HEALTH COVERAGE MEDICAL TERMS Flashcards
What is the Allowed Amount?
This is the maximum payment the plan will pay for a covered health care service. May also be called ‘eligible expense’, ‘payment allowance’, or ‘negotiated rate’.
What is an Appeal?
A request that your health insurer or plan review a decision that denies a benefit or payment (either in whole or in part).
What is Balance Billing?
When a provider bills you for the balance remaining on the bill that your plan doesn’t cover.
What is a Claim?
A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered.
What is Coinsurance?
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.
What are Complications of Pregnancy?
Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section generally aren’t complications of pregnancy.
What is a Copayment?
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.
What is Cost Sharing?
Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called ‘out-of-pocket costs’). Some examples of cost sharing are copayments, deductibles, and coinsurance.
What are Cost-sharing Reductions?
Discounts that reduce the amount you pay for certain services covered by an individual plan you buy through the Marketplace. You may get a discount if your income is below a certain level, and you choose a Silver level health plan or if you’re a member of a federally recognized tribe.
