The minimum number of hours per week that an employee is required to work to qualify for and maintain eligibility for benefits.

A trained expert who can help you understand or apply for benefit programs. Their goal is to help you avoid financial complications while developing a sustainable plan for the future. To find a benefits planner in California, use the DB101 Benefits Planner Directory.

A program that pays for private health insurance premiums for individuals who are disabled due to HIV or AIDS and who do not qualify for Medi-Cal/HIPP. Enrollment is administered through AIDS organizations authorized by CARE/HIPP.

The portion of the payment for medical services that an individual is responsible for. For example, your health coverage may pay for 80% of the costs of a service, while you will have to pay the remaining 20%.

The federal government pays benefits planners in communities around the country to help people think ahead about work incentives and benefits issues. CWIC'S are benefits planners who are trained by the Social Security Administration to assist beneficiaries with programs including Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) in addition to other related programs.

A set amount you have to pay when you receive medical services. For example, you may have to pay $10 or $20 every time you visit the doctor or get a prescription refilled. This is known as a "copayment."

The date an individual is enrolled in coverage. The effective date is usually not the same as the date of hire.

The amount an individual is responsible for paying for health care services before the insurer begins to pay.

A person, usually a child, who is economically dependent on another person. Different programs have different specific definition of when someone is a dependent.

Definition of disability may be two-tiered: an inability to participate in the employee's own occupation (regular work) on the first tier, and an inability to participate in any occupation (any work) on the second tier. Refer to policy for definitions of disability.

A service that a health coverage plan won't pay for. Cosmetic surgery, for example, is not covered under most plans.

A statement from your health insurance company showing the health care services you have received and how much the insurance company has paid for those services.

A plan where an insurance company takes on the risk. In general, health coverage protections specific to California only apply to fully-insured plans, and self-insured plans are regulated by federal laws. Ask your employer or health plan which type of plan you are participating in.

Coverage offered to an individual through a group, such as employer-sponsored, association-affiliated or professional group coverage.

A common type of health care coverage plan. HMOs require that you only see certain doctors and that your primary care physician decides when you need to see a specialist.

A type of health insurance plan. You pay monthly premiums and usually have coinsurance and a yearly deductible as well. Also known as fee-for-service.

The first time an individual is eligible to enroll in a group’s benefits programs. During this period, the individual’s medical history is not subject to review. Once enrolled, however, pre-existing condition exclusionary periods may apply.

A limit of how much an insurer will spend on you. For example, a plan might cover medical costs until they've spent $100,000, at which point they will no longer help pay for your medical costs.

A window of time prior to enrollment in a new health plan used to define pre-existing conditions. If, for example, your health plan has a “6-month look-back,” any health condition that you received medical advice, diagnosis, care, or treatment for within the six months prior to enrollment would be considered a pre-existing condition.

Any medical care received by an individual for a medical condition. Examples of medical treatment include being prescribed medication, physician consultations, and therapy for a mental or physical condition.

The review of an individual’s medical history and/or medical records to determine if the individual is eligible for coverage. Medical underwriting, which may include new medical testing, can be used to deny coverage or determine if a particular pre-existing condition will be covered.

A group of doctors or medical service providers who have signed a contract with a health coverage plan. If you have health coverage through a Health Maintenance Organization (HMO), you generally have to see doctors within the network. Preferred Provider Organizations (PPOs) and Point of Service (POS) plans allow you to see doctors outside of your network, but you will have to pay more.

The annual time period when an individual may add or change coverage in an employer-provided or association-affiliated insurance plan. Changes during most of these annual periods will require medical underwriting to add benefits not elected during the initial enrollment period. The federal government calls this period "open season", and other insurers may use different terms.

The maximum amount of money that you have to spend on health costs in a year. After you reach the out-of-pocket maximum, your policy will pay the entire cost of covered services. The out-of-pocket maximum does not count the premiums you pay and certain other costs may or may not be counted.

A type of health coverage that allows you to choose between HMO, PPO, and Indemnity coverage. You can choose to pay less and have your care managed by a physician, or pay more to have more choices in the doctors you can see.

Any condition for which “medical care” was received within six months prior to the effective date of insurance coverage. Medical care includes the use of prescription drugs and physician consultations and services. During a pre-existing condition exclusionary period, coverage for that condition is either not provided or can be limited.

The period of time from the coverage effective date that the insurer does not cover a pre-existing medical condition. The individual will normally be covered for the condition once the specified time has elapsed.

A type of health insurance plan. You pay a monthly premium and, when you use medical services, copayments and deductibles. PPOs have networks of physicians. You can see any doctor in the network without getting prior authorization from a primary care physician. Seeing a doctor outside of the network is more expensive.

A regularly scheduled payment to an insurer or health care plan.

The doctor, nurse practitioner, or other medical service provider who is in charge of your medical care in a Health Maintenance Organizations (HMO). In HMOs, you have to see a PCP in order to get a referral to see a specialist. Other types of health coverage might not have PCPs, or might charge you more if you see a specialist without getting a referral from a PCP.

In some cases, your doctor or medical service provider must get permission from your health care plan before providing you with certain services. This is known as "prior authorization."

Coverage that is not funded by local, state or federal government. Private health coverage can be paid for by an individual, employer, or association.

A plan that covers an individual’s medical expenses with company funds set aside to pay health claims. In general, self-insured plans are subject to federal, but not state, health coverage laws. Ask your employer or plan to find out if you are in a self-insured plan.

The period of time an individual is required to be employed by a company or be a member of an association before becoming eligible to enroll for the group’s health coverage. Also known as the minimum service requirements.

Rights that allow an individual to qualify for health coverage without having to undergo medical underwriting. Special Enrollment Rights can be requested from an employer within 30 days after previous health coverage is exhausted or terminated. They apply to individuals who do not enroll during the initial enrollment period or have lost their health coverage.

See Service Wait.