of $1,000).

The deductible may not apply to all types of services, the most common being preventive care. Some group medical plans have no deductible for office visits and many of them have no deductible for prescription drugs, but in both cases, a copay will usually apply.

Eligible Employee
Refers to employees who are eligible to participate (enroll) in an employer's group insurance plan. Employees can be ineligible (not eligible) to participate if they work less than a specified number of hours per week, have not completed their probationary period, belong to a class of employees that is not eligible (such as union employees who are covered by their union's health and welfare plan), etc.

Exclusion
Services or supplies that are not covered by a plan.

Common exclusions in medical plans are: cosmetic surgery and supplies; custodial care; hearing aids; investigational services or supplies; in-vitro fertilization; artificial insemination; marital and family counseling; over-the-counter drugs; over-the-counter contraceptive supplies and devices; services or supplies not medically necessary for illness, injury or physical disability; surgery or treatment for sexual dysfunction/impotence or transsexualism; routine hearing and vision exams (unless specifically covered), etc. Individual/family plans do not include mental health benefits and most do not cover treatment for chemical dependency.

Common exclusions in dental plans are: bleaching of teeth; charges for missed dental appointments; preventive orthodontic procedures or other orthodontic treatment; dental services started prior to the date that you become eligible for services under a plan; dentistry for cosmetic purposes; investigational services and supplies; replacement of teeth that were missing prior to becoming covered by a plan, etc.

Formulary (Prescription Drug Formulary)
A list of preferred drugs covered by a health plan. A committee of physicians and pharmacists prepare a health plan's formulary based on clinical studies showing relative effectiveness, safety and health outcomes of the drugs.

Limitation
A limit in the number of treatments or maximum dollar amount covered by a plan for certain services or supplies.

Common limitations in medical plans are: number of spinal manipulations allowed per calendar year (in many cases 10 or 12); number of outpatient mental health visits; number of days allowed per year for inpatient mental health care; maximum amount paid for preventive care; maximum amount paid for rehabilitative care, maximum amount paid for a transplant, etc.

Common limitations in dental plans are: number of routine oral exams allowed per year; how often a full-mouth series of x-rays is allowed; number of cleanings per year; benefit for temporomandibular joint disorder (TMJ) limited to $1,000 per year and $5,000 per lifetime, etc.

Maximum Benefit
The maximum benefit amount paid by a plan. This can be a plan's overall lifetime maximum such as $1,000,000, $2,000,000 or $5,000,000 in a medical plan. Or it can be a maximum for certain services or supplies as described above under "Limitation." Most dental plans include a $1,000, $1,500 or $2,000 maximum benefit per calendar year.

Out-of-Pocket Maximum (Stoploss Limit)
The maximum coinsurance you'll need to pay before a medical plan begins paying 100% of your covered medical expenses. This is sometimes also called a "stoploss limit."

The maximum is usually based on a calendar year. Typical stoploss limits are $1,000, $2,000, $2,500, $3,000 or higher. Some plans have a stoploss limit per family equal to 2X or 3X the individual stoploss limit. For example, if the individual stoploss limit is $2,500 and the family limit is 3X, the maximum stoploss limit is $7,500 for the family. This could help if 4 or more family members are enrolled.

Here's an example of how the out-of-pocket maximum (stoploss limit) works. Let's assume a plan has a $200 calendar year deductible, 80%/20% coinsurance (the plan pays 80%; you pay 20%) and a $2,500 stoploss limit. The carrier keeps a tally of the 20% coinsurance you pay during the calendar year. Once all the 20% coinsurance amounts you pay equal $2,500, the carrier will pay 100% for the rest of the calendar year for covered expenses. Following is an illustration of how this works based on $50,000 of expenses that apply to the stoploss limit.

Participation Percentage
Refers to a group insurance plan in which Washington State law or a carrier requires that a minimum percentage of eligible employees must participate (be enrolled) in the plan. In general, if an employer has 3 or fewer eligible employees, all of them must enroll. If an employer has 4 or more eligible employees, at least 75% must participate. Some plans have a higher participation requirement even when more than 4 employees are eligible, particularly if the employer pays for all of the employee's cost of the plan.

Plan Name
The name a carrier assigns to a medical, dental or other type of health care plan to identify it. For example, Regence BlueShield's "Selections Comprehensive" and "Preferred Catastrophic" plan, or LifeWise Health Plan of Washington's "Preferred80" plan.

Plan Type
In general, there are four major plan types. They identify the provider network (physicians, hospitals, etc.) that can be used, whether a Primary Care Physician (PCP) must be chosen when enrolling, if referrals are required and at what percentage benefits are paid if using providers that belong to the network. The major features of each plan type are compared in the table below followed by descriptions of each. Please note that because so many products are available from different carriers, the table and descriptions provide generalizations; there may be exceptions to the rule.

Chances are excellent that your current physician and other providers are part of a PPO network. As long as a PPO provider treats you, you'll receive the highest benefits (usually 20% to 30% more).

There is no requirement to choose a PCP when you enroll and referrals are not required.

When you enroll, you must pick a PCP who will manage your medical care. This is sometimes referred to as a "gatekeeper" arrangement. PCPs are usually family practice, general practice, internal medicine, and pediatrics physicians. A different PCP can be chosen for each member of your family.

When you need medical care, you must first contact and/or visit your PCP. As long as you do this, you'll receive the highest benefits of the plan (usually 20% to 30% more). If the PCP cannot treat your condition and refers you to a specialist within the POS plan's network, you’ll still receive the highest benefits. If you seek treatment without first contacting and/or visiting your PCP, a benefit will be paid at the “non-network” level (except in the case of an emergency) which is typically 20% to 30% less.

The most important thing to remember about a POS plan is that you always need to contact and/or visit your PCP first to receive the highest “network” benefits.

As with a POS plan, when you enroll, you must pick a PCP who will manage your medical care (the same "gatekeeper" arrangement as with a POS plan). When you need medical care, you must first contact and/or visit your PCP. If you select this type of plan, you must be treated by a physician, clinic, facility, hospital or other provider that belongs to the HMO network.

If an HMO provider does not treat you, no benefit will be paid, except in the case of an emergency.

Pre-existing Condition
A condition for which medical advice was given or for which a health care provider recommended or provided treatment before the effective date of your coverage.

Preventive Care
Services such as routine physical exams, well-child care, routine immunizations and cancer screenings in medical plans; and routine periodic exams, cleaning of teeth and x-rays in dental plans.

Primary Care Physician (PCP)
A physician who is primarily responsible for most of your health care services. PCPs are usually family practice, general practice, internal medicine, and pediatrics physicians. Types of plans that usually require you to choose a PCP are POS and HMO plans.

Probationary Period
The period of time between when an employee begins working for an employer and when the employee is eligible to enroll in the employer's group plan. The length of the probationary period is determined by the employer. Common probationary periods are 30, 60 or 90 days. An employee typically becomes eligible to enroll in the employer's plan on the first day of the calendar month coinciding with, or next following, completion of the probationary period. For example, if an employee is hired on February 12 and is subject to a 90-day probationary period, the employee will be eligible to enroll in the group plan effective June 1 (the first day of the month following 90 days of employment).

Provider
A provider of health care services such as a physician, chiropractor, hospital, laboratory, pharmacy, urgent care facility, ambulance company, etc.

Provider Network (Network)
Refers to a collection of health care services providers such as physicians, hospitals, labs, pharmacies, etc. that have signed a contract agreeing to participate with a carrier. Carriers may have several different provider networks such as Traditional, PPO and POS.

Rate (Premium)
The cost (price) of a medical, dental, life or disability insurance plan. The terms "rate" and "premium" are used synonymously to describe the monthly, quarterly, semi-annual or annual cost of a plan.

Waiting Period
The period of time between when your coverage begins and the date a medical or dental plan will begin to pay for certain services. Many medical plans have a 6-month or 12-month waiting period before you'll be eligible to receive benefits for a transplant. Some dental plans have a 6-month or 12-month waiting period before they'll pay for "Major Services" such as crowns, bridges, dentures, inlays and onlays.