Frequently Asked Questions
1. What is a network?
Insurance carriers will negotiate with and contract providers to be within the carrier's "network of providers" to provide health care services to plan members at a discounted rate. As for providers that do not participate in the insurance carrier's network (out-of-network providers), they are not contracted with the plan to accept the negotiated rates. This means that it may cost more for members who are visiting out-of-network providers.
2. What is a deductible?
To access insurance coverage, you need to pay out-of-pocket for covered services initially. This threshold needs to be met to have the plan start paying for covered services. For example, the Mid Medical Plan option has a $500 in-network deductible for employee-only coverage. The employee will be responsible for paying out-of-pocket up for covered in-network medical services to the $500 threshold in order for coverage to kick in.
3. What is coinsurance?
This is essentially the cost-sharing structure for when the deductible has been satisfied. Coinsurance is a percentage split between what the plan will pay and what the member is responsible for. For example, an employee that is only covering themself (employee-only coverage) for medical insurance is enrolled in the 'Low Plan'. Once the employee pays out-of-pocket for covered medical services up until the $1,500 deductible is reached, coverage will start to kick in - meaning the plan will begin to pay at 80%. At this point, the plan will pay 80% of covered medical services, while the employee is responsible for the remaining 20% up until the out-of-pocket maximum is reached.
4. What is a copay?
A copay is a fixed cost for a covered medical service. For example, on the Base medical plan option, a specialist visit is a $40 copay. This means that for each time a covered member visits a specialist, they will be responsible for the $40 copay on a per visit basis. The copays on the medical plans are not subject to the deductible, but will also accumulate toward the out-of-pocket maximum.
5. What is the out-of-pocket maximum?
The Out-of-Pocket maximum is the maximum dollar amount you will be required to pay out-of-pocket. Once you meet your out-of-pocket maximum, the plan will pay 100% of incurred costs for the remainder of the plan year.
6. What is an Explanation of Benefits (EOB)?
This is a statement that comes from your insurance carrier and is NOT a bill. This document outlines what the plan is responsible for and what the member is responsible for. The EOB should be compared against the bill from your provider following a service/visit to ensure that they match up.
6. What does ‘Annual Maximum’ mean for dental coverage?:
An annual maximum is the maximum dollar amount that a dental benefit plan will pay toward the cost of dental care within a calendar year on a per-person basis. It will be the member's responsibility to cover any additional dental costs over the annual maximum within a calendar year.
7. What is evidence of insurability (EOI)?
Evidence of Insurability is an application process to inquire if an employee or dependent is in good health based on past and current health events. The EOI also helps the insurance carrier determine if the employee or dependent qualifies for the requested coverage.
8. What is Guaranteed Issue?
Guaranteed Issue is the "no questions asked" coverage. Guaranteed Issue allows employees and dependents to obtain coverage or obtain coverage up to a specified amount regardless of age, health status, gender, etc.
3. Why is it important to have a beneficiary?
A beneficiary is the designated person or entity that is to receive the benefit from your policy when you pass away. You can designate multiple beneficiaries, whether they are persons or entities, as long as it adds up to 100%. It is important to name your beneficiaries as it will eliminate confusion and save time for the benefit to pay out - a named beneficiary will have quicker access to the death benefit in the event you pass away.
9. What expenses are eligible for FSA reimbursement?
You may use your Medical FSA funds to pay for eligible medical expenses such as health plan copays, deductibles, coinsurance, prescription eyewear, dental care, prescription and over-the-counter medications, menstrual care products as well as certain medical supplies are covered. You can access the below link for the eligible expenses list. You can determine if an item is eligible, ineligible, or eligible with a letter of medical necessity.
