Accidental Death & Dismemberment (AD&D)

An additional life insurance benefit. This covers death due to a sudden, unexpected accident. You may also get a percentage of the benefit amount if you lose the ability to use a part of your body in an accident.

Active Enrollment

Active enrollment is a benefits enrollment method that requires team members to manually update their benefit selections each year. During an active enrollment, team members must re-evaluate their previous benefit choices and elect from current options for the upcoming year. If a team member doesn’t make a selection, they won’t receive benefits.

Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act, commonly called the Affordable Care Act is a United States federal statute signed into law by President Barack Obama in March 2010. The law puts in place comprehensive health insurance reforms.

Allowed Amount

The maximum amount that a carrier will consider to pay for a service, including any amount that the patient will be responsible for paying.

Annual Maximum

Total dollar amount a plan pays during a calendar year toward the covered expenses of each person enrolled.

Balance Billing

When a provider bills you the difference between the provider's charge and the carrier's allowed amount.

Brand Formulary Drugs

The brand formulary is an approved, recommended list of brand name medications. Drugs on this list are available to you at a lower cost than drugs that do not appear on this preferred list.

Calendar Year Deductible

A deductible beginning on January 1 and ends on December 31. Calendar-year deductibles reset every January 1.

Child(ren) (as eligible dependents)

You or your spouse’s or eligible domestic partner’s child who resides within the U.S. and is under age 26 (regardless of student status, marital status, residence or financial dependence). Children will be covered on the medical, Rx and life plans until the end of the year in which they turn 26 (or day before their 30th birthday for dental and vision). Such children include:

• A natural child
• A stepchild
• A legally adopted child
• Child placed for adoption
• Child for whom you or your spouse or domestic partner is the legal guardian
• Unmarried child age 26 or older who is or becomes permanently disabled
• A child for whom health care coverage is required through a Qualified Medical Child Support Order (QMCSO) or other court or administrative order

Coinsurance

A percentage of the medical costs, based on the allowed amount, you must pay for certain services after you meet your annual deductible.

Conversion

A team member changes or “converts” her/his Group Life coverage to an Individual Life Insurance policy without having to answer any medical questions. Conversion is for a team member who is leaving her/his job, reducing hours or has reached the age when coverage may be reduced or eliminated and still wants to maintain the protection that life insurance provides.

Copayment (Copay)

A set dollar amount you pay for network doctors’ office visits, emergency room services and prescription drugs.

Deductible

Total dollar amount, based on the allowed amount, you must pay out of pocket for covered medical expenses each calendar year before the plan pays for most services. The deductible does not apply to network preventative care and any services where you pay a co- payment rather than coinsurance. Some of your dental options also have an annual deductible, generally for basic and major dental care services.

Dependent

A benefits-eligible dependent is a spouse, domestic partner or a child.

Domestic Partner (as an eligible dependent)

A domestic partnership is a relationship between a team member and one other person of the same or opposite sex. Both persons must:

• Not be so closely related that marriage would otherwise be prohibited;
• Not be legally married to, or the other domestic partner of, another person under either statutory or common law;
• Be at least 18 years old; Live together and share the common necessities of life;
• Be mentally competent to enter into a contract.

Durable Medical Equipment (DME)

Equipment and/or supplies ordered by for everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches, and blood testing strips.

Embedded (Deductible)

In the case of deductibles, each person covered on the plan has an individual deductible. When each personal deductible is met, coverage begins for that individual only, and when the family deductible is reached, coverage begins for everyone. The individual deductible is “embedded” within the family deductible, allowing a single family member to access medical benefits sooner if they reach their individual deductible before the total family deductible is met.

Emergency Medical Condition

An illness or injury so serious that one must seek care right away to avoid severe harm.

Event Date

The day in which you become injured, sick, or give birth. The event date marks the beginning of your disability claim regardless of whether it is for short-term or long-term disability.

Evidence of Insurability (EOI)

Requirement under the insurer for the covered person to provide a completed application that details the condition of your health or your dependent's health in order to be considered for coverage.

Exclusive Provider Organization (EPO)

A form of insurance where you can use the doctors and hospitals within a network but cannot go outside the network for care. There are no out-of-network benefits, except in cases considered an emergency.

Excluded Services

Healthcare services that your insurance doesn't cover.

Flexible Savings Account (FSA)

Account offering tax savings by allowing you to contribute pre-tax dollars from your salary for eligible medical and wellness expenses. Restrictions apply based on the medical plan elected. Funds do not carry over year-over-year and must be used or forfeited.

Generic Drugs

These drugs are usually the most cost effective. Generic drugs are chemically identical to their brand name counterparts. Purchasing generic drugs allows you to pay a lower out-of-pocket cost than if you purchase formulary or nonformulary brand name drugs.

Guaranteed Issue

The amount of life insurance available to you without having to complete an Evidence of Insurability.

Habilitation Services

Health services that help one keep or improve skills and functioning for daily living. These include physical and occupational therapy, speech therapy, and treatments for a variety of other disabilities.

Health Maintenance Organization (HMO)

A form of insurance combining a range of coverage in a group basis. A group of doctors and other medical professionals offer care through the HMO for a monthly rate with no deductibles. Only visits to professionals within the HMO network are covered by the policy.

Health Savings Account (HSA)

A portable savings account that allows you to set aside tax-free money for healthcare expenses. You must be enrolled in a High Deductible Health Plan (HDHP) to open an HSA. An HSA rolls over from year to year, pays interest, can be invested, and is owned by you even if you leave the company.

High Deductible Health Plan (HDHP)

A High Deductible Health Plan (HDHP) is a plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (also called your deductible).

Hospice Services

Services to comfort and support individuals in the last stages of a terminal illness.

In-Network

Doctors or services that have a negotiated partnership with your plan. Using in-network doctors and facilities saves you money.

In-Network Co-Insurance

The percent you pay for covered health care services to providers who contract with your health insurance. In-network co-insurance typically costs less than out-of-network co-insurance.

In-Network Co-Payment

A set amount that you pay for covered services to providers who contract with your health insurance. In-network co-payments typically cost less than out-of-network co-payments.

Long-Term Disability

Insurance that protects your income if you are unable to work due to a long illness or injury. This insurance goes into effect after you have been out of work for a specific period of time.

Mail-Order Medication

Medications that you get only after you sign up for the mail-order program with Optum. Once you sign up, your medications can be mailed directly to your home address and, generally, in a higher quantity (e.g., 90-day supply). Signing up for mail-order medications can save you money, but it is not a guarantee. Consult with your doctor and Optum to see if this is a good solution for you.

Maintenance Drugs

Prescriptions commonly used to treat conditions that are considered chronic or long term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

Medical Necessity or Medically Necessary

Health care services or supplies needed to prevent, evaluate, diagnose or treat an illness, injury, condition, disease or its symptoms, that are all of the following as determined by UnitedHealthcare:

• Generally accepted standards of medical practice.
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, substance use disorder, disease or its symptoms.
• Not mainly for your convenience or that of your doctor or other health care provider.
• Not more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.

Network

A group of health care providers, including dentists, physicians, hospitals and other health care providers, that agrees to accept predetermined rates when serving members.

Non-Embedded Deductible

Also known as an "aggregate deductible," a non-embedded deductible is a feature of a family health insurance policy. Unlike an embedded deductible, with a non-embedded deductible, there is only a family deductible. All family members’ out-of-pocket expenses count towards the family deductible until it is met. This means insurance will only start paying for services once the entire family deductible has been met, even if only one member has claims. This type of deductible can be simpler than an embedded deductible but may lead to higher out-of-pocket expenses for individual family members if they have significant medical costs.

Non-Formulary Drugs

These drugs are not on the recommended formulary list. These drugs are usually more expensive than drugs found on the formulary. You may purchase brand name medications that do not appear on the recommended list, but at a significantly higher out-of-pocket cost.

Non-Preferred Provider

A provider without a contract with your insurance plan. You'll generally pay more to see a non-preferred provider.

Out-of-Network

Doctors or services that do NOT have a negotiated partnership with your plan and might cost you more money.

Out-of-Network Co-insurance

The percent you pay for covered health care services to providers who do not contract with your health insurance. In-network co-insurance typically costs more than out-of-network co-insurance.

Out-of-Pocket Limit

The most you'll pay before your insurance begins to pay 100% of the allowed amount. The limit never includes your premium or services that your plan doesn't cover.

Out-of-Pocket Maximum

The maximum amount of coinsurance a Plan member must pay toward covered medical expenses in a calendar year for both network and non-network services. Once you meet this out-of- pocket maximum, the Plan pays the entire coinsurance amount for covered services for the remainder of the calendar year. Deductibles and copays apply to the annual out-of-pocket maximum.

Passive Enrollment

Passive enrollment is a benefits enrollment method that rolls over team member benefits elections from the previous enrollment period. During a passive enrollment, team members who take no action during open enrollment receive the benefits they had the previous year (if available).

PDP Fee

PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefit maximums.

Physician Services

Services provided by a licensed medical physical (M.D. or D.O.)

Plan

A benefit your employer or union provides to pay for your healthcare.

Portability

A team member carries or “ports” her/ his current Group Life coverage after employment ends, without having to answer any medical questions. Portability is for an associate who is leaving her/his job and still wants to maintain the protection that life insurance provides.

Preferred Provider Organization (PPO)

Preferred Provider Organization (PPO) plans allow members to use any healthcare professional without a referral. Staying in-network means smaller copays and more coverage. If you go out-of-network, you'll have higher out-of-pocket costs, and not all services may be covered.

Premium

The amount that must be paid for your health insurance by you and your employer. Typically paid monthly.

Pre-tax Plan

A plan for active team members that is paid for with pre-tax money. The IRS allows for certain expenses to be paid for with tax-free dollars. The state takes premiums out of your check before taxes are calculated, increasing your spendable income and reducing the amount you owe in income taxes. Consequently, the IRS has tax laws that require you to stay in the plans you select for a full plan year (January through December). You can only make changes during Open Enrollment or if you have a Qualifying Event.

Preventive Care

Healthcare services that you get when you are not sick or injured. These are designed to keep you healthy. They include annual checkups, gender- and age-appropriate health screenings, well-baby care, and immunizations recommended by the American Medical Association.

Prior Authorization or Pre-Authorization

Getting approval from your provider for the recommended medicine, services or supplies prior to receiving them. Without this prior approval, your health plan may not provide coverage, or pay for the medication, services or supplies. Not all covered health services require prior authorization.

Primary Care Physician (PCP)

A physician (M.D or D.O.) who provides or coordinates a variety of healthcare services.

Provider

A physician (M.D. or D.O.), health care professional or facility that is licensed and certified as required by state law.

Qualifying Life Event (QLE)

An occurrence that qualifies the subscriber to make an insurance coverage change outside of Open Enrollment.

Reasonable and Customary Charge (R&C)

R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of: (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services, as determined by MetLife.

Reconstructive Surgery

Surgery and treatment needed to correct a part of the body due to birth defects, accidents, or medical conditions.

Rehabilitation Services

Services that help a person keep or reclaim skills and functioning for daily living lost due to an illness or injury. Examples include occupational therapy, speech therapy, and select psychiatric services.

Retail Medication

Medications that you get from a physical pharmacy, such as Walgreens, CVS, or Target. Generally, retail medications are offered only as a 30-day supply.

Short-Term Disability

An income replacement benefit that provides a percentage of pre-disability earnings on a weekly basis when employees are unable to work due to an illness or injury that’s unrelated to their job. It typically covers off-the-job accidents and illnesses that workers’ compensation would not cover.

Skilled Nursing Care

Services for licensed nurses in a nursing home or your own home.

Specialist

A physician that focuses on a specific area medicine or group of patients to diagnose, prevent, or treat certain conditions.

Specialty Drugs

Prescription medications that require special handling, administration or monitoring. These drugs may be used to treat complex, chronic and often costly conditions.

Spouse (as an eligible dependent)

The person to whom you are legally married.

Summary of Benefits and Coverage (SBC)

A straightforward summary that allows you to compare costs and coverage between different health plans.

Usual, Customary and Reasonable (UCR)

The amount paid for a service in a geographic area based on what local providers typically charge.

Urgent Care

Care for a condition or injury serious enough that one would seek care right away, but not one severe enough to require emergency room care.

Voluntary Life Insurance

Additional life insurance on top of the group life Insurance. You can enroll in this coverage for yourself, your spouse or child(ren). Your dependents are eligible to enroll only if you are also enrolled yourself. You are responsible for the full premium.