It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

Glossary
In-network Copayment: A fixed amount
(for example, $15) you pay for covered
health care services such as specialty
formulary prescription drugs to the
provider who contracts with your PBM.
In-network copayments usually are less
than out-of-network co-payments.
It’s Your Choice Open Enrollment Period:
The annual opportunity for eligible
employees and currently insured
annuitants to change from one health
plan to another, newly enroll or change
from single to family coverage for the
upcoming year without restrictions.
Mandated Benefits: Benefits that are
required by either federal or state law.
Medically Necessary: Health care
services or supplies needed to prevent,
diagnose or treat an illness, injury,
condition, disease or its symptoms
and that meet accepted standards of
medicine.
Medicare: The federal health insurance
program for those who are eligible
for coverage due to age, disability or
blindness. The original federal Medicare
program provides coverage under
Medicare Part A and Part B.
Medicare 1 (Family Premium Rate): The
rate for a family plan where at least one
member is enrolled in Medicare Parts A
and B (and Medicare is the primary (first)
payer) and at least one family member is
not enrolled in Medicare.
Medicare 2 (Family Premium Rate): The
rate for a family plan where all members
are enrolled in Medicare Parts A and B
and Medicare is the primary (first) payer.
Network: The facilities, providers and
suppliers your health insurer or plan has
contracted with to provide health care
services.
Non-Preferred Provider: A provider who
doesn’t have a contract with your health
insurer or plan to provide services to
you. In a PPO, you’ll pay more to see a
non-preferred provider.
Non-Qualified Plan: Health plans that
offer a limited amount of providers in a
county.
Out-of-Network Coinsurance: In a PPO,
the percent (for example, 30%) you
pay of the allowed amount for covered
health care services to providers who do
not contract with your health insurance
or plan. Out-of-network coinsurance
usually costs you more than in-network
coinsurance.
Out-of-Network Copayment: A fixed
amount (for example, $50) you pay
for covered health care services such
as specialty formulary prescription
drugs from the provider who does not
contract with your PBM. Out-of-network
copayments usually are more than
in-network copayments.
Out-of-Pocket Limit (OOPL): The most
you pay during a policy period (usually
a year) before your health insurance or
plan begins to pay 100% of the allowed
amount. This limit never includes your
premium, balance-billed charges or
health care your health insurance
or plan doesn’t cover. Some health
insurance or plans don’t count all of your
copayments, out-of-network payments or
other expenses toward this limit.
Decision Guide Page 91