Allowed Amount
Maximum amount on which payment is based for covered health care services. This may also be called “eligible expense”, “contracted rate”, or “negotiated rate”. In-network participating providers cannot charge you more than the allowed amount.
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 remaining $30 would be a balance-billed amount. Participating providers may not balance bill you for covered services.
Coinsurance
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).
Copayment
A fixed dollar amount that you pay for a covered health care service, usually at the time you receive the service. The amount can vary based on the type of health care service.
Deductible
The amount you owe for health care services before your insurance plan begins to pay. For example, if your deductible is $2,000, your plan does not begin paying until you have met that amount for the plan year. The deductible does not always apply to all services.
Non-Preferred Provider
Also referred to as an out-of-network provider or non-participating provider – a provider who does not have a contract with your health insurer or plan to provide services to you. You will pay more out-of-pocket to see a non-preferred provider and you can also be balance-billed.
Out-of-Pocket Maximum
The most you pay during a plan year before your health insurance begins to pay 100% of the allowed amount on all claims. This limit does not include your premium, balance-billed charges, or excluded services.