Glossary
Benefits, decoded.
Seventy benefits terms in plain English. Definitions written from regulatory sources (IRS, DOL, CMS, NY DFS). Reviewed annually for the current plan year.
The short version
The TMRW Benefits glossary covers 70 essential health insurance and employee benefits terms — from ICHRA and ERISA to QSEHRA, Form 5500, HSA, HDHP, COBRA, and more. Definitions are written in plain English from primary regulatory sources (IRS, DOL, CMS, NY DFS) and reviewed annually for the current plan year. Each term has its own page with cross-links to related concepts.
Plan types
8 terms
HMO (Health Maintenance Organization)
In-network only with PCP referrals. Lowest premiums.
Read definitionPPO (Preferred Provider Organization)
See any provider, no referrals. Broadest networks.
Read definitionEPO (Exclusive Provider Organization)
In-network only, but no referrals required.
Read definitionPOS (Point of Service)
Hybrid HMO/PPO. Requires PCP but covers some out-of-network.
Read definitionHDHP (High-Deductible Health Plan)
Higher deductible, lower premium. Pairs with an HSA.
Read definitionCatastrophic plan
Low-premium ACA plan for under-30s or hardship-exempt.
Read definitionShort-term medical
Bridge coverage. NOT ACA-compliant.
Read definitionHealth-sharing ministry
Faith-based cost-sharing. Not insurance.
Read definitionCost-sharing
8 terms
Premium
Monthly payment to keep coverage active.
Read definitionDeductible
Out-of-pocket amount you pay before insurance starts paying.
Read definitionCopay
Flat fee per service. Often not subject to the deductible.
Read definitionCoinsurance
Percentage of cost you pay after deductible.
Read definitionOut-of-pocket maximum (OOP max)
Annual cap on your covered in-network costs.
Read definitionAllowed amount
Maximum the plan considers reasonable for a service.
Read definitionBalance billing
Out-of-network provider bills you the gap.
Read definitionCost-sharing reduction (CSR)
ACA subsidy lowering deductibles and copays on Silver plans.
Read definitionTax-advantaged accounts
9 terms
HSA (Health Savings Account)
Triple-tax-advantaged. Pairs with HDHP. Rolls over.
Read definitionFSA (Flexible Spending Account)
Pre-tax employer account. Use it or lose it.
Read definitionLimited-purpose FSA
FSA for dental and vision only. HSA-compatible.
Read definitionDependent Care FSA (DCFSA)
Pre-tax account for childcare or eldercare expenses.
Read definitionHRA (Health Reimbursement Arrangement)
Employer-funded reimbursement account.
Read definitionICHRA (Individual Coverage HRA)
Employer reimburses for individual insurance. No size limits.
Read definitionQSEHRA (Qualified Small Employer HRA)
HRA for under-50-FTE employers without group health.
Read definitionEBHRA (Excepted Benefit HRA)
Limited supplemental HRA. Low annual cap.
Read definitionGCHRA / Integrated HRA
Group-coverage HRA supplementing a traditional group plan.
Read definitionFunding models
9 terms
Fully-insured plan
Carrier takes claims risk. Fixed premium.
Read definitionSelf-funded (self-insured) plan
Employer pays claims directly. Stop-loss limits risk.
Read definitionLevel-funded plan
Hybrid self-funded with stop-loss. Year-end refund possible.
Read definitionStop-loss insurance
Caps employer exposure on catastrophic claims.
Read definitionSpecific stop-loss
Caps individual-claimant exposure.
Read definitionAggregate stop-loss
Caps total annual group claims.
Read definitionMEWA (Multiple Employer Welfare Arrangement)
Health plan covering employees of multiple unrelated employers.
Read definitionTPA (Third-Party Administrator)
Processes claims for self-funded plans. Not a carrier.
Read definitionPBM (Pharmacy Benefit Manager)
Manages prescription drug benefits.
Read definitionCompliance & legal
12 terms
ERISA (Employee Retirement Income Security Act of 1974)
Federal law governing most private-sector benefit plans.
Read definitionCOBRA (Consolidated Omnibus Budget Reconciliation Act)
Continue group coverage up to 18-36 months after losing eligibility.
Read definitionACA (Affordable Care Act)
2010 federal law restructuring U.S. health insurance markets.
Read definitionHIPAA (Health Insurance Portability and Accountability Act of 1996)
Federal law protecting health information privacy.
Read definitionSection 125 (Cafeteria plan)
IRS code allowing pre-tax benefits payments.
Read definitionPremium-only plan (POP)
Simplest Section 125 plan. Pre-tax premiums only.
Read definitionMEC (Minimum Essential Coverage)
Coverage level satisfying ACA mandate requirements.
Read definitionACA essential health benefits
Ten benefit categories ACA-compliant plans must cover.
Read definitionESR (Employer Shared Responsibility)
ACA penalty rule for ALEs not offering affordable coverage.
Read definitionALE (Applicable Large Employer)
Employer with 50+ FTEs. Subject to ESR rules.
Read definitionFPL (Federal Poverty Level)
Federal income threshold defining poverty.
Read definitionCommon-law employee
IRS-defined employee subject to employer control.
Read definitionFiling & administration
9 terms
Form 5500
Annual ERISA report for plans with 100+ participants.
Read definitionSPD (Summary Plan Description)
Plain-language plan explanation for participants.
Read definitionPlan Document
Legal document establishing an ERISA plan.
Read definitionWrap document
Combines carrier certs with ERISA elements.
Read definitionSAR (Summary Annual Report)
Annual Form 5500 summary for participants.
Read definitionForm 1094-C / 1095-C
IRS ACA reporting forms for ALEs.
Read definitionSBC (Summary of Benefits and Coverage)
Standardized ACA plan-comparison summary.
Read definitionCHIP notice
Annual employer notice about Medicaid/CHIP premium assistance.
Read definitionFiduciary
Person with legal duty to act in plan participants' interest.
Read definitionNetworks & providers
6 terms
In-network
Providers contracted with your insurer at negotiated rates.
Read definitionOut-of-network
Providers without an insurer contract. Higher cost.
Read definitionNarrow network
Smaller-than-typical provider network. Lower premiums.
Read definitionPCP (Primary Care Physician)
Main doctor coordinating care. Required for HMOs.
Read definitionProvider directory
Carrier list of in-network providers.
Read definitionTiered network
Providers grouped into tiers with different cost-sharing.
Read definitionPharmacy
5 terms
Formulary
List of drugs covered by a plan, in tiers.
Read definitionPrior authorization
Insurer pre-approval for certain treatments.
Read definitionStep therapy
Try lower-cost drugs before insurer covers expensive alternatives.
Read definitionGeneric vs brand drugs
Generic = same chemistry, lower cost than brand.
Read definitionSpecialty drug
High-cost drug for complex conditions. Higher tier.
Read definitionEnrollment
5 terms
Open Enrollment Period (OEP)
Annual ACA marketplace enrollment window.
Read definitionSpecial Enrollment Period (SEP)
60-day window after a qualifying life event.
Read definitionQualifying Life Event (QLE)
Event triggering a Special Enrollment Period.
Read definitionWaiting period
Time before new hires become eligible for benefits.
Read definitionRetroactive enrollment
Coverage backdated to an earlier effective date.
Read definitionGovernment programs
6 terms
Medicare
Federal program for age 65+ and certain disabilities.
Read definitionMedicare Advantage (Part C)
Private-carrier-administered Medicare plans.
Read definitionMedicaid
Federal-state low-income health program.
Read definitionCHIP (Children's Health Insurance Program)
Federal-state coverage for children above Medicaid threshold.
Read definitionTRICARE
Health coverage for military service members and families.
Read definitionVA (Veterans Affairs) health care
Department of Veterans Affairs health system.
Read definitionACA-specific terms
6 terms
Premium tax credit (PTC)
ACA subsidy reducing marketplace premiums for 100-400% FPL.
Read definitionSubsidy cliff
Income threshold where ACA subsidies disappear.
Read definitionMetal tier
ACA marketplace plan classification by actuarial value.
Read definitionHealthcare.gov
Federal ACA marketplace website.
Read definitionNY State of Health
New York's state-based ACA marketplace.
Read definitionMarketplace
ACA exchange where individuals shop for plans.
Read definitionBroker & industry
5 terms
Broker
Licensed insurance professional representing multiple carriers.
Read definitionGeneral Agency (GA)
Wholesale carrier distributor sub-appointing brokers.
Read definitionCaptive agent
Agent representing a single carrier.
Read definitionNAIC
National Association of Insurance Commissioners.
Read definitionState DFS / DOI
State insurance regulator. NY = DFS; most states = DOI.
Read definitionTerm not listed?
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