When you are billed by a provider 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 $60, you may be billed by the provider for the remaining $40.
Your share of the cost of a covered healthcare service, calculated as a percent of the allowed amount for the service, typically after you meet your deductible.
The fixed amount you pay for healthcare services received, as determined by your insurance plan.
The amount you owe for healthcare services before your insurance begins to pay its portion. For example, if your deductible is $1,000, your plan does not pay anything until you’ve paid $1,000 for covered services. This deductible may not apply to all services, including preventive care.
Evidence of Insurability is the process of providing health information to the insurance company when you apply for certain benefits, like Life or Critical Illness Insurance, above the Guaranteed Issue amount. The insurer uses this information to decide if you qualify for coverage and at what amount. Approval is required before you can receive the additional coverage.
A statement from your insurance carrier that explains which services were provided, their cost, what portion of the claim was paid by the plan, and what portion is your liability, in addition to how you can appeal the insurer’s decision.
A special tax-free account you put money into that you use to pay for certain out-of-pocket healthcare costs. You’ll save an amount equal to the taxes you would have paid on the money you set aside. FSAs are “use it or lose it,” so funds not used by the end of the plan year will be lost. Some Healthcare FSAs do allow for a grace period or rollover into the next plan year.
A pre-tax benefit account used to pay for eligible medical, dental, and vision care expenses that aren’t covered by your insurance plan. All expenses must be qualified as defined in Section 213(d) of the Internal Revenue Code.
A pre-tax benefit account used to pay for dependent care services. For additional information on eligible expenses, refer to Publication 503 on the IRS website.
Guaranteed Issue means you can enroll in a benefits plan, like Critical Illness or Life Insurance, without answering any health questions or going through a medical exam. If you sign up during the Guaranteed Issue period, you are automatically approved for coverage up to a certain amount, making it easier to get protection for you and your family.
Also known as market transparency or medical transparency. Online cost transparency tools, available through health insurance carriers, allow you to search an extensive national database to compare varying costs for services.
A group of physicians, hospitals, and healthcare providers that have agreed to provide medical services to a health insurance plan’s members at discounted costs.
Providers that contract with your insurance company to provide healthcare services at the negotiated carrier discounted rates.
Providers that are not contracted with your insurance company. If you choose an out-of-network provider, services will not be covered at the in-network negotiated carrier discounted rates.
Providers that have declined entering into a contract with your insurance provider. They may not accept any insurance and you could pay for all costs out of pocket.
The period set by the employer during which employees and dependents may enroll for coverage.
The most you pay during the plan year before your health insurance begins to pay 100% of the allowed amount. This does not include your premium, out-of-network provider charges beyond the Reasonable & Customary, or healthcare your plan doesn’t cover. Check with your carrier to confirm what applies to the maximum.
Medications available without a prescription.
Medications prescribed by a doctor. Cost of these medications is determined by their assigned tier: generic, preferred, non-preferred, or specialty.
Drugs approved by the U.S. Food and Drug Administration (FDA) to be chemically identical to corresponding preferred or non-preferred versions. Usually the most cost-effective version of any medication.
Brand-name drugs on your provider’s approved list (available online).
Brand-name drugs not on your provider’s list of approved drugs. These drugs are typically newer and have higher copayments.
Prescription medications used to treat complex, chronic, and often costly conditions. Because of the high cost, many insurers require that specific criteria be met before a drug is covered. These medications are usually required to be filled at a specific pharmacy.
A requirement that your physician obtain approval from your health insurance plan to prescribe a specific medication for you.
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 R&C amount is sometimes used to determine the allowed amount. Also known as the UCR (Usual, Customary, and Reasonable) amount.
Mandated by healthcare reform, you are provided with a summary of your benefits and plan coverage.
The document(s) that outline the rights, obligations, and material provisions of the plan(s) to all participants and their beneficiaries.