Glossary of Texas Health Insurance Plans Terms

Below are some terms and their definitions that may help you as you research Texas health insurance plans and policies. It can be very confusing to understand the different types of Texas health insurance plans and policies out there, and what kind of coverage and benefits each of them offers. If you are completely overwhelmed, you may want to consider consulting with a licensed, independent insurance broker to help you navigate the land of Texas health insurance plans.

A carrier is a business or company that provides Texas health insurance plans coverage. This can be either a business or a Health Maintenance Organization managed care company. They will sell the benefits to the individual through the use of Texas health insurance plans.

Coinsurance is the percentage that the individual member is responsible to pay out of their own pocket. The remaining percentage will be paid by the Texas health insurance plans carrier.

Coordination of benefits is the process of ensuring that the individual is not covered by more than one Texas health insurance plans. Or if there are two plans, it is about coordinating which policy pays which portion, and which one pays first, and which one pays the remaining balance. This is particular important when children are covered by Texas health insurance plans, or if someone is covered by their own group health plan, as well as his or her spouse’s.

The deductible is the amount that you must pay out of your own pocket before the carrier begins to pay its portion of claims. Sometimes the deductible is individual, and other times it applies to the whole family. Check carefully whether your Texas health insurance plans allow every family members’ deductible to apply to one cumulative total, or if each person has to meet each separate deductible.

When you are applying for Texas health insurance plans, you may have to provide evidence of insurability, which is basically proof that you are in good health. This may be done through communication from a physician, or through a listing of your medical history.

There are usually certain medical services that are excluded or limited. This means that certain conditions will not be covered by the Texas health insurance plans, perhaps under specified circumstances. Other times it applies to treatment of conditions that already existed at the time of enrollment in the plan. Other times it applies to some services that are not a part of the policy, such as behavioral health, vision, or dental services.

Different benefits apply whether a medical procedure is done as an outpatient or inpatient service. For example, behavioral health services are paid differently when provided on a weekly basis at a provider’s office than when an individual is hospitalized to receive mental health care. There will also be different benefits depending on whether services are given by a Texas health insurance plans network provider or not.

All coverage and benefits in all Texas health insurance plans will be subject to medically necessary criteria. This means that benefits are only paid if deemed to be medically necessary by the health insurance carrier. This is why the Texas health insurance plans network physician or health care provider must document a medical diagnosis for your treatment. The insurance carrier will review the services rendered, and if there are questions about their medical necessity, they may call up the physician or health care provider to determine need. You always have the right to appeal.