Employer Healthcare Reference
Plain-English definitions of the terms that drive your benefits decisions — and your budget.
Healthcare benefits conversations are full of acronyms and industry jargon that can make it hard for HR leaders and CFOs to ask the right questions or evaluate the advice they receive. This glossary cuts through the complexity with clear, employer-focused definitions — explaining not just what each term means, but what it means for your organization, your plan design, and your bottom line.
A self-funded health plan lets employers pay employee claims directly instead of paying fixed premiums to a ca…
A fully insured health plan transfers all claims risk to a carrier in exchange for a fixed premium. Understand…
Level-funded health plans blend the predictability of fully insured plans with the data access and savings pot…
Stop-loss insurance protects self-funded employers from catastrophic claim costs. Learn how specific and aggre…
A captive insurance arrangement lets employers pool self-funded risk with other employers to gain buying power…
EPO, PPO, and HMO are the most common health plan network structures. Learn how each works, what employees exp…
A pharmacy benefit manager (PBM) administers prescription drug benefits for health plans. Learn how PBM pricin…
Reference-based pricing sets a fixed reimbursement ceiling for medical services, often tied to Medicare rates.…
Understanding the difference between an employee benefits broker and a consultant is essential for employers. …
Benefits administration covers the systems and processes employers use to manage employee health benefits. Lea…
Open enrollment is the annual period when employees select or change their health benefits. Learn best practic…
A claims audit reviews your health plan's claims data for billing errors, fraud, and overpayments. Learn why c…
The Medical Loss Ratio (MLR) rule requires health insurers to spend a minimum percentage of premiums on claims…
COBRA allows employees and dependents to continue group health coverage after a qualifying event. Learn employ…
The ACA employer mandate requires applicable large employers to offer affordable, minimum-value health coverag…
An ICHRA allows employers of any size to reimburse employees for individual health insurance premiums tax-free…
An HRA is an employer-funded account that reimburses employees for qualified medical expenses tax-free. Learn …
An HSA is a triple-tax-advantaged account paired with a high-deductible health plan. Learn HSA eligibility rul…
A Flexible Spending Account (FSA) allows employees to set aside pre-tax dollars for qualified medical expenses…
The out-of-pocket maximum is the most an employee will pay in a plan year before the health plan covers 100% o…
A health plan deductible is the amount employees pay out of pocket before insurance begins covering costs. Lea…
Co-pays are fixed dollar amounts; co-insurance is a percentage of costs. Learn the difference and how each aff…
In-network providers have contracted rates with your health plan; out-of-network providers do not. Learn how n…
A formulary is a list of drugs covered by a health plan, organized by cost-sharing tiers. Learn how formularie…
Prior authorization requires pre-approval before certain healthcare services are covered. Learn how prior auth…
Utilization management programs review healthcare services for clinical necessity and appropriateness. Learn h…
Network adequacy refers to whether a health plan's provider network offers sufficient access to care. Learn th…
Specialty pharmacy drugs are complex, high-cost medications for chronic or serious conditions. Learn how speci…