Insurance Terminology Glossary
Plain-language definitions of common health insurance terms with real-world therapy examples to help you understand your coverage.
Health insurance comes with its own language—deductibles, coinsurance, allowed amounts, EOBs. Understanding these terms is essential to knowing what you'll pay and how your benefits work. This glossary defines the most important insurance terminology in plain language, with examples based on mental health therapy costs.
Terms are organized by category for easy navigation. Click any term to expand its full definition, see how it works, and understand why it matters for your care.
How to Use This Glossary
Each term includes:
- • Simple definition in plain language
- • How it works with detailed explanation
- • Real therapy example using typical session costs ($150-180)
- • Why it matters for your coverage and costs
- • Related terms to explore (where applicable)
Cost-Sharing Terms
Understanding what you pay and when
Definition: The amount you pay every month to keep your health insurance active, whether you use it or not. Like a membership fee for being in the plan.
How It Works:
You (or your employer) pay your premium monthly. If you stop paying, coverage can end. Premiums are separate from what you pay when you actually see a therapist (deductibles, copays, coinsurance).
Therapy Example:
Your plan's monthly premium is $450 for your family. Your employer pays $300 and you pay $150 per month. Even if you don't go to therapy that month, you still pay $150 to keep coverage.
Why It Matters:
Premiums do NOT count toward your deductible or out-of-pocket maximum. Higher premiums often mean lower deductibles or copays, but you almost always have some out-of-pocket costs when you receive care.
Related Terms: Deductible, Out-of-Pocket Maximum
Definition: How much you pay out-of-pocket each year for covered services before your plan starts sharing the cost. Can be individual (per person) or family (for everyone together).
How It Works:
If your individual deductible is $1,000, you'll usually pay 100% of covered therapy session costs (at the allowed amount) until you've paid $1,000 total. After meeting your deductible, you typically pay only a copay or coinsurance. Deductibles reset annually with your plan year (often January 1).
Therapy Example:
Plan year runs January-December. Individual deductible $1,000. In-network allowed amount for therapy $125 per session.
- • Sessions 1-8: You pay $125 each = $1,000 total (deductible met)
- • Session 9 onward: Plan pays 80%, you pay 20% coinsurance ($25 per session)
Why It Matters:
Therapy can be expensive early in the year when you're working toward your deductible. Ask your plan how much you've already paid toward your deductible this year—it affects what you'll owe per session.
Common Misconception:
"I have a $30 copay, so I don't have a deductible." Many plans have BOTH a deductible and copays—check your Summary of Benefits.
Related Terms: Copay, Coinsurance, Allowed Amount, Out-of-Pocket Maximum
Definition: A fixed dollar amount you pay for a covered service, like $30 per therapy visit.
How It Works:
Usually due at time of visit. Amount depends on type of service (preventive care, primary care, specialist, emergency). Some plans require copays only after you meet your deductible; other plans charge copays regardless of deductible status.
Therapy Example:
Your plan has a $30 copay for in-network specialist visits (including therapists). The allowed amount for the session is $150. You pay $30 at your appointment; your plan pays the remaining $120.
Why It Matters:
Copays are predictable—you know exactly what you'll owe each visit. However, copays count toward your out-of-pocket maximum, so track them throughout the year.
Common Misconception:
"My copay is all I'll ever pay." Not always. Some services may still require coinsurance or have separate deductibles (like prescriptions).
Related Terms: Coinsurance, Deductible, Allowed Amount
Definition: A percentage of the allowed cost of a service that you pay after meeting your deductible. For example, you pay 20% and the plan pays 80%.
How It Works:
After you meet your deductible, each therapy session is split between you and the plan based on percentage. Your coinsurance is always calculated on the allowed amount, not the therapist's full fee.
Therapy Example:
Deductible already met. Allowed amount $150 per session. Coinsurance split: you pay 20%, plan pays 80%. You owe $30 per session (20% of $150); plan pays $120.
Why It Matters:
Unlike copays (fixed amounts), coinsurance varies based on the service cost. Higher-cost services mean higher coinsurance amounts—but it's still a smaller share than paying 100% yourself.
Common Misconception:
"20% coinsurance means I pay 20% of whatever my therapist bills." No—it's 20% of the allowed amount, which is often lower than the billed charge.
Related Terms: Allowed Amount, Deductible, Out-of-Pocket Maximum
Definition: The most you will pay in a plan year for covered, in-network services through deductibles, copays, and coinsurance. After hitting this limit, your plan pays 100% of covered in-network costs for the rest of the year.
How It Works:
What counts toward your OOP max: Deductibles, copays, coinsurance for covered in-network services.
What does NOT count: Monthly premiums, balance-billed charges, non-covered services, out-of-network costs (on most plans).
Once you reach your OOP max, your plan covers 100% of covered in-network care for the remainder of the plan year.
Therapy Example:
Your OOP max is $4,000. Over the year you pay:
- • $1,000 deductible
- • $1,200 therapy coinsurance
- • $800 medication copays
- • $1,000 medical coinsurance
- = $4,000 total (max reached)
For the rest of the year, all covered in-network therapy is 100% covered—no copay or coinsurance.
Why It Matters:
The OOP max protects you from catastrophic costs. If you have ongoing therapy or other healthcare needs, you may hit your max mid-year, making care essentially "free" (beyond premiums) for the remainder of the year.
2025 Marketplace Limits:
Maximum OOP limits for ACA Marketplace plans: $9,200 individual / $18,400 family.
Related Terms: Deductible, Copay, Coinsurance, Premium
Definition: The maximum your plan will consider paying for a covered service from an in-network provider. Also called the "negotiated rate" or "maximum allowable charge."
How It Works:
For in-network care: The provider agrees to accept the allowed amount as payment in full for covered services. You pay your copay or coinsurance based on the allowed amount; the provider cannot charge you more.
For out-of-network care: If the provider charges more than your plan's allowed amount, you may be billed the difference (balance billing).
Therapy Example:
Therapist's standard fee: $180. In-network allowed amount: $140. Your coinsurance: 20%.
- • You pay: 20% of $140 = $28
- • Plan pays: 80% of $140 = $112
- • Therapist writes off: $180 - $140 = $40 (difference between fee and allowed amount)
You're never charged the extra $40 for covered in-network services.
Why It Matters:
Understanding the allowed amount helps you see why in-network care saves money. The negotiated discount protects you from paying full fees, even when you have cost-sharing responsibilities.
Related Terms: In-Network, Coinsurance, Balance Billing
Definition: When a provider bills you for the difference between their full charge and your plan's allowed amount.
How It Works:
In-network providers usually cannot balance bill for covered services—they've agreed to accept the allowed amount as payment in full.
Out-of-network providers often can balance bill, meaning you pay your coinsurance PLUS the difference between the provider's fee and the plan's allowed amount.
Therapy Example:
Out-of-network therapist's fee: $200. Plan's out-of-network allowed amount: $110. Your coinsurance: 40%.
- • You pay coinsurance: 40% of $110 = $44
- • You pay balance bill: $200 - $110 = $90
- • Total you pay: $44 + $90 = $134
Why It Matters:
Balance billing can make out-of-network care very expensive. The No Surprises Act protects you from balance billing in many emergency and hospital settings, but generally does NOT protect against balance billing for routine outpatient therapy.
Related Terms: Out-of-Network, Allowed Amount, No Surprises Act
Definition: The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar service.
How It Works:
For out-of-network claims, your plan may ignore what the therapist actually charges and instead use their UCR amount to determine payment. UCR is determined by the plan's own data or commercial databases—not what the provider bills.
Therapy Example:
Out-of-network therapist charges $175. Plan's UCR for your area: $120. Plan covers 60% of UCR.
- • Plan pays: 60% of $120 = $72
- • Your coinsurance: 40% of $120 = $48
- • Your balance bill: $175 - $120 = $55
- • Total you pay: $48 + $55 = $103
Why It Matters:
UCR rates are often lower than what providers actually charge, leaving you responsible for larger out-of-pocket amounts when using out-of-network benefits. Always ask your plan how they calculate UCR before assuming reimbursement levels.
Related Terms: Out-of-Network, Allowed Amount, Balance Billing
Network Terms
Understanding provider relationships and how they affect your costs
Definition: The group of providers, hospitals, and facilities that have contracts with your health plan to provide services to members.
How It Works:
Plans design networks to control costs and access. Providers in the network agree to accept negotiated rates and follow the plan's rules for billing and authorization. Network type (HMO, PPO, EPO, POS) affects whether you need referrals and whether out-of-network services are covered.
Why It Matters:
Not all plans with the same carrier name share one network. For example, all Blue Cross plans don't use the same network—there can be different networks and products under the same brand.
Related Terms: In-Network, Out-of-Network, Provider Directory
Definition: A provider who has a contract with your health plan to provide services at agreed-upon rates. Lower costs for you.
How It Works:
In-network providers accept your plan's allowed amount as payment in full for covered services. Your copays/coinsurance/deductibles are usually lower in-network. Providers cannot balance bill you for the difference between their standard fee and the allowed amount for covered services.
Therapy Example:
Therapist's standard fee: $180. Plan's in-network allowed amount: $140. Your coinsurance: 20% = $28. Therapist cannot bill you the extra $40 difference—you only pay $28.
Why It Matters:
In-network care protects you from balance billing and reduces your overall costs. Always verify a provider is in-network with your specific plan, not just the carrier.
Related Terms: Allowed Amount, Network, Balance Billing
Definition: Providers who do not have a contract with your health plan. Usually means you pay more, and the provider can often balance bill you.
How It Works:
Many HMO and EPO plans don't cover out-of-network care except for emergencies. PPO and POS plans may cover out-of-network care with higher deductibles, higher coinsurance, and you may need to file your own claims.
Therapy Example:
Out-of-network therapist's fee: $180. Plan's out-of-network allowed amount: $110. Your coinsurance: 40%.
- • Coinsurance: 40% of $110 = $44
- • Balance bill: $180 - $110 = $70
- • Total you pay: $44 + $70 = $114 per session
Why It Matters:
Out-of-network costs often have separate, higher out-of-pocket maximums—or no maximum at all. Balance billing can make OON care significantly more expensive. Learn more about out-of-network benefits →
Related Terms: Balance Billing, UCR, Superbill, In-Network
Definition: A list of doctors, therapists, hospitals, and other providers who participate in a plan's network.
How It Works:
Usually available online through the insurance company's website. Shows provider name, location, specialty, network status, and whether they're accepting new patients. Plans must update directories regularly.
Why It Matters:
Directories are not always perfectly accurate. Always confirm network status with both the provider AND your plan before scheduling. Ask: "Are you in-network with [specific plan name], not just [carrier]?"
Related Terms: Network, In-Network, Out-of-Network
Coverage & Authorization Terms
What's covered and what approvals you need
Definition: The healthcare services your plan agrees to pay for, either fully or in part, under its rules.
How It Works:
Covered services are described in your Summary of Benefits and Evidence of Coverage. "Covered" doesn't mean free—it means the plan shares the cost with you according to your deductible, copay, or coinsurance.
Why It Matters:
Under the ACA, most plans must cover mental health and substance use disorder services as an essential health benefit. However, specific therapy types or session frequencies may still require medical necessity or prior authorization.
Related Terms: Excluded Services, Medical Necessity, Prior Authorization
Definition: Services your health plan does not pay for at all. If you get an excluded service, you pay 100% of the cost.
How It Works:
Every plan has a list of excluded services. Common mental health exclusions might include certain couples counseling (when there's no covered mental health diagnosis), life coaching, educational services, or non-evidence-based treatments.
Therapy Example:
Your plan documents state they don't cover "marital counseling when the primary diagnosis is relationship difficulty without a covered mental health diagnosis." If you pursue couples therapy under this exclusion, you pay the full session cost out-of-pocket.
Why It Matters:
Charges for excluded services don't count toward your deductible or out-of-pocket maximum. Always check your plan's coverage documents before starting treatment.
Related Terms: Covered Services, Medical Necessity
Definition: A service is needed to diagnose, treat, or manage an illness or condition and meets accepted medical standards.
How It Works:
Plans decide medical necessity based on clinical guidelines, diagnosis, symptoms, and treatment history. For mental health therapy, plans often look at symptom severity, level of impairment (work, school, relationships), and safety concerns.
Therapy Example:
You want twice-weekly therapy for anxiety. Your plan's clinical guidelines state once-weekly therapy is usually sufficient for outpatient anxiety treatment. The plan may approve only once-weekly as medically necessary unless your therapist provides documentation of higher acuity.
Why It Matters:
The plan's criteria ultimately control coverage, not just your therapist's opinion. If a service is denied as not medically necessary, you have appeal rights.
Related Terms: Prior Authorization, Covered Services, Appeal
Definition: When your health plan requires your provider to get advance approval before it will agree to cover a service.
How It Works:
Your provider sends clinical notes and treatment plans to the plan showing the service is medically necessary. The plan may approve, approve with limits (e.g., 10 sessions instead of 20), or deny. Failing to obtain required prior authorization can result in reduced or denied coverage.
Therapy Example:
Your plan covers 10 therapy sessions per year without prior authorization. Your therapist submits a prior authorization request for 20 additional sessions. The plan reviews your diagnosis and treatment progress and either approves, denies, or approves a different number of sessions.
Why It Matters:
Prior auth can delay access to care but is legally required for certain services. Ask upfront: "Does my plan require prior authorization for outpatient therapy?"
Related Terms: Medical Necessity, Session Limit, Mental Health Parity
Definition: The 12-month period your plan uses to track your coverage, deductibles, and out-of-pocket maximum. Often January 1 - December 31.
How It Works:
At the start of a new plan year, your deductible resets to zero, your out-of-pocket maximum resets, and new benefit limits take effect. Some employer plans use different cycles (e.g., July 1 - June 30).
Why It Matters:
When switching plans mid-year, deductible and out-of-pocket totals usually do not transfer to the new plan. If you've met your deductible in December, it resets in January, and you start over.
Related Terms: Deductible, Out-of-Pocket Maximum, Open Enrollment
Billing & Claims Terms
How bills are processed and what you receive
Definition: A request for payment sent to your health plan after you receive services, asking the plan to pay its share.
How It Works:
In-network providers almost always submit claims for you. Out-of-network providers sometimes submit directly, or they may ask you to pay in full and file your own claim using a superbill. Claims include service codes (CPT), diagnosis codes (ICD-10), dates, and charges.
Processing Times:
Typically 2-4 weeks for electronic claims, 4-6+ weeks for paper claims. Filing deadlines vary by plan (usually 90 days to 1 year from date of service).
Why It Matters:
Claims must be submitted properly and timely, or coverage can be denied. Save all documentation and track submission dates. Learn more about the billing process →
Related Terms: EOB, Superbill, CPT Codes
Definition: A summary from your health plan showing what was billed, what the plan allowed, what the plan paid, and what you may owe. It is NOT a bill.
Key EOB Fields:
- • Patient and provider information
- • Date of service
- • Procedure code and description (CPT)
- • Billed amount (what provider charged)
- • Allowed amount (plan's negotiated rate)
- • Not covered / adjustments
- • Deductible applied
- • Copay/coinsurance
- • Amount paid by plan
- • Patient responsibility (what you owe)
- • Remark/reason codes
Therapy Example:
Provider bills $180. EOB shows: billed $180, allowed $140, plan adjustment $40, plan paid $112, you owe $28 (coinsurance). Compare this to your actual bill from the provider to ensure it matches.
Why It Matters:
Always review EOBs for errors. Mistakes can happen—wrong allowed amount, incorrect diagnosis codes, duplicate charges. EOBs also track progress toward your deductible and out-of-pocket max.
Related Terms: Claim, Allowed Amount, Coinsurance
Definition: A detailed receipt from your therapist that you can send to your insurance company to ask for reimbursement, usually for out-of-network services.
Required Information:
- • Provider name, credentials, NPI, Tax ID
- • Patient name and date of birth
- • Date of service
- • CPT codes (procedure codes)
- • ICD-10 codes (diagnosis codes)
- • Place of service
- • Charge amount
- • Payment information
How It Works:
Used when the therapist is out-of-network and you pay the full fee at time of service. You submit the superbill to your insurer for possible reimbursement based on your out-of-network benefits.
Therapy Example:
Out-of-network therapist charges $180/session. You submit monthly superbills for 4 sessions ($720 total). Plan's allowed amount: $140/session = $560 total. Plan pays 60% of allowed ($336). Your net cost: $720 - $336 = $384 for 4 sessions.
Why It Matters:
Superbills give you a way to get partial reimbursement for out-of-network care, but you still bear more financial responsibility than with in-network care. Learn more about superbills →
Related Terms: Out-of-Network, UCR, Claim, CPT Codes
Definition: How insurance companies decide which plan pays first when you're covered by more than one health plan.
How It Works:
Rules determine which plan is primary (pays first) and which is secondary (pays some or all of what's left). The therapist bills the primary plan first; remaining amounts are sent to the secondary plan.
Therapy Example:
You're covered by your employer's plan (Plan A) and your spouse's plan (Plan B). Plan A is primary. Therapy allowed amount: $150.
- • Plan A (primary) pays 70% = $105
- • You owe 30% = $45
- • Plan B (secondary) covers 80% of remaining $45 = $36
- • You end up paying: $9
Why It Matters:
Two plans coordinate to avoid double payment or paying more than 100% of the cost. Inform providers if you have dual coverage so claims are processed correctly.
Related Terms: Primary Insurance, Secondary Insurance, Claim
Plan Type Terms
Understanding different insurance plan structures
Definition: Plan that usually limits coverage to care from providers who work for or contract with the HMO. Generally doesn't cover out-of-network care except for emergencies.
Key Requirements:
- • Usually requires choosing a Primary Care Physician (PCP)
- • Often requires PCP referrals to see specialists
- • Must use in-network providers (except emergencies)
Cost Structure:
Lower premiums, predictable copays, but limited flexibility. Little to no coverage for out-of-network care.
Mental Health Impact:
May require PCP referral to see a therapist, depending on plan design. Must stay within the HMO's network of mental health providers.
Related Terms: PPO, EPO, POS, Referral, Network
Definition: Plan that contracts with providers to create a network. You pay less for in-network care, but can also use out-of-network providers at higher cost.
Key Requirements:
- • Usually no PCP required
- • No referrals needed for specialists
- • Can see out-of-network providers (higher cost)
Cost Structure:
Higher premiums than HMOs, but more flexibility. Out-of-network coverage available but with higher deductibles, higher coinsurance, and separate out-of-network out-of-pocket max.
Mental Health Impact:
Direct access to in-network therapists without referrals. Out-of-network coverage available, though expensive (balance billing common).
Related Terms: HMO, EPO, In-Network, Out-of-Network
Definition: Managed care plan where services are covered only if you go to providers in the plan's network, except for emergencies. A middle ground between HMO and PPO.
Key Requirements:
- • Must use in-network providers
- • Many don't require PCP or referrals
- • No out-of-network coverage (except emergencies)
Cost Structure:
Premiums typically between HMOs and PPOs. More flexibility than HMOs (often no referrals needed), but must stay in-network.
Mental Health Impact:
If mental health networks are narrow, this can limit therapist choices. No reimbursement for out-of-network therapy.
Related Terms: HMO, PPO, Network, In-Network
Definition: Plan where you pay less if you use in-network providers and must get a referral from your PCP to see specialists. Mix of HMO and PPO features.
Key Requirements:
- • Requires choosing a PCP
- • Requires referrals to see specialists
- • Out-of-network coverage available at higher cost
Cost Structure:
Premiums between HMOs and PPOs. Lower costs with referrals and in-network care; higher costs for out-of-network or care without referrals.
Mental Health Impact:
May require PCP referral to see a therapist. Some plans allow self-referral for mental health; check your specific plan rules.
Related Terms: HMO, PPO, Referral, PCP
Definition: Plan with a higher deductible than traditional plans and usually lower monthly premiums. Can be paired with a Health Savings Account (HSA).
2025 IRS Thresholds:
- • Self-only: At least $1,650 deductible
- • Family: At least $3,300 deductible
Cost Structure:
Lower monthly premiums, high deductibles. You pay the full cost of most services (at allowed amounts) until you meet your deductible, then coinsurance applies.
Mental Health Impact:
Therapy is subject to the deductible plus coinsurance, meaning sessions can be expensive early in the year. However, you can use HSA funds (pre-tax) to pay for therapy.
Related Terms: HSA, Deductible, Coinsurance
Definition: Tax-advantaged savings account you can use to pay for qualified medical expenses with pre-tax dollars. Must be enrolled in an HSA-qualified HDHP.
2025 Contribution Limits:
- • Self-only: $4,300
- • Family: $8,550
- • Age 55+ catch-up: Additional $1,000
Triple Tax Benefit:
- • Contributions are pre-tax or tax-deductible
- • Growth is tax-free
- • Withdrawals are tax-free for qualified medical expenses
Portability:
Funds roll over year to year—you never lose them. You keep your HSA even if you change jobs or health plans (though you can only contribute while enrolled in an HSA-qualified HDHP).
Mental Health Use:
Therapy copays, coinsurance, and deductibles are qualified medical expenses. Use HSA funds tax-free to pay for sessions.
Related Terms: HDHP, HRA, FSA
Definition: The employer pays claims directly using its own funds rather than buying a fully-insured policy. Often hires an insurance carrier for administration only (ASO arrangement).
How It Works:
Employer bears the financial risk. They hire a third-party administrator (TPA) or insurance carrier to provide network access, process claims, and handle customer service—but the employer funds the actual claims.
Statistics:
67% of covered workers are in self-funded plans (2025 KFF); 80% at large employers (200+ workers).
Regulation:
Governed by federal ERISA law, exempt from most state insurance mandates. Appeals and coverage disputes follow federal ERISA rules.
Why It Matters:
Your insurance card may say "CareFirst" or "Aetna," but the employer—not the carrier—is the actual payer and decision-maker. Network and coverage can differ from fully-insured plans with the same carrier name.
Related Terms: Fully-Insured Plan, ASO, ERISA
Definition: Financing model where mental health and substance use benefits are managed by a separate company instead of your medical insurer.
Common Carve-Out Companies:
- • Optum Behavioral Health
- • Magellan Healthcare
- • Carelon Behavioral Health
- • Beacon Health Options
Why It Matters:
You must check the correct network for mental health providers (not just your medical network). Prior authorization and appeals procedures may differ. Claims can be sent to the wrong entity if you don't know about the carve-out.
How to Identify:
Look at the back of your insurance card for a separate "Behavioral Health" phone number or company name. Call Member Services and ask: "Is my mental health managed by a carve-out vendor?"
Related Terms: Network, Prior Authorization, Mental Health Parity
Enrollment & Rights Terms
When you can enroll and what protections you have
Definition: The once-a-year window when you can sign up for, change, or drop health insurance plans without a special reason.
Typical Timeframes:
- • Marketplace plans: November 1 - January 15
- • Employer plans: Set by employer (often in fall)
- • Medicare: October 15 - December 7
Why It Matters:
Outside open enrollment, you generally can't make changes unless you qualify for a Special Enrollment Period due to a life event. Missing open enrollment can leave you without coverage or stuck in a plan that doesn't meet your needs.
Related Terms: Special Enrollment Period, Qualifying Life Event, Plan Year
Definition: Extra window outside open enrollment when you're allowed to sign up for or change health coverage because of certain life events.
Qualifying Events:
- • Loss of other coverage
- • Moving to a new state or coverage area
- • Marriage or divorce
- • Birth or adoption of a child
- • Changes in income affecting subsidy eligibility
Timeline:
Usually must act within 60 days of the qualifying event. Documentation typically required (termination letters, marriage certificate, proof of address).
Why It Matters:
Allows plan changes mid-year if you experience major life changes. Knowing your SEP rights ensures you don't go without coverage during transitions.
Related Terms: Open Enrollment, Qualifying Life Event, COBRA
Definition: A formal request asking your health plan to reconsider a decision—usually a denial of payment or coverage.
How It Works:
Internal appeal: Plan reviews its own decision. External review: Independent third party reviews the denial. You typically have at least 180 days from the denial to file an internal appeal.
Therapy Example:
Your plan denies payment for 8 therapy sessions, saying they're "not medically necessary." You file an appeal with supporting letters from you and your therapist explaining symptom severity and treatment progress.
Why It Matters:
Appeals can overturn denials, especially when denials are based on incomplete information or misapplication of coverage rules. Keep all documentation and follow deadlines carefully.
Related Terms: Grievance, Medical Necessity, Prior Authorization
Definition: Written estimate of expected charges for healthcare items or services for uninsured or self-pay patients, required under the No Surprises Act.
Required Timeframes:
- • Service scheduled 10+ business days ahead: Within 3 business days of scheduling
- • Service scheduled 3-9 business days ahead: Within 1 business day
- • Upon request (no scheduling): Within 3 business days
Dispute Rights:
If your final bill exceeds the GFE by $400 or more for the same services, you can dispute it through the Patient-Provider Dispute Resolution (PPDR) process within 120 days of receiving the bill.
Why It Matters:
Gives self-pay patients cost transparency before receiving care and recourse if bills are significantly higher than estimated. Learn more about Good Faith Estimates →
Related Terms: No Surprises Act, Self-Pay, Out-of-Network
Definition: Federal law (Mental Health Parity and Addiction Equity Act of 2008) requiring mental health and substance use disorder benefits be no more restrictive than medical/surgical benefits.
Three Parity Areas:
- • Financial requirements: Deductibles, copays, coinsurance, out-of-pocket maximums
- • Quantitative treatment limits (QTLs): Visit limits, day limits, dollar limits
- • Non-quantitative treatment limits (NQTLs): Prior authorization, medical necessity criteria, network standards
Therapy Example:
If your plan doesn't require prior authorization for 20 physical therapy sessions per year, they generally can't require prior auth for the first 20 mental health therapy sessions—that would violate parity.
Why It Matters:
Parity protects against discriminatory treatment of mental health benefits. If you believe your plan violates parity, you can file a complaint with the Department of Labor or your state insurance department.
Related Terms: Prior Authorization, Session Limit, NQTLs, Behavioral Health Carve-Out