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Beneits Terminology
A handy reference for the insurance terms used in this guide.
Deductible A deductible is the set amount you must pay for medical or dental expenses (aside from copays
that may apply) before insurance begins to cover all or a portion of your costs. Deductibles reset
January 1 each year.
Copay A copay (or copayment) is a set, lat fee that you pay for medical services or prescriptions in
addition to what the insurance company covers.
Coinsurance Once the deductible is met, coinsurance is the percentage you pay of each service until you
reach your out-of-pocket maximum.
Out-of-Pocket Maximum An out-of-pocket maximum is a limit to the amount of money that you must pay before your
expenses are covered at 100% for in-network only services.
In-Network In-Network providers or healthcare facilities are part of a health plan’s network, and you usually
pay less for using these providers.
Out-of-Network Out-of-Network providers are not part of the health plan provider network. Expenses for
services are not discounted through the insurance carrier, and are covered at a lesser amount
by GLG’s plan. In addition, the provider can bill you for any amount not covered by your plan.
Flexible Spending An FSA allows you to set aside a portion of your pre-tax earnings to pay for eligible medical,
Account (FSA) dental, vision, or daycare expenses. Money deducted from your pay into an FSA is not subject to
payroll taxes, resulting in a substantial payroll tax savings.
Limited Purpose A Limited Purpose Flexible Spending Account (LFSA) is a lexible spending account option
Flexible Spending for employees enrolled in a Health Savings Account (HSA) Program with a High Deductible
Account (LFSA) Health Plan (HDHP), or whose spouse is enrolled in a HDHP with an HSA. The LFSA is limited
to eligible dental and vision expenses only.
Health Savings Account A Health Savings Account (HSA) is a tax-advantaged medical savings account you can
(HSA) contribute to and draw money from for certain medical expenses tax-free. HSAs can be used for
out-of-pocket medical, dental, and vision expenses.
Prior Authorization Prior authorization, sometimes called pre-approval, is notiication required by the insurance
company before obtaining certain medical services. To obtain prior authorization for a service,
just call the insurance company. If you do not obtain prior authorization before your appointment,
the insurance company can deny your claim and the service will not be covered.
Premium The premium is the amount that must be paid for your health insurance per paycheck.
Claim A claim is a request to the insurance company to pay for your healthcare services. For in-
network services, your provider submits a claim on your behalf. For out-of-network services, you
must pay the provider up front and submit a claim to the insurance company for reimbursement.
Tip: If you do not understand the costs associated with a healthcare service bill or believe your
claim may have been processed incorrectly, Zest Health can help.
Explanation of Beneits Provides information about how your claim was processed by the carrier. The EOB outlines what
(EOB) portion of the claim was paid by the plan and what portion is your responsibility.
Preventive Care Preventive Care is routine healthcare that includes screenings, check-ups, and patient
counseling to prevent illnesses, disease, or other health problems. Preventive care and
immunizations will be covered without any cost sharing (covered at 100%). Some examples of
preventive care are well-baby/well-child, well-person exams, mammograms, prostate cancer
screenings, and various immunizations (including the lu vaccine).
Annual Maximum The Annual Maximum Beneit is the maximum dollar amount a dental plan will pay toward the
Beneit cost of dental care within a speciic beneit period (January through December). The patient is
personally responsible for paying costs above the annual maximum.
Evidence of Insurability Evidence of Insurability (EOI) is an application process in which you provide information on
(EOI) the condition of your health or your dependent’s health in order to be considered for additional
life insurance.
35
A handy reference for the insurance terms used in this guide.
Deductible A deductible is the set amount you must pay for medical or dental expenses (aside from copays
that may apply) before insurance begins to cover all or a portion of your costs. Deductibles reset
January 1 each year.
Copay A copay (or copayment) is a set, lat fee that you pay for medical services or prescriptions in
addition to what the insurance company covers.
Coinsurance Once the deductible is met, coinsurance is the percentage you pay of each service until you
reach your out-of-pocket maximum.
Out-of-Pocket Maximum An out-of-pocket maximum is a limit to the amount of money that you must pay before your
expenses are covered at 100% for in-network only services.
In-Network In-Network providers or healthcare facilities are part of a health plan’s network, and you usually
pay less for using these providers.
Out-of-Network Out-of-Network providers are not part of the health plan provider network. Expenses for
services are not discounted through the insurance carrier, and are covered at a lesser amount
by GLG’s plan. In addition, the provider can bill you for any amount not covered by your plan.
Flexible Spending An FSA allows you to set aside a portion of your pre-tax earnings to pay for eligible medical,
Account (FSA) dental, vision, or daycare expenses. Money deducted from your pay into an FSA is not subject to
payroll taxes, resulting in a substantial payroll tax savings.
Limited Purpose A Limited Purpose Flexible Spending Account (LFSA) is a lexible spending account option
Flexible Spending for employees enrolled in a Health Savings Account (HSA) Program with a High Deductible
Account (LFSA) Health Plan (HDHP), or whose spouse is enrolled in a HDHP with an HSA. The LFSA is limited
to eligible dental and vision expenses only.
Health Savings Account A Health Savings Account (HSA) is a tax-advantaged medical savings account you can
(HSA) contribute to and draw money from for certain medical expenses tax-free. HSAs can be used for
out-of-pocket medical, dental, and vision expenses.
Prior Authorization Prior authorization, sometimes called pre-approval, is notiication required by the insurance
company before obtaining certain medical services. To obtain prior authorization for a service,
just call the insurance company. If you do not obtain prior authorization before your appointment,
the insurance company can deny your claim and the service will not be covered.
Premium The premium is the amount that must be paid for your health insurance per paycheck.
Claim A claim is a request to the insurance company to pay for your healthcare services. For in-
network services, your provider submits a claim on your behalf. For out-of-network services, you
must pay the provider up front and submit a claim to the insurance company for reimbursement.
Tip: If you do not understand the costs associated with a healthcare service bill or believe your
claim may have been processed incorrectly, Zest Health can help.
Explanation of Beneits Provides information about how your claim was processed by the carrier. The EOB outlines what
(EOB) portion of the claim was paid by the plan and what portion is your responsibility.
Preventive Care Preventive Care is routine healthcare that includes screenings, check-ups, and patient
counseling to prevent illnesses, disease, or other health problems. Preventive care and
immunizations will be covered without any cost sharing (covered at 100%). Some examples of
preventive care are well-baby/well-child, well-person exams, mammograms, prostate cancer
screenings, and various immunizations (including the lu vaccine).
Annual Maximum The Annual Maximum Beneit is the maximum dollar amount a dental plan will pay toward the
Beneit cost of dental care within a speciic beneit period (January through December). The patient is
personally responsible for paying costs above the annual maximum.
Evidence of Insurability Evidence of Insurability (EOI) is an application process in which you provide information on
(EOI) the condition of your health or your dependent’s health in order to be considered for additional
life insurance.
35
