Words on a medical bill

The most a health plan pays for a covered service. For in-network care it is the price the plan negotiated with the provider, and your cost sharing is worked out from it.

When an out-of-network provider bills you for the difference between its charge and what your plan allowed. The No Surprises Act bans it in most emergencies and in some other situations.

The second-lowest-cost silver plan in an area on the Affordable Care Act (ACA) marketplace. Premium tax credits are set against its price.

A provider's list price for a service before any discount. Insurers rarely pay it, but uninsured patients are sometimes asked to.

A hospital's master list of billed charges for everything it does. The prices on it are usually far above what insurers pay.

Your share of the allowed amount, as a percentage, after you have met your deductible. With 20% coinsurance on a $1,000 allowed amount, you pay $200.

A fixed dollar amount you pay for a service, such as $30 for an office visit, whatever the service costs.

What you pay toward covered care yourself: deductibles, coinsurance and copays. Premiums are not cost sharing.

Current Procedural Terminology: the five-character codes for medical procedures and services, maintained by the American Medical Association. A brain MRI with and without contrast is 70553.

The amount you pay for covered care each plan year before your plan starts paying its share. Many plans cover some preventive care before the deductible.

The statement your insurer sends after processing a claim, showing what was billed, the allowed amount, what the plan paid and what you may owe. It is not a bill.

A charge from a hospital, or a clinic a hospital owns, for the use of its facility. It comes on top of the clinician's own fee.

Free or discounted care for patients who qualify, often by income. Tax-exempt hospitals must have a written financial assistance policy. Also called charity care.

An estimate of expected charges that providers usually must give patients who are uninsured or not using insurance, when care is scheduled at least three business days ahead or when the patient asks.

Healthcare Common Procedure Coding System: codes for supplies, drugs, equipment and services that CPT codes do not cover, such as ambulance rides.

A provider that has a contract with your health plan. In-network care costs you less because the plan's negotiated price applies.

The federal process under the No Surprises Act for settling payment disputes between insurers and out-of-network providers. An arbiter picks one side's offer.

A bill that lists every service separately, with its date, billing code and charge. Useful for spotting duplicates and mistakes.

The large data files hospitals and insurers must publish listing their prices in a format computers can read.

Private health plans that provide Medicare benefits in place of traditional Medicare, often with their own networks and prior authorization rules.

Medicare Severity Diagnosis Related Group: a code that groups a hospital inpatient stay by diagnosis and treatment, so one price covers the whole stay. A major hip or knee replacement is MS-DRG 470.

The price an insurer and a provider have agreed for a service. Hospitals must publish theirs, payer by payer.

The federal law that protects patients from most surprise out-of-network bills, including in emergencies and from out-of-network clinicians at in-network hospitals. It took effect on January 1, 2022.

When you stay in a hospital as an outpatient rather than an admitted inpatient. It can change what you pay and, under Medicare, whether a later nursing home stay is covered.

A provider without a contract with your health plan. Unless a protection applies, you may pay more, and the provider may bill you for the balance.

The most you pay for covered in-network care in a plan year. After you reach it, the plan pays the full allowed amount. Premiums do not count toward it.

A company that runs prescription drug benefits for health plans and employers: it negotiates with drugmakers, sets which drugs are covered and processes pharmacy claims.

What you or your employer pay each month to keep a health plan, whether or not you use care.

The federal subsidy that lowers ACA marketplace premiums, based on household income and the price of the benchmark plan.

The federal rule, in effect since January 1, 2021, requiring hospitals to post their prices online, including a machine-readable file of all items and services.

Approval a health plan requires before certain care, drugs or equipment, for the plan to cover them.

A four-digit code on hospital bills that shows which department or type of service a charge came from, such as pharmacy, lab or room and board.

A service you can schedule in advance, such as an MRI or a colonoscopy. Hospitals must show prices for shoppable services in a consumer-friendly format.

Paying the same price for a service whether it is done in a hospital outpatient department or in a doctor's office.

The federal rule requiring most health insurers and employer plans to publish their negotiated rates with in-network providers in machine-readable files.