BENEFITS
USEFUL DEFINITIONS

US Dept of Labor Health Benefits Advisor Glossary

Balance Billing – When a plan allows the use of out-of-network providers, the plan pays a percentage of covered charges based on usual and customary charges as determined by the plan. The provider may bill your for the balance due.

Brand Name Drug – A prescription drug which is protected by trademark registration.

Center of Excellence – A designation given to very highly rated medical centers, clinics, and hospitals, often specializing in the care and treatment of potentially terminal illness or disease.  Example:  Sloane-Kettering Cancer Center in New York; Mayo Clinic.

Co-Insurance – This term refers to a percentage of the total charges you are required to pay for certain services.  Example:  Our dental plan has co-insurance:  the plan pays 80% and you pay 20% for fillings, etc.

Co-Pay – A co-pay is the fixed amount you are required to pay when you visit an in-network health care provider.  Your insurance plan pays the balance of charges due to the provider.  Co-pay amounts may differ, depending on the service you receive.  Example:  Family physician visit $10; Brand Name Drug, $20, etc.

Deductible – A deductible is an amount that may be required for YOU to pay BEFORE your plan pays anything toward the services you receive.  Example:  Our dental plan has a $50 annual deductible.  You will pay the first $50 each year toward any services needed, other than your cleanings twice a year, for which no deductible is required.

Emergency Care – The treatment given in a hospital's emergency room to evaluate and treat medical conditions of a recent onset and severity. Includes a condition, sickness, or injury of such a nature that failure to get immediate medical care could result in:
-Placing the person's health in serious jeopardy
-Serious impairment to bodily function
-Serious dysfunction of a body part or organ
-In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Evidence of Insurability - (also known as "EOI").  This is the long form optional life insurance application you must complete, providing requested personal health information and history, in order to be approved for participation in the group optional life insurance plan.

Flexible Spending Account – Also known as an "FSA".  Flexible Spending Accounts are accounts you can enroll in and contribute your own TAX-FREE dollars in order to cover out-of-pocket expenses incurred by you or members of your household throughout the plan year.  There are two types:  Medical Reimbursement Account, and Dependent Care Reimbursement Account.  You may elect participation in one or both plans either as a new hire, or during our annual open enrollment period.  See the basic definitions below. PLEASE STUDY COMPLETE PLAN DESCRIPTIONS BEFORE YOU ENROLL!

Medical Reimbursement Account – Also known as "MRA".  This is an account that is designed specifically to reimburse you (with your own tax-free dollars) for medical, pharmacy and over-the-counter drugs, dental, and vision expenses NOT covered by your benefits plans.  Example:  Co-pays and co-insurance for any of those services to yourself and all family members, regardless of their enrollment in your benefits plans.

Dependent Care Reimbursement Account – Also known as "DCRA".  This account is specifically designed to cover your expenses for required day care of family members (children, disabled dependents, or elderly parents) while you are at work.  Example:  your dependent/child under the age of 13 for whom you pay child care expenses for after-school and/or during the summer months.  OR, a physically or mentally handicapped dependent incapable of caring for him or herself who spends at least 8 hours a day in your home.

Formulary – A formulary is a list of preferred drugs the health plan covers.  The list includes both brand-name and generic drugs.  Example:  Our plan provides a three-tier formulary, which will cover any drug your doctor prescribes for you ("lifestyle drugs" are specifically excluded) at some level:  Generic $10, Brand Name $20, or Non-Formulary $35.  The formulary will change on an annual basis, but can change at any time throughout the plan year without notice.

Generic Drugs – A generic drug is a chemically equivalent version of a brand-name drug whose patent has expired.  Even though generic drugs are available through our plan the lowest co-pay ($10 from the local pharmacy and FREE through mail order), remember that not all generic drugs are listed on our formulary.  If the generic drug you take is NOT on our formulary, you will pay the highest co-pay for that drug, even though it is a generic.  However, if the cost is less than the co-pay, you will only pay the lesser amount.

Guaranteed Issue Amount – (also known as the "GI" amount).  This term refers to the purchase of optional life insurance.  It is the maximum amount of life insurance pre-approved for you to purchase if you choose to participate during your new-hire election period.  You may purchase LESS than the GI amount; however, you may not purchase MORE without submitting Evidence of Insurability (also known as "EOI"), and receiving the approval of the carrier. 

In-Network - Refers to the use of providers who participate in the health plan's provider network.

Late Enrollee – An individual who enrolls in a group health plan on a date other than either the earliest date on which coverage can begin under the plan terms or on a special enrollment date. Under HIPAA, a late enrollee may be subject to a maximum pre-existing condition exclusion of up to 18 months.

Lifetime Maximum – This term refers to the maximum amount a plan will pay for your medical expenses, and includes ALL monies paid out for a member by the plan.  When that lifetime maximum is reached, the plan will pay NO MORE expenses for that member.  Example:  You or a member of your family has a very serious long-term illness, requiring lengthy hospitalizations, expensive medications, etc., and the plan has paid its lifetime maximum in less than two years.  That member would be dropped from the plan and would have to obtain insurance elsewhere.
PLEASE NOTE:  Our plans (Aetna Select Open Access; and Aetna Choice POSII In-Network) DO NOT HAVE a lifetime maximum.  Out-of Network benefits available in the Aetna Choice POSII plan DO have a lifetime maximum of one million dollars ($1,000,000). 

Mail Order Pharmacy – Aetna's mail order pharmacy allows you to order your prescriptions to treat chronic conditions, such as diabetes, heart disease, hypertension, high cholesterol, and others, and have your meds sent directly to your home.

Out-of-Network - Theuse of health care providers who have not contracted with the health plan to provide services.  If you go out of the network for covered expenses, you will pay additional costs in the form of deductibles and co-insurance based, on usual and customary charges.  Remember: The Aetna Select  plan has NO out-of-network benefits.

Out-of-Pocket Maximum – This is the maximum amount of money you will pay for the plan during the plan year.  When you have paid that amount out of your own pocket, you will not have to pay anymore for the rest of the year.  The annual out-of-pocket maximum for our medical plans is $1,500 for an individual, or $3,000 per family.  Your Explanations of Benefits statements will show you in the lower left-hand corner how much of your maximum has been met.  Certain services you receive are NOT included and cannot be counted toward that maximum.  Example: drugs are not included.

Pre-Existing Condition - Pre­existing conditions are those for which you incurred expenses, received medical treatment, took prescription drugs, or consulted a doctor during the six months immediately prior to your most recent effective date of insurance.  Pre-existing condition limitations vary by benefit plan.  The Lee County Benefits Plans have NO PRE-EXISTING CONDITIONS!

Specialist – A physician who practices in any generally accepted medical or surgical sub-specialty, and is providing other than routine medical care.

Urgent Condition – A sudden illness, injury, or condition that:
-Is severe enough to require prompt medical attention to avoid serious deterioration of the covered person's health;
-Includes a condition which would subject the covered person to severe pain that could not be adequately managed without urgent care or treatment
-Does not require the level of care provided in the emergency room of a hospital
-Requires immediate outpatient medical care that cannot be postponed until the covered person's physician becomes reasonably available

Usual and Customary (U&C) Charges - U&C charges are the provider fees determined for a specific geographic location, based on zip code, by the benefit plan insurance carrier.  Each insurance carrier maintains a comprehensive database detailing what providers charge for every procedure and treatment.

Lee County Human Resources

2115 Second Street, First Floor 

Fort Myers, FL 33901-0398

239-533-2245