A Brief Glossary of Terms
Health care coverage plans use several terms to describe costs associated with the plans.
- Deductible: the amount you are required to pay before your plan covers any major medical benefits per year.
- Eligible dependent: A spouse, household member and any children who are less than age twenty-six (26), or until age 27 (for GVSU Standard PPO Plan, HDHP/HSA and Dental), if the child is currently a full-time student in an accredited school. Your cost will depend upon the plan you select and the coverage you choose. Physically or mentally handicapped children may be covered regardless of their age. The term "children" includes your natural children, adopted children, or children placed for adoption, stepchildren who live with you, or children for whom you are the legal guardian and who live with you.
- A newborn child, adopted, or child placed for adoption will be covered if enrolled within the thirty-one (31) day period following birth, adoption, or adoption placement.
- If coverage for a dependent (including new borns, adopted children, or children placed for adoption) is applied for more than thirty-one (31) days following the date that dependent becomes eligible for coverage, the dependent may only be able to enroll during the open enrollment/election period.
- Co-payment: the amount you are required to pay each visit in sharing eligible expenses with the plan. Co-payments are usually a set amount or a percentage. The plan pays the remainder.
- Annual out-of-pocket expense limit: the maximum medical expense you would have to pay per year, after which the plan pays 100% of most eligible expenses for the rest of the year. The out-of-pocket limit does not include deductibles, co-pays or any amounts exceeding reasonable and customary.
- Reasonable and Customary: All of the medical plan options contain "reasonable and customary" language, which means that eligible medical expenses will be covered up to the reasonable and customary amount. A reasonable and customary ("R & C") charge will be the usual charge made by a physician or supplier of services, medicines, or supplies and will not exceed the general level of charges made by others rendering or furnishing such services, medicines, or supplies within the area in which the charge is incurred for the illness or injury being treated. The term "area" as it would apply to any particular service, medicine, or supply means a county or such greater areas as is necessary to obtain a representative cross section of the level of charges.
You will incur out-of-pocket costs only for amounts exceeding the reasonable and customary rates for services obtained outside of the appropriate network: PPO, Delta Dental and/or Eyemed Vision.
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