Allowed Amount 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. (See Balance Billing.)

Appeal

A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing

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.

Broker

A licensed person or organization you pay to look for insurance on your behalf.

Cancellation

The termination of insurance coverage during the policy period. Flat cancellation is the cancellation of a policy as of its effective date, without any premium charge.

Children's Health Insurance Program (CHIP)

A program offering coverage to children from families that may not qualify for Medicaid but cannot afford private insurance. May be applied for at any time.

Claim

Notice to an insurer that under the terms of a policy, a loss maybe covered.

Claimant

The first or third party; any person who asserts right of recovery.

Co-insurance

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.

Co-payment

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.

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 non-emergent cesarean section aren’t complications of pregnancy.

Decline

The company refuses to accept the request for insurance coverage.

Deductible

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.

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Emergent Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergent Medical Transportation

Ambulance services for an emergency medical condition.

Emergent Services

Evaluation of an emergent medical condition and treatment to keep the condition from getting worse.

Expiration Date

The date on which the policy ends

Grace Period

A specified period immediately following the premium due date during which a payment can be made to continue a policy in force without interruption. Check your policy to be sure that a grace period is offered and how many days, if any, are allowed.

Health Insurance

A policy that will pay specified sums for medical expenses or treatments.

Health Insurance Literacy

The knowledge, ability, and confidence to effectively choose and use health insurance

Health Savings Account (HSA)

An account which allows individuals to pay for current expenses while saving for future qualified medical expenses on a pre-taxed basis.

High Deductible Health Plan (HDHP)

Health plan product that combines a health savings account (HSA) with traditional medical coverage. Typically include higher annual deductibles and out-of-pocket maximums, but preventative care services are fully covered.

In Network

Facilities, providers, and suppliers like doctors, hospitals, and pharmacies that your health insurance company contracts with to provide health care at a discounted rate.

Incontestable Clause

A policy provision in which the company agrees not to contest the validity of the contract after it has been in force for a certain period of time, usually two years.

Insured

The policyholder; the person(s) protected in case of a loss or claim.

Insurer

The insurance company.

Marketplace Plan

An insurance plan operated through the federal government, where people can shop and apply for health insurance. You will need your income, household information, and employer information to see if you qualify.

Open Enrollment

The designated time each year when you can purchase, apply for, and make changes to an insurance plan for the upcoming year. It is typically November 15th through December 1st, unless modified by an employer.

Out of Network

Facilities, providers, and suppliers like doctors, hospitals, and pharmacies that your health insurance company does not contract with. Going to an out of network facility is typically associated with a higher rate.

Out of Pocket Maximum

A limit in the amount of money paid for covered health care services in a plan year. If met, your health plan will pay 100% of all covered health care costs for the rest of the year.

Policy

The written contract of insurance.

Policy Limit

The maximum amount a policy will pay, either overall or under a particular coverage.

Preferred provider organization (PPO)

A type of health plan that contracts with medical providers to create a network of participating providers. Costs are lower within the network and higher outside of the network for healthcare.

Premium

The amount of money an insurance company charges for insurance coverage.

Qualifying Life Event

Any change in a personal situation (loss of coverage, changes in household, changes in residence, or other similar events) that make you eligible for a Special Enrollment period outside yearly Open Enrollment.

Quote

An estimate of the cost of insurance, based on information supplied to the insurance company by the applicant.

Reinstatement

The restoring of a lapsed policy to full force and effect. The reinstatement may be effective after the cancellation date, creating a lapse of coverage. Some companies require evidence of insurability and payment of past due premiums plus interest.