Glossary of Terms

Maximum amount on which payment is based for covered medical services. This may be called "eligible expense," "payment allowance" or "negotiated rate". If an Out-of-Network provider charges more than the allowed amount, you may have to pay the difference. See Balance Billing.

Occurs when an Out-of Network provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. An in-network provider cannot balance bill you for the covered services.

Your share of the costs of a covered medical service calculated as a percent of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the medical plan's allowed amount for a medical service is $100 and you've met your deductible and your coinsurance payment is 25%, then you would pay $25. The medical plan pays the rest of the allowed amount.

A fixed amount which you pay at the time of service. Copays are most common for emergency room, urgent care and prescription drugs. In some cases, you may be responsible for paying a copay as well as a percentage of the remaining charges.

The amount you must pay for eligible expenses before the plan begins to pay benefits. A deductible may be per service/test, per visit, per supply or per coverage year. For example, if your individual deductible is $2,250, your plan will not pay anything for certain medical services until you have paid $2,250. The deductible may not apply to all services (i.e. services that are covered by a copay).

An HSA account is a great way to set aside pre-tax dollars to help pay for medical expenses. The funds do roll over from year to year. The account is yours to keep if you should leave employment with Vertex Education.

An FSA is a special account you put money into that you use to pay for certain out-of-pocket health care costs. The funds do not roll over from year to year.

The percent you pay of the allowed amount for covered medical services to providers who contract with our health insurance carrier. In-Network coinsurance costs you less than Out-of-Network coinsurance payments.

Medical services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

The facilities, providers and suppliers our health insurance carrier has contracted with to provide medical services. Your out-of-pocket expenses will be lower and you will not be responsible for filing claims if you visit a participating in-network provider.

The most you pay during a policy period (a calendar year) before your plan begins to pay 100% of the allowed amount. This limit does not include your premium or balance-billed charges.

A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see a non-preferred provider.

The percent you pay of the allowed amount for covered medical services to providers who do not contract with our health insurance carrier. Out-of- Network coinsurance costs you more than In- Network coinsurance. An Out-of-Network provider can balance bill you for charges over the allowed amount. See Balance Billing.

The most you pay during a policy period (calendar year) before your plan begins to pay 100% of the allowed amount. This limit does not include your premium or balance-billed charges.

A medically necessary determination by our health insurance carrier for a medical service, treatment plan, prescription drug, medical or prosthetic device or certain types of durable medical equipment. Sometimes called prior authorization, prior approval or precertification, our plans may require preauthorization for certain services before you receive them, except in an emergency.

A provider who has a contract with your health insurer or plan to provide services to you at a discount.

The amount the employee contributes through payroll deductions that must be paid for your health insurance or plan.

Coverage that helps pay for prescription drugs and medications covered under the health insurance carrier's formulary. A formulary is the list of FDA approved drugs covered under the medical plan. Each drug is classified into a tier and each tier determines the copayment you will pay for the drug. These tiers typically are: Generic, Preferred Brand, Non-Preferred Brand and Specialty.

A physician who directly provides or coordinates a range of medical services for a patient. Primary Care Physicians include Medical Doctors, Doctors of Osteopathic Medicine, Internists, Family Practitioners, General Practitioners, OB/GYNs and Pediatricians.

A physician, healthcare professional or healthcare facility, certified or accredited as required by state law.

A physician specialist who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.

Prescription medications that require special handling, administration or monitoring. These drugs are used to treat complex, chronic and often costly conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.

Care for an illness or injury serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Wellness refers to a healthy state of being.