Plan Terms & Abbreviations | Emplova Benefits Explorer

Abbreviations in the comparison tables

The deductible applies before the plan begins paying for the service.

Coinsurance applies to the service.

D&C

The deductible and coinsurance apply.

The listed benefit applies after the deductible.

OON

Out-of-network. Costs and reimbursement may differ from in-network care.

UCR

Usual, customary and reasonable reimbursement methodology.

Mdcr

Reimbursement shown as a percentage of the Medicare rate.

Medical plan basics

Premium: The amount paid each month to keep coverage, usually shared between the employer and the employee.
Deductible: What you pay for covered care each plan year before the plan starts sharing the cost. Preventive care is usually covered before the deductible.
Copay: A flat dollar amount you pay for a service, such as $30 for a primary care visit.
Coinsurance: Your percentage share of a covered cost after the deductible. With 20% coinsurance, you pay 20% and the plan pays 80%.
Out-of-pocket maximum: The most you pay for covered in-network care in a plan year. Once you reach it, the plan pays 100% of covered services for the rest of the year.
Family is 2×: In the comparison tables, the family deductible and out-of-pocket maximum are two times the individual amount shown.
Network: The doctors, hospitals and pharmacies that contract with the plan. In-network care costs less.
EPO: Exclusive Provider Organization. Covers in-network care only, except for emergencies.
PPO: Preferred Provider Organization. Covers both in-network and out-of-network care; out-of-network care costs more.
HSA-qualified plan: A high-deductible plan that meets IRS rules, so you can contribute to a Health Savings Account. Office visits and prescriptions are generally paid toward the deductible first.
Prescription tiers: Drug copays are listed by tier, lowest-cost tier first. The plan's drug list (formulary) shows which tier each medication is in.
Balance billing: When an out-of-network provider bills you for the difference between their charge and what the plan pays. Federal law protects you from balance bills for most emergency care and for certain out-of-network care at in-network facilities.

Disability and life insurance

Elimination period: How long you must be disabled before disability benefits begin, such as 7 days for STD or 180 days for LTD.
Income replacement: The share of your pre-disability earnings the plan pays, up to the plan's maximum benefit.
Own occupation: You're considered disabled if you can't perform the main duties of your own job. Some plans later switch to "any gainful occupation": any job you're reasonably suited for.
AD&D: Accidental Death & Dismemberment. Pays an additional benefit if death or certain serious injuries result from a covered accident.
Evidence of insurability: A health questionnaire the insurer may require before approving coverage above a set amount or outside your first enrollment window.
Portability: The option to keep group life coverage, at your own cost, after you leave your employer, subject to the carrier's rules and deadlines.
Conversion: The option to change group life coverage into an individual policy when group coverage ends.
Waiver of premium: Keeps life coverage in force without premiums while you're disabled, after a waiting period.
Accelerated benefits: Lets you receive part of your life insurance benefit early if you're diagnosed with a terminal illness.

Tax-advantaged accounts

FSA: Flexible Spending Account. Pre-tax money for eligible medical, dental and vision costs. Your full annual election is available on day one.
HSA: Health Savings Account. Pre-tax savings you own, paired with an HSA-qualified plan. Unused money rolls over every year and stays with you if you change jobs.
Limited Purpose FSA: An FSA for dental and vision costs only, so it can be used alongside an HSA.
Run-out period: The time after the plan year ends, or after your coverage ends, to submit claims for expenses you already had.
Carryover: The unused FSA balance, up to the IRS limit, that moves into the next plan year.

A GOOD PLACE TO START

Compare the care you expect to use most.

Begin with network access, then compare the deductible, maximum out-of-pocket amount, office visits, prescriptions and any expected dental or vision needs.