Benefits terminology can be confusing. Here’s help with the definitions for some of the most commonly unfamiliar terms and phrases.
Annual coinsurance maximum
The most you have to pay each plan year in coinsurance before the medical plan starts paying 100% for covered services up to usual, customary and reasonable (UCR) limits. Copays don’t count toward the annual coinsurance maximum. For example, assume a plan has a $2,500 calendar year deductible and a $3,500 coinsurance maximum. After you meet the $2,500 deductible, coinsurance pays 75% and you pay 25% for services of network providers. The carrier keeps a tally of the 25% coinsurance payments you make throughout the calendar year. Once you have paid $3,500 worth of coinsurance payments, the carrier pays 100% for the rest of the calendar year for covered expenses.
The amount you must pay before your coinsurance begins. Once you meet your deductible, the plan begins to pay its share of covered expenses for the year. You may be required to satisfy an individual deductible or a family deductible, depending on your plan. It’s possible to satisfy an overall family deductible before any single family member has met his or her individual deductible. For example, assume your deductible is $2,500. You pay your medical expenses out of pocket until you’ve paid $2,500. Once you’ve paid $2,500 worth of medical expenses, coinsurance begins paying a certain percentage of your medical costs.
Brand-name prescription drug
A prescription drug with a proprietary name assigned to it by the manufacturer or distributor. This is a company-owned brand name that can be confirmed by Medi-Span or any other similar publication designated by Aetna or an affiliate.
Certificate of creditable coverage
A written certificate that states the period of time one is covered by a health plan. It’s issued either by a group health plan or health insurance issuer when an individual loses coverage under the plan, becomes entitled to elect COBRA continuation coverage or exhausts COBRA continuation coverage. Certificates of creditable coverage contain information about the length of time of coverage as well as the length of any waiting period for coverage.
After meeting your deductible for each plan year, you pay a percentage of costs and the plan pays the rest, up to:
• The discounted levels for network providers (you’re not responsible for the amounts over the discount)
• The usual, customary and reasonable (UCR) limits for out-of-network physicians (emergency only)
• The out-of-network fee schedule limits for out-of-network facilities (emergency only)
The amount you pay is called coinsurance. Once your coinsurance amount reaches the annual coinsurance maximum, the plan pays covered expenses at 100% for the rest of the year. Out-of-network expenses for emergencies are subject to an out-of-network limited fee schedule. You’re responsible for paying any costs above that fee schedule as these charges are not covered and don’t count towards your deductible or coinsurance maximum. So, stay in-network as much as possible.
A life insurance or voluntary benefits policy can be converted into another type of policy. You can convert the HISD benefit plan to an individual policy without evidence of insurability after you’re no longer employed by HISD. The conversion policy is a separate policy between you and the carrier. More information is available here.
A set dollar amount you pay for certain medical care or prescription drugs.
Medical, dental, vision or hearing services and supplies shown as covered under a plan document. To review your plan documents, visit the Plan documents and legal notices page.
A person’s prior medical coverage as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Such coverage includes:
• Health coverage issued on a group or individual basis
• Health care for members of the uniformed services
• A program of the Indian Health Service
• A state health benefits risk pool
• The Federal Employees’ Health Benefit Plan (FEHBP)
• A public health plan (any plan established by a state, the government of the United States, or any subdivision of a state or of the government of the United States, or a foreign country)
• Any health benefit plan under Section 5(e) of the Peace Corps Act
• The State Children’s Health Insurance Program (S-Chip)
Durable medical equipment (DME)
Any medical equipment used in the home to aid in a better quality of living, such as nebulizers, CPAP machines, catheters, hospital beds and wheelchairs.
The treatment given in a hospital's emergency room to evaluate and treat an emergency medical condition. All of the medical plan options cover emergency room care. However, you pay more if you go to the emergency room for non-emergency care. Under the Consumer options, non-emergency care you receive in an emergency room is NOT covered.
Emergency medical condition
A recent and severe medical condition, including (but not limited to) severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, illness or injury is of such a nature that failure to get immediate medical care could result in:
Placing your health in serious jeopardy
• Serious impairment to bodily function
• Serious dysfunction of a body part or organ
• In the case of a pregnant woman, serious jeopardy to the health of the fetus
Explanation of benefits (EOB)
A summary the health plan carrier mails to you after a claim has been processed outlining medical expenses and services that are covered. This is where you find information about how the claim was paid and your financial responsibility. The EOB provides the date of service received, the medical care provided, the amount paid by the plan and your patient responsibility. It’s a good idea to pay a medical provider’s bill only after you have received the EOB to ensure that you pay the correct amount. Once a claim is processed, you can also obtain EOB information by logging on to Aetna Navigator.
A list of preferred drugs that meet a patient's clinical needs at a lower cost than other drugs. Formulary drugs are FDA-approved and selected for their safety, quality, effectiveness and cost efficiency. The primary drug list is included in your Prescription Drug Benefit Kit and is available here. This list is subject to change.
Generic prescription drug
A prescription drug, whether identified by its chemical, proprietary or non-proprietary name, that is accepted by the U.S. Food and Drug Administration as therapeutically equivalent and interchangeable with drugs having an identical amount of the same active ingredient. This information can be confirmed by Medi-Span or any other publication designated by Aetna or an affiliate.
An HISD-funded account for those enrolled in one of the Consumer or Select plan options that may be used to pay for any service or supply covered by the medical plan, up to plan limits. Effective January 1, 2017, HISD no longer offers the HealthFund. You may continue to use any funds you have left over from previous years to pay for eligible expenses as long as you are enrolled in an HISD Consumer or Select medical plan. The HealthFund is Aetna’s name for this account. The common name used by the IRS is a Health Reimbursement Account (HRA).
After March 19, 2018, you may check your HealthFund balance at myCigna. You need to register before accessing the system. You can also get your balance by calling Cigna member services.
Providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at a lower cost to the insurance companies with which they have contracts.
Maximum out-of-pocket limit
The maximum amount of money that you pay for your medical expenses. Your deductibles, payment percentage, copays and other eligible out-of-pocket expense apply to the maximum out-of-pocket limit. Once you satisfy the maximum amount, the plan pays 100% of covered expenses that apply toward the limit for the rest of the calendar year.
The medical plan options only cover expenses for services and supplies that are medically necessary and are not above usual, customary and reasonable (UCR) limits. Services and supplies are considered medically necessary if they’re essential to diagnose or treat an illness or injury. Services and supplies that don’t meet these criteria, as determined by Aetna, aren’t covered. This includes expenses for experimental treatment or treatment for cosmetic purposes.
Any provider, facility or service that is not in your plan network is considered to be out-of-network. Out-of-network expenses are not covered for any of the medical plans, except in case of an emergency where there are no in-network providers nearby. You can use out-of-network providers with the Vision and Legal plans; however, you may incur higher out-of-pocket costs than if you use in-network providers for vision and legal services.
Pre-existing condition limitation
You may be subject to pre-existing condition limitations if you haven’t had HISD medical coverage in the past. A pre-existing condition is any sickness or loss for which medical advice or treatment was received or recommended within 12 months prior to the effective date of coverage. Pre-existing condition limitations are waived or reduced for pre-existing conditions that were covered under a previous group health plan if there was less than a 63-day break in coverage and a HIPAA certificate of creditable coverage can be provided by the prior plan. The plan pays for pre-existing conditions after your medical coverage is in place for nine consecutive months, but only for treatment or services received after the nine-month waiting period. This limitation does not apply to children under age 18.
The amount of money charged by an insurance company for active coverage.
Pre-notification and pre-certification
Pre-authorization/approval or pre-notification of the plan carrier before you receive certain care or services. The care you receive may not be covered if the carrier isn’t contacted as required. Although your provider may contact the carrier for authorization on your behalf, you’re ultimately responsible for making sure carrier’s approval is received, if required.
The ability to transfer your benefits from one job to another. More information is available here.
A hospital, clinic, health care facility, health care professional or group of health care professionals who provide a service to patients.
Primary care dentist (PCD)
A dentist who provides general and continuing tooth and mouth care and diagnosis, as well as continuing care for various oral conditions, not limited by cause or diagnosis for patients with a Dental HMO plan.
Primary care physician (PCP)
A doctor, usually an internist or family practitioner, who provides both the first contact for a person with an undiagnosed health concern, as well as continuing care for various medical conditions, not limited by cause, organ system or diagnosis. Another term for primary care physician is general practitioner.
A formal process that authorizes a medical plan member to get care from a specialist or hospital. If you’re enrolled in the Consumer or Open Access plan options, you don’t have to get a referral to see a specialist. You do need to pay attention to possible network restrictions, though.
Skilled nursing facility
An institution that is licensed to provide, and does provide, specific services on an inpatient basis for persons convalescing from illness or injury.
A doctor whose practice is limited to a particular branch of medicine or surgery. For example, oncologists, gastroenterologists, dermatologists, podiatrists, neurologists, cardiologists, orthodontists, etc.
Usual, customary and reasonable (UCR)
The average rate charged for a particular health care service by most providers in a specific geographic area. The plan pays benefits based on the UCR amount. You’re responsible for paying any amount charged by a provider that is in excess of the UCR amount. In-network services are contracted and can’t exceed UCR limits.