Coinsurance: Your share of the costs of a covered healthcare service, calculated as a percentage (for example, 20%) of the allowed amount for the service. Your coinsurance will begin after you have met your deductible. For example, if the charge for an office visit is $100, and you have met your deductible, your coinsurance payment of 20% would be $20. Your health insurance pays the rest of the allowed amount.
A copay is a fixed-dollar amount you pay for a healthcare service. The amount can vary by the type of service. Your copays will not count towards your deductible but will count towards your out-of-pocket maximum.
These are the services that are reimbursed through the insurance plans.
The amount you owe for covered healthcare services before your plan begins to pay benefits. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid the first $1,000 of the bill for your covered healthcare services subject to the deductible. Preventive Care is not subject to the deductible as it is covered 100% by either medical plan option.
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.
Explanation of Benefits (EOB):
This is a statement from the insurance company showing how claims were processed. The EOB tells you what portions of the claim were paid to the doctor or hospital and what portion of the payment, if any, you are responsible for paying.
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.
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 visit HealthSherpa.com to explore your options. Live chat is also available.
Highly Compensated Employee (HCE)
Highly Compensated Employees (HCEs) who work for BAYADA Home Health Care, BAYADA Home Care or Community Care Center of the Northeast are excluded from making employee contributions to the 401(K) plan; they will be eligible to make employee contributions only to the BAYADA Home Health Care 403(b) plan. All other HCEs will be eligible to contribute to the 401(k) plan and may contribute a maximum of 4% of their eligible compensation. Those who are age 50 or older in 2020 may make an additional $6,500 catch-up contribution. An employee is considered a Highly Compensated Employee (HCE) for 2020 due to compensation if he/she has earned more than $125,000 in eligible compensation during 2019. To be classified as an HCE for 2021, an employee must have earned 2020 eligible compensation in excess of $130,000.
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 network is comprised of all contracted providers. Insurers request providers to participate in their network, and, in return, providers agree to offer discounted services to their patients. If you pick an out-of-network provider, your claims could cost more because you will not receive the discounts that an in-network provider offers.
Prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines.
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 at choosemylo.com. If you do not wish to enroll in BAYADA coverage, you can contact Mylo for guidance with private policies.
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 out-of-pocket maximum is designed to protect you in the event of a catastrophic illness or injury. Your out-of-pocket maximum includes your deductible, coinsurance, and copays that you pay for out of your own pocket. After you have paid the specified out-of-pocket maximum during a policy year, your health insurance pays the remaining covered services at 100%.
POS (Point-of-Service) Plan
A hybrid medical plan where you may select any physicians and hospitals in and outside the plan’s network of preferred providers.
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.
Routine healthcare services that can minimize the risk of certain illnesses or chronic conditions. Examples of Preventive Care services include, but are not limited to: physical, mammogram, flu vaccine, prostate test, smoking cessation, etc.
Primary Care Physician (PCP)
In the Core, Buy-Up, 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 within 31 days of the date of the event.
A doctor with additional training who specializes in a certain area of medicine. Specialists include gynecologists and obstetricians, orthopedists, and oncologists.
A class of lipid-lowering medications that have been found to reduce cardiovascular disease and mortality in those who are at high risk of cardiovascular disease.
The use of telecommunications technologies to provide medical information and services.