TL/DR: Balance billing can happen to you if you go out-of-network for health care.  

If you have a claim for care from an out-of-network provider (doctor, hospital, lab, etc.), and your plan carrier doesn’t cover the whole bill, you might be expected to pay the difference between what your plan carrier agrees to pay and what the provider expects to be paid. That’s balance billing—you get billed for the balance—and it’s in addition to your regular out-of-network cost share under your benefit plan.

Because out-of-network providers aren’t contracted with our plans, they’re not required to accept the carrier’s payment as “paid in full,” and you can get stuck paying the difference. (Workday cannot prevent the provider from passing on the difference.) Using in-network providers whenever possible protects you from this situation.

COBRA is the acronym for a federally mandated program which, under certain circumstances, allows a Workmate and/or eligible dependent(s) to continue health benefits provided by their Workday health plan (at the full cost) for a limited time when they lose their coverage. Learn more about COBRA.

If you’re covered by two different benefit plans (e.g., your medical coverage at Workday and medical coverage through your spouse), coordination of benefits describes how they work together. One plan pays first (the primary payer) and when applicable, the other plan (secondary payer) pays, well, second. 

If this applies to you, you can review your plan’s Evidence of Coverage (EOC) or Summary Plan Description (SPD). You can also call your plan carrier’s Member Services number for more details on how your two plans may coordinate.

Coinsurance is the amount—usually calculated as a percentage—that you pay for a service after you’ve met your deductible. For example, “20% coinsurance” means that, after you meet your deductible, you pay 20% of the cost, and your plan carrier pays 80%.

This is different from coinsurance. If your plan requires a copay, you’ll pay a preset amount for health care services. Some plans have copays just for office visits and prescription drugs, while other plans have different copays that are specific to the services you receive. 

A copay might apply even if you’ve already met your deductible, and copays don’t generally count toward your deductible. Check your plan’s Summary of Benefits for details.

Your deductible is how much you’ll pay out-of-pocket for eligible expenses each year before your plan carrier begins to pay its share of expenses. (Deductibles reset at the beginning of the plan year.) 

The deductible may not apply to all services, and some plans have separate deductibles for medical and prescription drug expenses. Check your plan’s Summary of Benefits for details.

An EOB is a summary of health care charges and payments that your plan carrier sends to you after you’ve seen a provider or incurred an expense for a service (lab work, for example). An EOB is not a bill; it’s meant to help you track the services you receive, how much of the cost is covered by your health plan, and how much you’re responsible for.

An EOC is a plan document explaining in detail what your plan does and does not cover, the plan’s limitations, and more. Pretty important stuff. An EOC expands upon what’s listed in a plan’s Summary of Benefits.

A plan carrier might ask you to complete the EOI process if you want to increase your coverage amount—think life insurance or accidental death and dismemberment (AD&D) insurance—or if you’re enrolling as a new hire and request a coverage amount higher than the guarantee issue amount. The EOI process typically involves the insured person answering questions about their health status and/or additional medical evaluation.

This identifies Workday’s plan to a provider or a plan carrier’s Member Services team, so they can look up details on how your specific coverage works. You can find your Group/Plan Number on your ID card, when you log in to your carrier’s website, or on Workspace.

Typically applying to life insurance, guarantee issue refers to the maximum amount of coverage a plan carrier will approve without requiring the person covered by the policy (the insured) to provide evidence of insurability (EOI).

When a company provides certain benefits at no cost to an employee, the IRS says the cost of that benefit must be counted as income. Imputed income is the income value or amount assigned to specific benefits where Workday covers some or all the cost, which may be subject to taxes. The IRS (not Workday) defines which benefits must be considered imputed income and how the amount is determined. 

Example 1: Workday automatically provides Workmates with basic life and AD&D insurance at 2x their annual salary, up to $1 million, at no cost. So, IRS regulations say the Workmate is responsible for paying imputed income tax on the cost of any coverage amount above $50,000. 

Example 2: If you are covering a domestic partner (which is not defined as a dependent by the IRS) through your health plan, you will owe imputed income tax on the value of that coverage. 

Workday cannot calculate a Workmate’s imputed income. You can find more information about imputed income in IRS Publication 15-B; but it’s best to talk to a tax professional if you have questions.

In-network

Your health plan covers more of the tab when you visit in-network providers, because they have contractual, negotiated prices with your plan carrier. 

Out-of-network

Your wallet may take a bigger hit when you visit a provider that does not accept or work with your plan and does not have a contractual relationship with Workday’s plan carriers. It typically costs you more to visit these providers, because you’re paying market price for treatment or services, and you may be subject to balance billing.

Form 1095-C

It’s a tax form Workday issues to Workmates that confirms the time period during the tax year that you were covered under an employer-sponsored plan. 

Form 1095-B

Kinda like the 1095-C, it’s also a tax form that confirms the time period during the tax year you were covered under an employer-sponsored plan, except this one is issued by a health plan carrier. The good news is, if your coverage was confirmed on the 1095-C, you probably won’t receive a 1095-B form.

The maximum amount a plan carrier will pay toward a specific service over the lifetime of an enrolled individual.

A form of leave payment that provides financial help when you can’t work for an extended period of time. Workday’s LTD insurance begins paying a benefit if you’re unable to work for over one year and continue to have an approved disability claim. Learn more about LTD.

The maximum amount a plan carrier will reimburse you for out-of-network services. You will typically need to refer to your plan’s EOC or SPD for information on how that maximum is calculated.

The OOP max is like a financial safety net that catches you if your medical expenses start piling up. Once your eligible expenses reach the OOP max, your plan carrier starts to cover eligible expenses at 100% for the rest of the plan year. Keep in mind that any costs you incur over the maximum reimbursable charge do not count toward the OOP max and are your responsibility to pay.

High-Deductible Health Plan (HDHP) 

This term is descriptive, but it leaves out two-thirds of the story! An HDHP is a type of medical plan with a higher deductible than other plans, but at Workday, it also comes with a lower paycheck cost. Also, Workmates who enroll in an HDHP may be eligible to open a Health Savings Account (HSA). Good stuff to know, right? 

HMO

Its full name is health maintenance organization (HMO), but everybody just uses its nickname. An HMO is a type of medical plan where all the providers are typically within a specific network, sometimes housed in one physical location. You usually must choose a primary care provider (PCP) who guides and manages your care and refers you to specialists as needed. 

Out-of-network providers and services are generally not covered by HMOs, except in the case of true medical emergencies. Review your plan’s documents, or call your plan carrier’s Member Services team for more details. 

PPO

A preferred provider organization PPO is a type of medical plan. A PPO will typically offer a network of providers to choose from, and using those in-network providers will generally save you money. You can visit any provider you choose, and you may not need a referral to see a specialist. A PPO generally offers coverage for out-of-network services, but you’ll pay more for that flexibility.

The 12-month period of coverage offered by a plan—like a subscription for your benefits that renews annually. Workday’s plan year for health care and most other benefits are based on the calendar year—January 1 through December 31.

In benefits, port is typically associated with a life insurance policy that is portable; meaning, you can transfer your policy to an individual one if you leave Workday or we no longer offer it. Outside of benefits, it can be a place for boats, a dessert wine, or the left side of a ship.

This is an easy one—the premium is how much it costs to have coverage under a plan. You contribute your share of the premiums for your Workday benefits through paycheck deductions, which are taken on a semimonthly basis (24 deductions per year). See premium contribution amounts.

You know that “ounce of prevention, pound of cure” thing? Totally about health care. Preventive care consists of routine health care services (like annual physicals, age-appropriate screenings, flu shots, visits, etc.) that are performed to help avoid bigger health issues. At Workday, eligible preventive care services are 100% covered under our medical plans.

This term is commonly used to refer to the expenses you can pay for with the funds in your Health Savings Account (HSA) or Health Care Flexible Spending Account. Qualifying health care expenses are defined and published by the IRS. For the latest version of the list of qualifying expenses, view Publication 502 on the IRS website.

This is benefits-speak for “when something happens that lets you change your benefits outside of Annual Enrollment”—like getting married, having a baby, your kid turning 26, etc. If you experience one of these events, you only have 60 calendar days—starting on the day of the event—to initiate a benefit change request and submit changes to your benefits in Workday. 

View a list of qualifying life events, and learn about making changes.

You’re automatically enrolled in the Workday Salary Continuation program, which continues a portion of your pay while you’re on a leave of absence. The length of time and the amount you’re paid depends on the type of leave you take and the state you live in. Learn more about salary continuation.

If you’re looking for plan highlights without too much nitty-gritty, the Summary of Benefits is your ticket. It outlines what your plan covers, deductible amounts, copays, coinsurance amounts, and more, but it’s less detailed than a Summary Plan Description (SPD) or Evidence of Coverage (EOC). 

A plan document that explains in detail what your plan does and does not cover, limitations, and plan terms. This document expands upon what’s listed in a plan’s Summary of Benefits.

Health Savings Account (HSA)

An HSA is a special kind of bank account for qualifying health care expenses. An HSA gives you three ways to save money on taxes (who doesn’t like that?), earns interest, and belongs to you (forever!). Better yet, Workday kicks in free money if you’re eligible. For details and eligibility terms, learn more about HSAs.

Flexible Spending Accounts (FSAs)

Flexible Spending Accounts let you set aside money from your paycheck that you can use to pay for certain eligible expenses—and you don’t pay income tax on that money. Sweet! But there are use-it-or-lose-it considerations.  

The Dependent Care FSA is for expenses you pay for child or adult day care services that allow you and your spouse or partner to work or attend school full time.

The Health Care FSA is for qualifying health care expenses that aren’t otherwise covered by a medical, dental, or vision plan—including copays, coinsurance, deductibles, and lots more.

The IRS says you can’t contribute to both a Health Care FSA and a Health Savings Account (HSA) in the same year. But you can have a Limited Purpose FSA which you can use for dental, hearing, and vision expenses until you reach your medical plan deductible. Then, you can start using it like a regular Health Care FSA.

The Health Care and Limited Purpose FSAs allow you to carry over a limited amount of funds into the following year.

Get the lowdown on Flexible Spending Accounts.

Health services online or over the phone. It’s a doctor visit, minus the hassle, the driving, and the waiting room blues. And you can do it from pretty much anywhere in the United States. Learn more about virtual care.