Transparency in Coverage

The Centers for Medicare and Medicaid (CMS) requires issuers that offer plans on the Health Insurance Marketplace provide consumers with “Transparency in Coverage” information about the qualified health plans they offer. Transparency in Coverage information is intended to give you information about certain aspects of the coverage. The links below will provide explanation on the identified topics. If you need further information regarding this Transparency in Coverage information, please contact us

Out-of-network liability and balance billing

Enrollee claims submission

Grace periods and claims pending policies during the grace period

Retroactive denials

Enrollee recoupment of overpayments

Medical necessity and prior authorization timeframes and enrollee responsibilities

Drug exceptions timeframes and enrollee responsibilities

Information on Explanations of Benefits (EOBs)

Coordination of benefits (COB)



The percentage of the bill you pay after your deductible has been met.


A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 


The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.


Includes behavioral health treatment, counseling, and psychotherapy

in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)


Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.


If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.


The amount you pay to your health insurance company each month. 

Preventive services

Health care services that focus on the prevention of disease and health maintenance.


Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).


A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.