Glossary

Agent – A person licensed to sell insurance policies and/or represents a health benefit plan. TexHealth 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 into the program.

Annual Plan Maximum Benefit – The maximum dollar amount TexHealth will pay for medical services during the calendar year.

Cancellation – Termination of a member or group of members by the company or individual before the renewal date.

Claim – A request by a TexHealth member (or his/her provider) to pay for services obtained.

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.  Co-pays, deductibles, and non-covered charges are in addition to this amount.

Complaint – A written communication primarily expressing a grievance against TexHealth, United Healthcare or a TexHealth Certified Representative.

Contract – For TexHealth, a contract is considered to be an agreement between TexHealth and the employer.

Co-payment – An arrangement where a member pays a specified amount for a health care service and TexHealth pays the remainder. The member must pay his or her co-payment at the time services are rendered. You do not need to pay the Deductible before receiving services for a Co-payment.  Co-payments do not count toward co-insurance (Member Share) or Out of Pocket Maximum.

Deductible – The amount the member must pay before any payment is due from TexHealth.

Effective Date – The first date on which a member is covered by TexHealth. TexHealth effective dates are always the first of the month provided applications or changes are received by the 20th of the prior month.

Exclusion and Limitations – Provisions in the TexHealth program that denies coverage for certain services or conditions.

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 will be covered but services received from out-of-network providers unless it is for appropriate Emergency Room care.  The TexHealth network is United HealthCare ChoicePlus.

Out-of-Network – Physicians, hospitals, or other health care providers who do not contract with the United Healthcare Choice Plus network. Expenses incurred for services provided by out-of-network providers are not covered by TexHealth 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 the rest of that calendar year or until the Annual Plan Maximum Benefit is met.

Policy- A contract is issued by TexHealth 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.

Pre-Existing Condition Waiting Period – A period of time in which TexHealth does not provide coverage for a particular pre-existing condition.

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.  TexHealth is a PPO.

Premium – The monthly amount paid by a member to TexHealth to obtain or maintain coverage under the TexHealth benefits program.

Providers – Usually refers to doctors or those who are providing a medical service.

Renewal – Continuation of a policy after its expiration date.

Rescission – The termination of a contract by TexHealth when material misrepresentation has occurred.

Subrogation – Assignment of rights of recovery from another coverage program or insurer by the member.

Third-party claim – A claim filed against a non-TexHealth member’s insurance policy

Usual and customary – The charge for medical services approved by the carrier for payment.  These charges may be based on rates usually charged by physicians and providers in your area; rate averages compiled by independent rating services; or rate averages compiled by United Healthcare or another company.