Actively at Work
Plan provision that requires the employee to be performing the duties of his occupation where the employee normally works in order for coverage to commence. If the employee is absent due to illness or injury, the coverage does not commence until the employee returns. This rule does not include adding a newborn to health insurance (such as an employee on maternity leave) nor does it extend to absences for annual leave provided the employee was not ill on the last scheduled day before annual leave.

Allowed Fees
Term used by some dental plans for their participating dentist fees and/or maximum payable for a non-participating dentist.

Balance Billing
Non-participating provider practice of billing the patient for any difference between the provider's billed charges and the patient's insurance plan maximum allowance (indemnity or PPO).

Benefits Plan Year
(Jan 1 - Dec 31) Plan year for Health, Dental, Life and Disability Insurance plans (for purposes of enrollment and limitations for annual maximum benefits/out-of-pocket expenses).

Billed Charge
The amount the provider bills for services rendered.

Calendar Year
(Jan 1 - Dec 30) Tax Sheltered Annuity plan year (for purpose of maximum contributions); Flexible Spending Account plan year (for purpose of annual enrollment and reimbursement).

Coinsurance
The division of the allowed amount to be paid by the insurance company and the patient, i.e., 80/20 or 90/10. (The first percentage is paid by the company - 80 or 90).

Co-payment
The fixed fee that must be paid to the provider at the time services are provided, such as the pharmacist for a prescription.

Deductible
The initial amount the patient must pay out of their pocket for covered services before benefits are payable by the insurance carrier in indemnity and PPO plans.

Fiscal Year
(July 1 - June 30) Retirement plan year for purposes of maximum contributions and possible changes to established contribution rates.

Health Maintenance Organization (HMO)
A medical plan providing comprehensive medical benefits, including preventive care, when you agree to use a select group of network providers. Generally, all care is directed by your chosen Primary Care Physician (PCP) who will refer you to a specialist if medically appropriate.

Indemnity Plan
A medical or dental plan which allows you to choose any licensed provider to provide health care. Members are reimbursed for eligible medical or dental expenses according to the benefit schedule in effect, including deductibles and coinsurance.

 In-Network
Services provided by a contracted provider in accordance with all plan requirements.

Non-participating Provider
A provider with no contractual limitation on what he may bill and thus may practice balance-billing, as well as require payment at the time services are rendered.

Point of Service (POS) Plan
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a Co-payment, or to an out-of-network provider and pay a deductible and/or a coinsurance charge.

Preferred Provider
A provider who has signed an agreement with the insurance carrier not to charge that carrier's members more than the insurer's allowed fees.

Pre-certification
Review processes that verifies the medical necessity and appropriateness of proposed services or supplies.

Pre-existing Condition
A condition diagnosed and/or treated prior to the effective data of your coverage or for which a prudent person would have been treated.

Preferred Provider Organization (PPO) PlanA plan that provides benefits in an indemnity fashion, but pays a higher percentage of the cost of services if patients use a PPO-network provider than if they use non-PPO providers.

Primary Care Physician (PCP)
The physician responsible in an HMO for directing all patient care including referrals to specialists and obtaining necessary pre-certifications. This physician is usually a General Practice, Family Practice, Pediatric or Internal Medicine specialist. In some plays, women may choose an OB/GYN as their primary care physician.

Rehabilitation
Usually physical therapy, speech therapy and/or occupational therapy.