Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. Back to Glossary

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Back to Glossary

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Ambulance services for an emergency medical condition. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Health care services that your health insurance or plan doesn’t pay for or cover. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Care in a hospital that usually doesn’t require an overnight stay. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium. balance-billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or pre-certification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Back to Glossary Interested in a Free Benefits Consultation? LET’S MEET