Glossary of Insurance Terms
It is important to understand the below commonly used health insurance terms to understand your insurance benefit.
Ancillary Services: Services provided by healthcare providers other than a physician, such as laboratory, radiology or other diagnostic imaging and anesthesiology.
Balance Billing: When the provider bills the covered member for the difference between the provider’s charge and the amount allowed by the health plan. This should only apply to Out-of-Network providers.
Claim: Request for payment that a healthcare provider submits to the health insurance company for items or services rendered.
Coinsurance: Percent of the cost of covered health care services paid by covered members. The member pays coinsurance plus any deductibles and copayments that are owed.
Coordination of Benefits (COB): Practice that determines the order of insurance payment in a situation where you have more than one insurance policy. This practice is to ensure that benefits are paid on a ‘shared’ basis and that no benefits are paid more than the amounts charged.
Copayment (Copay): Flat fee or fixed amount (e.g. $25) members pay for a covered health care service, usually at the time of service. Copays vary by the type of covered service, such as seeing a doctor, filling a prescription, or going to the emergency room.
Cost-Sharing: Share of costs covered by your health insurance that a plan member pays out of their pocket. This generally includes deductible, coinsurance and copayments.
Deductible: The amount covered members owe for health care services before the health insurance or plan begins to pay.
Dependent: Anyone other than the employee added to the insurance coverage. Typically includes spouse and children.
Exclusion: Specific service or medication a health plan will not cover.
Explanation of Benefits (EOB): Statement received from the insurance company showing the services, amounts paid by the plan and total for which you may be responsible for. These are not bills or a request for payment.
Flexible Spending Account (FSA): Optional account(s) that allow employees to set aside pre-tax dollars out of their paycheck for healthcare and/or dependent care expenses. These accounts have a “use it or lose it” provision where funds are forfeited at the end of the plan year.
Formulary: List of medications that is covered by your health insurance plan. Medications may apply to different tiers or cost-sharing levels.
Fully-Insured: Type of plan where the employer pays a premium to an insurance carrier. The insurance carrier is responsible for paying the claims.
Health Insurance: Contract between a covered member and an insurance company. Health insurance helps people pay for medical costs and protects them from very high expenses.
Health Reimbursement Account (HRA): Employer-funded account that reimburses employees for qualified covered medical and/or pharmacy expenses. Services are paid directly by the administrator of the plan to pay the provider. Employees do not contribute to the HRA. LSU First and the Pelican HRA 1000 both include an employer-paid HRA. This account is available as long as you remain enrolled in either LSU First or Pelican HRA 1000.
Health Savings Account (HSA): Employee-owned tax-saving account used to pay for qualified covered medical expenses, including deductible, copays/coinsurance, prescriptions, and other eligible medical, dental, and vision expenses. The Pelican HSA 775 includes a HSA that both employees and the employer contributes towards. This account is owned by the employee and can follow the employee if they change employers.
In-Network Provider: The select doctors, clinics, hospitals, and other medical providers your insurance company contracts with to provide health care to its members at negotiated rates.
Inpatient: Service provided after you are admitted to the hospital. Inpatient stays typically last 24 hours or longer.
Maximum Allowable Charge (MAC): Routine charge for a medical service by similar professional medical providers in the same geographical area.
Out-of-Network Provider: Healthcare rendered to a plan member outside of the health insurance company's network of preferred providers. Members can be balance billed for any amount not paid by the health insurance.
Out-of-Pocket Maximum: The maximum amount you will be required to pay each year for deductibles and coinsurance. This is a stated dollar amount set by the insurance company, in addition to regular premiums.
Plan Member: Any employee, retiree and dependent(s) covered under a health insurance plan.
Plan Year: Time period of your health plan coverage. Occurs on a calendar year basis from January 1 – December 31. Deductible, coinsurance, copayments, and out-of-pocket maximums reset each plan year.
Premium: Amount paid for health insurance. Members and/or their employers usually paid monthly. Premiums vary depending on: health care coverage, deductibles, copayments and coinsurance.
Primary Care Physician (PCP): Monitors your health and diagnoses, treats minor health problems, and refers you to specialists if you need another level of care.
Prior Authorization: Your health insurance may require authorization for certain services and medications before you receive them. Sometimes called preauthorization or precertification.
Provider: Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Self-Funded: Type of plan in which an employer takes on most or all of the costs of benefit claims. A third-party may manage the payments, but the employer pays the claims.
Summary Plan Document: Legal document issued by the insurance plan which outlines the terms and conditions of the insurance.
Frequently Asked Questions
Please visit Qualifying Life Events for what is considered a qualifying life event.
Begin by adding your newborn into Workday as a dependent. This will require the submission of an Add Dependent Event. In this event, an attachment of the birth letter or birth certificate is required. Once the Add Dependent event is submitted, it will route to the benefits department for approval. After approval, a Change Benefits Event submission is needed. Please remember, this must be done within 30 days after the birth of your child.
Begin by adding your spouse into Workday as a dependent. This will require the submission of an Add Dependent Event. In this event, an attachment of the marriage certificate is required. Once the Add Dependent event is submitted, it will route to the benefits department for approval. After approval, a Change Benefits Event submission is needed. Please remember, this must be done within 30 days after the date of your marriage.
- Birth/adoption – Date of Birth
- Marriage – Date of Marriage
- Divorce – Date of Divorce
- Loss of Coverage – The date LSU coverage should begin
- Gain of Coverage – The date LSU coverage should end
No, a dependent is classified as legal spouse or child.
Please refer to our HSA and HRA comparison.
No, the money in the HSA follows the member even if he or she changes jobs or retires.
Yes, IRS regulations state that if all the money in the account is not used by the end of the Plan Year, the remaining balance must be forfeited (known as the “Use-it-or-Lose-it rule”). However, we do offer a grace period through March 15 of the following plan year.
No, employees can elect to contribute additional funds but it is not required to receive the initial $200.
Premiums are paid one month in advance.
Once your child reaches 26, he/she will automatically drop from insurance on the last day of the month in which they turned 26.
Yes, forms will need to be completed to vendors prior to child’s 26th birthday.
Allows employees and his/her dependents to continue coverage for up to 18 month after separation from the University. Paperwork is mailed to the employee directly from the insurance provider after the active coverage ends.
Employees must have participated in state health plan in order to be vested.
- 19% - less than 10 years
- 38% - 10-15 years
- 56% - 15-20 years
- 75% - more than 20 years
Your benefits will terminate on the last day of the month of your separation date. You will receive a letter in the mail from our office with instructions on what should be done should you choose to continue or convert your current benefits.
A FSA allows you to reimburse yourself (with your own money) for eligible Healthcare and/or Dependent care expenses, tax free. Participation is voluntary.
There are two types of Flexible Spending Accounts you can elect:
- Healthcare Reimbursement Account – used to reimburse you for out of pocket healthcare expenses not covered under your health insurance plan.
- Dependent Care Reimbursement Account – used to reimburse you for out of pocket dependent care expenses for individuals such as children 12 or younger and any individual you reside with who rely on you for at least half of their support or are physically or mentally unable to care for themselves.