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 We’re here to help.

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.

Appeal: A request asking your health plan to review a decision on denial of coverage or payment. Learn more: Individuals and Family, Medicare Advantage, US Family Health Plan (USFHP)

Brand Name Drug: A drug sold under a specific, trademarked brand name, available by prescription or over the counter.

Claim: A request for payment from your health insurance provider for services, procedures or a drug.

Coinsurance: A percentage of costs for a covered benefit the member pays after the deductible is met.

Copayment: A set amount a member pays for a service when it is received, like a doctor’s office visit or getting a prescription filled.

Deductible: The amount a member must pay before the health plan starts to pay.

Dependent: A child or other person claimed by another for a personal tax exemption.

Exchange: A resource that helps individuals, families and small businesses learn about and enroll in health insurance plans. Also known as a health insurance marketplace.

Formulary: A list of prescription drugs chosen and covered by a health insurance plan with prescription drug benefits.

Generic Drug: 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 name drugs.

Grievance: A formal complaint about service or quality of a health plan or provider. Learn more: Individuals and Family, Medicare Advantage, 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.

Maximum Out-of-Pocket: 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.

Medicare: 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.

Network: Facilities, providers and pharmacies contracted with your chosen health plan to provide health care services.

Open Enrollment: 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 typically November 1st - December 15th each year.

Original Medicare: A fee-for-service health plan consisting for two parts: Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

Premium: A monthly, quarterly or annual amount you pay for health insurance coverage.

Prescription Drug Coverage: A health plan that helps a member pay for their prescription drugs and medications.

Preventive Services: Routine health care, including screenings, checkups and patient counseling in an effort to prevent illness, disease or other health problems.

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 US citizen.

Referral: 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.

Specialist: 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.

TRICARE: 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.

Last Updated: 10/27/2022