The number assigned by your provider (hospital, physician, home care service, etc.) when medical services were provided.
A job-based health plan covering only the employee that costs 9.61% or less of the employee’s household income. If a job-based plan is “affordable,” and meets the “minimum value” standard, you’re not eligible for a premium tax credit if you buy a Marketplace insurance plan instead.
- The plan used to define affordability is the lowest priced “self-only” plan the employer offers — meaning a plan covering only the employee, not dependents. This is true even if you’re enrolled in a plan that costs more or covers dependents.
- The cost is the amount the employee would pay for the insurance, not the plan’s total premium.
- The employee’s total household income is used. Total household income includes income from everybody in the household who’s required to file a tax return.
- Employee’s monthly household income = $4,083 (about $49,000 per year)
- 9.61% of the employee’s monthly household income = $392
- Monthly cost to the employee of the lowest-priced plan the employer offers for self-only coverage = $300
- Is the plan affordable? YES. The employee’s share of the lowest cost self-only plan ($300) is less than 9.61% of the employee’s household income ($392).
- Employee’s monthly household income = $2,333 (about $28,000 per year)
- 9.61% of the employee’s monthly household income = $224
- Monthly cost to the employee of the lowest-priced plan the employer offers for self-only coverage = $275
- Is the plan affordable? NO. The employee’s share of the lowest-cost self-only plan ($275) is more than 9.61% of the employee’s household income ($224).
The portion of your bill that your provider has agreed to write off.
Annual Deductible Combined
Usually in Health Savings Account (HSA) eligible plans, the total amount that family members on a plan must pay out-of-pocket for health care or prescription drugs before the health plan begins to pay.
Advance Premium Tax Credit
A tax credit you can take in advance to lower your monthly health insurance payment (or “premium”). When you apply for coverage in the Health Insurance Marketplace®, you estimate your expected income for the year. If you qualify for a premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your premium.
- If at the end of the year you’ve taken more premium tax credit in advance than you’re due based on your final income, you’ll have to pay back the excess when you file your federal tax return.
- If you’ve taken less than you qualify for, you’ll get the difference back.
Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.
Admission date (admit date)
The date admitted for treatment.
Words or phrases your doctor uses to describe your condition.
Advance beneficiary notice (ABN)
A notice your provider gives you before you are treated, informing you that Medicare will not pay for the treatment or service. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.
Determined by your insurance to be the amount your provider is due for a particular service. This amount is usually less than the amount billed by the provider and is determined by pre-negotiated contracts or regulations. The combined total paid by you and your insurance to a provider should not exceed the allowed amount when we are in-network with your plan. Call your insurance company for more information.
Outpatient surgery or surgery that does not require an overnight hospital stay.
Amount not covered
What your insurance company does not pay, including deductibles, co-insurances and charges for non-covered services.
The inpatient services you receive beyond room and board charges, such as laboratory tests, therapy, surgery, etc.
A process by which you, your doctor or your hospital, can object to your health plan when you disagree with the health plan’s decision to deny payment for your care.
Applied to deductible
A portion of your bill, as defined by your insurance company, that you owe your provider.
Assignment of benefits
An agreement you sign that allows your insurance to pay the provider directly.
The doctor who orders your treatment and who is responsible for your care.
A number stating that your treatment has been approved by your insurance plan. Also called a Certification Number, Prior Authorization Number or Treatment Authorization Number.
Beneficiary eligibility verification
A way providers can retrieve information about whether you have insurance coverage.
The legal agreement between a health plan and you. This contract establishes the full range of benefits available to you through your healthcare plan. A Benefits Contract is also sometimes referred to as a certificate of coverage or evidence of coverage.
The extent to which your insurance coverage will pay for services provided to you. Benefits may describe what portion of the allowed amount may be due from you, the level to which they will pay for services provided by various providers, and what types of services they will or will not cover.
A printed summary of your medical bill.
Drugs made and sold by a major drug company. Brand-name drugs may or may not be listed on a formulary. For any health need, there may be competing drugs from different companies. Your health plan formulary may list a specific brand-name drug if a price agreement has been made with that company. This brand-name drug will cost more than the generic version, but cost less than other brand-name drugs that are not on the formulary. If you buy brand-name drugs that are not on the formulary, you often pay more because your health plan pays more.
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.
A year of benefits coverage under an individual health insurance plan. The benefit year for plans bought inside or outside the Marketplace begins January 1 of each year and ends December 31 of the same year. Your coverage ends December 31 even if your coverage started after January 1. Any changes to benefits or rates to a health insurance plan are made at the beginning of the calendar year.
A number stating that your treatment has been approved by your insurance plan. Also called an Authorization Number, Prior Authorization Number or Treatment Authorization Number.
Insurance linked to military service. ChampVA shares the cost of certain medically necessary procedures and supplies with eligible beneficiaries. ChampVA does not have a network of health care providers, so eligible members can visit most authorized providers.
Your medical bill that is sent to an insurance company for payment.
A number assigned by your insurance company to an individual claim.
Centers for Medicare and Medicaid (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid programs.
Clinical research, clinical trial or research study (Also see “Experimental or investigational treatments”)
Research conducted to evaluate the safety and/or effectiveness of a treatment, diagnostic procedure, preventive measure or similar medical intervention by testing the intervention on patients in a clinical setting. Participation in clinical research is voluntary. The informed consent form discusses who will pay the costs of services that are part of the clinical trial. Each study is different, but in many cases insurance will pay for medically necessary services that are part of the research study. Sometimes research services are paid for by the study. Check with your insurance plan or the study team to determine coverage.
CMS 1500 form
The standard paper form used by healthcare professionals and suppliers to bill insurance companies.
COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law that protects employees and their families in certain situations by allowing them to keep their existing health insurance for a specified amount of time. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. The individual must pay the premium cost to keep his/her insurance plan, but the costs are usually less expensive than individual health coverage.
COBRA applies only under certain conditions, such as job loss, death, divorce or similar events. COBRA usually applies to group health plans offered by companies with more than 20 employees.
Coding of claims
Translating clinical information from your medical record into numbers (such as diagnosis and procedure codes) that insurance companies use to pay claims.
The amount you must pay after your insurance has paid its portion, according to your Benefit Contract. In many health plans, patients must pay for a portion of the allowed amount. For instance, if the plan pays 70% of the allowed amount, the patient pays the remaining 30%. If your plan is a preferred provider organization (see “Preferred Provider Organization (PPO)”) or other narrow network type of product, your co-insurance costs may be lower if you use the services of an in-network provider on the plan’s preferred provider list. Call your insurance company for more information.
Commercial insurance plan
Commercial health insurance is typically an employer-sponsored or privately purchased insurance plan. Commercial plans are not maintained or provided by any government-run program. Commercial policies can be sold individually or as part of a group plan.
Consent for treatment
An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals.
A predetermined, fixed fee that you pay at the time of service. Copayment amounts vary by service and may vary depending on which provider (in-network, out-of-network, or provider type) you see. The amounts also may vary based on the type of service you are receiving (for instance, primary care vs. specialty care). For prescriptions, copayment amounts may vary depending on name-brand versus generic drugs. Call your insurance company for more information.
Coordination of benefits
How insurance companies work together when you have more than one insurance plan. A patient may be covered by more than one commercial insurance plan, such as through an employer as well as a spouse’s, parent’s or domestic partner’s employer. If you have more than one insurance plan, check with the secondary policy to find out how it covers expenses left over after your primary coverage has paid its part.
Services that your insurance company pays for in full or in part.
The days that your insurance company pays for in full or in part.
CPT (Current Procedural Terminology) code
A 5-digit numbering system that helps standardize professional and outpatient facility billing. There is a CPT code for certain types of medical services. Using this code allows healthcare providers and insurance companies to communicate and track billing more efficiently.
Date of bill
Bill preparation date. It is not the same date as the date of service.
Date of service (DOS)
The amount a patient pays before the insurance plan pays anything. In most cases, deductibles apply per person per calendar year. With preferred provider organizations (PPOs), deductibles usually apply to all services, including lab tests, hospital stays and clinic or doctor’s office visits. Some insurance plans waive the deductible for office visits. Some plans have service-specific deductibles.
Diagnosis-related groups (DRGs)
A payment system used by many insurance companies for inpatient hospital bills. This system categorizes illnesses and medical procedures into groups. Hospitals are paid a fixed amount for each admission.
The time a patient is discharged from the hospital.
The dollar amount removed from your bill, usually because of a contract between your provider and your insurance company.
Drugs that do not require administration from doctors or nurses. Your insurance plan may not cover these when provided as part of an outpatient service.
Due from insurance
The amount your insurance company has agreed to pay.
Due from patient
The amount you owe.
Durable medical equipment (DME)
The medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.
The date on which a Benefit Contract for coverage begins.
A determination of whether or not a person meets the requirements to participate in the plan.
Eligible payment amount
The medical services covered by an insurance company.
Care provided in a hospital Emergency Department.
The part of a hospital that treats patients with emergency or urgent medical problems.
An estimate of payments from your insurance company.
A person who is covered by health insurance.
Estimated amount due
The amount the provider estimates you or your insurance company owes.
Experimental or investigational treatments (Also see “clinical research, trial or research study”)
A drug, device, diagnostic procedure, treatment, preventive measure or similar medical intervention that is not yet proven to be medically safe and/or effective. Services considered to be investigational are typically not covered by health insurance. If offered as part of a clinical research study, the study itself may cover the costs. Check with your insurance plan or study team if applicable to see if coverage is available for experimental or investigational treatments.
Explanation of benefits (EOB)
A statement sent to you by your insurance after they process a claim sent to them by a provider. The EOB lists the amount billed, the allowed amount, the amount paid to the provider and any co-payment, deductibles or coinsurance due from you. The EOB may detail the medical benefits activity of an individual or family.
Federal tax ID number
A number assigned by the federal government to doctors and hospitals for tax purposes.
Financial assistance program
Free or reduced rates for care provided to patients with demonstrated financial hardship.
The amount of your bill you have to pay.
Flexible spending account (FSA or flex account)
An employee benefit that allows a fixed amount of pre-tax wages to be set aside for qualified expenses. Qualified expenses generally include out-of-pocket medical expenses. The amount set aside must be decided in advance and employees lose any unused dollars in the account at the end of the year.
A list of preferred prescription medicines. The formulary sorts drugs into groups, or tiers, based on how much of the costs your health plan will pay and how much you have to pay.
Drugs with proven benefits that cost less because they are not made by major drug companies and do not carry brand names. In almost all cases, you pay the least out of pocket for drugs in this group. Not all drugs have generic options.
The person responsible to pay the bill. The guarantor is always the patient unless the patient is an incapacitated adult or an unemancipated minor (under age 18), in which case, the guarantor is the patient’s parent or legal guardian.
Healthcare common procedure coding (HCPC)
A five-digit numbering system that helps standardize professional and outpatient facility billing. There is a HCPC code for certain types of medical services. Using this code allows healthcare providers and insurance companies to communicate and track billing more efficiently.
The party that provides medical services, such as hospitals, doctors or laboratories.
Health maintenance organization (HMO)
Health maintenance organization (HMO) (refers to health insurance) — These health insurance plans require enrolled patients to receive all their care from a specific group of providers (except for some emergency care). The plan may require your primary care doctor to make a referral before you can receive specialty care. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
A health plan refers to the type of health insurance you have. You may be part of a group health plan through your employer, you may have purchased an individual plan on the Health Insurance Exchange, be covered under workers’ compensation for a work-related injury, or have coverage through a government health plan such as Medicare and Medicaid.
Health savings account (HSA)
An account associated with a high deductible health plan that allows you to set aside pretax dollars to pay your deductible or other qualified medical expenses. Contributions are made into the account by the individual or the individual’s employer and are limited to a maximum amount each year. Unlike a flexible spending account, funds roll over and accumulate year after year if not spent.
The federal Health Insurance Portability and Accountability Act sets standards for protecting the privacy of your health information.
High deductible health plan (HDHP)
A high deductible health plan (HDHP) with a health savings account (HSA) provides medical coverage and a tax-free way to save for future medical expenses. A high deductible health plan does not usually cover healthcare costs until the deductible has been met, which means you will be responsible for healthcare costs out-of-pocket until you meet your deductible. Once the deductible has been met, eligible healthcare expenses will be covered by the plan.
Home health agency
An agency that treats patients in their homes.
The group that offers inpatient, outpatient and home healthcare for terminally ill patients.
This refers to the charges for services rendered in a hospital outpatient clinic or department.
The amount of money the hospital charges for a particular medical service or supply.
The person or persons liable or under obligation for the bill.
Lifetime maximum coverage
The Affordable Care Act prohibits health plans from putting annual or lifetime dollar limits on most benefits you receive. Plans can put an annual dollar limit and a lifetime dollar limit on spending for healthcare services that are not considered essential health benefits. The essential health benefits include at least the following:
- Outpatient services
- Emergency services
- Pregnancy, maternity and newborn care
- Mental health
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Lab services
- Preventative and wellness services
- Pediatric services
Grandfathered individual health insurance policies are not required to follow the rules on annual limits. Grandfathered plans are those that were in existence on March 23, 2010 and haven’t been changed in ways that substantially cut benefits or increase costs for consumers. Insurers must notify consumers with these policies that have a grandfathered plan.
The care received in a nursing home.
A type of insurance plan that requires patients to only see providers (doctors and hospitals) that have a contract with the managed care company, except in the case of medical emergencies or urgent care, if the patient is out of the plan’s service area.
Medicaid is a jointly funded federal and state health insurance plan administered by states for low income adults, pregnant women, children and people with certain disabilities. For additional information, please see Your Health Insurance Coverage.
Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). For additional information, including explanations of the different parts of Medicare, please see Your Health Insurance Coverage.
Medical record number
The number assigned by your doctor or hospital that identifies your individual medical record.
Medicare + Choice
A Medicare HMO insurance plan that pays for preventive and other types of healthcare provided by designated doctors and hospitals.
A type of Medicare health plan offered by an insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits, plus benefits that Original Medicare does not cover. For additional information, please see Your Health Insurance Coverage.
Providers who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.
A Medicare card with a unique number is assigned to each person covered under Medicare. The number is used by providers for billing, eligibility and claim status. The Medicare Beneficiary Identifier (MBI) replaces the SSN-based Health Insurance Claim Number (HICN).
Medicare Part A
Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.
Medicare Part B
Assists with paying for doctor services, outpatient care and other medical services not paid for by Medicare Part A.
Medicare summary notice (MSN)
A statement that Medicare sends to you after they process a claim from a provider for services provided to you. Also called an Explanation of Medicare Benefits (EOMB). The EOMB lists the amount billed, the allowed amount, the amount paid to the provider and any copayment, deductible or co-insurance due from you. The EOMB may detail the medical benefits activity of an individual or family.
Medicare supplements or “Medigap” policies
Policies that supplement Medicare coverage. Most times, these policies pay the Medicare co-pays and deductibles, but nothing extra. Check with your supplemental insurance to find out how it coordinates benefits with Medicare.
A hospital outpatient service ordered by a physician when the physician isn’t yet sure that you will need inpatient hospital care, but feels you need outpatient monitoring at the hospital in the meantime.
A doctor or other healthcare provider who is not part of an insurance plan, doctor or hospital network. (See “Non-participating provider”)
Out of network
A doctor, hospital or other healthcare provider who is not part of an insurance plan, doctor or hospital network. (See “Non-participating provider”)
The costs the patient is responsible for because Medicare or other insurance does not cover them.
The most money you will have to pay before your insurance company covers all costs. Each plan sets a dollar limit for the calendar year. Once that limit is reached, the plan will pay 100% of the allowed amount for eligible charges for the rest of the calendar year. Some insurance companies do not include certain costs in this limit, such as fertility treatments or prescription drugs. Other insurance companies increase the out-of-pocket maximum for care provided by out-of-network providers.
Drugs that do not require a prescription. They can be bought at a pharmacy or drugstore and be dispensed to patients, while at the hospital or doctor’s office.
Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans (HMOs) usually require a referral from your primary care doctor to see a specialist or for special procedures.
Release of information
A signed statement from patients or guarantors that allows providers to release medical information so that insurance companies can pay claims.
The explanation the hospital receives, usually with payment, from your insurance company after your medical services have been processed.
The person responsible for paying your hospital bill, usually referred to as the guarantor.
A billing code used to name a specific room, service or billing sum.
An organization other than the patient (first party) or healthcare provider (second party) involved in paying healthcare claims. Third-party payers include insurance companies, governmental agencies and employers.
Treatment authorization number
A number stating that your treatment has been approved by your insurance plan. It is also referred to as an Authorization Number, Certification Number or Prior Authorization Number.
Tricare is a health care program for active duty and retired uniformed service members and their families. If members become eligible for Tricare benefits, they are no longer eligible for ChampVA.
Type of admission
The reason for your admission, such as emergency, urgent or elective, etc.
UB-04 claim form
The standard claim form used by institutional providers, like hospitals, to bill insurance companies for medical services.
Units of service
Measures of medical services a patient received, such as the number of hospital days, pints of blood, treatments or laboratory tests.
Usual, customary and reasonable (UCR)
In general terms, the price charged by the provider. Specifically, a charge for a particular service is considered to be “usual and customary” if it falls within the range of prices charged for the same service by other providers in the same geographical area.
The amount of time members must wait after enrolling in an insurance plan before they are eligible for certain benefits.