Employer Benefits Glossary

Coverage that caps total plan claims in a plan year.

The dollar threshold at which stop-loss coverage begins.

ACA requirement for large employers to offer affordable coverage.

IRS methods employers use to demonstrate coverage is affordable.

A contract where an insurer administers a self-funded plan.

A benchmark drug price used in PBM contract pricing.

The total claims threshold that triggers aggregate stop-loss coverage.

An intermediary who helps employers select and manage benefits.

When a provider bills a patient for the difference between their charge and the plan's payment.

A biologic drug that is highly similar to an already-approved reference product.

Comparing your health plan costs and design against similar employers.

A formal insurance entity owned by the insured to fund risk.

Federal law requiring continuation of group health coverage.

Drug pricing based on actual acquisition cost plus a fee.

Designated high-quality facilities for specific high-cost procedures.

The percentage of costs a member pays after meeting their deductible.

A fixed dollar amount a member pays for a covered service.

Employer health plan obligations under the 2021 federal spending law.

Prior health coverage that counts toward satisfying waiting periods or Medicare Part D requirements.

Amount a member pays before plan benefits begin.

A primary care model with a flat monthly membership fee and no insurance billing.

A review to verify that enrolled dependents meet plan eligibility requirements.

An arrangement where an employer contracts directly with providers, bypassing traditional networks.

Federal law governing employer-sponsored benefit plans.

ACA penalty for large employers who fail to offer adequate coverage.

A confidential counseling and referral service for employees and families.

A party with a legal duty to act in the plan participants' best interest.

A list of covered prescription drugs and their cost-sharing tiers.

A health plan where the employer pays a fixed premium to an insurer.

A pre-tax account for eligible healthcare or dependent care expenses.

A class of drugs used for diabetes and obesity management.

A health plan with higher deductibles that qualifies for HSA pairing.

A tax-advantaged account paired with an HDHP for medical expenses.

An employer-funded account that reimburses employees for medical expenses.

Federal law protecting the privacy and security of health information.

A health plan designed to deliver superior value through strategic design and vendor selection.

An HRA that reimburses employees for individual health insurance premiums.

Claims for services rendered during a specific period, regardless of when paid.

A stop-loss provision that excludes or limits coverage for a known high-cost claimant.

A hybrid funding arrangement with fixed monthly payments and potential year-end refunds.

A PBM pricing method that caps reimbursement for generic drugs.

ACA standard requiring plans to cover at least 60% of expected costs.

Federal law requiring equal coverage for mental health and medical/surgical benefits.

The minimum level of health coverage required under the ACA.

The percentage of premium revenue a carrier spends on medical claims.

A service that guides members to high-quality, cost-effective care.

The most a member pays for covered services in a plan year.

The annual period when employees can elect or change benefit coverage.

An intermediary that manages prescription drug benefits for health plans.

An ACA fee on health plans funding comparative effectiveness research.

A requirement for advance approval before certain services are covered.

The group of doctors, hospitals, and facilities contracted with a health plan.

A cost metric dividing total plan costs by covered employees and months.

A health plan with a network of preferred providers and out-of-network flexibility.

The 12-month period for which a health plan is in effect.

The administration of prescription drug benefits on behalf of health plans.

A life event that triggers a special enrollment period or COBRA eligibility.

A payment from a drug manufacturer to a PBM for formulary placement.

A plan design that pays providers a set amount based on a benchmark.

The time after a stop-loss contract ends during which claims can still be submitted.

Claims incurred before a stop-loss contract period but paid during it.

Annual CAA requirement for health plans to report prescription drug and healthcare spending.

The employer's plan for evaluating and responding to an annual health insurance renewal.

A health plan where the employer bears the financial risk for claims.

A high-cost drug typically requiring special handling or administration.

Coverage that reimburses claims above a per-person deductible.

A PBM practice of charging the plan more than it pays the pharmacy.

A requirement to try lower-cost drugs before accessing higher-cost ones.

A required ERISA document explaining plan benefits and rights.

An IRS-qualified plan allowing employees to pay benefits premiums pre-tax.

An additional premium charged when a spouse has access to other employer coverage.

Insurance that protects self-funded employers from catastrophic claims.

Abbreviation for Summary Plan Description.

Responsibility for claims incurred but not yet paid at contract end.

A company that administers self-funded health plan claims and benefits.

Federal rule requiring health plans to publish machine-readable price files.

Abbreviation for Third-Party Administrator.

Programs that review and manage the use of health services.

Healthcare services delivered remotely via technology.

An ERISA plan document that wraps around insurance certificates to create a compliant SPD.