Health Insurance

33 Common Terms Allowed amount or negotiated rate —The most that your insurance will pay for a service. If your provider charges more than the allowed amount, you may have to pay the difference. Balance billing —When a provider bills you for the difference between their usual charge and your insurance company’s allowed amount. For example, if the usual charge is $100 and the allowed amount is $70, your provider might send you a bill for $30. In California, a provider in your preferred provider network may not balance bill you. Claim —A claim is a request to your insurance company to pay for a health care service you received. Co-insurance —This is your share of cost for a health care service. It is a percent (for example, 20%) of the allowed amount for the service. For example, if the charge for an office visit is $150 and your co-insurance is 20%, you pay $30 and your plan pays $120. Co-pay —This is a fixed amount (such as $15) that you pay for a service. You usually pay the co-pay when you get the service. Deductible —The amount you pay before your insurance company covers any costs. For example, if your deductible is $1,000, your plan will not pay anything (except preventive care—see page 6) until you’ve met your $1,000 deductible. You may choose a higher deductible to lower your premium. Essential health benefits(EHBs) —These are the benefits that all individual and small group insurance policies have to cover. Grandfathered policies may not have to cover EHBs. EHBs are defined by the State of California and meet the Affordable Care Act’s minimum essential coverage standard. Exclusions, excluded services —Services that your health plan does not pay for.