Texas Health Insurance Glossary

Additional Insured: Any other person covered under your health insurance plan that is not named as insured in your documentation from the insurance company.

Benefit: The dollar amount your insurance carrier will pay when you file a claim for a covered expense.

Benefit Period: The interval during which you will be eligible for benefits. In general, your benefit period begins with the first medical service you received for a specific illness and ends after you have not been treated for that same condition for 60 days.

Carrier: The insurance company you receive your policy from.

Certificate of Insurance: This is the printed description of your benefits and coverage limits that forms a contract between you and your carrier. It details precisely what will be covered, what won't, and the dollar maximum limits.

Claim: A claim refers to any request to your insurance company to pay benefits.

COBRA: This acronym refers to the Consolidated Omnibus Budget Reconciliation Act of 1985. The law requires group medical plans covering 20 employees or more to offer participants the option to receive continued healthcare benefits for up to 18 months after the cancellation of their group plan.

Coinsurance: This is the amount you will be required to pay for a particular medical expense, usually after you have met your deductible. Coinsurance is measured as a percentage of the total medical bill.

Co-payment: Also called copay. This is a cost-sharing arrangement in which you will be responsible for a specific charge for a specific medical service ($25.00 per doctor office visit, or $10.00 per generic prescription).

Covered Expenses: The various medical procedures that your insurance compnay has agreed to provide coverage for.

Deductible: The amount you will be required to pay for healthcare expenses before your insurance plan will begin to reimburse you. Some expenses on some plans, like doctor copays, are given to you without you having to meet the deductible

Exclusion: A specific circumstance or health condition that is not covered by your insurance policy.

Effective Date: The date on which your insurance coverage will actually begin to cover you.

Fee-for-Service: This is a payment system for healthcare where your provider is paid for each service after it is performed. You receive reimbursement after you file a claim.

HMO: Health Maintenance Organization. HMO plans were once popular health benefit programs with employers. While rarer today, some carriers still offer HMO plans for small group employers. With an HMO, you will pay monthly premiums in return for managed coverage for your checkups, doctor visits, hospital stays, surgeries, emergency care, preventive care, lab tests, diagnostic tests and X-rays. If you join an HMO, you will select called a Primary Care Physician who will be responsible for coordinating your healthcare and making referrals to specialists that you require. You must also to use doctors, hospitals and clinics who participate in your of your HMO plan network.

In-network: Healthcare providers or facilities who are members of your health plan.

Lifetime Limit: This refers to the maximum level (or cap) on benefits available through a policy.

Maximum Out-of-Pocket Expenses: The most you will have to pay during any one year in the form of deductibles and coinsurance fees.

Managed Care: This insurance term refers to a broad assortment of health plans that manage healthcare costs and usage. There are three major types of managed health plans: HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and POS (Point-Of-Service plans).

Medicaid: Medicaid is a joint state/federal health insurance program, administered by the state, that provides health coverage for low-income individuals, especially pregnant women, children and the disabled.

Medicare: Medicare is a federally-sponsored healthcare program that offers coverage for medical and hospital care primarily to those over the age of 65, and also some people under 65 with certain health conditions or disabilities.

Network: A network is a group of doctors, hospitals and other medical providers who have contracted to provide discounted healthcare services to your insurance carrier's policyholders.

Out-of-Network: This typically refers to any doctors, hospitals or other healthcare professionals considered to be non-participants by your insurance plan. Depending on your plan guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.

POS: Point-of-Service Plan. A POS is a managed healthcare plan that combines the features of a Health Maintenance Organization and a Preferred Provider Organization. These plans allow you to decide for yourself whether or not you will use an in-network provider or an out-of-network provider.

Pre-existing Conditions: This refers to any healthcare issues you had prior to the effective date of your insurance plan. Many policies will refuse to cover pre-existing conditions, while others may not cover the condition for a short time, as outlined in the policy offer.

PPO: Preferred Provider Organization. PPOs are networks of healthcare providers who have negotiated discount contracts with health insurance carriers. You can choose which providers you will see, but there are greater financial incentives for you to select providers within the PPO network.

Preventive Care: Health services that focus solely on preventative care measures such as physicals, immunizations, diagnostic tests and mammograms.

Premium: The dollar amount you will pay, generally on a monthly basis, in exchange for your insurance coverage.

Primary Care Physician: Most HMOs and POS plans will require you to select one family physician, pediatrician or internist to monitor your health, treat your health problems, and refer you to specialists when he/she deems necessary.

Provider: This term refers to any individual (physician, nurse, or specialist) or institution (hospital, clinic or laboratory) that provides you with care.

Rider: This refers to any policy attachment that makes additions, limitations or changes to your original insurance plan.

Short Term Health Insurance: Short term medical plans are healthcare plans purchased to provide you with benefits during coverage gaps between jobs, after a move, or while you are traveling overseas.

Small Business Health Insurance: This is a type of healthcare coverage that is available to businesses employing between 2-50 employees. It offers discounted premiums to employees and tax advantages to small business owners; also in most cases, the coverage cannot be denied to any employee, despite pre-existing conditions.

Travel Health Insurance: Travel insurance is purchased to provide you with coverage when you are traveling abroad. Some health insurance policies will not provide care outside the U.S., so travel insurance can be purchased for your trip.

Waiting Period: A waiting period is a pre-specified time period during which you will not be covered by your insurance (for a particular healthcare issue).