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The amount you owe for health care services that your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
A deductible is a specific amount of money that you agree to pay before you receive any benefits for covered services from the health insurance carrier. Deductibles can vary, but if your policy has a $1,500 deductible, and you receive doctor’s care and medication that costs $1,200, you must pay for all of it. The carrier is not responsible for the amount of the covered service or medication you pay for up to the amount of deductible.
In addition to the monthly premium, or cost to be covered by insurance, you must also pay for all covered services until you reach the deductible amount. Generally, the higher the deductible is, the lower the monthly premium will be. If you agree to pay a $10,000 deductible, your premium would be lower, but if you are sick or injured, you will have to pay $10,000 worth of medicine and treatment before the carrier pays anything. (Check your policy to see what the options are.)
The entire deductible has to be met before your carrier will cover many of the services you could need, including hospital stays.
After you reach the deductible amount during a specific period of time, the carrier will begin reimbursing for covered medical services and treatment as specified in the policy. This may be at 100% co-insurance or could be another percentage, such as 50% of your medical treatment and services.
Once you meet your deductible then you’re done for that calendar year or for the period specified in your policy. The following year, or next deductible period, you have to start satisfying the deductible all over again.
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.
The amount you must pay out-of-pocket for health care for services covered by your health insurance or plan before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
The amount you must pay for medical services each year before your insurance begins paying.
A dollar amount that a patient must pay for health care services each year before the insurer will begin paying claims under a policy.
- Browse Related Terms: Access Fee, Catastrophic Health Insurance, Catastrophic Health Plan, Co-insurance, Co-pay, Co-payment, Coinsurance, Cost Sharing, Deductible, Doctor Visits, Limited Benefit Health Insurance Policies, Medicare Supplement (Medigap) Insurance, Out-of-Pocket Costs, Out-of-Pocket Limit, Out-of-Pocket Maximum, Out-of-pocket maximum/limit, Stop-Loss
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An insurance company decision to withhold a claim payment or preauthorization. A denial may be made because the medical service is not covered, not medically necessary, or experimental or investigational.
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Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. In the Marketplace, dental coverage is available either as part of a comprehensive medical plan, or by itself through a "stand-alone" dental plan.
- Browse Related Terms: Actuarial Value, Benefit Level, Coordination of Benefits, Dental Coverage, Excluded Services, Hospital Outpatient Care, Major Medical Health Insurance, Net Capital Gains, Subsidy, Total Cost Estimate (for health coverage)
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The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).
- Browse Related Terms: Benefits, Centers for Medicare & Medicaid Services (CMS), Children's Health Insurance Program (CHIP), Department of Health and Human Services (HHS), Dependent Coverage, Disability, Domestic Partnership, Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT), Federal Poverty Level (FPL), fee, Health Coverage, Health Insurance Marketplace, Maryland Children’s Health Program (MCHP), Medicaid, Medicaid/Medical Assistance, Metal Level, State Health Insurance Assistance Program (SHIP), State Medical Assistance Office, Subsidized Coverage, TRICARE
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A child or other individual for whom a parent, relative or other person may claim a personal tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction. Under the Affordable Care Act, individuals may be able to claim a premium tax credit to help cover the cost of coverage for themselves and their dependents.
- Browse Related Terms: Advanced Premium Tax Credit, Banding, Catastrophic Plan, Consumer Operated and Oriented Plans, dependent, Hardship Exemption, Health Savings Account (HSA), High deductible health plan (HDHP), High-Cost Excise Tax, Individual mandate, MinnesotaCare, Payment Frequency, Premium Tax Credit, Risk corridor
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Insurance coverage for family members of the policyholder, such as spouses, children, or partners.
- Browse Related Terms: Benefits, Centers for Medicare & Medicaid Services (CMS), Children's Health Insurance Program (CHIP), Department of Health and Human Services (HHS), Dependent Coverage, Disability, Domestic Partnership, Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT), Federal Poverty Level (FPL), fee, Health Coverage, Health Insurance Marketplace, Maryland Children’s Health Program (MCHP), Medicaid, Medicaid/Medical Assistance, Metal Level, State Health Insurance Assistance Program (SHIP), State Medical Assistance Office, Subsidized Coverage, TRICARE
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A limit in a range of major life activities. This includes limits on activities such as seeing, hearing, and walking and on tasks such as thinking and working. Because different health insurance programs may have different disability standards, please check the program you’re interested in for its disability standards.
A limit in a range of major life activities. This includes activities like seeing, hearing, walking and tasks like thinking and working. Because different programs may have different disability standards, please check the program you're interested in for its disability standards.
- Browse Related Terms: Benefits, Centers for Medicare & Medicaid Services (CMS), Children's Health Insurance Program (CHIP), Department of Health and Human Services (HHS), Dependent Coverage, Disability, Domestic Partnership, Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT), Federal Poverty Level (FPL), fee, Health Coverage, Health Insurance Marketplace, Maryland Children’s Health Program (MCHP), Medicaid, Medicaid/Medical Assistance, Metal Level, State Health Insurance Assistance Program (SHIP), State Medical Assistance Office, Subsidized Coverage, TRICARE
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(of medical history and status). When applying for individual health coverage, you will be asked to “disclose” any existing medical conditions, existing medications and past medical history. You must answer the questions truthfully. If the health insurance carrier learns that you have not provided all requested information about your health status, the policy may be cancelled and your coverage denied.
- Browse Related Terms: Creditable Coverage, Creditable Coverage or Prior Qualifying Coverage, Disclosure, Discount Health Plan, Elimination period, Exclusion, High Risk Pool Plan (State), High-risk pool, Maryland Health Insurance Program (MHIP), Minnesota Comprehensive Health Association (MCHA), Portability, Pre-existing Condition, Pre-Existing Condition (Job-based Coverage), Pre-existing condition exclusion, Pre-Existing Condition Exclusion Period (Individual Policy), Pre-Existing Condition Exclusion Period (Job-based Coverage), Pre-existing Condition Insurance Plan (PCIP), Rider (exclusionary rider)
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A “discount health plan” refers to a type of “buyers’ club” that specifically markets reduced-rate health care services. The Plan typically charges a membership fee in exchange for a list of health care professionals who will provide services at a discounted rate to members of the Plan. Plans may be marketed to consumers as a way to save money on various health services, such as medical, dental and vision care, as well as pharmacy and/or chiropractic services.
Be aware that state laws protecting consumers of insurance will not protect people who buy Discount Health Plans. For example, health insurance laws that guarantee access to providers, do not apply to these plans. Discount Health Plans do not qualify as “creditable health insurance coverage.” This means that if you drop your health insurance after purchasing a Discount Health Plan and later decide to purchase health insurance again, your new insurance may not — and probably will not — cover pre-existing conditions for a period of time.
- Browse Related Terms: Creditable Coverage, Creditable Coverage or Prior Qualifying Coverage, Disclosure, Discount Health Plan, Elimination period, Exclusion, High Risk Pool Plan (State), High-risk pool, Maryland Health Insurance Program (MHIP), Minnesota Comprehensive Health Association (MCHA), Portability, Pre-existing Condition, Pre-Existing Condition (Job-based Coverage), Pre-existing condition exclusion, Pre-Existing Condition Exclusion Period (Individual Policy), Pre-Existing Condition Exclusion Period (Job-based Coverage), Pre-existing Condition Insurance Plan (PCIP), Rider (exclusionary rider)
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A broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from more expensive inpatient and acute care to areas such as preventive medicine, patient counseling and education, and outpatient care. The process is intended to reduce health care costs and improve the quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition.
- Browse Related Terms: Accountable Care Organization, Chronic Disease Management, Disease managem ent, Essential Health Benefits, prevention, preventive, Preventive Medicine, Preventive Services, Well-baby and Well-child Visits
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A payment made by a for-profit corporation to its shareholders. This payment is a portion of the corporate earnings and may be paid a certain number of times each year (like each quarter).
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For some plans, you can receive benefits like doctor visits before you meet your deductible.
- Browse Related Terms: Access Fee, Catastrophic Health Insurance, Catastrophic Health Plan, Co-insurance, Co-pay, Co-payment, Coinsurance, Cost Sharing, Deductible, Doctor Visits, Limited Benefit Health Insurance Policies, Medicare Supplement (Medigap) Insurance, Out-of-Pocket Costs, Out-of-Pocket Limit, Out-of-Pocket Maximum, Out-of-pocket maximum/limit, Stop-Loss
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Two people of the same or opposite sex who live together and share a domestic life, but aren't married or joined by a civil union. In some states, domestic partners are guaranteed some legal rights, like hospital visitation.
- Browse Related Terms: Benefits, Centers for Medicare & Medicaid Services (CMS), Children's Health Insurance Program (CHIP), Department of Health and Human Services (HHS), Dependent Coverage, Disability, Domestic Partnership, Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT), Federal Poverty Level (FPL), fee, Health Coverage, Health Insurance Marketplace, Maryland Children’s Health Program (MCHP), Medicaid, Medicaid/Medical Assistance, Metal Level, State Health Insurance Assistance Program (SHIP), State Medical Assistance Office, Subsidized Coverage, TRICARE
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Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
- Browse Related Terms: Annual Deductible Combined, Brand Name (Drugs), Donut Hole, Medicare Prescription Drug, Drug Formulary, Drug List, Essential Benefits, Excluded Drugs, Flexible Spending Account (FSA), Formulary, Generic Drug, Generic Drugs, Medicare, Medicare Part D, Medicare Prescription Drug Donut Hole, Name-brand Drug, Out-of-Pocket Estimate, Over-the-Counter Drug, Prescription Drug, Prescription Drug Coverage, Prescription Drugs
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A list of drugs that an insurer will pay for. Drugs that are not on the formulary ("off-formulary") are sometimes covered but are more expensive (see "excluded drugs"). To you, the cheapest drugs are generic drugs that are on the formulary, and the most expensive drugs are name-brand drugs that are off-formulary.
- Browse Related Terms: Annual Deductible Combined, Brand Name (Drugs), Donut Hole, Medicare Prescription Drug, Drug Formulary, Drug List, Essential Benefits, Excluded Drugs, Flexible Spending Account (FSA), Formulary, Generic Drug, Generic Drugs, Medicare, Medicare Part D, Medicare Prescription Drug Donut Hole, Name-brand Drug, Out-of-Pocket Estimate, Over-the-Counter Drug, Prescription Drug, Prescription Drug Coverage, Prescription Drugs
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A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.
- Browse Related Terms: Annual Deductible Combined, Brand Name (Drugs), Donut Hole, Medicare Prescription Drug, Drug Formulary, Drug List, Essential Benefits, Excluded Drugs, Flexible Spending Account (FSA), Formulary, Generic Drug, Generic Drugs, Medicare, Medicare Part D, Medicare Prescription Drug Donut Hole, Name-brand Drug, Out-of-Pocket Estimate, Over-the-Counter Drug, Prescription Drug, Prescription Drug Coverage, Prescription Drugs
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Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
- Browse Related Terms: Chronic Condition, Durable Medical Equipment (DME), Emergency Medical Condition, Hospice Services, Major Medical Plan, Public Health, Reconstructive Surgery, Special Health Care Need, Urgent Care