Preferred Provider Organization: A type of health insurance plan that contracts with medical providers, such as hospitals and physicians, to create a network of participating providers. There is a financial incentive to use in-network providers by offering higher benefit coverage than out of network providers. Health care services received from providers that are “in-network” are covered at an in-network benefit level, while out of network providers are covered by out of network benefits, which are typically more expensive. Patients can typically self-refer to specialists, but are responsible themselves for making sure that all providers are in-network.
Exclusive Provider Organization: A type of health insurance plan in which choosing a primary care provider is not required, but providers seen must be within the predetermined network. Out of network care is not covered except in an emergency. Patients can typically self-refer to specialists, but are responsible themselves for making sure that all providers are in-network.
Health Maintenance Organization: A type of health insurance plan that limits coverage to primary care providers and specialists who work for or are contracted with the HMO. You typically must have a referral and authorization for any specialist services. It generally does not cover out of network care except in emergency.
Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Co-insurance: The percentage of costs of a covered health care service you pay (20%, for example) after you have paid your deductible.
Out of Pocket Maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit does not include your monthly premiums. It also does not include anything you may spend for services your plan does not cover.
Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you do not get a referral first, the plan may not pay for the services.
Authorization: An approval from your health plan for a specific service, usually within a certain window of time. Many plans, including HMOs, require authorizations for all specialist services/procedures.
Primary Care Provider: Health provider that covers a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.
Specialist: A physician that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
For more glossary terms, please visit Healthcare Glossary.