Gator's Dockside Open Enrollment

HMO Health Maintenance Organization

A managed care plan where all non-emergency care must come from a defined local network of providers.

Network & referrals

You choose an in-network Primary Care Physician (PCP), and you need a PCP referral to see a specialist.

Out-of-network

Not covered, except for life-threatening emergencies.

Cost

Lowest premiums and lower copays, with the least provider flexibility.

PPO Preferred Provider Organization

A flexible plan with a broad network of preferred doctors and facilities, plus partial coverage for out-of-network care.

Network & referrals

No PCP required. You can see specialists directly without a referral.

Out-of-network

Covered, but with separate, higher deductibles and coinsurance.

Cost

Highest premiums in exchange for the most freedom to choose providers.

EPO Exclusive Provider Organization

Combines the direct specialist access of a PPO with the network limits of an HMO.

Network & referrals

No PCP or specialist referrals needed, but care is covered only at in-network providers.

Out-of-network

Not covered, except emergencies. You pay 100% for non-emergency out-of-network care.

Cost

Moderate premiums, lower than PPOs and similar to HMOs.

POS Point of Service

Combines HMO-style coordinated care with the option to go out of network like a PPO.

Network & referrals

You choose an in-network PCP and get PCP referrals for specialist visits.

Out-of-network

Covered. If your PCP refers you, the plan pays more. If you go on your own, coverage drops and you may need to file the claim yourself.

Cost

Moderate premiums with PCP-coordinated care.

HDHP High-Deductible Health Plan

A plan with a higher deductible and out-of-pocket maximum set by IRS rules, in exchange for lower premiums.

HSA compatible

A qualified HDHP is the only type of health plan you can pair with a Health Savings Account (HSA).

How you pay

Except for preventive care, which is covered at 100%, you pay the full contracted rate for care and prescriptions until you meet the deductible.

Cost

Lowest payroll deductions, with more cost up front when you use care.

Premium

The fixed amount paid every pay period or month to keep your coverage active, whether or not you use care. With employer plans, the cost is usually split between the employer and your pre-tax payroll deduction.

Deductible

The amount you pay each plan year for covered services before the plan starts paying.

Embedded

On a family plan, each person has their own deductible. Once one person meets it, the plan starts paying for them even if the family total is not met.

Aggregate

The full family deductible must be met before the plan pays coinsurance for anyone on the plan.

Copayment (Copay)

A flat dollar amount you pay at the time of service, for example $25 for primary care or $15 for a generic prescription. Copays are predictable, usually are not subject to the deductible on non-HDHP plans, and count toward your out-of-pocket maximum.

Coinsurance

Your percentage share of covered costs after you meet the deductible. On an 80/20 plan, the plan pays 80% of the allowed amount and you pay 20% until you reach your out-of-pocket maximum.

Out-of-Pocket Maximum

The most you will pay for covered in-network care in a plan year. Deductibles, copays and coinsurance all count toward it. Premiums, out-of-network balance bills and non-covered services do not. Once you reach it, the plan pays 100% of allowed in-network costs for the rest of the year.

Allowed Amount & Balance Billing

Allowed amount

The maximum payment the insurer and an in-network provider have agreed on for a service.

Balance billing

When an out-of-network provider bills you for the difference between their full charge and the allowed amount. The federal No Surprises Act prohibits this for emergency care and other care you could not choose.

HSA Health Savings Account

Who owns it

You own it. It goes with you if you change jobs or retire.

Who can contribute

Employee and/or employer

Plan requirement

Must be enrolled in a qualified HDHP

Rollover rules

Funds roll over every year. No use-it-or-lose-it rule.

FSA Health Care Flexible Spending Account

Who owns it

Employer-owned. Stays with the company if you leave.

Who can contribute

Employee and/or employer

Plan requirement

Available with any plan, or no plan

Rollover rules

Use it or lose it, subject to a grace period or limited carryover.

Limited-Purpose FSA

Who owns it

Employer-owned. Stays with the company.

Who can contribute

Employee and/or employer

Plan requirement

Paired with an HDHP and HSA

Rollover rules

Limited carryover. Dental and vision expenses only.

Dependent Care FSA

Who owns it

Employer-owned. Stays with the company.

Who can contribute

Employee and/or employer

Plan requirement

Available with any health plan

Rollover rules

Use it or lose it. Covers qualifying child and elder day care.

HRA Health Reimbursement Arrangement

Who owns it

Employer-owned and 100% employer-funded.

Who can contribute

Employer only

Plan requirement

Set by the employer

Rollover rules

Set by the employer's plan document.

HSA Triple Tax Advantage

• Contributions go in pre-tax or are tax-deductible.
• Your balance grows tax-free through interest or investments.
• Withdrawals are tax-free when spent on IRS-qualified medical expenses.
• At age 65 and older, you can withdraw for non-medical expenses without penalty, paying only ordinary income tax.

Qualifying Life Event (QLE)

A major life change that lets you change your benefits outside of open enrollment, also called a Special Enrollment Period.

Common events

Marriage, divorce, birth or adoption, death of a covered dependent, or losing other group coverage, such as when a spouse changes jobs.

Timeline

Changes generally must be made within 30 days of the event, or 60 days for loss of Medicaid or CHIP.

Section 125 / Cafeteria Plan

The IRS rule that lets your premiums, FSA and HSA contributions come out of your paycheck before federal income, Social Security and Medicare taxes. Because of this rule, once open enrollment closes your elections are locked in for the full plan year unless you have a qualifying life event.

Prior Authorization & Step Therapy

Prior authorization

Your provider must get the insurer's approval, showing medical necessity, before a procedure, surgery or specialty drug is covered.

Step therapy

You may need to try a lower-cost or generic drug first before the plan covers a higher-cost brand.

Formulary & Drug Tiers

The formulary is your plan's list of covered prescription drugs.

Tier 1

Generic. Lowest cost, with the same active ingredients as the brand name.

Tier 2

Preferred brand. Brand-name drugs on the plan's preferred list.

Tier 3

Non-preferred brand. Higher-cost brands when a generic or preferred option exists.

Tier 4

Specialty. High-cost biologics, injectables and complex therapies, often requiring prior authorization.

Summary of Benefits and Coverage (SBC)

A standard document required by the Affordable Care Act for every plan. It lists covered services, deductibles and copays, with sample cost scenarios such as having a baby, so you can compare plans side by side.

Short-Term Disability (STD)

Replaces part of your weekly income, typically 50% to 70%, if a non-work illness, injury or recovery from childbirth keeps you from working, after a short waiting period.

Long-Term Disability (LTD)

Replaces part of your monthly income when a disability lasts beyond the short-term period, typically starting after 90 or 180 days, until you recover, reach retirement age or hit the benefit limit.

Critical Illness Insurance

Pays a lump-sum cash benefit directly to you when you are diagnosed with a covered illness such as cancer, heart attack or stroke, separate from your health plan.

Accident Insurance

Pays set cash amounts for accidental injuries and related care, such as ER visits, fractures, dislocations and concussions.

Hospital Indemnity

Pays a fixed cash benefit directly to you for each day you are admitted to the hospital, helping cover high deductibles.

EAP (Employee Assistance Program)

A free, confidential program offering short-term counseling, legal consultations and financial wellness support for you and your household.