Health Insurance includes medical, dental, long term care, and disability insurance. Each of these policies can be purchased through a group or individual (family) plan.
Back to top
Basic Medical Expense Coverages include hospital expense insurance, surgical expense insurance, physicians’ visits insurance, and coverage for additional medical services.
Back to top
Hospital Expense Insurance covers medical expenses while the patient is in the hospital, such as daily room-and-board and miscellaneous expenses incurred during the hospital stay.
Back to top
Surgical Expense Insurance covers part or all of a physician’s fee for a surgical operation.
Back to top
Physicians’ Visits Insurance covers nonsurgical care provided by an attending physician other than a surgeon.
Back to top
Major Medical Insurance covers medical expenses resulting from illness or injury that are not covered by a basic medical expense plan.
Back to top
Supplemental Major Medical Policy covers medical expenses that exceed the limits of the underlying basic medical expense policy. It also covers certain medical expenses not covered by the basic policy.
Back to top
Comprehensive Major Medical Policy combines basic medical expense coverages and major medical insurance into one policy.
Back to top
Calendar-Year Deductible is medical insurance deductible an insured must meet only once during the calendar year.
Back to top
Coinsurance is a medical insurance provision that requires the insured to pay part of the covered medical expenses in excess of the deductible.
Back to top
Stop-Loss Provision limits the amount the insured must pay by reimbursing 100% of covered expenses in excess of this limit for the rest of the calendar year.
Back to top
Preexisting Conditions Clause excludes coverage for any preexisting medical condition (one that existed before the policy effective date) for a limited period after an insured enters the plan.
Back to top
Portability is characteristic of a health plan that requires a new employer or health plan to give credit for prior, continuous health insurance coverage.
Back to top
Coordination-of-Benefits Provision indicates the order of payment when an insured is covered under two or more group health insurance plans; limits the insured’s total recovery under all applicable policies to 100% of covered expenses.
Back to top
Health Maintenance Organization (HMO) is a managed care plan that provides a range of comprehensive health care services to its members for a fixed, prepaid fee; members’ choice of healthcare providers is usually restricted to those in the HMO network.
Back to top
Preferred Provider Organization (PPO) is a managed care plan that contracts with health care providers for medical services provided to plan members at discounted fees; members’ choice of healthcare providers is not restricted but members have a financial incentive to choose contracted providers.
Back to top
Point-of-Service (POS) Plan is a managed care plan that combines the characteristics of an HMO and a PPO; has a network of preferred providers. If plan members receive care from these preferred providers, they pay little or nothing out of pocket. However, if care is received outside the network, the care is covered, but the patient must pay substantially higher coinsurance charges and a deductible.
Back to top
Dental Insurance is a form of health insurance that covers normal dental care and damage to teeth in an accident. Dental insurance has the major advantage of helping insureds and covered dependents pay for the cost of routine dental care. The coverage also encourages insureds to regularly see a dentist, who can detect or prevent serious dental problems.
Back to top
Long Term Care Insurance pays for extended medical care or custodial care received in a nursing home, hospital, or home.
Back to top
Disability Income Insurance pays periodic income payments to an insured who is unable to work because of sickness or injury.
Back to top
Elimination Period is initial time period in a health insurance or disability income policy during which benefits are not paid.
Back to top
Medicare is social insurance program that covers the medical expenses of most individuals age sixty-five and older.
Back to top
Medicaid is federal-state welfare program that covers the medical expenses of low-income persons, including those who are aged, blind, or disabled; members of families with dependent children,; and pregnant women as well as certain children.
Back to top
Note: Information provided at this Learning Center is extracted from various text books written by the American Institute for Chartered Property Casualty Underwriters (AICPCU) and from the Texas Department of Insurance (TDI).