Accelerated death benefits – This policy provision may be available with a life insurance policy to allow you to get your death benefit while you’re alive if you’re diagnosed with a serious illness or need help with activities of daily living. The company will subtract the accelerated amount from the death benefit owed to your beneficiaries when you die.
Accident-only policies – Policies that pay only if you have an accident or are injured.
Accidental death benefits – Provides an additional life insurance payment if you die because of an accident. For instance, if you have a policy with a $500,000 death benefit and a $500,000 accidental death rider, your beneficiary would get $1 million if you die because of an accident. There are some restrictions.
Accumulation phase – The first phase of an annuity contract. During the accumulation phase, you’re contributing money to the annuity. The second phase is the payout phase when you’ll withdraw money from the annuity.
Affordable Care Act (ACA) – The ACA is a comprehensive health care reform law enacted by Congress in March 2010.
Agent – A person who sells insurance. Some agents work for a specific insurance company, while others represent several companies. Agents must be licensed by TDI to legally sell insurance in the state.
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.)
Annuity – A contract in which you pay money to a life insurance company for investment. Most people use annuities to provide an income for retirement or to build savings. They can also provide money for your heirs. Annuities are best for long-term income, not short-term income.
Appeal – A request for your health insurance company or plan to review a decision or a grievance.
Association health plans – Health plan that is set up by a member-based association or an employer association. These plans are sometimes exempt from state and federal laws and might not cover as many services as major medical plans.
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.
Beneficiary – The person, people, or entity who will get the death benefits from a life insurance policy or annuity.
Carrier – A company or HMO that provides health care coverage.
Cash surrender option – An option in a life insurance policy that lets you cancel the coverage and receive the cash value in a lump sum. This is often called “cashing out” a policy.
Catastrophic plans – Health insurance plans that protect from worst-case health scenarios, like getting seriously sick or injured. Catastrophic plans often have low monthly premiums and very high deductibles. These plans are intended for people under 30, but are available to anyone with a hardship or affordability exemption. Note: You pay most routine medical expenses yourself.
Coinsurance – Your share of the costs of a covered health care service. Coinsurance is calculated as a 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 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% 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.
Consumer choice plans – Health plans that don't include all of the benefits that state or federal law says must be included in health plans (also called mandated benefits). These plans should give you a disclosure statement and a list of the benefits that aren't covered.
Contestable period – A period of up to two years during which a life insurance company may deny payment of a claim because of suicide or a material misrepresentation on an application.
Contingent beneficiary – The other person or people who will get paid by a life insurance policy if the primary beneficiary dies before the person whose life is insured.
Conversion privilege – The right to change (convert) a life insurance coverage from one type of policy to another. For example, the right to change from a term insurance policy to a whole life insurance policy.
Coordination of benefits – A provision in a health benefit plan that says who will pay if you have more than one health plan. This ensures that more than one company doesn’t pay for the same set of services.
Copayment / Copay – A fixed amount that you must pay for a covered health care service, usually when you receive 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.
Credit life insurance – Pays off a loan or charge account balance if you die. Some lenders or sellers may require credit life insurance before they will approve a loan.
Death benefit – The amount paid to the beneficiary of your life insurance policy when you die.
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.
Deferred annuity – A type of annuity that allows you to save money for retirement or other reasons, while deferring the taxes on your earnings (or contributions if it’s an IRA) until you withdraw the earnings.
Disability benefits – Payments for your lost wages if you can’t work because you’re ill or injured.
Disclosures – A list of a health plan’s terms, including its benefits, exclusions, cost-sharing, service area, and preferred provider network. The disclosures are part of your policy or evidence of coverage. You can ask an insurance company or health maintenance organization for a copy of a plan’s disclosures before buying the plan.
Discount health plans – Members of discount plans pay monthly fees to get reduced rates on specific health care services. Some common discount plans cover vision, hearing, or pharmacy services. While they may use the term “PPO” (preferred provider organization) to describe their provider network, they aren’t traditional health plans.
Dread disease policies – Health plans that pay only if you contract the illness specified in the policy. (Also called specified disease policies.)
Drug formulary – A list of generic, brand name, and specialty prescription drugs that are covered by your health plan. Sometimes called the “preferred drug list.” Use the drug formulary to determine which drugs are covered and the level of cost-sharing you will pay.
Eligible employee – An employee who meets the eligibility requirements for coverage in a group health plan. To be eligible to join a group plan, you usually must work full-time for at least 30 hours a week.
Emergency 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.
Employer plans (also known as Group coverage) – Health plans that cover a group of individuals usually offered by an employer or employee organization. Small group coverage is for businesses with 2-50 employees. Large group coverage is for businesses with more than 50 employees.
ERISA plan (also known as a self-funded plan) – A type of health plan offered by employers under the Employee Retirement and Income Security Act (ERISA). Employers that offer ERISA plans pay the cost of their employees’ claims themselves. Employers may contract with an insurance company to administer an ERISA plan, but the insurance company doesn’t pay claims. The U.S. Department of Labor, not the state, regulates most ERISA plans.
Evidence of insurability – Life and disability insurance companies will usually ask you about your health and lifestyle when deciding if they want to sell you insurance and at what price.
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).
Face value – The amount of a life insurance death benefit as shown on the face page of the policy. The actual death benefit may be higher or lower depending on the options selected, outstanding policy loans, or premium owed.
Free examination period – This is the time after you get a life insurance policy or annuity that you have to look at the policy and decide if you want to keep it or return it to the company for a full refund. This is also called a “free look.”
Grievance procedure – The appeals process for you to protest your HMO’s decision about medical necessity or a claim payment. Some insurance companies also have grievance procedures.
Group coverage – Health coverage that’s available only to members of a specific group, such as an employer’s employees.
Group life insurance – This type of life insurance provides coverage to a group of people under one contract. Businesses and associations often buy these policies to provide life insurance for their employees.
Guaranteed renewable – Policies that generally must be renewed and may not be canceled by an insurance company. An insurance company may cancel a guaranteed renewable policy only if you don’t pay your premiums, or if you commit fraud or intentionally give the company wrong information. A company also may cancel a policy if it leaves the Texas insurance market.
Habilitation services – Health care services that help a person keep, learn, or improve skills and functioning for daily living. For example, 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 sharing ministries – Nonprofits that limit membership to people of a similar faith. Members agree to make monthly payments to pay for the medical expenses of other members. These plans aren’t regulated by the state and there is no guarantee they will pay claims. They also might not cover preexisting conditions or provide as many benefits as major medical plans.
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 to see a specialist.
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 confinement policies – Policies that pay a fixed amount each day you’re in the hospital.
Hospital outpatient care – Care in a hospital that usually doesn’t require an overnight stay.
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.
Incontestability – A provision in a life insurance policy that says the company can’t deny payment of a claim because of suicide or a material misrepresentation on your application after a certain amount of time, usually two years.
Indemnity plan – A type of health insurance policy that covers a portion of your health costs and pays the same amount regardless of which doctor or facility you choose. But you’ll usually have to pay for your health care when you get it and file a claim with your plan to be paid back. (Also known as fee-for-service.) Indemnity plans existed before PPOs and HMOs and are no longer offered, except under limited benefit and short-term limited duration health plans.
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.
Irrevocable beneficiary – A named beneficiary whose rights to life insurance policy proceeds are vested and can’t be canceled unless the beneficiary gives their permission
Levels of coverage – Level of plans in the health insurance marketplace: Bronze, Silver, Gold, and Platinum. Sometimes called “metal levels,” these categories are based on how you and your insurance plan split costs. Categories have nothing to do with quality of care. For each plan, you will pay a different percentage of total yearly costs of your care. Your insurance company will pay the rest.
The percentages the plans pay, on average, are 60%(Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). Total costs include premiums, deductibles, and out-of-pocket costs such as copayments and coinsurance. You will pay the highest premium for a plan where the company pays the highest portion of your health care bills.
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. The federal Affordable Care Act prohibits most health plans from including lifetime dollar limits on essential health benefits.
Limited benefit plans – Also known as short-term health insurance, these are major medical insurance plans that provide limited coverage for a defined time period. These plans can have a lower premium than other forms of major medical insurance. These plans do not meet the minimum essential coverage requirements under the federal Affordable Care Act.
Long-term care insurance – Insurance that pays for care you might need if you can’t take care of yourself because you’re ill or have a disability. Benefits can range from help with daily activities while recuperating at home to skilled nursing care in a nursing home.
Major medical policies – Health care policies that usually cover hospital stays and physicians´ services, both 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.
Major medical plans – There are four types of major medical health plans in Texas. Major medical plans cover a broad range of health care services. The four types are HMO plans, HMO point-of-service (POS) plans, exclusive provider (EPO) plans, and preferred provider (PPO) plans.
Managed health care – A system that organizes doctors and hospitals into networks with the goal of lowering costs while still providing quality 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. Certain preventive health services are required to be covered by most health plans without cost sharing. The federal 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.
Maximum out-of-pocket expense – The most you would have to pay during a certain time period for health care that is covered by your health plan. Until the maximum is reached, you have to pay a copayment or coinsurance each time you visit a doctor or get treatments.
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.
Metal level – A system for comparing the amount of coverage health plans provide. Plans sold to individuals and small employer groups are separated into four categories: bronze, silver, gold, and platinum. The categories are based on the percentage of the cost of a covered health service that a plan will pay. On average, bronze plans pay 60% of the cost, silver plans pay 70%, gold plan pay 80%, and platinum plans pay 90%. The names indicate only the percentage of costs the plan will pay, not the quality of care you receive.
Multiple employer welfare arrangement (MEWA) – In general, a MEWA is an ERISA plan that provides benefits to employees of more than one employer. MEWAs are regulated by both the federal government and the state. If the MEWA assumes all or part of the plan’s insurance risk, it must be licensed by TDI.
Network adequacy – The extent to which a health plan has enough doctors and facilities within its network to provide every service the plan covers. Network adequacy include distance to providers and scheduling wait times.
Non-network providers – Health care providers – doctors, hospitals, and treatment facilities — not under contract with a particular HMO, PPO, or EPO.
Out-of-area – The area outside the counties or ZIP codes in which an HMO provides regular and preventive coverage.
Out-of-network coinsurance – The percentage 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 costs – 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 health 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% 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.
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.
Paid-up – A life insurance policy that is paid in full and still active. You won’t have to pay any more premiums.
Paid-up additions – Additional amounts of life insurance that you can buy using dividends. You won’t have to pay any more premiums.
Payout phase – After you’ve paid into the accumulation phase of your annuity contract, your annuity enters its payout phase. This is sometimes called the annuitization phase. During this phase, you’ll get payouts on your annuity.
Point of service plan – A type of plan in which you pay less if you use doctors, hospitals, and other health care providers who belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor to see a specialist.
Policy loan – An advance made by a life insurance company to a policy owner. The advance is secured by the cash value of the policy.
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 insurance company or plan to provide services to you at a discount. A group of preferred providers makes up a plan's network. Insurance companies negotiate lower medical rates with their network and you receive these discounts when visiting preferred providers.
Preferred provider organization (PPO) plan – 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 load – An amount deducted from each life insurance premium payment to cover expenses.
Premium tax credit – A tax credit to help you afford health coverage. To get the credit, you must buy a plan through the federal marketplace at healthcare.gov.
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.
Qualifying life event – A change in your life, such as having a child, getting married, or losing health coverage, that might allow you to enroll in health insurance plans outside the open enrollment period.
Rated policy – A life insurance policy with a higher rate than usual because the person it’s for is considered a greater-than-average risk, usually because of a health condition or a dangerous occupation.
Referral – A written order from your primary care doctor for you to see a specialist or get certain medical services. In many health maintenance organizations (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.
Rescission – The termination of an insurance contract by the company if they find material misrepresentation. This would typically occur retroactive to the policy effective date and be accompanied by a return of all premiums paid, less any paid claims. The result is as if the policy were never issued.
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.)
Short-term limited-duration health plans – Health plans that offer fewer benefits and have lower coverage amounts than typical major medical plans. They often last 12 months or less, but sometimes can be renewed up to 3 years. When a short-term plan ends, you will have to buy a new plan. If you’re sick, you might not be able to get another short-term plan. You might have to wait until open enrollment on Healthcare.gov.
Single-premium whole life policy – A type of limited-payment policy that you only pay one premium payment for.
Specified disease policies (also called dread disease policies) – Policies that pay only if you get the illness specified in the policy. For instance, a cancer policy will pay only if you have cancer. It won’t pay if you have another disease.
Subscription health plans – Members pay a monthly or annual fee to use a doctor or service. These plans are not health insurance but may be helpful for people with high deductible health plans who need to visit the doctor frequently. There may be other fees for each visit, lab work, or other services. If you need care that the plan doesn’t cover, you will have to pay the full cost yourself. These are also known as direct care or concierge care plans.
Suicide clause – A clause in a life insurance policy that says the company won’t pay if the insured person commits suicide within a certain period of time after the policy is issued.
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.
Surrender charges – Charges that are deducted if you cash in (surrender) a life insurance policy or annuity. These charges also are deducted if you borrow money on the policy or if the policy lapses for non-payment.
Underwriting – The process some insurance companies use to decide whether they’ll sell you a plan and what they’ll charge you. Companies that use underwriting look at your health history. Only short-term health plans and other limited benefit plans may use underwriting. These plans may deny coverage to people with costly illnesses and charge higher rates for people likely to need more care. They may also look at your health history and deny a claim if you have a preexisting condition. Federal law prohibits major medical plans from using underwriting. This means a major medical plan must cover you and may not charge you more, even if you have a preexisting condition.
Universal life insurance – A type of life insurance that allows you to change the amount of your premiums and death benefit. But any changes you make could affect how long your coverage lasts. If your premiums are lower than the cost of insurance, the difference is taken from the cash value. If the cash value reaches zero, your policy could lapse. Your company must tell you if you are in danger of losing your policy.
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.
Usual and customary charge – This term is sometimes used as a basis for the maximum amount the health plan will pay for care when the plan and provider have not agreed upon a price. This is an objective term that refers to the amount that doctors in your area usually charge.
Utilization review – A process that HMOs and insurance companies use to reduce health care costs by avoiding unnecessary care. The review includes looking at requests for medical treatment and determining, on a case-by-case basis, whether that treatment is necessary.
Variable annuity – A form of annuity policy that allows you to choose between sub accounts that are similar to mutual funds. Your earnings potential is higher, but there isn’t a guaranteed return. Variable annuities are higher risk because there’s a chance you could lose some or all of your money.
Variable life insurance – A type of whole life insurance policy in which the death benefit and the cash value change according to the investment performance of a separate account fund that you select.
Whole life insurance – A life insurance policy that stays in effect for your entire life unless you cash the policy in or stop paying premiums. Some whole-life policies might pay a dividend each year that you can get in cash, add to your policy's cash value, or use to pay premiums. Dividends aren't guaranteed and can be lower than the company’s projection.