Allowed charge: Allowed charge is a discounted fee that an insurer negotiates with hospitals doctors, and other healthcare companies within their network to reduce costs. This is the main reason why you get lower charges on your medical bills when you visit doctors within your network because they accept discounted fees.
Allowed Maximum Benefits: Allowed Maximum Benefits refers to the maximum amount of benefit an insurer will pay per year. You must pay the difference in costs if your healthcare costs become so expensive that it goes over your allowed maximum benefit.
Benefits: Your benefits are coverage such as supplies or services that your healthcare provider agrees to cover. The services, covered benefits and excluded services may vary from plan to plan.
Catastrophic coverage: Catastrophic coverage provides health services for expensive services such as hospitalization. Because catastrophic plans have a lower premiums, it might seem appealing but they also have a high deductable so you could be paying as much as $ 10,000 before your insurance company picks up your coverage.
Claim : A claim is a request to the insurance company to make payments for the services or supplies that are covered by the insurance plan such as hospital bills, doctor’s payment, medication, or any other health provider.
Co-insurance: This is a percentage of the bill amount that has to be paid by the consumer when the medical expenses are being paid for.
Copay : A fixed dollar amount that you will have to pay each time you use any services. For example you may have to pay $20 every time you visit your doctor.
Cost sharing: cost sharing is an agreement that defines terms of sharing costs and payments between you and your insurer. Anything that you pay towards a medical bill out of your pocket such as copay, co-insurance, and deductibles are forms of cost sharing. However, your monthly premium, uncovered health care supplies or service fees, or fees paid to see a doctor outside of your network is not considered copay.
Deductible: the amount you must pay to your insurer every year before your healthcare provider starts to provide service for you. For example if your deductible is $1000, you must pay that amount first in order to receive health care benefits from your insurer.
Denial: If an insurance company decides to turn down an applicant for coverage, it is called a denial. The process of denial is called underwriting. The medical insurer may turn down your application if they discover any pre-existing conditions after physical examination or blood tests or they suspect any sudden health risk.
Essential health benefits: these are the categories of health services a service provider must offer to its consumers as a primary requirement by the Affordable Care Act. These are outpatient surgeries, preventive and wellness services, emergency services, mental health and substance abuse services, and hospitalizations, maternity and newborn care, including rehab and prescription drugs, devices, lab services, chronic disease management and pediatric services which include oral and vision care.