Medical Terms

A Brief Glossary of Terms
Health care coverage plans use several terms to describe costs associated with the plans.

Annual out-of-pocket expense limit: the maximum medical expense you would have to pay per year, after which the plan pays 100% of most eligible expenses for the rest of the year. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary. 

Co-payment: the amount you are required to pay each visit in sharing eligible expenses with the plan. Co-payments are usually a set amount or a percentage. The plan pays the remainder. 

Deductible: the amount you are required to pay before your plan covers any major medical benefits per year. 

Qualified Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby). Human Resources must be notified within 30 days if a dependent, who is covered under your policy, becomes ineligible for any reason

Open Enrollment: A period during which a health insurance company or HMO is statutorily required to accept applicants without regard to health history. A period when employees can change insurance plans offered by their employer, without proof of insurability. Open Enrollment is held during the Fall of each year. Changes made during Open Enrollment take effect on January 1st of the following year.

Reasonable and Customary: All of the medical plan options contain "reasonable and customary" language, which means that eligible medical expenses will be covered up to the reasonable and customary amount. A reasonable and customary ("R & C") charge will be the usual charge made by a physician or supplier of services, medicines, or supplies and will not exceed the general level of charges made by others rendering or furnishing such services, medicines, or supplies within the area in which the charge is incurred for the illness or injury being treated. The term "area" as it would apply to any particular service, medicine, or supply means a county or such greater areas as is necessary to obtain a representative cross section of the level of charges. 
You will incur out-of-pocket costs only for amounts exceeding the reasonable and customary rates for services obtained outside of the appropriate network: PPO, Delta Dental and/or EyeMed Vision.


Page last modified October 23, 2020