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Indiana Group Health Insurance Terminology

Calendar Year Deductible – This is the amount the insured must pay before insurance starts paying covered claims during calendar period.

Certificate of Coverage – This is a written documents from the insurance company
Explaining the terms of the health insurance contract. Access to the document is through the carrier’s online portal or can be mailed upon request.

Coinsurance – Portion of covered health care
costs that the insurance company will pay after deductible is met. (In & out of network)

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)  – COBRA applies to employers who generally employ 20 or more full-time equivalent employees. This applies for former employees and dependents no longer covered under the group health plan, to continue coverage

Deductible – The amount the insured must pay before the insurance starts paying for covered claims. Depending on plan designs, co pays may be excluded.

Flexible Spending Account (FSA) – The Flexible Spending Account portion of IRS code125 allows employee or employer to contribute contributions to a specific savings account on a pretax basis. These funds then are used towards medical claims.

Health Insurance Portability and Accountability Act (HIPAA) – This is a federal law that governs the privacy of protected health information.

HRA (Health Reimbursement Account) – An account which a employers can make contributions (not taxable) which employees can use for certain medical expenses.

HSA (Health Savings Account) – A custodial account, if health plan is eligible, both employer and employee can contribute, which funds can be used for medical expenses. The contributions are nontaxable.

Keep Your Coverage Transitional Relief – Centers for Medicare and Medicaid Services (CMS) passed guidance to allow, but not require, state to authorize health insurers to renew small group health coverage that was purchased in 2013.

Med/Rx Deductible Combined – Health insurance plan designs in which both medical and prescriptions drug claims apply towards the deductible.

Metallic Levels – Qualified health plans level of coverage is determined on the actuarial value, which determine the amount of cost the insured member is responsible for. Bronze 60%, Silver 70%, Gold 80%, & Platinum 90%.

Monthly Medical Premium – The amount paid to the insurance company for the group health plan.

Split Office copays for Primary Care & Specialist – This is the fixed dollar amount the insured must pay directly to the medical provider. Primary Care Doctors (PCP) has a lower fixed copay, while the specialist has a higher.

Out of Network – Insured and their covered dependents receiving medical services outside the insurance carrier’s network. This coverage can create additional cost to the insured vs a in network provider.

Out of Pocket Max – The maximum dollar amount the insured will pay for covered health insurance services.

Patient Protection and Affordable Care Act (PPACA) – Also known as the “Affordable Care Act”, was passed in 2010 with the intention of expanding health care access to Americans. The ACA governs all qualified health plans.

Plan Deductible – The fixed dollar amount that has to be paid before insurance coverage starts.

Policy Year Deductible – The amount the insured must pay before the insurance starts paying towards medical expense.

Pre-Tax Premium – This allows the employer to deduct employee’s contributions towards health insurance premium from paychecks before deductions are taken out.

Rate – The amount of money paid on a monthly basis, for health insurance coverage.

Renewal Date – This is the date that the group health insurance became in force.

Subscriber – The person who is enrolled in the group health coverage.