Page 6 - CPSS Benefit Guide Class 3 Employee

What Does That Word Even Mean?

Term Definition

Annual Deductible The amount you are required to pay per year before certain benefits are paid for
(Feb 1 - Jan 31) by the plan. Once you meet the deductible amount, expenses are covered by the
plan based on the coinsurance percentage. This deductible starts over every
February 1st.

Annual Out-of- The most you pay in a year for covered services that are subject to
Pocket Maximum coinsurance/copays. The deductible is included in this amount. If you reach the
(Feb 1 - Jan 31) annual out-of-pocket maximum, the plan pays 100% of covered in-network
eligible expenses for the remainder of the plan year. Office visits and prescription
copays are included in the annual out-of-pocket maximum for our medical plan.
This maximum starts over every February 1st.

Balance Billing When you are billed for the difference between the provider’s actual charge and
the amount reimbursed under the medical or dental plan. This occurs when you
go outside of the preferred provider network. Balance billing does not apply
towards the out-of-pocket maximum.

Coinsurance The percentage you pay for covered expenses after you hit your deductible until
you reach your out-of-pocket maximum. The percentage you pay for in-network
services is lower than if you go out-of-network.

Copayments or The flat dollar amount you pay for certain in-network services. The PPO plan has
Copays copayments for certain services that the HSA plan has coinsurance. Some of
these services include visiting your primary care provider, seeing a specialist or
going to urgent care. For example, you will always pay a $30 copayment to see
an in-network primary care provider until you hit your out-of-pocket maximum
with our PPO plan.

Explanation of Provides information about how your claim was processed by the insurance
Benefits (EOB) company. The EOB details what portion of the claim was paid by the insurance
company and what portion is your responsibility.

Preventive Many generic preventive drugs and those used to treat chronic conditions like
Maintenance diabetes, high blood pressure, high cholesterol and asthma are designated on
Generic Drugs the Preventive/Chronic Condition Drug List as preventive. These prescriptions
are covered at 100% (no cost to you) when you use an in-network pharmacy.

Generic Drugs A drug that offers equivalent uses,doses, strength, quality and performance as a
brand name drug, but is not trademarked.

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