Glossary of Terms
The dollar amount a provider sets for services rendered before negotiating any discounts to arrive at the actual price. The charge will likely be different from the amount paid.
A percentage of the negotiated price due from the patient which usually applies after an annual deductible has been paid.
A pre-defined amount that a patient is required to pay at the time of a specific healthcare service.
An amount of money determined by the patient's insurance plan that must be paid before the insurance company pays for any healthcare services.
Financial Assistance or Charity Care:
Free care or discounts provided to patients who are uninsured, underinsured, or who do not have adequate financial resources to pay for necessary healthcare services provided. Determinations are generally based on family size and income in accordance with the Federal Poverty Guidelines, and awarded based on a sliding scale.
Is an acronym that stands for Health Insurance Portability and Accountability Act. A U.S. law that took effect on April 14, 2003 and is designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospital and other health care providers. Developed by the Department of Health and Human Services, these standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed.
You are an inpatient starting when you are formally admitted to a hospital bed with a physician's order designating you as an Inpatient admission.For a Medicare patient, the general expectation is you will stay in a hospital bed greater than 2 midnights.
A person who has or is covered by an insurance policy.
Organizations set up to facilitate the purchase of insurance in each state in accordance with the Patient Protection and Affordable Care Act (ACA). Marketplaces provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance policies eligible for federal subsidies.
A program that covers a wide range of healthcare services. Eligibility is determined based on income, family size and medical condition. Since Medicaid is a program run by individual states, eligibility requirements vary greatly.
A program that pays for healthcare services. You may be eligible if you are over 65 years old, or have a disability. This program has three parts: Part A - covers most inpatient hospital bills. Part B - covers doctor's bills and outpatient hospital charges. Part D - covers most prescribed medications.
The amount allowed for covered services, which is agreed upon in the contract between the healthcare provider and the insurance company. This amount is paid to the provider by the insurance company and/or the patient and the provider agrees to accept this amount for the services provided.
A patient is observation status starting when you are placed in a hospital bed with a physician's order designating you need to stay in a hospital bed with observation services. For a Medicare patient, the general rule is you will stay in the hospital less than 2 midnights.
You are an outpatientif you receive tests, treatments or procedures in a hospital but the physician has not written an order to keep you in a hospital bed as an inpatient or observation status.The patient generally leaves the hospital the same day or for certain procedures you can stay overnight in a bed.
The portion of total payment for the medical services and treatment for which the patient is responsible, including copayments, co-insurance and deductibles. Out-of-pocket payment also includes amounts for services that are not included in the patient benefit design and amounts for services balance billed for out-of-network providers.
Patient Financial Responsibility:
Amount owed by the patient following a provided service including (but not limited to) a patient's copayment, coinsurance and deductaible, or the amount a self pay patient is responsible for paying after the self pay discounts are applied.
The information on the list of "Patient Financial Responsibility Estimates for the most common tests and procedures" page is based on an average of what most patients will pay out-of-pocket for services after their deductible has been met. Many patients will pay below the amount shown and some may pay more.
An organization that negotiates or sets prices for provider services, collects revenue through premium payments or tax dollars, processes provider claims for service and pays provider claims using collected premium or tax dollars.
PPACA or ACA:
The Patient and Protection and Affordable Care Act (PPACA) - also known as the Affordable Care Act (ACA) - is the health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. This legislation includes a long list of health-related provisions that began in 2010 such as: free preventive care, prescription discounts for seniors, insurance coverage for dependents up to age 26 and the elimination of pre-existing conditions, etc.
The total amount a provider expects to be paid by payors and patients for healthcare services.
A means of providing healthcare consumers pricing information so they can make more informed healthcare decisions. In healthcare, readily available information on the price of healthcare services, combined with additional information, can help patients compare options to find the best solution to meet their needs and prepare their patient financial responsibility expectations.
An entity, organization, or individual that furnishes a healthcare service (e.g., hospital, physician, clinic, pharmacy, ambulance service, ambulatory surgical center, rehabilitation center or skilled nursing facility).
Self Administered Drugs:
Drugs that a patient normally administers on their own. These drugs are not typically covered by Medicare Part B if the patient is in the hospital and classified as an outpatient/observation patient. Patients covered under Medicare Part D may have benefits for drugs not covered under their Part B benefits. A complete list of self administered drugs can be found on
Patients who have no insurance coverage, are not eligible for benefits under a third party payor or a government plan such as Medicaid or Medicare, or whose insurance does not cover the procedure of service provided.
A patient is defined as underinsured if they lack adequate insurance benefits to cover their medical expenses.
The quality of healthcare service in relation to the total price paid for the service by care purchasers.