Deductible
Amount of money you pay out-of-pocket for care before the plan begins to pay for benefits.
Premium
The monthly cost that the employee will pay for an insurance policy.
Copay
Flat dollar amount you'll pay for covered services at the time of service.
Coinsurance
Percentage you pay for covered services after you've reached your deductible.
Out-of-Pocket Maximum
Most you pay for covered services in plan year after paying deductibles, copays & coinsurance.
Network
A group of doctors, hospitals, and other healthcare providers contracting with a health or dental plan.
Preventative Care
Type of care such as routine physical exams and immunizations. The emphasis is on preventing illnesses before they occur.
Claim
A request for payment under the terms of an insurance policy.
Covered Expenses
Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.
Dependent
A person for who the insured has some legal obligation. For most plans, it is the insured's spouse and/or children.
Drug Formulary
The plan will cover a schedule of prescription drugs approved for use and dispense through participating pharmacies.
In-patient
A patient is admitted to a hospital or other similar medical facility as a resident patient.
Non-Preferred Provider (Out-of-Network)
A provider who has not signed a contract with Wellmark Blue Cross & Blue Shield of Iowa or Delta Dental of Iowa.
Office Visit
Services are provided in the physician's office.
Out-of-Network
Health care services that are received outside the PPO network.
Enrollment Period
The amount of time an employee has to enroll, confirm, or waive benefits enrollment. Eligible new hires have 30 days from the hire date to enroll. The annual open enrollment period is every year around November with a Jan. 1 effective date.
Explanation of Benefits (EOB)
EOBs are forms the policyholder receives from Wellmark or Delta Dental once a claim has been processed. The EOB form shows how the claim was paid, to whom, and any amount not covered.
Generic (Medication)
When a new drug is on the market, the pharmaceutical company patents it under a brand name and has an exclusive right to sell it under this name. However, others can sell the drug under its chemical/generic name once its patent expires. Generics are typically cheaper, but the FDA requires to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."
Outpatient
A patient who is not a bed patient in the hospital in which they are receiving treatment.
Over-the-Counter Drugs (OTC)
A drug that can be purchased without a prescription.
Preferred Provider (In-Network Provider)
A provider who has signed a contract with Wellmark Blue Cross & Blue Shield of Iowa and Delta Dental of Iowa.
Primary Care
Basic health care is provided by doctors who practice family care, pediatrics, and internal medicine.
Referral
Occurs when a physician or other health plan provider receives permission to consult another physician or hospital.