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2015 Individual & Family Plans
Common
Insurance Terms
Annual maximum out-of-pocket:
The maximum amount a member would pay for covered health care services in a
plan year before the plan would pay 100 percent of the charges.
Benefit maximum:
A limit on a covered service or supply. A service or supply may be limited by duration or frequency.
Coinsurance:
Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for
the service. You pay coinsurance plus any deductibles you owe first. For example, if Dean Health Plan’s allowed amount
for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. Dean Health
Plan pays the rest of the allowed amount.
Copay:
A fixed amount that you pay for a covered health care service, usually when you get the service. The amount can
vary by the type of covered health care service.
Deductible:
The amount you must pay for covered health care services each year before the plan begins to pay. For
example, if your deductible is $1,000, Dean Health Plan won’t pay anything until you’ve met your $1,000 deductible for
covered health care services subject to the deductible. The deductible may not apply to all services.
Formulary:
A list of prescription drugs covered by an insurance plan offering prescription drug benefits. Also called a
drug list. Normally a formulary will also tell you what tier (or cost sharing level) a particular drug will be in.
Health Savings Account (HSA):
A medical savings account available to taxpayers who are enrolled in a high
deductible health plan. The funds contributed to the account aren’t subject to federal income tax at the time of deposit.
Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year
to year if you don’t spend them.
Out-of-network providers:
Physicians, hospitals or other health care providers who are not contracted with Dean
Health Plan, which could result in a greater cost for services for you.
Preventive care:
Routine health care that includes screenings, checkups and patient counseling to prevent illness,
disease or other health problems.
Prior authorization:
Approval from a health plan that may be required before you receive a certain service or fill a
prescription in order for the service or prescription to be covered by your plan.
Prohibition on pre-existing condition exclusion:
A requirement that health plans cannot deny you coverage
based on your health status.
Rating rules:
A requirement that health plans can only rate your plan based on age, geographic area, family status and
tobacco use.