Glossary
The words, defined honestly.
Insurance, sharing and billing terms in plain English, including the ones where the honest definition makes a CoreMed membership look like the wrong choice. A glossary that only flatters the company publishing it is not worth reading.
- Actual charge vs. allowed amountBills and billing
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The actual charge is what a provider bills. The allowed amount is what an insurer has agreed to pay. They are often wildly different, and the gap is the reason a bill can say $9,000 and settle for $1,400.
Worth saying: If you are paying cash, neither number applies to you automatically. You have to ask for the self-pay rate, which is a third number again.
- Amounts generally billed (AGB)Bills and billing
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A limit in federal law on what a non-profit hospital can charge a patient who qualifies for its financial assistance policy. It ties their bill to what insured patients are generally billed rather than the list price.
- Balance billingBills and billing
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When a provider bills you for the difference between what they charged and what your plan paid. Banned in specific situations by the No Surprises Act.
- ChargemasterBills and billing
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A hospital's internal list price for every item and service. Bears little relationship to what anyone actually pays, which is why an itemised bill can look absurd.
- Charity careBills and billing
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A hospital programme that reduces or eliminates a bill based on your income. Non-profit hospitals are federally required to have one. The formal name is a financial assistance policy.
Worth saying: Almost nobody is told about this at the point of billing. You usually have to ask.
- COBRAInsurance terms
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The right to keep an employer plan for a period after leaving the job, usually up to 18 months, if the employer had 20 or more employees. You pay the whole cost including the share your employer used to pay.
Worth saying: It is the default option and usually the most expensive one on the table.
- CoinsuranceInsurance terms
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A percentage of a bill you pay after meeting your deductible. Twenty percent coinsurance on a $40,000 surgery is $8,000.
- CopayInsurance terms
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A fixed amount you pay for a service, like $30 for an office visit, regardless of what the visit actually cost.
- DeductibleInsurance terms
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What you pay yourself each year before an insurance plan starts paying. It resets annually, which is why a January diagnosis and a December one cost very different amounts.
Worth saying: This is the one people confuse with an IUA. They are not the same thing and the difference matters.
- Direct primary care (DPC)Kinds of care
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A clinic that charges a monthly membership instead of billing per visit or through insurance. Smaller patient panels, longer appointments, and you can usually reach your doctor directly.
Worth saying: DPC handles everyday care. It does nothing for a surgery or a hospital stay, which is why it is normally paired with something else.
- Explanation of benefits (EOB)Bills and billing
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The statement an insurer sends after a claim showing what was billed, what was allowed, what they paid and what is left for you. It is not a bill, though it often looks like one.
- Federal poverty level (FPL)Money and eligibility
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An annual income figure set by the federal government and adjusted for household size. Used as the yardstick for Medicaid eligibility, marketplace subsidies and hospital charity care.
- Good faith estimateBills and billing
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A written estimate of what scheduled care will cost, which providers must give uninsured and self-pay patients for care booked at least three business days ahead.
Worth saying: If the final bill exceeds it by $400 or more you can formally dispute it. Hardly anyone knows to ask for one.
- Health sharing / medical cost sharingHealth sharing terms
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A non-profit community whose members contribute monthly toward each other's eligible medical costs. It is not insurance, there is no guarantee of payment, and eligibility is set by the community's own guidelines.
Worth saying: The absence of a payment guarantee is a real difference from insurance, not a technicality. It suits some households and not others.
- HRA (QSEHRA and ICHRA)Employer terms
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Arrangements that let an employer reimburse employees for their own healthcare instead of buying a group plan. QSEHRA is for employers under 50 full-time equivalents and is capped annually; ICHRA is open to any size with no federal cap.
Worth saying: Tax-free reimbursement generally requires care meeting the federal minimum standard, which a sharing membership does not meet.
- In-network / out-of-networkInsurance terms
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Whether a provider has a contract with your insurer. Out-of-network care usually costs more and sometimes is not paid at all.
Worth saying: Sharing memberships have no network, which removes this problem and introduces a different one: no negotiated rate is arranged for you either.
- Machine-readable file (MRF)Money and eligibility
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The price file every hospital must publish under federal price transparency rules. Since 2026 they must contain actual negotiated dollar amounts drawn from real claims data rather than estimates.
Worth saying: They are technically public and practically unreadable, which is most of why price transparency has not changed much for ordinary patients yet.
- MedicaidMoney and eligibility
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Public healthcare for people on lower incomes. Montana covers adults up to 138% of the federal poverty level, and the programme's expiry date was removed by the legislature in March 2025. You can apply at any time of year.
Worth saying: Many people who qualify never check because they assume they earn too much.
- Open enrolmentInsurance terms
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The annual window for taking up or changing a marketplace plan. Outside it you generally need a qualifying life event.
Worth saying: Membership and sharing arrangements typically have no enrolment window, which is a genuine practical advantage.
- Out-of-pocket maximumInsurance terms
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The most an insurance plan will make you pay in a year before it covers everything else. Sharing memberships work differently and do not have a direct equivalent.
- Pre-membership medical conditionHealth sharing terms
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A sharing community's term for something you were examined for, diagnosed with, medicated for or had symptoms of before joining. Sharing for these is usually limited and phases in over several years.
Worth saying: Insurance cannot exclude you for medical history. Sharing communities can and do limit it. This is one of the clearest trade-offs between the two.
- Preventive careKinds of care
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Screening and check-ups intended to catch problems early rather than treat something already wrong. Which specific services count varies by plan or community.
- Prudent layperson standardBills and billing
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The test for whether something counted as an emergency: whether a reasonable person would have believed they needed immediate care. Judged on what you knew at the time, not on the eventual diagnosis.
- Self-payBills and billing
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Paying a provider directly rather than through a plan. Saying so up front is what unlocks the self-pay rate, which is frequently far below the billed price.
Worth saying: The single most useful sentence in American healthcare is asking what the self-pay rate is before you are treated.
- Sharing requestHealth sharing terms
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The submission that asks a sharing community to share in a medical cost. The equivalent of a claim, with different rules and deadlines.
- Special enrolment periodInsurance terms
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A window, normally 60 days, to take up a plan outside open enrolment after a qualifying life event such as losing a job, moving, marrying or turning 26.
No term matches that. Tell us what you were looking for and we will add it.
Who publishes this. CoreMed Healthcare is a Montana healthcare membership company. We publish these guides because we think the information should be easy to find, and because our own members need it. They are written to answer your question rather than to sell you a membership: where the right answer is a hospital charity care programme or a different kind of plan, that is what they say. Nothing here is legal, tax or medical advice.
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