Making Coverage Affordable
Agent – A person licensed to sell insurance policies and/or represents a health benefit plan. TexHealth is a licensed insurance agency and uses licensed insurance agents who have been trained by TexHealth and are considered TexHealth Certified Representatives.
Application – A form to be filled out with personal information that a health benefits plan will use to enroll a person in to the program.
Annual Plan Maximum Benefit – The maximum dollar amount an insurer will pay for medical services during the calendar year. This has been outlawed by the Affordable Care Act.
Cancellation – Termination of a member or group of members by the insurance company before or on the renewal date.
Claim – A request by an insured member (or his/her provider) to pay for healthcare services received.
Claimant – A person who makes a claim.
Co-insurance (Member Share) – The percentage of each health care bill a person must pay out of their own pocket up to a certain limit. Co-pays, deductibles and non-covered charges are in addition to this amount.
Complaint – A written communication primarily expressing a grievance against an insurer or a TexHealth Certified Representative.
Continuation – Texas allows for three (9) months of continued coverage for any person terminating their employment for any reason. The employee will be required to pay the employer share, employee share plus 2%. The TexHealth subsidy, if any, is waived during continuation coverage.
Deducible – The amount a member must pay before any payment is due from the insurer for non-copay services. Once the deductible is met, the insurer will pay a percentage of the remaining balance.
Effective Date – The first date on which a member is covered by an insurer or TexHealth. TexHealth effective dates are always on the first day of the month provided all required documentation is received by the deadline.
Emergency Room – Emergency room definition established by the US Government: “ an emergency medical condition, is a condition manifesting itself by ACUTE symptoms (not chronic) of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any body organ or part.” United States legal, 42 U.S.C. §1395 dd(a)
Evidence of Coverage (EOB) – A statement (not an invoice) from insurer listing healthcare services you received and the amount paid on your behalf.
Exclusion and Limitations – Provision in the insurance program that denies coverage for certain services or conditions.
Formulary – This is the list(s) of medications covered by an insurer. These lists classify medications by category. The category will determine your co-pay for the medication (for example, $15 for generic, $50 for brand formulary and $50 for non-formulary brand).
In-Network – Physicians, hospitals or other health care providers who contract with a network to provide services to its members. Coverage for services received from in-network providers are covered but services received from out-of-network providers are not always covered unless it is for appropriate Emergency Room care.
Out-of-Network – Physicians, hospitals and other health care providers who do not contract with the insurer. Expenses incurred for services provided by out-of-network providers may not be covered by the insurer except for Emergency Room care.
Out-of-Pocket Maximum – The total amount paid each year by the member for the deductible and coinsurance (Member Share). After reaching the out-of-pocket maximum, the plan pays 100% of the eligible charges for covered services for the rest of that calendar year.
Policy – A contract is issued by an insurer to the employer company
Policy period – The period a policy is in force, from the beginning or effective date to the expiration date, usually one year. Also known as “Plan Year.”
Pre-Existing Condition – Denying, raising premium or reducing coverage due to Pre-Existing Conditions is no longer legal.
Preferred Provider Organization (PPO) - A type of managed care plan in which doctors and hospitals agree to provide discounted rates to plan members. You do not need a referral to see a network specialist in a PPO plan.
Premium – The monthly amount, split between the employer and a member, paid to an insurer for health insurance coverage.
Primary Care Provider (PCP) – Family doctor who will see you regularly and manage your health care needs. It is very important everyone have a PCP. Family Practice Physicians, Internists, General Practitioners, OB/GYN Specialists and Pediatricians may all be classified as PCPs.
Provider – A health care (clinical) professional. It refers to doctors, specialists, nurses, nurse practitioners, physician assistants, medical assistants, radiologists, etc.
Nurse Care Manager – A licensed nurse who will assist you in the management of your health status.
Renewal – Continuation of a policy after its expiration date.
Rescission – The termination of a contract by an insurer when material misrepresentation has occurred.
Subrogation – Assignment of rights of recovery from another coverage program or insurer by the member.
Summary Plan Description (SPD) – This is a document that gives the details of your health insurance coverage. You can locate this information on the insurer’s website.
Third-party claim – A claim filed against a member’s insurance policy.