Exploring Benefits Lingo

Exploring Benefits Lingo

We all know how confusing and complex benefits and healthcare terms can be- the difference between deductible and co-insurance is a common question for many and there are plenty of others like it.  When you are comfortable and confident in how your plan works, you can make an informed decision on HOW to use and take advantage of your benefits!

We have created a list and explanation of the most common terms to help you understand and better utilize your health benefits:

  • Co-payment:  An amount you pay as your share of the cost for a medical service or item, like a doctor’s visit.  Co-pays are most common for emergency room, urgent care and prescription drugs. In some cases, you may be responsible for paying a co‐pay as well as a percentage of the remaining charges.
  • Co-insurance:  Your share of the cost for a covered health care service, usually calculated as a percentage (like 20%) of the allowed amount for the service. For example, if your plan has a 30% co-insurance rate, the carrier will pay 70% of the allowed amount while you pay the balance.
  • Deductible: The amount you owe for covered health care services before your health insurance or plan begins to pay.  For example, many plans require an individual to pay $1,000 in cumulative deductibles before they begin paying out.
  • Dependent coverage:  Health insurance coverage extended to the spouse and unmarried children up to age 26 who are totally or substantially reliant on their parents for support, thereby defined as “dependent children”.
  • Explanation of Benefits (EOB): Every time you use your health insurance, your health plan sends you a record called an “explanation of benefits” (EOB) or “member health statement” that explains how much you owe. The EOB also shows the total cost of care, how much your plan paid and the amount an in-¬network doctor or other healthcare professional is allowed to charge a plan member (called the “allowed amount”).
  • In-Network Provider: A provider who has a contract with your health insurer or plan to provide services to you at a discount. In-Network Providers have contracted with the insurance carrier to accept reduced fees for services provided to plan members. Using in-network providers will cost you less money. When contacting an In-Network Provider, remember to ask, “are you a contracted provider with my plan?” Never ask if a provider “takes” your insurance, as they will all take it. The key phrase is contracted.
  • Open Enrollment: A period during which a health insurance company is required to accept applicants without regard to health history.
  • Out-of-Network Provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you at a pre-negotiated discount. You’ll pay more to see an out-of-network provider, sometimes referred to as an out-of-network provider.
  • Out-of-Pocket Maximum: The limit or most you’ll pay out of your own pocket for services during your insurance plan period (usually one year).
  • Premium: The amount you pay for your health insurance or plan each month.
  • Qualifying Life Event (QLE): A change in your life that allows you to make changes to your benefits’ coverage outside of the annual open enrollment period. These changes include a change in marital status (marriage, divorce, death of spouse), a change in the number of eligible children (birth, adoption, death, aging-out), and a change in a family member’s benefits eligibility under another plan (losing a job, Medicare or Medicaid eligibility, etc.)

In addition to understanding these common terms, there are other ways to utilize your benefits, save money and make an informed decision based on your specific needs.

  • Flexible Spending Account (FSA): Funded through pre-tax payroll deductions, an FSA is a cost-savings tool that allows you to pay for qualified healthcare-related expenses with pre-tax dollars. Funds deposited in an FSA must be spent in the same year in which they are set aside, or they are forfeited. This rule is often referred to as “use it or lose it.”
  • Health Reimbursement Account (HRA): An employer-funded savings plan that will reimburse you for out-of-pocket medical expenses. Unlike an FSA, however, you don’t “use it or lose it” – unused balances will roll over and accumulate over time, though the account cannot be “cashed-out.”
  • Health Savings Account (HSA): A savings product that serves as a substitute for traditional health insurance. HSAs enable you to pay for current health costs. They also allow you to save for future medical and retiree health costs tax-free. Unlike an FSA, however, you don’t “use it or lose it” – unused balances will roll over and accumulate over time and can be “cashed-out.”

Understanding all of the terms and acronyms can feel like learning a new language, so it’s helpful to have a basic reference chart.  With a good understanding of what some healthcare “benefits lingo” means, it will be easier to find a plan that meets your needs and budget. To explore more healthcare terms, visit https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/common-health-benefit-terms-glossary.aspx

Health Plan PCORI Fees Are Due August 2

Health Plan PCORI Fees Are Due August 2

Do you offer coverage to your employees through a self-insured group health plan? Do you sponsor a Health Reimbursement Arrangement (HRA)? If so, do you know whether your plan or HRA is subject to the annual Patient-Centered Research Outcomes Institute (PCORI) fee?

This article answers frequently-asked questions about the PCORI fee, which plans are affected, and what you need to do as the employer sponsor. PCORI fees for 2020 health plans and HRAs are due August 2, 2021.

What is the PCORI fee?

The Affordable Care Act (ACA) created the Patient-Centered Outcomes Research Institute to study clinical effectiveness and health outcomes. To finance the nonprofit institute’s work, a small annual fee is charged on health plans.

Most employers do not have to take any action because most employer-sponsored health plans are provided through group insurance contracts. For insured plans, the carrier is responsible for the PCORI fee and the employer has no duties.

If, however, you are an employer that self-insures a health plan or an HRA, it is your responsibility to determine whether PCORI applies and, if so, to calculate, report, and pay the fee.

The annual PCORI fee is equal to the average number of lives covered during the health plan year, multiplied by the applicable dollar amount:

  • If the plan year end date was between January 1 and September 30, 2020: $2.54.
  • If the plan year end date was between October 1 and December 31, 2020: $2.66.

Payment is due by July 31 following the end of the calendar year in which the plan year ended. If July 31 falls on a weekend, the due date is the next following business day. So the due date for plan years ending in 2020 is August 2, 2021.

Does the PCORI fee apply to all health plans?

The fee applies to all health plans and HRAs, excluding the following:

  • Plans that primarily provide “excepted benefits” (e.g., stand-alone dental and vision plans, most health flexible spending accounts with little or no employer contributions, and certain supplemental or gap-type plans).
  • Plans that do not provide significant benefits for medical care or treatment (e.g., employee assistance, disease management, and wellness programs).
  • Stop-loss insurance policies.
  • Health savings accounts (HSAs).

The IRS provides a helpful chart indicating the types of health plans that are, or are not, subject to the PCORI fee.

If I have multiple self-insured plans, does the fee apply to each one?

Yes. For instance, if you self-insure one medical plan for active employees and another medical plan for retirees, you will need to calculate, report, and pay the fee for each plan. There is an exception, though, for “multiple self-insured arrangements” that are sponsored by the same employer, cover the same participants, and have the same plan year. For example, if you self-insure a medical plan with a self-insured prescription drug plan, you would pay the PCORI fee only once with respect to the combined plan.

Does the fee apply to HRAs?

Yes. The PCORI fee applies to HRAs, which are self-insured health plans, although the fee is waived in some cases. If you self-insure another plan, such as a major medical or high deductible plan, and the HRA is merely a component of that plan, you do not have to pay the PCORI fee separately for the HRA. In other words, when the HRA is integrated with another self-insured plan, you only pay the fee once for the combined plan.

On the other hand, if the HRA stands alone, or if the HRA is integrated with an insured plan, you are responsible for paying the fee for the HRA.

What about QSEHRAs? Does the fee apply?

Yes. A Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) is special type of tax-advantaged arrangement that allows small employers to reimburse certain health costs for their workers. Although a QSEHRA is not the same as an HRA, and the rules applying to each type are very different, a QSEHRA is a self-insured health plan for purposes of the PCORI fee. The IRS provides guidance confirming that small employers that offer QSEHRAs must calculate, report and pay the PCORI fee.

What about ICHRAs and EBHRAs? Does the fee apply?

An Individual Coverage Health Reimbursement Arrangement (ICHRA) is a new type of tax-advantaged arrangement, first offered in 2020, that allows employers to reimburse certain health costs for their workers. The IRS has not provided specific guidance regarding ICHRAs and the PCORI fee, but it appears the fee applies since an ICHRA is a self-insured health plan.

An Excepted Benefits Health Reimbursement Arrangement (EBHRA) also is a self-insured health plan but it is limited to “excepted benefits,” such as dental and vision care costs. So the PCORI fee does not apply to EBHRAs.

Can I use ERISA plan assets or employee contributions to pay the fee?

No. The PCORI fee is an employer expense and not a plan expense, so you cannot use ERISA plan assets or employee contributions to pay the fee. (An exception is allowed for certain multiemployer plans (e.g., union trusts) subject to collective bargaining.) Since the fee is paid by the employer as a business expense, it is tax deductible.

How do I calculate the fee?

Multiply $2.54 or $2.66 (depending on the date the plan year ended in 2020) times the average number of lives covered during the plan year. “Covered lives” are all participants, including employees, dependents, retirees, and COBRA enrollees.

You may use any one of the following counting methods to determine the average number of lives:

  • Average Count Method: Count the number of lives covered on each day of the plan year, then divide by the number of days in the plan year.
  • Snapshot Method: Count the number of lives covered on the same day each quarter, then divide by the number of quarters (e.g., four). Or count the lives covered on the first of each month, then divide by the number of months (e.g., 12). This method also allows the option — called the “snapshot factor method” — of counting each primary enrollee (e.g., employee) with single coverage as “1” and counting each primary enrollee with family coverage as “2.35.”
  • Form 5500 Method: Add together the “beginning of plan year” and “end of plan year” participant counts reported on the Form 5500 for the plan year. There is no need to count dependents using this method since the IRS assumes the sum of the beginning and ending of year counts is close enough to the total number of covered lives. If the plan is employee-only without dependent coverage, divide the sum by 2. (If Form 5500 for the plan year ending in 2020 is not filed by August 2, 2021, you cannot use this counting method.)
  • Any Reasonable Method: This method is an exception allowed only for plan years ending between October 1, 2019 and September 30, 2020. Typically, only the first three methods above are allowed. The IRS recognizes, however, that plan sponsors may not have tracked counts using those methods since the fee had expired before it was unexpectedly reinstated by Congress in late 2019. In Notice 2020-44, the IRS explains that plan sponsors may use any reasonable method to determine the plan’s average number of covered lives

For an HRA, QSEHRA or ICHRA, count only the number of primary participants (employees) and disregard any dependents.

How do I report and pay the fee?

Use Form 720, Quarterly Excise Tax Return, to report and pay the annual PCORI fee. Report all information for self-insured plan(s) with plan year ending dates in 2020 on the same Form 720. Do not submit more than one Form 720 for the same period with the same Employer Identification Number (EIN), unless you are filing an amended return.

The IRS provides Instructions for Form 720. Here is a quick summary of the items for PCORI:

  • Fill in the employer information at the top of the form.
  • In Part II, complete line 133(c) and/or line 133(d), as applicable, depending on the plan year ending date(s). If you are reporting multiple plans on the same line, combine the information.
  • In Part II, complete line 2 (total).
  • In Part III, complete lines 3 and 10.
  • Sign and date Form 720 where indicated.
  • If paying by check or money order, also complete the payment voucher (Form 720-V) provided on the last page of Form 720. Be sure to fill in the circle for “2nd Quarter.” Refer to the Instructions for mailing information.

Caution! Before taking any action, confirm with your tax department or controller whether your organization files Form 720 for any purposes other than the PCORI fee. For instance, some employers use Form 720 to make quarterly payments for environmental taxes, fuel taxes, or other excise taxes. In that case, do not prepare Form 720 (or the payment voucher), but instead give the PCORI fee information to your organization’s tax preparer to include with its second quarterly filing.


If you self-insure one or more health plans or sponsor an HRA, you may be responsible for calculating, reporting, and paying annual PCORI fees. The fee is based on the average number of lives covered during the health plan year. The IRS offers a choice of different counting methods to calculate the plan’s average covered lives. Once you have determined the count, the process for reporting and paying the fee using Form 720 is fairly simple. For plan years ending in 2020, the deadline to file Form 720 and make your payment is August 2, 2021.

By Kathleen A. Berger, CEBS

Originally posted on Trustmineral.com

Exploring In-Network and Out-of-Network Benefits

Exploring In-Network and Out-of-Network Benefits

You have surely heard the terms “in-network” and “out-of-network” when referring to doctors or care facilities and your insurance plan. It can be confusing and make you wonder why it matters to you, as the consumer. Let’s explore these terms and find out more!

What are Health Insurance Plan Networks?

Health insurance plans create networks of doctors and facilities with which they have contracted to accept negotiated rates for the services they provide.  When you subscribe to a specific insurance plan, you can look up the list of these contracted providers to see which ones are “in-network.” Most plans have helpful search tools online like “Find a Doctor” to save you time as you look for your specific doctor. You can also call the facility or healthcare provider and ask if they are considered “in-network” or “out-of-network” for your particular health insurance plan.

Why Choose “In-network” Providers?

When you make the choice to see an “in-network” healthcare provider or visit an “in-network” facility, you will typically pay less for the service (doctor visit, screening, hospital stay, etc.) than if you chose to use a provider outside of the plan’s network. Your insurance plan has negotiated a discounted cost for the service and passes that savings on to you, the subscriber. See the table below for an example.

Additional Benefit to “In-Network” Care

Some health insurance plans allow you to visit “out-of-network” doctors and facilities with the understanding that you will pay more for these services since they are not in an agreement with one another. However, you may not be able to apply these expenses towards your annual deductible.  This means it may take you longer in the year, with more out-of-pocket expenses, to reach your deductible. Staying “in-network” alleviates this delay and any added costs.

Staying with “in-network” providers truly equals greater cost-savings to the consumer. By doing a little research upfront to find the doctors and facilities in your plan network, you will end up with less out-of-pocket expenses for your health care each year. While the choice is ultimately up to you on who you see for your care, looking within your plan network will reap you great benefits.

Exploring Mental Health Benefits

Exploring Mental Health Benefits

The overall well-being of an employee has never been more of a priority for employers as it is right now. From health care to vision care to mental health care, the entirety of the employee’s health is important to the health of the organization.

Importance of Mental Health Benefits

Mental health and the cost of not treating its issues has far-reaching effects from the individual to the global world.

  • If left untreated, an employee’s poor mental health could lead to work related accidents, absenteeism, poor workplace productivity, and even workplace violence.
  • Mental health costs make up about 8% of the US’s total healthcare spending.
  • The National Institute on Mental Health estimates that major mental illness costs the US at least $193 billion per year in lost earnings.
  • Globally, depression and anxiety issues cost about $1 trillion a year.

Types of Mental Health Benefits

Mental health benefits can look different for each organization. Universally, businesses offer some sort of Employee Assistance Program (EAP) to its members. EAPs include services that are typically delivered online or by telephone. Services may include alcohol and substance abuse counseling, legal aid, and health and wellness counseling. These services are offered to the employee free of charge and are done anonymously.

As an extension of basic health care benefits, mental health benefits can also include one-on-one counseling with a licensed counselor for a certain number of sessions.  Mental health benefits may also incorporate wellness programs like relaxation and meditation classes, sleep techniques, and stress management lessons. Check your health insurance benefits package details as you may find mental health insurance coverage included under the behavioral health section.

During open enrollment, when employers present the employees with the upcoming year’s health insurance plans, the employee should also ask about mental healthcare options. Just as you assess the different healthcare plans and what fits best for you and your family, you can also assess the costs and coverage of mental health plans. Also, find out if your company offers a Flexible Spending Account as you can use that pre-tax money to pay for out-of-pocket mental health service costs.

Now, more than ever, people are more aware of the benefits to good mental health and how it affects their overall health and work performance.  Utilize the company sponsored EAP offerings and investigate the details of your health insurance plan to find out what mental health services are covered. Your overall health and well-being are important and so are you!

Exploring Year-Round Benefits Engagement

Exploring Year-Round Benefits Engagement

Just as with any good, healthy relationship, communication with employees is key. Only communicating with employees regarding their benefits package during open enrollment will most definitely result in them not taking full advantage of all it has to offer. In an effort to assist employees in understanding and maximizing their benefits, companies should use a year-round benefits engagement strategy.  Let’s explore some simple ways to set up your annual communication plan.


As you begin crafting your engagement plan, think of the overall goal you want to accomplish. Perhaps you simply want your employees to be better educated on their plan offerings. Maybe you’d like to reduce the number of questions that employees ask during open enrollment meetings. Or, maybe you want your employees to utilize a certain plan benefit that has been historically underused resulting in higher costs to the employee or the company. Whatever the case, first set your goal for the communication plan.


Now that you have an end-goal in mind, start thinking of how frequently you want to communicate.  Schedule your communication moments to post consistently. Maybe you start a “Benefits Minute” that hits the first Monday of the month. Or, start a “Benefits Blog” that posts every other Friday. Whatever the case, make the communication happen on a schedule so that employees know when to expect it and know what it’s called.


Wordy emails, drawn-out meetings, and forever long phone messages will quickly get ignored and deleted. Instead, follow this simple formula when crafting your communication:

  1. Here’s what you need to know about your benefits.

Give a quick overview of the benefit you are focusing on for this particular communication.

  1. Here’s why it’s important that you know this.

In a few short sentences, explain how this benefit benefits the employee whether it be a cost savings, time savings, or simply a great help to them.

      3.  Here’s what you need to do to find out more.

Provide a way to find out more information on this benefit by giving a link, an email address, or a phone number.


Communication isn’t one-size-fits-all. People learn in different ways—some may be visual learners while others may be oral learners. Make sure you mix up the way you communicate to cover both types. Also, change up the method of communication. Try emails, explainer videos, printed flyers, and quick, stand-up meetings. By using a variety of methods, you are able to engage a broader audience since your company is comprised of a range of ages, genders, learners, and tech users.

Engaging in a regular, year-round communication strategy for explaining employee benefits will support both the company as well as the employee. Set your strategy in motion by following the simple tips shared here. And, when you do this, you will see that your employees will reap the benefits of a healthy understanding of their benefit plan.

Exploring Disability Insurance

Exploring Disability Insurance

Disability insurance is a type of insurance coverage that replaces a portion of your monthly income in the event you are unable to perform your work functions due to illness or injury. This insurance gives both yourself, and those who are dependent on you and your paycheck, a sense of financial security while you are out of work. Let’s explore disability insurance.

Who Qualifies for Disability Insurance and Why?

According to the Social Security Administration, about 1 in 4 adults, who are currently in their 20’s, will have some sort of disabling event in their life that will cause them to be out of work for at least 3 months before they hit retirement age. And, while most people think that disability insurance is most used by those with an injury due to an accident, the majority of claims (90%) come from medical illnesses. In fact, the most common claims are related to cancer, back pain, cardiovascular disease, injury, pregnancy, and digestive disorders.

Types of Disability Insurance

There are two types of disability insurance than an individual can enroll in and one that is administrated by the government through the Social Security Administration. First, there is short-term disability insurance. This type pays paycheck benefits for, as the name suggests, a short-term disability due to injury or illness.  The time frame for these benefits is between 3-6 months and can cover between 40-60% of the participant’s income. Purchasing this type of insurance tends to be expensive and benefits usually begin about 14 days after the qualifying incident.

Long-term disability insurance pays between 60-80% of the participant’s income and typically lasts until they recover from the injury or illness or until a pre-determined number of years, for instance, until they are 65.  Benefits for long-term disability insurance usually begin after a 90-day waiting time.

Social Security Disability Insurance (SSDI) is administered by the Social Security Administration (SSA). To be eligible for these benefits, the person must be approved through a strict list of qualifications from the SSA, which can be found here. It is difficult to qualify for SSDI benefits and the average monthly benefit in 2019 was $1,234.

How to Enroll in Disability Insurance

When looking to buy disability insurance, first, look to see if your employer offers employer-sponsored coverage at work. Many times, employers pay for all or a portion of the premiums. Some employers offer disability insurance for employees to buy at a discounted rate as a voluntary benefit as part of their benefits package.  If you are part of a professional organization like a labor union or one for a specific profession, they may offer the ability to purchase disability insurance at a group rate. Also, you may purchase insurance through an insurance broker or directly from an insurance company.

COVID-19 and Disability Insurance

In some instances, disability insurance may cover the participant who is affected by the COVID-19 pandemic. Some benefits will cover if you are medically quarantined because of a positive COVID test or exposure to the coronavirus and you cannot complete your work function. This does not include state mandated “work from home orders.” Also, some COVID-19 survivors have lingering symptoms such as fatigue, headaches, and pain and these symptoms prevent them from being able to work. In these cases, short-term disability insurance may kick in. Check with your HR team or insurance broker to verify your coverage and eligibility.

Disability insurance provides the financial security needed by yourself and those who depend on you. In these uncertain times, having a backup plan in place will give you the confidence that an unforeseen illness or injury will not deplete your bank accounts while you get back on your feet. Check into disability insurance plans at your workplace, professional organization, or through a local broker. You and your family will be glad you did.

The information and content provided herein is for educational purposes only, and should not be considered legal, tax, investment, or financial advice, recommendation, or endorsement.