Key Terms and Definitions

Key terms and definitions provide clear explanations of important elements, helping ensure understanding of your SEHP benefits.

Active Enrollment

Employees must actively make health plan elections during Open Enrollment for their 2024 health plan coverage. If an employee is enrolled this year and does not make a medical plan election for next year, they will be defaulted to Plan N with an HRA account. Employees who have waived coverage will remain waived unless they make an election.

Benefit Description

The Benefit Description provides a detailed summary of the benefits and limitations of the coverage. It outlines member rights and processes for benefit questions, appeals and grievances.

Coinsurance

Once you meet the annual Deductible, you and the Plan share in the cost of covered medical expenses. This is called Coinsurance. When you use Network providers, your Out-of-Pocket is less than if you use Non Network providers.

Copay

A fixed amount you pay for a covered health care service each time a service is received (for example, a doctor’s visit). A Copay amount may vary by the type of covered service.

Deductible

A fixed dollar amount you must pay each calendar year before the Plan begins reimbursing for eligible expenses. There are two types of deductibles:

• Individual Deductible: The Individual Deductible applies separately to each covered person in the family. When a person’s Deductible expenses reach the Individual Deductible amount, the person’s Deductible is met.

• Family Deductible: The Family Deductible applies to the family as a group. When the combined Deductible expenses of all family members reach the family Deductible, the family Deductible is met.

Health Reimbursement Account (HRA)

An HRA is a tax-advantaged account available to members of Plans C, J or N that allows your employer to set aside money for you to use to pay for qualified medical expenses incurred during the Plan Year. Your employer contributes to your HRA.

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Health Savings Account (HSA)

An HSA is a tax-advantaged account available to members enrolled in a Qualified High Deductible Health Plan that allows you to save money for qualified medical expenses for this year and the future. Your employer contributes to your HSA, and you can too. 

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Network

The providers who have agreed to participate with the health plans to accept the Allowed Amount as payment in full, less any Deductibles, Copays or Coinsurance. Your Plan will charge less when you use Network providers.

Non Network

Providers who have NOT agreed to contract with the health plans to accept the Allowed Charge. You will pay more in Out-of-Pocket expenses to use Non Network providers, compared to Network providers.

Open Enrollment

The period of time when you may review, and enroll or waive benefits available to you through the State Employee Health Plan. Open Enrollment Period is in October each year.

Out-of-Pocket Maximum (OOP)

The most an employee could pay during the Plan Year for their share of the costs for covered services, including Copays, Coinsurance and Deductible. OOP does not include costs for services not covered by the plan, over-the-counter medications or amounts over the Allowed Charge.

Plan Year

The Plan Year for the State Employee Health Plan is January 1st thru December 31st of each year. This coverage is the period to accumulate your share of covered expenses toward your OOP limit.

Qualified High Deductible Health Plan (QHDHP)

A QHDHP meets federal requirements to allow an employee to establish and contribute to a HSA.

Summary of Benefits & Coverage (SBC)

The SBC is a detailed example that shows how the plan would cover health care services for some sample claims. For the complete terms of each medical plan, please reference the Benefit Description online document under the corresponding plan.