10-12-2022 PTL - Flipbook - Page 28
28 A Special Advertising Section of Baltimore Sun Media Group | Wednesday, October 12, 2022
GLOSSARY
Glossary of
health care and
insurance terms
By Margit B. Weisgal, Contributing Writer
D
efinitions are taken from several sources including CMS.gov, Maryland Health Appeal
Connection.gov and IRS.gov. Although these are fairly comprehensive, there
are variant definitions, some of which have been included. Health insurers may
modify these terms based on their particular standards and practices.
Advance Premium Tax Credit (APTC)
A tax credit that can reduce what you
pay for health insurance. When you apply
for coverage through Maryland Health
Connection, you’ll estimate your household income to find out if you qualify for
an advance payment of the tax credit that
lowers your premium, or monthly payment. You can apply some or all of this tax
credit right away to lower your monthly
payment. Maryland Health Connection
will send your tax credit directly to your
insurance company. Or, you can apply all
or some of the credit to your annual tax
return.
Allowed 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 allowed amount, you may have to pay
the difference. (See Balance Billing.)
An appeal is the action you can take if
you disagree with a coverage or payment
decision by your health plan. You can
appeal if your health plan denies one of
the following:
• Your request for a health care service, supply or prescription drug that
you think you should be able to get
• Your request for payment for health
care or a prescription drug you
already got
• Your request to change the amount
you must pay for a prescription drug
• You can also appeal if you’re already
getting coverage and your plan
stops paying.
Annual Limit
A cap on the benefits your insurance
company will pay in a year while you’re
enrolled in a particular health insurance
plan. Caps are sometimes placed on
particular services such as prescriptions
or hospitalizations. Annual limits may be
placed on the dollar amount of covered
services or on the number of visits that will
be covered for a particular service. After
an annual limit is reached, you must pay
Balanced Billing
all associated health care costs for the
When a provider bills you for the difrest of the year.
ference between the provider’s charge
and the allowed amount. For example, if
Annual Open Enrollment Period
a doctor charges $100 and the allowed
The period of time each year during
amount is $70, the doctor may bill you for
which any individual eligible to enroll in
the remaining $30. A preferred provider
a private health plan through Maryland
may not balance bill you for covered serHealth Connection may enroll or change
vices.
coverage. Open enrollment to buy a health
plan is Nov. 1 to Dec. 15. If you qualify for
Benefit Level
Medicaid, you can apply any time of year.
A benefit level is a group of plans that
have similar value. The groupings help
you compare plans with similar covered
benefits and costs to determine the plan
that best fits your needs. The percentage
represents the percent of your total benefit costs paid by the plan. You pay the rest.
Benefits
Products and services covered under
health plans.
Bronze Health Plan
One of four plan categories, also
known as metal levels. Bronze plans usually have the lowest monthly premiums,
but the highest costs when you get care.
They can be a good choice if you usually
use few medical services and mostly want
protection from very high costs if you get
seriously sick or injured.
Catastrophic Plan
A plan that covers an individual or family in the event of a major medical emergency. While the plan offers low monthly
premiums that often make it more affordable than other plans, its deductible is
much higher. This means that the individual or family typically pays out of pocket
for most medical care, unless there is a
very expensive health care event.
Health glossary,
continued on next page