Benefits glossary
Coinsurance or cost sharing
Copay or copayment
Deductible
Domestic partner
Emergency
Evidence of Insurability
Formulary
Generic
In-network provider
Negotiated rates
Non-embedded family deductible
Non-preferred brand
Out-of-network provider
Out-of-pocket maximum
Plan year
Preferred brand name
Proof of coverage
Qualified Life Event
Social Security normal retirement age
Specialty drugs
Coinsurance or cost sharing
This is the portion of covered health care costs for which you are financially responsible. Depending on the plan you choose, you and the plan may share the costs for services. For example, the plan may pay 80% of the cost of a service and you would pay the remaining 20%. Coinsurance does not include deductibles or copays.
Copay or copayment
A set amount you pay out of pocket for a particular service. The plan pays the balance.
Deductible
The out-of-pocket amount you must pay each plan year before the plan pays for eligible benefits.
Domestic partner
Benefits are available to same-sex and opposite-sex domestic partners of Ardent Health Services benefits-eligible employees. Ardent Health Services defines domestic partners as two people who have met all of the following criteria:
- For at least 12 months have shared the same principal residence in an intimate, committed relationship of mutual caring and intend to do so indefinitely.
- Agree to be responsible for each other’s basic living expenses during the domestic partnership and agree that anyone who is owed these expenses can collect from either of them.
- Are both 18 years of age or older and of sufficient mental competence to enter binding legal contracts.
- Are not married to anyone and are not so closely related by blood that a legal marriage between them would be prohibited for that reason in their state of residence.
- Do not presently have a different domestic partner.
- Did not have a different domestic partner in the last 12 months.
If you have an opposite-sex domestic partner and the two of you generally represent yourselves as married, you may have a common-law marriage if it is recognized by the state in which you reside. A common-law husband or wife is considered a “spouse” rather than a “domestic partner.” You should enroll him or her through the regular enrollment process.
Emergency
A serious medical condition or symptom resulting from injury or illness that arises suddenly and requires immediate care and treatment to avoid endangering life or health.
Evidence of Insurability
This is sometimes called “proof of good health” and is used to qualify for certain amounts of life insurance coverage. You will need to complete an Evidence of Insurability form if you choose to increase your life insurance coverage amount during annual enrollment.
Formulary
A formulary is a list of medications covered by your prescription plan. If you use a medication that is not on your plan’s formulary, you may be required to pay the full cost. To view the formulary for your plan, visit the plan’s website.
Generic
Your prescription drug copay depends on the class or group of your prescribed medication. A generic drug generally has the lowest copay level. A generic drug is one that is no longer produced only under a brand name. Once a drug’s patent expires, many companies can begin to manufacture “generic” versions of a previously brand-name-only drug. Generic drugs are identical to brand-name drugs in chemical makeup (“active ingredients”), usage, strength and dosage. They are regulated and approved by the FDA just like brand-name drugs; however, they are much less expensive.
In-network provider
A provider who has contracted with a health care plan (a medical, dental or vision plan) and agreed to certain rates. In most cases, you pay less and receive a higher benefit when you use in-network providers. Check with your plan for coverage details.
Negotiated rates
The costs for health care services negotiated between the insurance carrier and in-network health care providers. Negotiated rates are usually less than usual, customary and reasonable (UCR) charges.
Non-embedded family deductible
All family members’ expenses will be combined to meet the entire family deductible before the plan begins contributing toward your family’s health care expenses.
Non-preferred brand
Your prescription drug copay depends on the class or group of your prescribed medication. A non-preferred brand-name drug generally has the highest copay level because it is not on the plan’s list of preferred drugs. You can find out how different drugs are classified by your plan by visiting the plan’s website.
Out-of-network provider
A provider who has not contracted with a health care plan (medical, dental or vision plan) and has not agreed to certain rates. In most cases, you pay more and receive a lower level of benefits when you use out-of-network providers. See your plan for coverage details.
Out-of-pocket maximum
The maximum coinsurance amount you could pay in any plan year. Deductibles and copayments are not included in this amount. Eligible expenses above this amount are typically paid by the plan. Ardent's HDHP and HDHP Plus plans include an individual out-of-pocket maximum that is embedded in the family out-of-pocket maximum. This means if one family member meets the out-of-pocket max, that individual doesn't have to wait for the entire family OOP max to be satisfied before the plan pays 100% of his/her covered services.
Plan year
Ardent’s plan year is January 1 through December 31. You cannot change coverage in any of the benefit plans during this period unless you have a Qualified Life Event.
Preferred brand name
Your prescription drug copay depends on the class or group of your prescribed medication. A preferred brand-name drug may have a lower copay than a non-preferred drug because it has been identified by the plan as more cost-effective. You can find out how different drugs are classified by your plan by visiting the plan’s website.
Proof of coverage
A pre-existing conditions clause applies to the medical plan. Proof of coverage or a certificate of creditable coverage may be required for new hires or new participants in the plan. This is a document from your previous medical plan carrier providing information regarding your length of coverage under the previous plan. Creditable coverage under another group health plan would reduce your pre-existing conditions exclusion period.
Qualified Life Event
- Change in status, which includes marital, number of dependents, employment (yours or your spouse’s), change in residence or a dependent satisfies or ceases to satisfy eligibility requirements.
- Change due to a legal judgment, decree or court order.
- Significant cost or coverage changes.
- FMLA special requirements.
- Entitlement to Medicare or Medicaid.
- Spouse’s employer’s Annual Enrollment.
- HIPAA special enrollment rights.
You may make changes to your coverage when you have a Qualified Life Event; however, you must do so within 31 days of the event.
Social Security normal retirement age
Your retirement age under the Social Security Act, where retirement age depends on your year of birth. Visit the SSA website for more information.
Specialty drugs
Your prescription drug copay depends on the class or group of your prescribed medication. Specialty drugs require special handling, administration and/or monitoring. They are used to treat complex, chronic conditions such as HIV/AIDS, transplant antirejection, renal disease, etc.). You can find out how different drugs are classified by your plan by visiting the plan’s website.