Glossary

A

Allowed amount – The maximum amount a plan will pay for a covered health care service.  If your doctor or hospital charges more than the allowed amount, you may have to pay the difference. This is called balance billing.

Appeal – A request for your health insurance company or plan to review a decision or a grievance.

B

Balance billing – When a doctor or hospital bills you for the difference between their charge and the allowed amount. For example, if their charge is $100 and the allowed amount is $70, they may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Benefits – The health care items or services covered under a health insurance plan.

Billed amount – The amount billed by your physician or other healthcare provider for services you have received. Without insurance, this is the amount a provider would charge you.

C

Carrier – A company or HMO that provides health care coverage.

Coinsurance – Your share of the costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service. In most plans, after meeting your deductible, you must pay coinsurance until you reach your out-of-pocket limit. For example, if your plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20 percent would be $20. The health insurance or plan pays the rest of the allowed amount.

Coinsurance maximum – The most you will have to pay in coinsurance during a policy period (usually a year) before your health plan begins paying 100 percent of the cost of your covered health services. The coinsurance maximum generally does not apply to copayments or other expenses you might be required to pay.

Copayment – A fixed amount you must pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service. For example, your plan might charge you $15 for a generic prescription drug, $30 to visit your primary care doctor, and $50 to see a specialist.

Cost-sharing – The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, but it doesn’t include premiums, balance billing amounts, or the cost of services that are not covered.

D

Deductible – The amount you must pay out-of-pocket for covered services before your plan begins to pay its portion of your medical expenses. You usually must meet a deductible each year. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 out-of-pocket for covered health care services subject to the deductible. If you have a family plan that covers your spouse or dependents, you may have one deductible for the entire family, or you may have to meet a separate deductible for each family member.

E

Emergency care – Health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize sudden and severe medical conditions.

Emergency medical condition – An illness, injury, symptom, or condition that is so serious that a reasonable person would seek care right away to avoid severe harm.

Enrollee – A person who is enrolled in a health benefit plan.

Evidence of coverage (EOC) – The legal contract associated with health coverage under an HMO. An EOC details your benefits, exclusions, cost-sharing, and rights and responsibilities under the plan.

Exclusions or limitations – Health care services that your health insurance or plan doesn’t pay for or cover.

Exclusive provider organization (EPO) Plan – A type of health insurance plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

F

Facility-based provider – A health care professional who works at a health care facility such as a radiologist, anesthesiologist, pathologist, neonatologist, or an emergency department physician who works at a health care facility.

G

Group coverage – A health plan that covers a group of individuals usually offered by an employer or employee organization.

H

Habilitation services – Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and outpatient settings.

Health benefit plan – Refers to health insurance plan offered by a health insurance company that provides a set of covered services.

Health care facility – An entity that delivers health services such as a hospital or ambulatory surgical center.

Health insurance – A contract that requires your health insurance company to pay some or all of your health care costs in exchange for a premium.

Health maintenance organization (HMO) – A type of health benefit plan that usually limits coverage to care from doctors who work for or contract with the HMO. Out-of-network care is only covered in an emergency, or if you can’t access the care you need in-network. In an HMO plan, your care is managed by your primary care provider and you need a referral in order to see a specialist. HMO plans are similar to EPO plans, but HMOs are regulated differently than insurance companies.

Health savings account (HSA) – A medical savings account available to taxpayers who are enrolled in a high deductible health plan. Setting money aside in an HSA can help you afford cost-sharing expenses when you need care. The funds contributed to the account aren’t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses and roll over year to year if you don’t spend them.

Hospitalization – Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital outpatient care – Care in a hospital that usually doesn’t require an overnight stay.

I

In-network – Refers to services received from preferred providers, who have a business relationship with your health plan, which means they have agreed to the plan’s allowed amount and will not balance bill you. Services received in-network are covered according to your plan’s in-network cost-sharing provisions.

In-network coinsurance – The percent you pay of the allowed amount for covered health care services to doctors and hospitals who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

In-network copayment – A fixed amount you pay for covered health care services to doctors and hospitals who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Individual coverage – A health plan that covers you and your family. Individual coverage is not connected to your employer, so you can keep your plan even if you switch jobs.

Inpatient medical care – Health care that you get when you’re admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

L

Lifetime maximum – The total dollar amount a health care plan will pay over a policyholder´s lifetime. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

M

Major medical policies – Health care policies that usually cover both hospital stays and physicians´ services in and out of the hospital. This is a term that refers to the comprehensive health plans we normally think of when talking about health insurance, and which are subject to the Federal Affordable Care Act.

Managed health care – A system that organizes doctors and hospitals into networks with the goal of lowering costs while still providing appropriate medical services. Many managed care systems focus on preventive care and case management to avoid treating more costly illnesses. Most major medical policies are considered managed health care plans.

Mandated benefits – Health care benefits that state or federal law says must be included in health care plans. The Federal Affordable Care Act created two new types of mandated benefits. Certain preventive health services are required to be covered by most health plans without cost sharing. The essential health benefits package is required to be covered by most individual and small group health plans.

Mandated offerings – Health care benefits that state law says must be offered to the individual, employer or organization sponsoring a group policy. The individual or group sponsor is not required to purchase the benefits.

Medical bill mediation – An option for consumers to request negotiations between their insurer and provider for a reduction in balance billing.

Medically necessary – Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

N

Network – The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

Non-network providers – Health care providers – doctors, hospitals, and treatment facilities — not under contract with a particular HMO, PPO, or EPO.

Non-preferred provider – A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll usually pay more to see a non-preferred provider.

O

Out-of-area – The area outside the counties or ZIP codes in which an HMO provides regular and preventive coverage.

Out-of-network – Refers to services or costs received from non-preferred providers.

Out-of-network coinsurance – The percent you pay of the allowed amount for covered health care services to doctors and hospitals that do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network coinsurance.

Out-of-network copayment – A fixed amount you pay for covered health care services from doctors and hospitals that don’t contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Out-of-network services – Health care services from doctors and hospitals not in an HMO´s, PPO´s, or EPO’s network. Except in certain situations, HMOs and EPOs will only pay for care received from within its network. If you´re in a PPO plan, you will have to pay more to receive services outside the PPO´s network.

Out-of-pocket – Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered by your plan.

Out-of-pocket maximum or limit – The most you will have to pay during a policy period (usually a year) before you no longer have to pay cost-sharing for covered health services. Once you’ve reached your out-of-pocket maximum, your health plan generally pays 100 percent of your covered essential health benefits. You are still responsible for paying your premium. This maximum or limit does not include your premium, balance-billed charges, spending for non-essential health benefits, or spending for non-covered services.

Outline of coverage – An insurance document that summarizes a plan’s benefits, exclusions, premium, and cost-sharing. This document should be provided when you apply for coverage.

Outpatient services – Services usually provided in clinics, physician or doctor’s offices, hospital-based outpatient departments, home health services, ambulatory surgical centers, hospices, or kidney dialysis centers that usually doesn’t require an overnight stay.

P

Point-of-service plan (POS) – A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.

Policy – The legal contract associated with health coverage under an insurance company. A policy details your rights and responsibilities under the plan.

Preexisting condition – Health condition present before enrolling in medical insurance. The Affordable Care Act does not allow health plans to deny coverage, impose exclusions or waiting periods, or charge higher premiums due to a preexisting condition. However, some job-based plans that are grandfathered under the law may continue to take preexisting conditions into account. The ban on preexisting conditions doesn’t apply to Medicare supplement and long-term care insurance plans.

Preauthorization – Approval from a health plan that may be required before you get a service or fill a prescription. When a health plan provides this authorization, it means they agree that the service or prescription is medically necessary. Sometimes called prior authorization, prior approval, or precertification.

Preferred provider – A provider who has a contract with your health insurer or plan to provide services to you at a discount. A group of preferred providers makes up an insurer’s network. Insurers negotiate lower medical rates with their network and you receive these discounts when visiting preferred providers.

Preferred provider directory – A list of preferred providers associated with a health plan.

Preferred provider organization (PPO) – A type of health insurance plan that contracts with doctors and hospitals to create a network of preferred providers that can provide care to enrollees at a discounted cost. PPOs will cover some out-of-network costs, but you will pay more and may be balance billed.

Premium – The amount you pay for your health insurance every month. If you have health coverage through your work, your premium will likely be deducted from your paycheck.

Preventive care – Health care services such as routine physical examinations, immunizations, and screenings that are intended to prevent illnesses before they occur.

Primary care provider (PCP) – A doctor who directly provides or coordinates a range of health care services for a patient. HMOs generally have you choose a PCP when you enroll and require a written referral from your PCP before visiting a specialist.

Provider – A doctor, hospital, pharmacist, registered nurse, organization, institution, or person licensed to provide health care services in Texas. The term provider is often used collectively to refer to individuals or facilities that provide health services.

Provider area of practice – A provider’s field of expertise or specialty, such as: internal medicine, family/general practice, pediatric practitioner practice, obstetrics and gynecology, anesthesiology, psychiatry, or general surgery.

Provider network – All the doctors, specialists, hospitals, and other providers who agree to provide medical care to HMO, PPO, or EPO members under terms of a contract with the HMO or insurance company.

R

Referral – A written order from your primary care doctor for you to see a specialist or get certain medical services. In many health maintenance mrganizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

S

Self-funded plans – Plans funded strictly from employer contributions and employee premiums. These plans are authorized by the federal Employee Retirement and Income Security Act (ERISA) of 1974 and are regulated by the U.S. Department of Labor. State regulation of these plans is limited. Although an insurance company may be hired to administer the plan, the insurance company assumes no risk. (Also known as ERISA plans.)

Service area – The geographical area in which a plan’s network resides. It is important to know where you are located in regard to your plan’s network coverage.

Specialist – A doctor who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

Summary of benefits and coverage (SBC) – An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

U

Urgent care – Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe that it requires emergency room care.