Plan Features and Glossary

Benefits have a language all their own. Understanding how your insurance plans work is crucial to making the most out of your coverage. Become familiar with these commonly-used benefits terms to help you compare and choose plans.

Total Out-of-Pocket Costs

Here’s a simple equation that shows how much you’ll pay out-of-pocket for your health insurance each year.

Premiums + Deductible + Copays & Coinsurance (up to the Out-of-Pocket Maximum) = Total Employee Costs

Once you meet your plan's Out-of- Pocket Maximum, the plan pays 100% of your covered medical expenses for the balance of the year.

• Premiums: The amount you pay for your health insurance every month.
• Deductible: The amount you pay out-of-pocket for healthcare before plan starts to pay. (Please note, the deductible is not applicable to all services.) Separate in-and-out of network deductibles apply.
• Copays: A set amount (for example, $30) you pay for a covered healthcare service.
• Coinsurance: The percentage you pay for the cost of covered healthcare services, after you meet your deductible.
• Out-of-Pocket Maximum: This is a “cap” on your costs for the year; it is the most you’ll pay for healthcare services. Once you reach your out-of-pocket maximum, the plan pays 100 percent of your covered medical expenses for the balance of the year. Separate in- and out-of-network out-of-pocket maximums apply.
   

Deductibles

Understanding Your Deductibles

Your deductible is tied to your premium. Just like car insurance, a plan with a low deductible will cost you a higher premium. On the flip side, a health savings plan with a high deductible will have a lower premium.

• Low Deductible = Higher Premium
• High Deductible = Lower Premium

Consider if you have enough money in your budget—or in savings— to cover the deductible.
 

Types of Deductibles

Not all deductibles are created equal. Here are a few common types:

• Network Deductibles: GW’s health plans have separate annual deductibles for when you get in-network care versus out-of-network care. These amounts are usually different for individuals and families.
• Family Deductibles: With some plans, you’ll need to meet the deductible for each covered family member up to the family cap. For example, under the GW PPO, each person will need to meet the in-network individual deductible of $750 (capped at $1,500 per family). Once an individual meets the $750 deductible, coinsurance begins for that person.

The deductible for the GW PPO includes medical expenses only.

With other plans, one family member can meet the deductible for the entire family. For example, under the GW HSP, if you elect coverage for yourself and one or more dependents, the full family deductible (in-network family deductible is $4,000) will need to be met before coinsurance begins for any family member.

When you cover your family, review your family deductible closely.
 

Other Terms to Know

Benefits Salary: Sometimes referred to as a benefits eligible salary, the salary(ies) of your active benefits eligible primary and secondary positions.

Network: A group of doctors, labs, hospitals and other providers that your plan contracts with at a set payment rate.

Covered Services: Those services deemed by your plan to be medically necessary for the care and treatment of an injury or illness.

Formulary: Sometimes referred to as a preferred drug list, a list of prescription medications that are covered by a pharmacy plan. Drugs not on a formulary may not be available, may carry a higher cost-share amount or may be accessible only with prior authorization.

Generic: An FDA-approved drug, composed of virtually the same chemical formula as a brand-name drug. Ask for generics! Generic medications contain the same active ingredients as brand-name drugs, but cost less. Talk to your doctor about switching to generics and making sure your medications are on your plan’s formulary.

Specialty Drugs: Low-volume, high-cost medication prescribed for chronic and complex illnesses such as multiple sclerosis, hepatitis C and hemophilia, as well as some common diseases such as rheumatoid arthritis. Specialty drugs often require special storage and handling and are not readily available at the typical local retail pharmacy.

High Deductible Health Plan (HDHP): A plan with a higher deductible than a traditional insurance plan. These plans typically have lower monthly premiums, but you must pay more out-of-pocket initially (your deductible for medical and pharmacy) before the plan starts to pay. An HDHP can be combined with a Health Savings Account (HSA), which allows you to pay for certain medical expenses with pretax dollars. (The GW HSP is an HDHP.)

Preventive Care: Preventive care services include those that help you manage your health, such as routine physical exams, screenings and lab tests. These services are covered at 100 percent by the GW health plans, with no out-of-pocket costs (such as deductibles or copays) if the services are received in-network. Be sure your provider codes the services as “preventive.”

Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You may still use doctors, hospitals and providers outside of the network for an additional cost.

Claim: A request by a plan member, or a plan member's health care provider, for the insurance company to pay for medical services.

Reasonable and Customary: Usual, customary and reasonable charges are set by the insurance company, based on the prevailing cost of a service in your geographic area. The insurance company then determines how much it will pay for a given service in your area.

Qualifying Life Event: A life event that allows you to make changes to your insurance coverage that otherwise are only allowed during the annual Open Enrollment period. Examples of a qualifying life event include, but are not limited to, marriage, divorce, birth or adoption of a child, loss of prior coverage, relocation, and the arrival of a dependent from another country.

Preauthorization: Preauthorization (also known as ‘prior authorization’) means that approval is needed from your health plan before you have certain health tests or services. To help make sure your care is appropriate and avoid unexpected costs, it’s important that approval is received before you get these services. Usually, your network provider will take care of preauthorization before the service is performed. But it is always a good idea to check if your doctor has gotten the needed approval.

Explanation of Benefits (EOB): The statement sent to you by your health plan explaining the benefit calculation and payment of medical services that details the services rendered and the benefits paid or denied for each service. An EOB lists the charges submitted, the amount allowed, the amount paid and any balance owed as the patient's responsibility.

COBRA (Consolidated Omnibus Reconciliation Act): Federal legislation allowing an employee or an employee's dependents to maintain group health insurance coverage through an employer's health insurance plan, at the individual's expense, for up to 18 months after the loss of employment.

Summary of Benefits and Coverage (SBC): Understanding your health plan is important. The Summary of Benefits and Coverage (SBC) summarizes important information about your medical insurance plan in a straight-forward format to help familiarize you with your benefits. 

Summary Plan Description: An extensive description of the Health Benefits available to you and your covered family members, including summaries of who is eligible, services that are covered, exclusions, how Benefits are paid, and your rights and responsibilities under the Plan.