insurance cvrg Flashcards
Allowed Amount
Maximum payment the plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
Appeal
A request for your health insurer or plan to review a decision that denies a benefit or payment.
Balance Billing
When a provider bills you for the difference between the provider’s charge and the allowed amount. Typically occurs with out-of-network providers.
Coinsurance
Your share of costs for a covered service, expressed as a percentage (e.g., 20%) of the allowed amount.
Complications of Pregnancy
Conditions requiring medical care during pregnancy, labor, and delivery to prevent serious harm. Routine morning sickness and elective C-sections are generally not included.
Copayment (Copay)
A fixed amount (e.g., $15) you pay for a covered health service, typically at the time of service.
Cost Sharing
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.
Cost-sharing Reductions
Discounts that lower the amount you pay for covered services, available through the Health Insurance Marketplace for qualifying individuals.
Deductible
The amount you must pay for covered services before your health insurance starts to pay.
Diagnostic Test
Tests used to identify or diagnose a health condition, e.g., X-rays.
Durable Medical Equipment (DME)
Equipment ordered by a healthcare provider for long-term use, e.g., wheelchairs and oxygen equipment.
Emergency Medical Condition
A severe illness or injury requiring immediate medical attention to prevent serious health risks.
Emergency Medical Transportation
Ambulance services for emergencies, including transport by air, land, or sea.
Emergency Room Care/Services Services
provided in an emergency room to diagnose and stabilize an emergency medical condition.
Excluded Services
Services that your plan does not cover.
Formulary
A list of prescription drugs covered by your plan, organized by cost-sharing tiers.
Grievance
A formal complaint to your insurer about a health plan issue.
Habilitation Services
Services to help individuals develop or improve skills, e.g., therapy for children with developmental delays.
In-network Coinsurance
Your share of costs for covered services from in-network providers, typically lower than out-of-network coinsurance.
In-network Copayment
A fixed amount you pay for services provided by in-network providers.
Marketplace (Exchange)
A platform for comparing and purchasing health plans, with options for financial assistance.
Maximum Out-of-pocket Limit
The most you pay for covered services in a year before your plan covers 100% of the costs.
23 Medically Necessary
Services or supplies required to diagnose or treat a condition that meet accepted medical standards.
Minimum Essential Coverage
Basic health coverage that meets the individual mandate requirements.
