Group Benefits, for the average employee is something they may be lucky enough to have, but can often times be extremely complicated to understand. We are an industry full of “insurance speak” and with an unbelievable amount of acronyms. In today’s environment where employers are shifting some of the costs to employees in an effort to ensure sustainability, it makes sense to have a good understanding of at least the very basics. We call that being a “good consumer”.
Although I have certainly not captured every term in this blog, I have outlined some basic insurance terminology that I have found over the years has caused some (or a lot of) confusion … I hope you find these helpful.
Accidental Death & Dismemberment (AD&D) – Pays a benefit – in addition to any other life insurance benefits – if you die or lose a limb in an accident.
Administrative Services Only (ASO) – an arrangement where an employer funds its own employee benefit plan but hires an outside firm or insurance company to perform specific administrative services eg. Pay claims. The employer assumes all risk.
Co-ordination of Benefits (COB) – a provision that determines the sequencing of coverage when plan members and their dependents are eligible for benefits under more than one private health care plan. One insurer is the primary payor, while the other is secondary.
Copay – the portion of the claim cost the employee is responsible to pay out of pocket.
Co-insurance – the portion of the claim the insurance company is responsible to pay.
Critical Illness (CI) - Provides a lump-sum payment to help pay expenses while you recover from one of the serious medical conditions covered by your plan.
Deductible – A specified dollar amount that you are responsible to pay out of pocket for before your health insurance plans begin to make payments.
Dispensing Fee – is the professional fee charged by Pharmacists for filling your prescription. This fee could be different by Pharmacy and typically range anywhere from $5.00 to $13.00.
Dental Services – Covers expenses ranging from cleanings to orthodontics – partially or fully depending on your plan.
Emergency Travel – Covers medical and related expenses while travelling.
Employee Assistance Plan (EAP) - a confidential, short term, counselling service for employees with personal problems that may affect their work performance.
Generic drugs – a drug product that is comparable to a brand name drug in dosage form, strength, quality and performance characteristics. A generic drug must contain the same active ingredients as the brand name drug and is almost always priced more attractively than their brand name counterparts.
Hospital expenses – Helps cover hospital care costs, in the province you live in, that are not covered by your provincial plan.
Health Care Spending Account (HCSA) – A pre-determined amount of money provided to employees at the beginning of each benefit year for coverage of their CRA approved health and dental expenses. Eligible expenses are reimbursed at 100% up to the total dollar amount available in the HCSA. An HCSA can replace or exist alongside traditional medical and dental coverage.
Initial Days Supply – a brand new prescription is dispensed in a smaller amount (eg 30 days) to help prevent wastage in the event you can’t tolerate the drug.
Long Term Disability (LTD) - Pays a percentage of your monthly income if you can’t work because of a covered disability.
Medical underwriting – a term referring to the use of medical or health information in the evaluation of an applicant for coverage, typically for life or health insurance.
Ontario Drug Benefit (ODB) – a list of drugs covered under the ODB drug formulary. You are eligible on the first day of the month after you turn 65 years of age.
Over-the-counter Drug (OTC) – a drug that you can buy without a prescription from a drugstore or most general or grocery stores. Eg. Tylenol, Benadryl.
Prior Authorization – a cost containment measure that provides full or partial payment of health benefits but only if the drug or treatment plan has been approved ahead of time by the insurance company. This is common on high cost specialty drugs.
Paramedicals – Covers eligible paramedical expenses that may include the services of chiropractors, physiotherapists, registered massage therapists, acupuncturists and other medical professionals, depending on your plan.
Recall exam – a dental exam performed once or twice a year following the initial oral exam and usually includes polishing and scaling.
Short term disability (STD) - Pays a percentage of your weekly income if you can’t work because of a short term illness. Also known as Weekly Indemnity (WI).
Vision Care – Covers all or a portion of the cost of prescription eyeglasses or lenses. Eye examinations are either covered separately or part of your overall vision maximum.
Talk to us about your benefits plan today!
If you’d like to learn more about your options, please give me a call at 1-800-679-2640 Ext 416 or visit our Group Benefits page.
Laurie Bortolotti, GBA, PMP
Division Manager, Benefits
EasyInsure | P: (800) 679-2640 ext 416