ADL-disabled
A person is ADL-disabled if he or she is (a) physically unable to perform two or more ADL's without continuous physical assistance; or (b) cognitively impaired, and requires verbal cueing to protect himself/herself or others. ADLs are bathing, dressing, toileting, transferring, continence, and eating.

Annual Maximum Benefit
The maximum dollar amount that an insurance carrier will pay for all healthcare services for the insured during a year. If there is an annual maximum amount on the plan it will be specified in the plan's Certificate of Insurance.

Brand-name drug
Prescription drug marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents expire, generic versions of many popular drugs are offered at lower costs by other companies.

Carrier
The insurance company or HMO offering an insurance plan.

Certificate of Insurance
The printed description of the benefits and coverage provisions, disclosing what is covered, what is not covered, and any limits to coverage. This is the contract between the carrier and the customer. This is also referred to as a Benefits Booklet.

Claim
A request by an individual (or his or her health care provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.

COBRA (Consolidated Omnibus Budget Reconciliation Act)
Federal legislation that lets you, if you have worked for an insured employer group of 20 or more employees, tocontinue to purchase health insurance for up to 18 months if you lose your job, or your coverage is otherwise terminated. For more information, visit the Department of Labor.

Co-Insurance
After a deductible has been fulfilled, the co-insurance is the portion of a medical expense that you must contribute. It's usually expressed as a percentage, i.e. a 30% co-insurance means that after you meet your deductible, you pay 30% and the insurance company pays 70% of your medical expenses. This is usually subject to the insurers Reasonable & Customary fees.

Co-Payment
A fixed payment required for required for certain medical services, i.e. office visits, hospital admissions, and therapy sessions. Co-payments are usually specified as dollar amounts.

Deductible
The dollar amount that the insured individual needs to pay out-of-pocket before he/she is entitled to collect benefits from the insurance company.
Deductibles do not always apply for all medical expenses. Refer to your Certificate of Coverage for specific plan details.

Denial Of Claim
Refusal by an insurance company to honor a claim. A claim is a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.

Dependent
Individual(s) covered under the subscriber's insurance plan. A dependent is usually a spouse or child.

Dependent Coverage (including full-time students)
Coverage for individuals who can be covered under the subscriber's policy. Dependent coverage varies by plan. Refer to your Certificate of Insurance for specific plan details.

Domestic Partner
An unmarried adult who is not related to the member by blood in a manner that would bar marriage under applicable state laws, and who resides with the member in a continuous relationship of indefinite duration in which the member and the domestic partner have responsibility for each other's welfare and financial well-being.

Effective Date
The date when insurance coverage, or a change to coverage, will begin.

Elimination Period
For disability insurance, the elimination period is the period of time between the onset of the disability and when you are eligible to start receiving benefits. It is like a waiting period before your benefits begin.

Emergency Care
Care provided to the insured who suffers an accidental injury or the sudden onset of a medical condition with symptoms so severe, including severe pain, that without immediate medical attention the insured could reasonably expect that 1) his or health would be in serious jeopardy; 2) his or her bodily function would be seriously impaired; or 3) a bodily organ or part would be seriously damaged.

Benefits for Emergency Care vary by plan. Refer to your Certificate of Insurance for specific plan details.

EPO (Exclusive Provider Organization)
A health insurance plan which has in-network coverage only, but you are free to see whatever doctor or specialist you wish without needing to obtain a referral first. Doctor visits are subject to co-payments only. There is no coverage for care received from a non-network provider except in an emergency situation.

Exclusions
Medical services that are not covered by an individual's insurance policy.

Explanation of Benefits (EOB)
The statement you receive after you file a claim, or one has been filed on your behalf, with a summary of the action taken on your claim. This statement will show how much of the claim the insurance company has paid and any balance remaining, to be paid by the individual.

The EOB will usually include:
- In boldface, the statement, "THIS IS NOT A BILL".
- A "Claim Number," which is a handy piece of information to have available if you need to discuss your claim with your insurance company.
- The report of your "Beneficiary Liability," which is the dollar-amount that you owe: You can expect to be billed that amount by your doctor, or you might already have paid your portion of the bill at the time of treatment.
- Instructions for disputing a decision and filing an appeal if you believe that your claim has been incorrectly processed or denied.

Formulary
List of all brand name and preferred generic alternatives covered by a plan's prescription drug benefit. The decision to cover a brand name or generic drug is made exclusively by the insurance carrier. This list is usually provided on the insurance carrier's website and is subject to change at any time.

Generic Drug
A "twin" to a brand name drug available once the brand name company's patent has expired and other drug companies are allowed to sell a duplicate of the original. Generic drugs are usually less expensive than brand name drugs.

HIPAA Certificate
Certificate issued by the insurance provider which documents proof of prior coverage.

HMO (Health Maintenance Organization)
A health insurance plan where you select a primary care physician who is responsible for the overall management of your medical care. A referral by your PCP is required to see a specialist. Out-of-network benefits are not available.

HSA: Health Savings Account
- A supplement to a high-deductible health plan;
- A tax-advantaged savings account that you can use to pay for qualifying medical expenses;
- A portable account that you maintain as you move from job to job and project to project.

Independent Worker
Independent Workers are defined as individuals who work as freelancers, independent contractors or consultants, or who are self-employed, employed part-time, temporary workers, or work for multiple companies at the same time. You will not be considered an independent worker if, at the time of application, you are working full-time as a W-2 employee and have been for the last 18 months for the same employer. The only exception to this is if you work for a temporary or placement agency.

Infertility
The inability to have fertilization of an ovum for a specific period of time. The time period varies by insurance plan. Refer to your Certificate of Insurance for specific plan details.

In-Network and Out-of-Network
Insurance companies contract with networks of doctors, specialists, and hospitals that have agreed to discount their services to patients covered by a specific insurance plan. Some plans offer no coverage for out-of-network care (doctors, specialists, and hospitals that do not have a contracted agreement with the insurance provider), while others cover a certain percentage of expenses after a deductible has been paid.

Lifetime Maximum
Maximum amount of medical costs the insurance carrier will pay over your lifetime; usually ranges from $1 million to $5 million. This may also be expressed as an annual maximum benefit.

Long-term Disability Insurance
Insurance that pays the insured a percentage of their monthly earnings if they become disabled.

Network
A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies' customers. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using an in-network provider.

Open enrollment
Time during which you can make changes to your plan, such as switching plans and adding or dropping dependents from your policy. For current members of Working Today's Freelancers Union, Open Enrollment takes place once a year. For health insurance, the open enrollment period takes place in December, for changes effective January 1. For dental, disability, and life insurance, the open enrollment period takes place in September for changes effective October 1.

Outpatient
An individual (patient) who receives health care services (such as surgery) without an overnight stay in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.

PCP (Primary Care Physician)
General practitioner or physician who is responsible for your overall basic health care, arranges for specialized services, and provides referrals.

POS (Point-of-Service)
A health insurance plan which allows for both in- and out-of-network benefits. A referral is required to see specialists. A POS plan generally has a deductible for out-of-network benefits.

PPO (Preferred Provider Organization)
A health insurance plan with a network of physicians, but you are free to see whatever doctor or specialist you wish without needing to obtain a referral first. PPO plans usually offer coverage for out-of-network expenses once a deductible has been met.

Pre-existing condition
A pre-existing condition is any chronic condition that you're been diagnosed with or treated for within a certain period of time. Most insurance plans require a waiting period before a pre-existing condition will be covered.

Prescription drug
Medication which has been approved for use by the FDA, is medically necessary, not available over-the-counter, and taken under written order from a physician.

Pre-authorization
Approval that insureds must receive from the insurance company in advance of receiving certain services, such as inpatient hospital admissions (non-emergency), non-emergency outpatient hospital services, and ambulatory (outpatient) surgery services.

Premium
Fixed rate you pay monthly, bimonthly, or quarterly for your insurance. Most insurance companies increase their rates at least once a year.

Qualifying reason/event
An event that allows you to add or remove dependents from your insurance plan outside of the Open Enrollment period. These usually include marriage, divorce, death, the birth of a child, the adoption of a child, or the placement of a foster child.

Reasonable and Customary
Accepted standard costs of a medical procedure, typically based on guidelines published by the Health Insurance Association of America (HIAA). Insurance carriers usually refer to a percentage of Reasonable and Customary that they are willing to cover (you are responsible for anything beyond that amount). Also referred to as an Allowable Fee or Usual and Customary Reimbursement (UCR). Reasonable and Customary costs differ by carrier and are subject to change at any time.

Rider
An addendum to your coverage which increases or decreases the available benefits. Prescription benefits are an example of a rider. Any riders on Freelancers Union's plans are fixed and cannot be changed by an individual.

Skilled Computer User
A Skilled Computer User is one who uses specialized software in one or more of the following occupations: Graphic designArchitecture, Web design, Nanotechnology, Web programming, Content development, Music or song composition, Software development, Computer programming, Computer-related support to companies outside the computer industry. Some examples of software used in these fields are: Quark, Avid, Auto CAD, ProTools, Logic, Flash etc. If you have eligibility questions, please contact Member Services.

Specialist
A physician, other than a primary care physician, who specializes in a specific field. (For example: dermatologists, endocrinologists, cardiologists, etc.) Gynecologists are usually considered specialists, however you generally do not need a referral to see one.

Statement of Termination
A document composed and signed by the covered member stating that the domestic partnership has ended and noting the effective date of its termination.

Termination
Ending your insurance coverage. Terminations are usually processed to take effect for the last day of any given month and cannot be done retroactively.