Answers
Words, explained
Common words on medical bills, insurance letters and plan documents, in plain English — plus the official places to get help.
The words
- Coinsurance
- Your share of a covered cost as a percentage, for example 20%, usually after you have met your deductible.
- Copay
- A fixed amount, for example $30, that you pay for a covered visit or prescription.
- Deductible
- The amount you pay for covered care each plan year before your plan starts paying its share. Read the answer
- Denial
- A decision by your insurer not to pay all or part of a claim. The letter should give the reason and explain how to appeal. Read the answer
- Explanation of Benefits (EOB)
- A statement from your insurer showing what was billed, what the plan allowed and paid, and what is left for you. It is not a bill. Read the answer
- External review
- A review of a denied claim by an independent reviewer outside your insurer, usually after the internal appeal.
- Financial assistance policy
- A hospital's written policy for reducing or forgiving bills for patients who qualify. Also called charity care.
- In-network / out-of-network
- In-network providers have a contract with your plan. Out-of-network providers don't, and usually cost you more.
- Internal appeal
- Asking your insurer, in writing, to reconsider a denied claim. The deadline is printed on the denial letter. Read the answer
- Itemized bill
- A bill that lists every charge with its date, code, quantity and price, not just a total. Read the answer
- Observation status
- Being in the hospital as an outpatient under observation instead of being admitted as an inpatient. It can change what your plan pays.
- Out-of-pocket maximum
- The most you pay for covered care in a plan year. After you reach it, the plan pays 100% of covered costs. Read the answer
- Premium
- What you pay, usually every month, to have the insurance, whether or not you use care. Read the answer
- Prior authorization
- Approval your plan requires before certain care, drugs or equipment. Without it, the plan may not pay.
These are general definitions. Your own plan documents and letters decide the details. Sources: the HealthCare.gov glossary and Medicare.gov.
Official help
- Medicare.gov Coverage, appeals and 1-800-MEDICARE
- SHIP — State Health Insurance Assistance Program Free, unbiased Medicare counseling in every state
- HealthCare.gov Marketplace plans, appeals and deadlines
- Medicaid.gov State programs and eligibility
- Your state insurance department Complaints and external appeals for private plans
- CMS.gov The rules behind Medicare and Medicaid