Glossary
The words on your SBC, in plain English. Definitions only — not advice.
Open enrollment and plan documents use a small set of terms over and over. Here’s what they usually mean. Confirm anything that matters against your own Summary of Benefits and Coverage.
The percentage you pay for a covered service after you’ve met your deductible. Example: 20% coinsurance means you pay 20% and the plan pays 80%, until you hit the out-of-pocket maximum.
Where it shows up: SBC “What You Pay” columns; often next to deductible language.
A flat dollar amount you pay for a specific service — office visit, specialist, ER, generic Rx — usually at the time of care. Copays may or may not count toward deductible; check your SBC.
Where it shows up: SBC cost-sharing table by service type.
What you pay for covered services before the plan starts sharing most costs. Individual deductible applies to one person; family deductible applies across the family (rules vary — see embedded, below).
Where it shows up: Near the top of the SBC; also in plan comparison charts.
On many family plans, one person can meet their own individual deductible or out-of-pocket maximum before the full family amount is met. “Embedded” means that individual limit exists inside the family limit.
Where it shows up: Fine print on family plans; not always labeled “embedded” in bold — look for separate individual and family numbers.
The plan’s list of covered prescription drugs, usually in tiers (generic, preferred brand, non-preferred, specialty). Where a drug sits on the formulary changes what you pay.
Where it shows up: Carrier formulary PDF/tool; sometimes summarized on the SBC under prescription drugs.
An account you fund with pre-tax dollars for eligible healthcare (or dependent care) expenses. Healthcare FSAs usually have a use-it-or-lose-it rule (with limited carryover in some plans). Not the same as an HSA.
Where it shows up: Open enrollment elections; employer benefits guide.
A tax-advantaged account paired with an HSA-eligible high-deductible health plan. You (and sometimes your employer) can contribute; funds can roll over year to year. Contribution limits change annually — verify current IRS limits.
Where it shows up: Plan name or “HSA-eligible” label; enrollment materials; W-2 / payroll if you contribute.
Providers and facilities that have a contract with the plan. In-network care usually costs you less than out-of-network care. Out-of-network bills may not count the same way toward your out-of-pocket maximum.
Where it shows up: SBC columns often split “In-Network” vs “Out-of-Network”; carrier directory.
Care from providers who don’t have a contract with the plan. Your share is usually higher; balance billing is more common. Don’t assume out-of-network spending fully counts toward the same OOPM.
Where it shows up: Opposite column from in-network on the SBC.
The most you’d pay in a plan year for covered in-network services, under the plan’s rules. Once you hit it, the plan generally pays 100% of covered in-network care for the rest of the year. Premiums usually do not count toward OOPM.
Where it shows up: Near the top of the SBC next to deductible. This is the ceiling used in the healthcare liability calculator.
What you pay for coverage itself — usually per paycheck — whether or not you use care. Distinct from deductible, copays, and coinsurance.
Where it shows up: Enrollment system; pay stub; sometimes in the benefits guide, not always on the SBC.
Approval the plan requires before it will cover certain services or drugs. Skipping it can mean a denial or a bigger bill.
Where it shows up: Benefits guide; carrier portal; sometimes footnoted on the SBC for specific services.
A standardized short document every major medical plan must provide. It’s the fastest place to find deductible, OOPM, and examples of what you pay.
Where it shows up: Employer enrollment site; carrier site; ask HR if you can’t find it.
High-cost medications (often for complex conditions), usually on the highest formulary tier, sometimes limited to a specialty pharmacy.
Where it shows up: Formulary tier labels; SBC prescription section.
Put numbers on it
Run the healthcare liability calculator — worst-case total as a share of salary.
Educational definitions only. Not insurance, tax, or legal advice. Plan language controls — confirm against your SBC and plan documents.