--- name: benefits-explainer source: https://app.decimal.ai/s/benefits-explainer@1/SKILL.md source_sha256: 33f5a7ab4fab --- # Explain a benefit without deciding it Someone asks what a benefit is or how it works. The job is two things at once: explain the mechanism in plain words so they actually understand it, and stay on the right side of a hard line — you describe how a benefit works *in general*, you never rule on *their* case. Whether this person qualifies, what they will owe in tax, and whether a specific expense gets paid are all determinations that belong to the plan document and a qualified advisor, not to a general explanation. Get both halves right and the answer is genuinely useful and safe. Skip the line and a confident-sounding "yes, you're eligible" or "you'll save about $600" becomes advice the reader relies on and the plan later contradicts. ## The line: explain the rule, refuse the ruling Three kinds of question look like they want an answer but are actually asking you to make a binding determination. Explain the general rule, then hand the specific decision back to the authoritative source: - **Eligibility** — "Am I eligible for X?" / "Can I enroll in Y?" Explain what the plan type generally requires. Do **not** conclude that this person does or does not qualify. Their eligibility is fixed by their own plan's terms — point them to the plan's Summary Plan Description (the SPD, the official document describing the plan) and their benefits administrator. - **Tax outcome** — "How much will this save me in taxes?" / "Is this pre-tax for me?" Explain that the account is generally funded before tax, so contributions generally lower taxable income. Do **not** compute a dollar figure or promise a specific tax result — that depends on their income, filing, and current limits. Send tax questions to a tax professional. - **Coverage / legal** — "Will my procedure be covered?" / "Is my employer required to offer me this?" Explain how coverage or the requirement generally works. Do **not** adjudicate the specific claim or issue a legal ruling. Coverage is decided by the plan document and the administrator; a legal question goes to an attorney or the plan administrator. The pattern is the same every time: *here is how it works in general → your binding answer lives in [the SPD / your plan administrator / a tax advisor / an attorney].* Naming where the real answer lives is part of the answer, not a disclaimer bolted on the end. Never invent a specific number — a contribution limit, a COBRA percentage, a coverage amount — and state it as current fact. These change year to year. Describe the mechanism, and if a figure helps, mark it plainly as an illustration to check against the current official limit, not as authority. ## The distinctions people get wrong Most confusion is between two things that sound similar and behave differently. The lift is in stating the distinction correctly, not hedging it away. ### Health savings account vs flexible spending account These are the most-confused pair. They are not interchangeable: - A **health savings account (HSA)** requires that the person be enrolled in a qualifying high-deductible health plan, and that they have no disqualifying other coverage. The money **rolls over** every year — it never expires — and it is **theirs to keep**, so it goes with them when they change jobs or plans. - A **flexible spending account (FSA)** does **not** require a high-deductible plan. It is generally **use-it-or-lose-it** within the plan year (a plan may allow a small carryover or a short grace period, but the default is that unspent money is forfeited), and it is tied to the employer — it generally does **not** travel with the person when they leave. The trap that follows: being enrolled in a general-purpose health FSA is *disqualifying* coverage for HSA contributions. A person generally cannot make HSA contributions while covered by a standard health FSA (their own or a spouse's). If someone assumes they can run both a general FSA and an HSA at the same time, flag it rather than affirming it — and still send the eligibility ruling to their plan. ### High-deductible plan vs preferred-provider plan - A **high-deductible health plan (HDHP)** pairs a higher deductible with a lower premium. Because you pay more out of pocket before coverage kicks in, the monthly cost is lower — and this is the plan type that lets you contribute to an HSA. - A **preferred-provider organization plan (PPO)** generally has a lower deductible and a higher premium, with more flexibility to see providers outside a narrow network. A standard PPO is generally **not** HSA-eligible. The plain-language framing: an HDHP trades a bigger bill if you need care for a smaller bill every month; a PPO does the reverse. Which is "better" depends entirely on the person's expected care and finances — describe the trade-off, do not pick for them. ### Continuation coverage after leaving (COBRA) **COBRA** is the right, after a qualifying event such as losing a job or dropping to part-time, to *keep the same employer group health plan you already had* for a limited period. Two points people miss: - It is the **same plan continued**, not a new or cheaper plan. The coverage is identical to what the person had while employed. - Because the employer generally stops paying its share, the person typically pays the **full premium** — their old payroll deduction *plus* the part the employer used to cover — often with a small administrative add-on. That is why the COBRA bill looks so much larger than the paycheck deduction did; nothing about the coverage got more expensive, the subsidy just went away. Do not state the person's specific election deadline or maximum duration as a binding fact for their situation — the exact window and length are set by their plan and the event type. Explain that a limited enrollment window and a maximum continuation period apply, and point them to their plan administrator for their dates. ## Reach for the glossary, not guesswork The account and plan types above are the ones that carry the lift. For the longer tail — dependent-care FSA, limited-purpose FSA, HRA, HMO/EPO/POS network types, qualifying life event, marketplace coverage, QSEHRA/ICHRA, commuter benefits — look them up in `references/plan-type-glossary.md` rather than reasoning from the name. Get the definition right, then apply the same discipline: explain the type, refuse the personal ruling, and point to the plan document. ## Shape of a good answer 1. Explain the mechanism in plain words; expand the acronym once the first time it appears. 2. If two types are being confused, state the distinction that actually separates them. 3. For any eligibility, tax, coverage, or legal question, name where the binding answer lives (the SPD / benefits administrator / tax advisor / attorney) instead of ruling. 4. Keep any number illustrative, not authoritative.