Confused about your coverage? Don’t be. You can find definitions for health
insurance terms right here. These terms will help you understand everything
from the Affordable Care Act to deductibles and premiums.
If you have a question on these terms or your coverage, email us at CHRISTUS.HP.MemberService.Inquiry@christushealth.org. We’re here to
Affordable Care Act:
A law passed in 2010 to offer more health insurance options, discounts
and broader Medicaid coverage. Also known as ACA or Obamacare.
A request asking your health plan to review a decision on denial of
coverage or payment. Learn more:
Individuals and Family,
US Family Health Plan (USFHP)
Brand Name Drug:
A drug sold under a specific, trademarked brand name, available by
prescription or over the counter.
A request for payment from your health insurance provider for services,
procedures or a drug.
A percentage of costs for a covered benefit the member pays after the
deductible is met.
A set amount a member pays for a service when it is received, like a
doctor’s office visit or getting a prescription filled.
The amount a member must pay before the health plan starts to pay.
A child or other person claimed by another for a personal tax exemption.
A resource that helps individuals, families and small businesses learn
about and enroll in health insurance plans. Also known as a health
A list of prescription drugs chosen and covered by a health insurance
plan with prescription drug benefits.
A drug with the same active-ingredient formula as a brand name drug
without a trademarked name. Generic drugs are usually cost less than brand
A formal complaint about service or quality of a health plan or provider.
Individuals and Family,
US Family Health Plan (USFHP)
Health Maintenance Organization (HMO):
A type of health insurance plan that usually limits coverage to care from
providers contracted with the plan. HMOs generally do not cover
out-of-network care, unless it is an emergency.
A set amount capping what a member can spend on deductibles, coinsurance
and copays for the plan year. After the maximum is met, the plan covers
100% of expenses.
A federal health insurance program for people 65 years of age and
older, as well as certain younger people with disabilities and people
with End Stage Renal Disease (ESRD). There are four parts:
Medicare Part A:
This is hospital insurance provided under Medicare. It covers hospital or
nursing facility care, surgery, hospice and home health care. Often
referred to as Original Medicare when combined with Part B.
Medicare Part B:
Part B covers medical services including doctors’ care, outpatient care,
labs, tests, medical equipment and some preventive care. Often referred to
as Original Medicare when combined with Part A.
Medicare Part C: Also known as Medicare Advantage, this allows private companies, like CHRISTUS Health Plan, to provide plans as
alternatives to original Medicare. These plans cover the same things as
original Medicare Parts A and B, but they might have different restrictions
and added benefits like prescription drug coverage, dental or vision care.
Medicare Part D:
This is prescription drug coverage provided through private companies.
There are two ways of receiving Part D coverage: a Part D plan that works
with Original Medicare (Parts A and B) or a Part C Medicare Advantage plan,
which will often have it included.
Facilities, providers and pharmacies contracted with your chosen health
plan to provide health care services.
A yearly period when people can enroll in a health insurance plan that
takes place in the fall, unless you qualify for a Special Enrollment
Period. The enrollment period for Individual and Family Plans is November 1, 2018- December 15, 2018.
A fee-for-service health plan consisting for two parts: Medicare Part A
(hospital insurance) and Medicare Part B (medical insurance).
A monthly, quarterly or annual amount you pay for health insurance
Prescription Drug Coverage:
A health plan that helps a member pay for their prescription drugs and
Routine health care, including screenings, checkups and patient
counseling in an effort to prevent illness, disease or other health
Primary Care Provider (PCP):
The doctor, nurse practitioner or physician assistant who provides and
coordinates a range of health care services.
Qualifying Life Event:
A change in a member’s life, such as a birth, marriage or divorce, which
allows a member to make changes in a health plan outside of enrollment
periods. There are four major types: loss of health coverage, changes in a
household, changes in residence and other qualifying events like becoming a
A written order from a member’s PCP to see a specialist or receive
other medical services. Some plans require a referral before a member
can receive care from anyone except a PCP. Plans requiring referrals
may not pay for services received without a referral.
Service Area: A set geographic area where a health plan accepts members and where
those members can receive routine health care.
Special Enrollment Period:
A time outside Open Enrollment when you can sign up for a health
plan, usually following a Qualifying Life Event.
A provider who focuses on a specific area of medicine or group of
patients to diagnose, manage, prevent and treat certain types of
symptoms and conditions.
A health plan for active-duty and retired uniformed services members
and their families.
US Family Health Plan (USFHP):
A TRICARE Prime option available to retirees and their families and
active duty dependents residing in a defined service area.