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Glossary

Benefit terms can be confusing. Below you will find the most commonly used medical terms. 

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AD&D (Accidental Death and Dismemeberment)

A plan that provides benefits in the event of an accidental death or dismemberment (generally, an accident that results in death, loss of part of the body, or the loss of the use of part of the body).

Beneficiary

A person designated by a participant, or by the terms of an employee benefit plan, which is or may become entitled to a benefit under the plan.

In-Network Provider

A provider who has contracted with a health care plan (a medical, dental or vision plan) and agreed to certain rates. In most cases, you pay less and receive a higher benefit when you use in- network providers. Check with your plan for coverage details.

Negotiated Rates

The costs for health care services negotiated between the insurance carrier and in-network health care providers. Negotiated rates are usually less than usual, customary and reasonable (UCR) charges

Out-of-Network-Provider

A state-licensed health care provider who has not contracted with a health care plan (medical, dental or vision plan) and has not agreed to certain rates. In most cases, you pay more and receive a lower level of benefits when you use out-of-network providers. See your plan for coverage details.

Out-of-Pocket-Expenses

Copays, deductibles, and other expenses that are not covered by the health plan.

Benefits Summary

The benefits summary has more details about each benefit.

COBRA

Federal law (Consolidated Omnibus Budget Reconciliation Act of 1985) requiring certain employers that offer group health plans to provide continuation coverage to employees and their dependents who incur certain qualifying events.

Out-Of-Pocket Maximum

The maximum amount of money you will have to pay in a calendar year for medical expenses. When you reach the out-of-pocket maximum, medical benefits for the rest of the year are paid by the plan at 100%. The out-of-pocket maximum is not prorated for new hires. After you reach the out-of-pocket maximum, you no longer pay  copays or coinsurance for the remainder of the calendar year. .

Coinsurance or Cost Sharing

The portion of covered health care costs for which you are financially responsible. Coinsurance does not include deductibles or copays.

Qualifying Life Event

Certain events which may allow you to make allowable changes to your benefits. Qualifying events include: marriage, divorce, death, birth, adoption or placement for adoption, and significant change in employment.

Copay or Copayment

A set amount you pay out of pocket for a particular service. The plan pays the balance.

Deductible

The out-of-pocket amount you must pay each calendar year before the plan pays for eligible benefits.

Evidence of Insurability (EOI)

Many insurance companies require prospective clients/ individuals to prove that they are in good health and are therefore good insurance risks before the company will cover them.

Explanation of Benefits (EOB)

A statement from a plan explaining what portion of a claim was paid.

HIPAA Authorization

Under HIPAA, a document that authorizes the use or disclosure of an individual’s Protected Information by a Covered Entity for any purpose described in the document and meets specific requirements.

High Deductible Health Plan (HDHP)

This is a medical plan with a higher deductible than a traditional plan. A high deductible plan can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes. The Cigna HDHP PPO and the Kaiser HDHP HMO offered through Pulmonx are considered High Deductible Health Plans. For 2024, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,600 for an individual or $3,200 for a family. An HDHP’s total annual out-of-pocket maximum (including deductibles, copayments, and coinsurance) can’t be more than $8,050 for an individual or $16,100 for a family. (This limit doesn’t apply to out-of-network services.) 

Reasonable and Customary (R&C) or Usual, Reasonable and Customary (UCR)

A term used in many health plans, defined as the price at or below which the majority of health-care professionals of similar expertise charge for similar procedures within a specific geographic area.

Summary of Benefits and Coverage (SBC)

An easy-to-understand summary of your coverage which is made available from your health insurance plan under the Affordable Care Act.

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