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The time (usually a preset two-week or one-month period annually) when you can change health plans under your employer's group plan.
- Browse Related Terms: Affordable coverage (as it relates to APTC), Employee Retirement Income Security Act of 1974 (ERISA), Employer Shared Responsibility Payment (ESRP), Full-Time Employee, Full-Time Equivalent, Minimum value, Multi-Employer Plan, Open Enrollment, Plan, Tax credit, Vision or Vision Coverage
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A specified period during which individuals may enroll in a health insurance plan each year. In certain situations, such as if one has had a birth, death or divorce in their family, individuals may be allowed to enroll outside of the open enrollment period.
- The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For coverage starting in 2014, the Open Enrollment Period is October 1, 2013–March 31, 2014. For coverage starting in 2015, the proposed Open Enrollment Period is November 15, 2014–February 15, 2015. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. (See Special Enrollment Period and Qualifying Life Event)
- Browse Related Terms: Conversion, Family and Medical Leave Act (FMLA), HIPAA Eligible Individual, Individual Health Insurance Policy, Minimum Essential Coverage, Nondiscrimination, Open Enrollment Period, Special Enrollment Period, State Continuation Coverage, Waiting Period (Job-based coverage)
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Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A (Hospital Insurance) and/or Part B (Medical Insurance) benefits.
- Browse Related Terms: Capitation, claim, External Review, Federally Qualified Health Center (FQHC), Fee-for-Service, Health Care Workforce Incentive, Home Health Care, Internal review, Member Survey Results, Original Medicare, Penalty, Uncompensated Care, Value-Based Purchasing (VBP)
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The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
- Browse Related Terms: Competitive Bidding, Copayment, Coverage, Health Insurance, In-Network Co-Insurance, In-Network Co-Payment, In-network Coinsurance, In-network Copayment, Limited Benefits Plan, network, Network Plan, Non-preferred provider, Out-of-Network Co-Insurance, Out-of-Network Co-Payment, Out-of-network Coinsurance, Out-of-Network Copayment, Preferred Provider
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A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
- Browse Related Terms: Competitive Bidding, Copayment, Coverage, Health Insurance, In-Network Co-Insurance, In-Network Co-Payment, In-network Coinsurance, In-network Copayment, Limited Benefits Plan, network, Network Plan, Non-preferred provider, Out-of-Network Co-Insurance, Out-of-Network Co-Payment, Out-of-network Coinsurance, Out-of-Network Copayment, Preferred Provider
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The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
- The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
- Browse Related Terms: Competitive Bidding, Copayment, Coverage, Health Insurance, In-Network Co-Insurance, In-Network Co-Payment, In-network Coinsurance, In-network Copayment, Limited Benefits Plan, network, Network Plan, Non-preferred provider, Out-of-Network Co-Insurance, Out-of-Network Co-Payment, Out-of-network Coinsurance, Out-of-Network Copayment, Preferred Provider
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A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
A fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
- Browse Related Terms: Competitive Bidding, Copayment, Coverage, Health Insurance, In-Network Co-Insurance, In-Network Co-Payment, In-network Coinsurance, In-network Copayment, Limited Benefits Plan, network, Network Plan, Non-preferred provider, Out-of-Network Co-Insurance, Out-of-Network Co-Payment, Out-of-network Coinsurance, Out-of-Network Copayment, Preferred Provider
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For health plans that utilize an HMO or PPO, a health care provider (such as a hospital or doctor) that is not contracted to be part of the HMO or PPO network. Depending on the health plan's rules, an individual may not be covered at all or may be required to pay a higher portion of the total costs when he/she seeks care from an out-of-network provider.
- Browse Related Terms: Exclusive Provider Organization (EPO) Plan, Health Maintenance Organization, Health Maintenance Organization (HMO), In-Network provider, Managed Care, Medicare Advantage, Medicare Advantage (Medicare Part C), Medicare Cost Plans, Medicare Select Plans, Out-of-network provider, Point of Service (POS) Plans, Point-of-Service Plan (POS), Preferred Provider Organization (PPO), Primary Care Physician (PCP), Referral, Third-Party Payer
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The amount of money you pay for medical services after insurance has paid its contribution.
- Browse Related Terms: Allowed Amount, Balance Billing, interest, Out-of-Pocket, UCR (Usual, Customary, and Reasonable), Usual and Customary Charges (UCC), Usual, Customary and Reasonable (UCR), Usual, Customary and Reasonable (UCR) Charges, Usual, Customary and Reasonable charge (UCR), Usual, Customary, Reasonable (UCR), Utilization Review
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Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
An out-of-pocket expense is any cost or fee for medical services paid by the patient such as copayment or coinsurance. Out-of-pocket expenses will not be reimbursed by the insurance plan.
- 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 estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.
- 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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The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
An annual limitation on costs for which patients are responsible under a health insurance plan. Costs such as deductible and coinsurance generally apply to this limit. Copays may also be included. This limit does not apply to premiums, amounts in excess of the allowed amount out of network health care providers or other services that are not covered by the plan.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit.
- 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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The most you will have to pay in a year for deductibles and coinsurance for covered benefits.
- 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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The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.
- 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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You don't need a prescription to obtain over-the-counter drugs.
- 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