Glossary of terms
Within some plans, Care Advocates work to help employees get the right care at the right price by coordinating and negotiating care details. Read real-life stories to see how Care Advocates help improve care outcomes in the real world.
Unlike copay, coinsurance is the percentage of a service bill that a patient is responsible for covering. Coinsurance only begins to apply after the deductible has been met.
Copay is the predetermined rate that a member pays for healthcare services at the time of care. Different services carry different copays, and whether a provider is in-network or out-of-network will also impact the copay.
A deductible is the amount an employee is responsible for paying out-of-pocket before their health plan begins covering care expenses. Deductibles reset every year.
In-network providers, or participating providers, are a list of contracted healthcare providers that are part of a health plan. By using in-network providers, members pay less than if they use out-of-network providers.
Level-funded plans provide all the savings and benefits of self-funded plans and have the added benefit of a flat, monthly rate. To learn more, visit our about level-funded health plans page.
Maximum allowable charge
A maximum allowable charge is the highest amount that plans will cover or reimburse members for a specific healthcare service.
Out-of-network providers, or non-participating providers, do not have contracts with a particular plan. If members use an out-of-network provider, it can mean higher out-of-pocket costs than using a participating provider.
Pre-approval / prior authorization
Pre-approval or prior authorization is required for some healthcare services to ensure it is the most effective and appropriate treatment, procedure, or medication. This typically requires approval by a health plan before a service is delivered in order for it to be covered.
Preferred provider organization (PPO)
PPO is a type of health plan with a list of contracted providers that members can use. By using these in-network providers, members pay less than if they use out-of-network providers.
For level-funded plans, the premium equivalent is the cost per covered employee that the employer would expect to reflect the cost of claims paid and fixed costs (including administrative costs and stop-loss insurance premiums).
With self-funded health plans, employers set money aside to pay employee healthcare claims. Because these plans take into account the health of each employee and avoid some of the red tape associated with traditional insurance, they typically cost less for employers and employees.
Stop-loss insurance provides protection against catastrophic or unpredictable losses. All of the plans include this insurance to guard employers against unexpected claims costs.
Third-party administrators (TPA)
TPAs are often utilized in self-funded and level-funded health coverage to ensure compliance, manage secondary (stop-loss) insurance, and help expedite claims. The TPA for all plans is Verdegard.
Value-based pricing (VBP)
VBP has a variety of meanings in healthcare. Here, VBP Plans negotiate healthcare services with providers based on Medicare pricing — saving members up to 40% compared to traditional PPO networks, and in many cases eliminating out-of-pocket expenses.