Co-Insurance - The portion of healthcare services the member is responsible for. Usually on an 80% covered, 20% not covered basis.
Co-Payment - A fixed amount the member pays (usually in the $5 to $25 range) every time they visit a health plan provider and receives service.
Deductible - A fixed amount the member must pay each year before the insurer will begin covering the cost of care.
Health Maintenance Organization (insurance) - An organization that provides health care through a network of doctors, hospitals and other medical professionals. HMO members must use the network to be covered for that care. HMOs are a part of Managed Care.
Identification Card - A card certifying member as enrolled in a health plan and entitled to benefits. This card must be presented upon each visit to your PCP or when seeing a specialist that you have been referred to.
Managed Care - A type of health care delivery that stresses controlling costs and active coordination and arrangement of health services.
Medically Necessary Services - Covered services required to preserve and maintain the health status of a member based on established medical practice standards. These are primarily determined by your health plan.
Member - Anyone enrolled in an HMO and entitled to receive benefits.
Network - The doctors, clinics, health centers, medical group practices, hospitals, and other providers that an HMO, PPO, or other managed care network has selected and contracted with to care for its members.
Out-of-Network - Not in the HMO’s network of selected and approved doctors and hospitals. In many cases, if a member chooses to go out-of-network, care will not be paid for or there will be a penalty that the member is responsible to pay.
Point of Service (POS) - A type of HMO coverage that allows members to see providers outside of the network, usually at a slightly higher co-payment or deductible cost.
Preferred Provider Organization (PPO) - Slightly different from the typical HMO in that visits to specialists usually do not require authorization by a PCP. Also, unlike most HMOs, out-of-network usage is allowed by PPOs, though at a higher cost to the member.
Preventative Care - Predetermined course of care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include immunizations and regular screenings like Pap smears or cholesterol checks.
Primary Care - Preventive health care and routine medical care that is typically provided by a doctor trained in internal medicine, pediatrics, or family practice, or by a nurse, nurse practitioner or physician’s assistant.
Primary Care Physician (PCP) - Preventive health care and routine medical care that is typically provided by a doctor trained in internal medicine, pediatrics, or family practice, or by a nurse, nurse practitioner or physician’s assistant.
Pre-Authorization - Certain HMO services require health plan authorization before service is rendered.
Provider - Medical professional that provides covered services approved by the health plan’s contract. Providers include: physicians, pharmacies, hospitals, etc.
Referral - A formal process that authorizes an HMO member to receive care from a specialist or hospital. To assure coverage, an HMO member generally must get a referral from his or her primary care doctor before seeing a specialist.
Specialist - A doctor or other health professional whose training and expertise are in a specific area of medicine, like cardiology or dermatology. Most HMOs require members to get a referral from their primary care physician before seeing a specialist.