Terms You Should Know
Benefit Eligible. All full-time employees working an average of at least 30 hours per week are eligible for benefits. For new hires, your benefits begin on your date of hire. For Medical, Dental and Vision your qualified dependents include your legal spouse and children to age 26. For Voluntary Dependent Life, your covered dependents include your spouse and children to age 25 provided they are full-time students.
Limited Spousal Eligibility. If your spouse is employed and your spouse’s employer provides a medical plan for which the employer pays at least 50% of “Employee Only” coverage, your spouse must enroll in that plan in order to be eligible to enroll in any of the DePauw University Medical plans.
Deductible. The amount you pay for covered health care expenses before your insurance starts to pay. For example, with a $2,000 plan year deductible, you pay the first $2,000 covered services.
Coinsurance. The percentage of costs of a covered health care service you pay (for example 20%), after you have paid your plan year deductible.
Out-of-Pocket Maximum. The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
Network Benefits (In-Network). In network providers agree to accept the UMR’s approved amount for their services. You will see these savings listed as the “discounted amount” on your Explanation of Benefits statements.
Non-Network Benefits (Out-of-Network). Doctors or hospitals who are not in the network do not accept the UMR’s approved amount. You will be responsible for paying the difference between the provider’s full charge and your plan’s approved amount. This is called balance billing.
Preventive Care. Preventive care is the care you receive to prevent illnesses or diseases. Providing these services at no cost is based on the idea that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy. Services will be paid at 100% when you use a participating provider.
Embedded deductible plans. Under family coverage, an embedded deductible plan means that each family member has an individual deductible in addition to the total family deductible. Each individual's deductible is much lower than the total family deductible. When an individual meets their respective out-of-pocket total, the insurer begins to pay for that person's covered medical services, regardless of whether the family deductible has been fulfilled.
The benefit of embedded deductibles: in some cases, this double-layered deductible can actually enhance individuals' coverage, according to the Center for Health Insurance Reform at Georgetown University. If an individual family member incurs a significant amount of medical expenses, the individual will fulfill their deductible sooner because it is lower than the family deductible. This can save families thousands of dollars because the individual's insurance policy will begin to cover benefits even if the family deductible isn't met.
Non-embedded deductibles. Under a non-embedded deductible plan, also known as an aggregate deductible plan, the total family deductible must be paid out-of-pocket before the insurer starts paying for healthcare services for any individual member.
Non-embedded deductibles are not economical for some families. For some families, such as married couples without children, non-embedded deductible plans can cause families to spend thousands of dollars in extra out-of-pocket expenses that otherwise would have been covered had they purchased individual plans with lower deductibles or embedded family plans.
Plan Compliance Notifications. Federal required Notices including but not limited to the HIPAA Privacy and Security, Certificate of Creditable Coverage for Medicare and Market “Exchange” Notices. Health Care Reform Notices are available online on the human resources internet site or via paper, free of charge, upon request. Please contact human resources with questions.