Page 31 - KIPP NYC 2022 Benfits Summary

Glossary of Terms
Beneficiary
Calendar Year Maximum
A person designated by the insured to receive benefits upon the insured’s death.
Maximum amount payable for all eligible dental expenses in any calendar year. This maximum applies to each insured person.
A form of cost sharing in an insurance plan that requires an insured person to pay a shared percentage of covered expenses after the deductible amount, if any, is paid.
A small fixed amount required by a health insurer to be paid by the insured for each outpatient
(office) visit or prescription.
A fixed dollar amount during the benefit period — usually a year — that the insured pays, out of their own pocket, before the insurer begins to make payments for covered services. Plans may have both individual and family deductibles.
Organizations that contract with providers to form a network that offers plan participants healthcare services at a negotiated, discounted rate. Participants enrolled in an EPO plan DO
NOT have the option to see out-of-network providers.
An FDA approved, biologically equivalent, form of a brand name or wonder drug offered at a deeply discounted amount in an effort to control prescription drug costs (e.g., The generic form of Tylenol is acetaminophen).
A brand drug that is not on the prescription drug list. Such drugs are covered in the third tier of the prescription drug plan.
Maximum dollar amount a member is required to pay “out of his/her pocket” during a plan year.
Until the maximum is met, the insurance carrier and member share in the cost of covered expenses. After the maximum is reached, the insurance carrier pays the total cost of all covered expenses.
A Type B (Basic) Dental Procedure. A dental specialty that pertains to the treatment of diseases of the supporting and surrounding tissues of the teeth (gums).
Organizations that contract with providers to form a network that offers plan participants healthcare services at a negotiated, discounted rate. Participants have the option to see network or non-network providers. Non-network services are not provided at a discount and those providers will balance bill the participant for the difference between the provider’s fee and the insurance companies discounted rate.
Certain procedures require authorization by the insurance Company as stated in the plan certificate of coverage. This must be done before the procedure is performed or benefit paid and is generally provider initiated for in-network and member initiated for out-of-network.
A brand name drug on the prescription drug list that appears in the second tier of the prescription drug plan.
The prevailing cost for a procedure performed in a specific geographic area. This charge applies to medical and dental services performed by an Out-of-Network provider.
If step therapy is required for your prescription drug, you must first try one or more prerequisite medications before a step therapy medication will be covered.
Coinsurance Copay
Deductible
Exclusive Organization (EPO)
Provider
Generic Drug Non-Preferred Drug Out-of-Pocket Maximum
Periodontic Procedures
Preferred Organization
Pre-certification
Preferred Drug
Provider
Reasonable and Customary Charge
Step Therapy