Reference-Based Pricing
InsuranceHealth plan payment method setting maximum amount plan will pay for specific service based on reference price (often Medicare rate plus percentage). If provider charges more, patient may pay difference. Encourages price shopping. Can result in balance billing. More common in self-funded employer plans seeking cost control.
More Insurance Terms
Accident Insurance
Supplemental insurance that pays benefits if the policyholder is injured in a covered accident. Pays a lump sum or scheduled benefits for accidents resulting in emergency room visits, hospitalization, fractures, or other specified injuries.
Actuarial Value
The percentage of total average costs for covered benefits that a health plan pays. Bronze plans have 60% actuarial value, Silver 70%, Gold 80%, and Platinum 90%. The remaining percentage is what consumers pay through deductibles, copayments, and coinsurance.
Affordability Test
Under the employer mandate, coverage is considered affordable if the employee s share of self-only premium for the lowest-cost plan does not exceed 9.12% (2023) of household income. If coverage is unaffordable, the employee may qualify for marketplace premium tax credits.
Age Rating
The practice of charging different premiums based on age. Under the ACA, insurers can charge older adults up to 3 times more than younger adults (3:1 ratio). Some states impose stricter limits on age rating.
Aggregate Deductible
A family plan structure where the entire family deductible must be met before insurance begins cost-sharing for any family member. All family members' expenses count toward the single family deductible amount.
Allowed Amount
The maximum payment your insurance plan negotiates with providers for specific services. In-network providers agree to accept this rate as full payment. If a provider charges more than the allowed amount and is out-of-network, you may face balance billing for the difference.
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