Allowed Amount: The maximum amount the insurance company will use when deciding what to pay for a covered health care service. This is sometimes referred to as "payment allowance" or "negotiated rate." For services received from out-of-network providers, you may have to pay the difference if your provider charges more than the allowable amount.
Authorization: Authorization usually means that your health plan reviews whether the services you received, and the setting where you received them, are medically necessary and appropriate. Your health plan may require authorization of some services before you receive them, or on an ongoing basis. If you see an in-network provider, your provider should handle the authorization request. If you are in certain plans, particularly HMO plans, you may also need a referral from your primary care physician to see a specialist.
Balance Billing: If you receive covered services from an out-of-network provider, and the cost of these services is more than the allowable amount, the provider may be permitted to bill you for the difference. In some circumstances, you may be protected from balance billing. For example, if you are treated by a Maryland doctor in an emergency room, or if you are referred by your health plan to an out-of-network provider so you can get a timely and nearby appointment for mental health or substance use services, the law may protect you. If you have a choice of providers, and you choose an out-of-network provider without a referral from your health plan, you may have to pay the full amount of the provider’s bill.
Coinsurance: A percentage of the allowed amount you may be responsible for after you have paid your deductible.
Copay: This is a set dollar amount that you must pay for a particular service.
Deductible: The money you have to pay for your healthcare before your insurance starts covering the costs.
ERISA: The Employee Retirement Income Security Act (ERISA) is a federal law that applies to employee benefit plans, including health benefit plans. If an employer self-insures its employee health plan, even if the employer uses an insurance company as an administrator, then ERISA pre-empts state laws, so that many state laws do not apply to the health plan.
In-Network Provider: These are providers that have a contract with your insurance company or are employed by your HMO. If you receive covered services from an in-network provider, generally you will only need to pay your deductible and any applicable copay or coinsurance. You may not be billed by the provider for any additional balance due.
Mental Health Parity: The Mental Health Parity and Addiction Equity Act, commonly known as the Parity Act, generally requires insurance companies to provide you with mental health and substance use benefits at least equal to the benefits that are offered for medical treatments. Under the Parity Act, if your insurance company provides for unlimited doctor visits for a chronic physical health condition like migraine headaches or diabetes, in most cases it must also offer you unlimited visits for mental health conditions such as depression or alcohol addiction. The policy must not discriminate against mental health and substance use.
In addition to offering you the same numbers of office visits, your copays, coinsurance, deductible and the out-of-pocket maximum must also be comparable to the costs to you for physical health benefits. The process your insurance company uses to decide if your treatments are necessary must be comparable to the process used for approving or denying other medical benefits, including requirements for pre-authorization. The approval process for access to care can NOT be more stringent for mental health and substance use treatment than it is for medical and surgical health care services. These standards apply to services provided by both in-network providers and out-of-network providers. Your insurer has a process for you to request benefits to a specialist who is not under contract with the insurer.
Out-of-Network Provider: These are providers that do not have a contract with your insurance company or are not employed by your HMO. If you receive covered services from an out-of-network provider without a referral or prior approval from your insurance company or HMO, your health plan may not be required to pay any portion of the charges, or your copay or coinsurance may be larger than if the services had been provided by an in-network provider. You may also be subject to balance billing.
Out-of-Pocket Expenses: Money you pay for your health care. This includes deductibles, coinsurance, copayments, and similar charges. Your premium is not considered part of out-of-pocket expenses.
Out-of-Pocket Maximum: The maximum amount that you pay before your insurance will pay the full allowable amount.
Reasonable Access: Starting January 1, 2026, for many health plans in Maryland, if you are unable to get an appointment with a mental health or substance use disorder service provider within a reasonable time or distance from your home or workplace (as defined by Maryland regulation), your health plan is required to help you get an appointment with an out-of-network provider and provide coverage for the provider as if they are in-network, at no extra cost to you.
A “reasonable” time to wait for or distance to travel to an appointment for mental health or substance use disorder care varies depending on the type of care you need and whether you live in a rural, suburban, or urban area. For example, if you want behavioral health therapy that isn’t urgent, you should be able to get an appointment with an in-network provider within 10 calendar days. If that’s not possible, contact your health plan for a referral to an out-of-network provider with the experience and skills to meet your needs. Click here for the specific standards set by the Maryland Insurance Administration.
Get free help with your health coverage!
The Maryland Insurance Administration has a Health Coverage Assistance Team (H-CAT) to assist consumers. If you have questions or concerns about health coverage for you or your loved ones, the H-CAT staff is here for you.
- Get answers to your health insurance questions.
- Address health insurance problems or concerns.
- File a complaint about your health insurance issue or concern.
- Connect you to resources.
Phone: 410-468-2442
