All Harken Health Centers will be CLOSING ON JULY 31st, 2017.

Call a Membership Assistant at 800.797.9921 to designate a new Primary Care Doctor.

Health Insurance Glossary of Terms

Insurance language defined

Here are some commonly used insurance terms that you’ll find in your plan documents.

Coinsurance
Copay (Copayment)
Deductible
Full Price
Out-Of-Pocket Maximum
Premium
Prior Authorizations
Referrals
Specialty Medication
Step Therapy

Coinsurance

Coinsurance is a type of cost sharing in which both you and Harken Health each pay a percentage of the expense. For example, Harken Health might pay 60% of the cost of a medical service and you would pay 40%. Coinsurance usually applies after you have met your deductible.

Copay (Copayment)

Copays are a fixed amount that you pay for health services. Depending on your plan, you may pay copays for a service or prescription drug every time or you may only pay copays for services after you’ve paid your deductible.

Deductible

An individual deductible is the amount you pay for health care needs before Harken will pay for services for you. After you pay your deductible, you usually pay only a copay or coinsurance for covered services. If you have a family plan, you will also have a family deductible that applies to all members of your family.

Full Price

The cost of the care you received at the negotiated rate.

Out-of-Pocket Maximum

The most you pay during a policy period (usually a year) before your health plan begins to pay 100%.

Premium

The amount that must be paid for your health insurance or plan.

Prior Authorizations

Prior Authorizations are approvals that your Care Provider must get in order for specific prescription drugs, health care services or treatments to be covered by your plan, such as surgery and labs. View your plan documents to understand what services require a prior authorization.

Referrals

If you need care outside the Harken Health Center, you have access to a network of specialists and hospitals. Your Health Center Care Team will provide you with a referral to see an in-network specialist option for you.

Referrals are required from a Harken Health Center doctor, or you may choose to designate an in-network primary care doctor by calling a Membership Assistant. If you see a specialist without a referral, you will pay more and those costs may not count towards your deductible. The following are examples of specialties that require a referral:

  • Orthopedic Surgery
  • Cardiology
  • Gastroenterology
  • Ear, Nose, and Throat (Otolaryngology)
  • Podiatry
  • Allergy & Immunology

You can receive the following services without receiving a referral:

  • In-network OB/GYN Visits
  • Emergency Room Visits
  • Lab Work
  • In-network Mental Health &
  • Substance Abuse Treatment
  • Prescription Drugs

If you have an emergency, you can go to the nearest hospital or call 911. Emergency services will be covered as if you received in-network care.

View more FAQs about referrals.

Referrals for Children

Your child will need referrals from their primary doctor to see a specialist. You have two options for primary doctors:

1. Harken Health Center family practitioners can care for your child as their referring primary doctor.

-OR-

2. You can choose [designate] an in-network pediatrician to be your child’s referring primary doctor. Once you call a
Membership Assistant to officially designate an in-network pediatrician as your child’s primary doctor, that
pediatrician can then provide referrals.

If your child doesn’t have a referral from their primary doctor to see a specialist, then you may be charged higher out-of-pocket costs for a specialist visit.

Specialty Medication

We define a specialty medication as an injectable, an oral or an inhaled medication that:

  • May require ongoing clinical oversight and additional education for best management
  • Has unique storage or shipping requirements
  • May not be available at retail pharmacies

Step Therapy

Step Therapy is a clinical program that requires members to use a lower cost medication before accessing a higher cost medication that treats the same condition in substantially the same way.