Page 147 - An Indispensible Resource for Being a Credible Activist

Deductible—A fixed dollar amount during the benefit period—usually a year—that an
insured person pays before the insurer starts to make payments for covered medical
services. Plans may have both per individual and family deductibles. Some plans may
have separate deductibles for specific services. For example, a plan may have a hospi-
talization deductible per admission. Deductibles may differ if services are received from
an approved provider or if received from providers not on the approved list.
Flexible benefits plan (Cafeteria plan) (IRS 125 Plan)—A benefit program under Section
125 of the Internal Revenue Code that offers employees a choice between permissible
taxable benefits, including cash, and nontaxable benefits such as life and health insur-
ance, vacations, retirement plans and child care. Although a common core of benefits
may be required, the employee can determine how his or her remaining benefit dollars
are to be allocated for each type of benefit from the total amount promised by the
employer. Sometimes employee contributions may be made for additional coverage.
Flexible spending accounts or arrangements (FSA)—Accounts offered and administered
by employers that provide a way for employees to set aside, out of their paycheck, pre-
tax dollars to pay for the employee’s share of insurance premiums or medical expenses
not covered by the employer’s health plan. The employer may also make contributions
to a FSA. Typically, benefits or cash must be used within the given benefit year or the
employee loses the money. Flexible spending accounts can also be provided to cover
childcare expenses, but those accounts must be established separately from medical
FSAs.
Fully insured plan—A plan where the employer contracts with another company to assume
financial responsibility for the enrollees’ medical claims and for all incurred adminis-
trative costs.

Gatekeeper—Under some health insurance arrangements, a gatekeeper is responsible for
the administration of the patient’s treatment; the gatekeeper coordinates and authorizes
all medical services, laboratory studies, specialty referrals, and hospitalizations.

Group purchasing arrangement—Any of a wide array of arrangements in which two or
more small employers purchase health insurance collectively, often through a common
intermediary who acts on their collective behalf. Such arrangements may go by many
different names, including cooperatives, alliances, or business groups on health. They
differ from one another along a number of dimensions, including governance, functions
and status under federal and state laws. Some are set up or chartered by states while
others are entirely private enterprises. Some centralize more of the purchasing functions
than others, including functions such as risk pooling, price negotiation, choice of health
plans offered to employees, and various administrative tasks. Depending on their func-
tions, they may be subject to different state and/or federal rules. For example, they may
be regulated as Multiple Employer Welfare Arrangements (MEWAs).
Health Care Plans and Systems
● Indemnity plan—A type of medical plan that reimburses the patient and/or provider
as expenses are incurred.

130 The H R Toolkit