Health-Related Glossary of Terms

Please refer to the benefits summary for the plan(s) you have chosen for specific information about the costs, services associated with each of these general terms described below.

Co-Insurance

Co-insurance is the percentage of covered expenses paid by you each year after you have met applicable deductibles. Services that require deductibles and co-insurance are indicated in your benefits summary.

Co-Payment

Co-payment is a dollar amount (in 2005 this is usually $20) that you need to pay each time you see your PCP or specialist within the network

Covered Expenses

Covered expenses are expenses that are covered (paid for) either partially or fully by your plan.

Deductible

Deductible is an annual amount that you need to pay out of pocket to receive specific services under the plan that you have chosen. Once applicable deductibles have been paid, your plan will cover services you receive either on a partial or full basis.

Emergency Care

Emergency care is care received for medical emergencies (e.g., heart attack, stroke, loss of consciousness, broken bones, etc.) Emergency care typically is given in an emergency room and treats the acute condition. Any follow up care needed (including admission to the hospital) is typically not considered emergency care.

In-Network Care

In-Network care is care received within the approved network as described by the health plan option covering you.

Lifetime maximum benefit

The lifetime maximum amount is the amount the plan will pay in benefits for each covered person in a lifetime.

Medically Necessary

Medically necessary services are services that are deemed as necessary to treat a condition, illness, etc by the generally accepted standards of medical practice. These services are usually determined as medically necessary by your PCP.

Out-of-Network Care

Out-of-network care is care received outside of the approved network as described by the health plan option covering you. Generally, when receiving care out of the network, additional costs must be paid by the member receiving services (e.g. deductibles and co-insurance). If you have selected the HMO option, you will need a referral to see a health care provider other than your PCP for services in or out of the network.

Out-of-Pocket Limit

Your out-of-pocket maximum is designed to protect you against high medical expenses, and includes any deductibles and/or co-insurance that you have paid during the year. Once your out-of-pocket limit has been reached, you are not responsible for paying additional amounts for services received. Note that out-of-pocket limits only pertain to covered services and amounts within the usual and customary limits.

Primary Care Physician (PCP)

Your primary care physician (PCP) is a health care professional that you choose to coordinate all of your health services, visits, etc. Each plan has a network of physicians that you can select by looking on the web page of the plan that you choose, or in hard copy directories available in the Human Resources Department. Your PCP is considered your primary doctor and, as such, will be the first point of contact in understanding your health care needs and history. Your PCP will make arrangements for you to see specialists outside of his/her specialty if necessary. Typically, your PCP will refer you to a provider within the same hospital group in which they are affiliated. Note that you must choose a PCP if you are a member of either the POS or HMO plan.

Reasonable and Customary

Reasonable and customary fees represent the range of usual fees for comparable services charged by the medical or dental professionals in a geographic area. If your provider charges more than the reasonable and customary fee, you will be responsible for paying the difference. Usual and customary fees do not apply to the HMO.