Page 26 - HMO_Member_Kit

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Common Terms
Affiliated Provider
– provider contracted with us to give health care.
Allowable Amount
– maximum amount on which payment is based for covered health care services.
This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider
charges more than the allowable amount, you may have to pay the difference.
– a request for us to review a decision or grievance one more time.
Balance Billing
– when a provider bills you for the difference between the provider’s charge and the
allowable amount. For example, if the provider’s charge is $100 and the allowable amount is $70, the
provider may bill you for the remaining $30. A preferred provider may not balance bill you.
– the services a health plan covers, like doctor office visits, routine physicals, etc.
Brand-Name Drug
– a drug protected by a patent with a trade name from the original manufacturer.
The manufacturer keeps the rights to sell the drug for a set period of time. After that time is up, the
formula must be released, and other manufacturers can make a generic form of the drug.
– your share of the costs of a covered health care service, calculated as a percent
(for example, 20 percent) of the allowable amount for the service. You pay coinsurance plus any
deductibles you owe. For example, if the plan’s allowable amount for an office visit is $100 and you’ve
met your deductible, your coinsurance payment of 20 percent would be $20. The health insurance or
plan pays the rest of the allowed amount.
– a fixed amount (for example, $15) you pay for a covered health care service, usually when
you receive the service. The amount can vary by the type of covered health care service.
Cost Sharing
– set arrangements where members pay for designated portions of their covered care.
This may be through copays, coinsurance and deductibles and/or through payroll deductions funding
a part of the premium costs.
Covered Services
– medically necessary health care services and benefits that have been
preauthorized by an affiliated provider according to our accepted policies.
– the amount you owe for health care services your health insurance or plan covers before
your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t
pay anything until you’ve met your $1,000 deductible for covered health care services subject to the
deductible. The deductible may not apply to all services.