Question 1

Carrier

Accepted Answer

A provider or insurance company.

Question 2

Coinsurance

Accepted Answer

The percentage the plan or you pay for a covered service or supply. For example, the plan may pay 80 percent while you pay 20 percent.
How this works with your deductible: Typically, coinsurance doesn’t kick in until you’ve met your deductible.
In practice: Once your deductible has been met, a plan with 20% coinsurance for every in-network specialist visit, means you will owe $20 if a visit costs $100.

Question 3

Copayment (Copay)

Accepted Answer

A copay is a flat-dollar amount you pay for specific covered services upon each visit to the provider. It is not impacted by the plan deductible, coinsurance or out-of-pocket maximum.
How this works with your deductible: Typically, you don’t need to meet your deductible for the copay amount to apply, and the money spent on copays doesn’t count toward your deductible.
For example: If your plan has a $20 copay for every in-network specialist visit, you will owe $20 when you go in—period.

Question 4

Deductible

Accepted Answer

The amount you pay each year before the plan begins to pay coinsurance.

Question 5

Evidence of Insurability (EOI)

Accepted Answer

The documentation of the good health condition of the insurance beneficiary and his/her dependent’s health in order to be approved for coverage. It is only required in certain circumstances.

Question 6

Explanation of Benefits (EOB)

Accepted Answer

After you receive medical services, your insurance will provide you with an EOB. It will outline details regarding how your insurance processed your medical claim, including what portion of the charges your insurance paid and what portion, if any, you are responsible for paying.

Question 7

Flexible Spending Account (FSA)

Accepted Answer

An FSA is a tax-advantaged account that lets you put money aside on a pre-tax basis to pay for a wide range of health and/or dependent care expenses (as defined by the IRS) not covered by your plan that you incur during the plan year. Unlike the HSA, any unused funds remaining after the plan year ends will be forfeited.
 
For a complete list of eligible expenses, visitirs.gov/pub/irs-pdf/p503.pdf.

Question 8

Formulary

Accepted Answer

A medical plan’s formulary is a preferred brand-name drug list of the most cost-effective outcome-based drugs. You pay less when using a drug on the plan’s formulary list.

Question 9

Health Maintenance Organization (HMO)

Accepted Answer

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage.

Question 10

Health Savings Account (HSA)

Accepted Answer

An HSA is a tax-advantaged savings account for high-deductible health plan (HDHP) participants that lets you put money aside on a pre-tax basis to pay for a wide range of health care expenses (as defined by the IRS) not covered by your plan. Unused money remaining in the account at the end of the plan year rolls over to be used the next year. Please refer to IRS Publications 502 and 969 for complete details on eligible expenses.
 
For a complete list of eligible expenses, visitirs.gov/pub/irs-pdf/p502.pdf.

Question 11

High Deductible Health Plan (HDHP)

Accepted Answer

A plan that provides competitive health insurance along with a tax-advantaged health savings account (HSA) that lets you decide how to spend your health care dollars. Essentially, you pay a lower premium in exchange for a higher deductible, much like car insurance.

Question 12

HSA Contribution

Accepted Answer

This refers to a contribution, or “deposit,” an employee may make to his/her HSA, or a deposit made by the company to the HSA of an employee participating in the HDHP.

Question 13

In-and Out-of-Network Providers

Accepted Answer

Benefit plans develop networks by contracting with doctors, hospitals, labs, etc., who have agreed to provide health care services to members at negotiated rates. You generally pay less out of pocket when you use in-network providers.

Question 14

Out-of-Pocket-Maximum

Accepted Answer

The maximum amount you will pay out of pocket for covered medical expenses per calendar year, including your deductible. After your share of covered expenses reaches this annual limit, the plan pays 100 percent for eligible network services and supplies for the remainder of the calendar year.

Question 15

Preferred Provider Organization (PPO)

Accepted Answer

A type of health plan that contracts with doctors, hospitals, labs and other health care providers to create a network of participating providers. You generally pay less when you use providers that belong to the PPO network. You may use providers that fall outside of the plan’s network at an additional cost. This type of plan typically has higher premiums and a lower deductible than a high-deductible health plan (HDHP).

Question 16

Prescription Drug Out-of-Pocket Maximum

Accepted Answer

The maximum amount you will pay out of pocket for covered prescription drug expenses per calendar year. After your share of covered prescription drug expenses reaches this annual limit, the plan pays 100 percent for eligible prescription drugs for the remainder of the calendar year.
The prescription drug out-of-pocket maximum is separate from the medical out-of-pocket maximum.

Question 17

Reasonable & Customary (R&C) Charges

Accepted Answer

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The R&C amount sometimes is used to determine the allowed amount.

Question 18

Summary Plan Description (SPD)

Accepted Answer

An important document that tells plan participants what the plan provides and how it works.

2025 Benefit Guide

2026 Benefit Guide

Carrier

Coinsurance

Copayment (Copay)

Deductible

Evidence of Insurability (EOI)

Explanation of Benefits (EOB)

Flexible Spending Account (FSA)

Formulary

Health Maintenance Organization (HMO)

Health Savings Account (HSA)

High Deductible Health Plan (HDHP)

HSA Contribution

In-and Out-of-Network Providers

Out-of-Pocket-Maximum

Preferred Provider Organization (PPO)

Prescription Drug Out-of-Pocket Maximum

Reasonable & Customary (R&C) Charges

Summary Plan Description (SPD)

2025 Benefit Guide

2026 Benefit Guide

Carrier

Coinsurance

Copayment (Copay)

Deductible

Evidence of Insurability (EOI)

Explanation of Benefits (EOB)

Flexible Spending Account (FSA)

Formulary

Health Maintenance Organization (HMO)

Health Savings Account (HSA)

High Deductible Health Plan (HDHP)

HSA Contribution

In-and Out-of-Network Providers

Out-of-Pocket-Maximum

Preferred Provider Organization (PPO)

Prescription Drug Out-of-Pocket Maximum

Reasonable &amp; Customary (R&amp;C) Charges

Summary Plan Description (SPD)

Reasonable & Customary (R&C) Charges