Glossary

Short meanings of common words. Official names and abbreviations are kept so you can match them to your documents.

Allowed amount

The price your plan agrees to pay for a covered service. Your share is based on this amount, not the provider's full charge.

Also seen as: negotiated rate, eligible expense

Bill or EOB?

Appeal

A formal request asking your plan to review and change a decision, such as a denied claim or prior authorization.

Also seen as: grievance, reconsideration

Why was my claim denied?Prepare an appeal Prior authorization

Carryover and grace period

Optional healthcare FSA features. A carryover lets some unused money move to next year. A grace period gives extra time to spend it. A plan may offer one, not both, or neither.

Also seen as: rollover, use it or lose it

How much to put in

Catch-up contribution

An extra amount people 55 or older can put into an HSA each year. It is $1,000.

Also seen as: age 55

How much to put in

Claim

A request for payment sent to your health plan, usually by your provider, after you get care.

Also seen as: submission

Bill or EOB?Why was my claim denied?

Coinsurance

Your share of a covered cost as a percentage, such as 20%, usually after you meet your deductible.

Also seen as: percentage

Deductible, copay, and more Medicare basics

Copay (copayment)

A set dollar amount you pay for a covered service, such as $30 for a doctor visit.

Also seen as: copayment

Deductible, copay, and more Vision, dental, and prescriptions

Deductible

The amount you pay for covered care each plan year before your plan starts to share most costs.

Deductible, copay, and more Paying for prescriptions

Denial

A decision by your plan not to pay for all or part of a claim or a request for care. The notice should explain why.

Also seen as: denied, adverse benefit determination

Why was my claim denied?

Dependent-care FSA

A work account for child care or adult day care costs so you can work. It does not pay medical bills.

Also seen as: DCFSA, daycare

HSA, FSA, and HRA

Expedited (urgent) appeal

A faster review when waiting for a standard decision could seriously harm your health.

Also seen as: urgent appeal, fast appeal

Prepare an appeal Prior authorization

Explanation of Benefits (EOB)

A statement from your health plan showing what was charged, what the plan paid, and what you may owe. It is not a bill.

Also seen as: EOB, Medicare Summary Notice

Bill or EOB?

External review

A review of your plan's decision by an independent organization, usually after an internal appeal.

Also seen as: independent review, IRO

Prepare an appeal

Extra Help

A Medicare program that helps people with limited income and savings pay for Medicare drug coverage. It is also called the Low-Income Subsidy (LIS).

Also seen as: low-income subsidy, LIS, part d help

Paying for prescriptions

Extraordinary collection action

A serious step a nonprofit hospital may take to collect a bill, such as a lawsuit, a lien, reporting to credit bureaus, or selling the debt. Federal rules limit when it can be used.

Also seen as: ECA, collections, lawsuit

Applying for financial assistance

Facility fee

A charge from a hospital or clinic for the use of its space, staff, and equipment, separate from the clinician's fee.

Also seen as: hospital fee

Before an appointment

Financial assistance

A program that lowers or removes a medical bill for people who qualify, often based on income. Also called charity care.

Also seen as: charity care, hospital discount

When a bill is hard to afford Applying for financial assistance

Formulary (drug list)

The list of medicines your plan covers, often grouped into tiers with different costs.

Also seen as: drug list, tier

Vision, dental, and prescriptions Paying for prescriptions

Good faith estimate

A written estimate of expected charges that you can ask for if you are uninsured or not using insurance.

Also seen as: estimate, price estimate

Before an appointment

Health Insurance Marketplace

The government-run place to compare and buy individual health plans, such as HealthCare.gov or a state Marketplace.

Also seen as: exchange, Obamacare, ACA, HealthCare.gov

Find your plan's rules Medicaid and CHIP

Healthcare FSA (flexible spending account)

A work account where you set aside pay before federal tax for medical costs. Unused money is generally lost unless your plan offers a carryover or grace period.

Also seen as: FSA, flex account

HSA, FSA, and HRA How much to put in

High-deductible health plan (HDHP)

A health plan that meets federal deductible and out-of-pocket rules, which lets you contribute to an HSA if you meet other requirements.

Also seen as: HDHP, HSA-qualified plan

HSA, FSA, and HRA

HRA (health reimbursement arrangement)

An account funded only by your employer to pay certain medical costs. The employer sets its rules.

Also seen as: HRA

HSA, FSA, and HRA

HSA (health savings account)

A savings account you own for medical costs, available with an HSA-qualified high-deductible plan. Money rolls over each year.

Also seen as: HSA, health savings

HSA, FSA, and HRA How much to put in

In-network

Providers and facilities that have a contract with your plan for agreed prices. Usually costs you less.

Also seen as: participating provider, network

Before an appointment Vision, dental, and prescriptions

Itemized bill

A detailed bill that lists each service, supply, date, and charge. You can ask your provider for one.

Also seen as: detailed bill

Bill or EOB?When a bill is hard to afford Applying for financial assistance

Limited-purpose FSA

An FSA that pays mainly for dental and vision costs. It can be used alongside an HSA.

Also seen as: LPFSA, dental vision FSA

HSA, FSA, and HRA

Medicaid and CHIP

Public health coverage for people with limited income, and for children through CHIP. Each state runs its own program within federal rules.

Also seen as: CHIP, Medi-Cal

Find your plan's rules Medicaid and CHIP

Medically necessary

Care your plan agrees is needed to diagnose or treat a health condition, based on its rules. Plans may deny care they consider not medically necessary.

Also seen as: medical necessity

Why was my claim denied?Prepare an appeal Prior authorization

Medicare

Federal health insurance for people 65 and older and for some younger people with disabilities or certain conditions.

Also seen as: Original Medicare, Part A, Part B, Part D

Find your plan's rules Paying for prescriptions Medicare basics Medicaid and CHIP

Medicare Advantage (Part C)

A private plan approved by Medicare that bundles Part A, Part B, and usually drug coverage. It often uses a network and may require prior authorization.

Also seen as: Part C, MA plan

Medicare basics

Medigap

Extra insurance from a private company that helps pay your share of costs in Original Medicare. Plans are standardized and named by letters in most states.

Also seen as: Medicare Supplement, Plan G

Medicare basics

Out-of-network

Providers and facilities without a contract with your plan. Care often costs more or may not be covered.

Also seen as: non-participating

Before an appointment

Out-of-pocket maximum

The most you pay in a plan year for covered in-network care. After that, the plan pays 100% of covered in-network costs. Premiums do not count.

Also seen as: out of pocket max, OOP max, out-of-pocket limit

Deductible, copay, and more

Patient advocate

A person who helps patients understand and handle care, bills, insurance, and appeals. Some are free; some charge a fee.

Also seen as: advocate, navigator

Who can help

Payment plan

An agreement to pay a bill over time in smaller amounts. Ask whether it has interest or fees.

Also seen as: installments

When a bill is hard to afford

Premium

The amount you pay, often monthly or per paycheck, to keep your health coverage.

Also seen as: monthly payment

Deductible, copay, and more

Preventive care

Care to prevent illness or find it early, such as certain screenings and vaccines. Many plans cover listed services at no cost in network.

Also seen as: screening, checkup

Vision, dental, and prescriptions

Prior authorization

Your plan's approval before certain care. Approval is not a guarantee of payment.

Also seen as: preauthorization, pre-approval, precertification

Why was my claim denied?Prior authorization Medicare basics

Qualified medical expense

A cost that tax rules allow HSA, FSA, or HRA money to pay, such as many doctor visits, prescriptions, and dental care.

Also seen as: eligible expense

How much to put in

Referral

A written order from your primary care doctor to see a specialist. Some plans require it.

Before an appointment

Summary of Benefits and Coverage (SBC)

A standard, short summary of a plan's costs and coverage that most plans must provide.

Also seen as: SBC, plan summary

Find your plan's rules

Summary Plan Description (SPD)

A document for employer plans that explains benefits, rights, and how to file claims and appeals.

Also seen as: SPD, plan document

Find your plan's rules

Surprise billing

An unexpected bill from an out-of-network provider you did not choose. Federal law protects against many of these.

Also seen as: balance billing, No Surprises Act

Before an appointment

Glossary

Share the Knowledge