The Allowed Amount is the maximum amount on which payment is based for covered health care services. This may also be called “eligible expense” or “payment allowance” or “negotiated rate” or “allowable amount.” If your provider charges more than your...

An Appeal is a request from you for your health insurer or administrator to review a decision that denies a benefit or payment (or pays a lower-than-expected amount toward the billed charge for a medical service or treatment).  An Appeal...

Balance Billing occurs when a provider sends you a bill for the difference between a provider’s charge for a covered service or treatment and the insurance company’s Allowed Amount. For example, if the provider’s charge is $100.00 and the allowed...

Coinsurance is your share of the costs for covered health care services. It is calculated as a percentage (for example, 20%) of the allowable amount for the service. You pay the coinsurance amount plus your plan deductible (if not already...

Your co-payment is a fixed dollar amount (for example, $30) that you must pay for a covered health care service when you visit a provider.  This amount is usually due at the time the service is provided – not billed...

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federal law passed by Congress that, among other things, allows individuals to maintain health coverage following termination due to a qualifying event. The law applies both to insured employees...

Your deductible is a fixed dollar amount (for example, $500), which you must pay for health care service before your health insurance plan begins to pay.  If your deductible is $500, your plan will not pay anything until you have...

Your health insurance coverage start date is your “effective date.” It is the date your health insurance company begins to help you pay for your medical expenses.

Eligible Employee and Eligible Dependent refer to individuals who are eligible for coverage under the health plan.  For Affordable Care Act (ACA) plans, the only individuals eligible to receive tax-favored coverage are the employee, the employee’s spouse, and the employee’s...

Ambulance services for an Emergency Medical Condition, an illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.