insurance cvrg

Question 1

Allowed Amount

Answer 1

Maximum payment the plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”

Question 2

Appeal

Answer 2

A request for your health insurer or plan to review a decision that denies a benefit or payment.

Question 3

Balance Billing

Answer 3

When a provider bills you for the difference between the provider’s charge and the allowed amount. Typically occurs with out-of-network providers.

Question 4

Coinsurance

Answer 4

Your share of costs for a covered service, expressed as a percentage (e.g., 20%) of the allowed amount.

Question 5

Complications of Pregnancy

Answer 5

Conditions requiring medical care during pregnancy, labor, and delivery to prevent serious harm. Routine morning sickness and elective C-sections are generally not included.

Question 6

Copayment (Copay)

Answer 6

A fixed amount (e.g., $15) you pay for a covered health service, typically at the time of service.

Question 7

Cost Sharing

Answer 7

Your out-of-pocket share for covered services, such as copayments, coinsurance, and deductibles. It doesn’t include premiums or costs for services not covered.

Question 8

Cost-sharing Reductions

Answer 8

Discounts that lower the amount you pay for covered services, available through the Health Insurance Marketplace for qualifying individuals.

Question 9

Deductible

Answer 9

The amount you must pay for covered services before your health insurance starts to pay.

Question 10

Diagnostic Test

Answer 10

Tests used to identify or diagnose a health condition, e.g., X-rays.

Question 11

Durable Medical Equipment (DME)

Answer 11

Equipment ordered by a healthcare provider for long-term use, e.g., wheelchairs and oxygen equipment.

Question 12

Emergency Medical Condition

Answer 12

A severe illness or injury requiring immediate medical attention to prevent serious health risks.

Question 13

Emergency Medical Transportation

Answer 13

Ambulance services for emergencies, including transport by air, land, or sea.

Question 14

Emergency Room Care/Services Services

Answer 14

provided in an emergency room to diagnose and stabilize an emergency medical condition.

Question 15

Excluded Services

Answer 15

Services that your plan does not cover.

Question 16

Formulary

Answer 16

A list of prescription drugs covered by your plan, organized by cost-sharing tiers.

Question 17

Grievance

Answer 17

A formal complaint to your insurer about a health plan issue.

Question 18

Habilitation Services

Answer 18

Services to help individuals develop or improve skills, e.g., therapy for children with developmental delays.

Question 19

In-network Coinsurance

Answer 19

Your share of costs for covered services from in-network providers, typically lower than out-of-network coinsurance.

Question 20

In-network Copayment

Answer 20

A fixed amount you pay for services provided by in-network providers.

Question 21

Marketplace (Exchange)

Answer 21

A platform for comparing and purchasing health plans, with options for financial assistance.

Question 22

Maximum Out-of-pocket Limit

Answer 22

The most you pay for covered services in a year before your plan covers 100% of the costs.

Question 23

23 Medically Necessary

Answer 23

Services or supplies required to diagnose or treat a condition that meet accepted medical standards.

Question 24

Minimum Essential Coverage

Answer 24

Basic health coverage that meets the individual mandate requirements.

Question 25

Network

Answer 25

Providers and facilities contracted by your insurer to offer discounted rates.

Question 26

Orthotics and Prosthetics

Answer 26

Devices such as braces or artificial limbs, including necessary adjustments and repairs.

Question 27

Out-of-network Provider (Non-preferred Provider)

Answer 27

A provider without a contract with your insurer. Costs for using these providers are usually higher.

Question 28

Out-of-pocket Limit

Answer 28

The maximum amount you pay for covered services in a year, excluding premiums or non-covered costs.

Question 29

Physician Services .

Answer 29

Services provided by a licensed medical doctor (M.D. or D.O.)

Question 30

Plan

Answer 30

Health coverage offered directly to individuals or through employers, unions, or other groups.

Question 31

Preauthorization

Answer 31

Approval from your insurer for specific services before they are received.

Question 32

Premium

Answer 32

The amount paid for health insurance coverage, typically monthly or annually.

Question 33

Preventive Care

Answer 33

Routine health care, like check-ups or screenings, to prevent or detect illness early.

Question 34

Reconstructive Surgery

Answer 34

Surgery to correct or improve body parts due to birth defects, injuries, or medical conditions.

Question 35

Referral

Answer 35

A primary care provider’s written recommendation for specialist care or specific services.

Question 36

Rehabilitation Services

Answer 36

Services to recover or improve skills lost due to illness or injury, e.g., physical or speech therapy.

Question 37

Screening

Answer 37

Tests to detect potential health conditions before symptoms appear.

Question 38

Skilled Nursing Care

Answer 38

Nursing services provided or supervised by licensed nurses, typically in a home or facility setting.

Question 39

Specialist

Answer 39

A provider focusing on a specific field of medicine or patient group.

Question 40

Specialty Drug

Answer 40

High-cost medications requiring special handling or monitoring.

Question 41

Urgent Care

Answer 41

Medical care for conditions needing prompt attention but not severe enough for emergency room care.