Coinsurance is the percentage of the full cost of a health care service that you must pay. For example, if you have a lab test that’s not part of your preventive care exam, after you meet the plan’s deductible, you’ll pay a percentage of the cost of that test. The percentage you pay is called your coinsurance.
A copayment is a flat-dollar amount you pay for certain covered services. For example, in the Core and Buy-Up PPO plans, you pay only a copayment for doctor’s office visits and prescription drugs. The plan pays the rest.
These are the services that are reimbursed through the insurance plans.
A deductible is an annual-dollar amount that you must pay before the plan pays benefits. For example, in the High Deductible Health Plan, you must meet the deductible before the plan pays benefits for any services except preventive care (which is covered at 100%).
Doctors use medical tests and procedures to identify—or diagnose—what’s making you sick. Your doctor will ask you questions about your symptoms, and might even recommend additional lab or other tests. It’s important to understand that diagnostic care is covered differently from preventive care.
Generic drugs contain the same active ingredient as brand-name drugs, but they generally cost a lot less.
Health Savings Account (HSA)
An HSA is an account available to employees who enroll in the High Deductible Health Plan. An HSA lets you save money for health care expenses on a before-tax basis (before taxes are deducted from your paycheck). When you go to the doctor or pharmacy, you can use the money in your account to pay for your visit or prescription. That’s an automatic savings because the money you put aside in your HSA comes out before taxes. Best of all, you own 100% of the money in your account—even if you change jobs or retire. And any money you don’t use during the year stays in your HSA—earning interest—for you to use in the future. Learn more about the HSA and how you can use this to save for retirement.
An organization dedicated to making it easy for Americans to find quality, affordable health insurance. HealthSherpa has plans from over 200 carriers—all the same plans at the same prices as healthcare.gov. You can get free help from a representative by calling 855-772-2663, or go to the HealthSherpa website to explore your options. Live chat is also available.
Care in a hospital that requires admission as an inpatient, and usually requires you to spend one or more nights in the hospital.
In-Network (Also Known as Network)
A group of health care providers and facilities—including doctors, dentists, hospitals, and labs—that contracts with your health care plan to provide services at lower rates. You’ll usually pay less when you use these in-network health care professionals.
Mylo insurance experts will help you find the coverage you need, answering your questions and guiding you in the right direction. You can get free help by calling 844-863-5950 or go to the Mylo website.
Nonpreferred Brand-Name Drugs
A drug that has a trade name that is protected by a patent. Because only the company that holds the patent can produce and sell the drug, they are generally more expensive than generic and preferred brand-name drugs.
Health care professionals, hospitals, clinics, and labs that do not belong to your health care plan’s network. You’ll typically pay more and might have to pay in full at the time of your visit and then file a claim with the health plan for reimbursement. And because out-of-network providers may charge more, you might not be reimbursed for the full cost.
The maximum amount you’ll pay during the plan year for eligible covered expenses. After reaching this maximum, the health plan will pay 100% of any additional eligible expenses for the rest of the plan year. It’s important to note that certain expenses—such as expenses above reasonable and customary fees charged by out-of-network doctors—do not count toward the out-of-pocket maximum.
PPO (Preferred Provider Organization)
A group of doctors, hospitals, labs, and other health care providers who have agreed to charge less for their services.
Preferred Brand-Name Drugs
These are drugs for which generic equivalents are not available. However, they have been on the market for a time and are widely accepted. They cost more than generics but are less expensive than nonpreferred brand-name drugs.
The premium is the amount that’s deducted out of your paycheck each week for the cost of coverage.
Checkups and screenings to prevent instead of treat sickness. For example, an annual check up or physical exam. Preventive care includes age-appropriate screenings and vaccinations, such as blood pressure, cholesterol, and cancer screenings; gynecological exams and mammograms for women; vaccines for adults and children. All of the health plans provide in-network preventive care at no cost.
Primary Care Physician (PCP)
In the Core PPO, Buy-Up PPO, and High-Deductible Health Plans, Primary Care Physician (PCP) refers to the doctor you see for regular preventive care and when you have a minor illness. This is often referred to as your family doctor. In the HMO offered to Hawaii employees, a PCP is the doctor you must see for routine care. Your PCP is also the doctor who will give you referrals to specialists and other types of care.
Qualified Life Event
Certain changes in your life mean you can make changes to your benefits during the year. In the benefits world, these changes are known as qualified life events. They include having a baby or adopting a child; getting married, legally separated, or divorced; if your spouse gains or loses coverage; or if your child reaches the maximum age for coverage. If you have a qualified life event, contact the Benefits office at 877-291-3000 or by email.
A doctor with additional training who specializes in a certain area of medicine. Specialists include gynecologists and obstetricians, orthopedists, and oncologists.