Health Insurance Glossary
We want you to know the ins-and-outs of health insurance. That's why we've built this glossary of terms because we know that although the words are English, they often have different meanings than what we know them to be. You can check for a specific term that you are curious about or read the entire glossary if you are prepared for the most fun-filled day you have ever had. Enjoy.A-C D-F G-K L-N O-Q R-T U-Z
An Office Visit refers to medical service provided by a physician in their office.
An Open Access plan is a managed care health insurance plan that allows members to choose any provider without first visiting a primary care provider (PCP) and offers some level of benefit. The highest level of benefits occur when the member chooses a Primary Care Physician in the network and co-ordinates healthcare under the primary care physician using referrals. Reduced benefits occur when the member visits and out-of network provider. Benefits are generally paid at 80% of usual and customary charges but may vary by health insurance plan.
Open Enrollment Period
An Open Enrollment Period is a length of time an individual may enroll in a group health insurance plann. This period of time typically does not require evidence of insurability.
In an Open Formulary, a reasonably unrestricted list of prescription drug options are available through the health insurance plan.
Out-of-Network Care is a term that refers to physicians, hospitals or other medical providers who are not participants in a health insurance plan. Depending upon the type of plan, these groups many not be covered by insurance.
An Out-of-Pocket cost is the share a member must pay for items like coinsurance, co-payment, deductible, etc.
The Out-of-Pocket Maximum is the predetermined limit that a person has to pay before a health insurance company will pay. .
An Outpatient is a patient who receives medical services that do not require an overnight stay.
Outpatient Surgery is a type of medical procedure that does not require hospitalization.
Over-The-Counter (OTC) Drugs
OTC Drugs are those that do not requird a prescription.
A Part-Time Employee is any person who works less than a full-time schedule and may receive certain health insurance benefits. The work hours are typically less than 30 hours a week.
A Partially Disabled person is an individual who, as a result of a sickness or injury, cannot perform all duties assigned.
A Participating Provider is a medical services provider who has a contractual agreement with another medical contractor such as a PPO or HMO.
A Peer Review is a review of healthcare services of a physician by a panel of medical professionals equal to the servicing ability of that professional.
Periodic Health Exam
A Periodic Health Exam is an evaluation of a patient's health status for preventive purposes.
Periodic OB-GYN Exam
A Periodic OB-GYN Exam is a routine exam performed by an OB-GYN for preventative healthcare.
Physical Therapy are duties performed by a medical professional for the treatment of rehabilitation. Duties may include assisting patients in walking and exercising.
Physician Hospital Organization (PHO)
A Physician-Hospital Organization is a group of providers and hospitals joined to share in the financial risk of managed care risk contracts.
Place of Service
A Place of Service is the designated location that the actual medical service is being performed.
A Point of Service is a type of manage care health insurance plan that allows the member to use a provider who is within the preferred provider network or to visit an out of network provider. The POS offers the savings of an HMO, with the flexibility of a PPO. When you enroll in a Point of Service plan, you choose a primary care physician (PCP) from the preferred provider network. The primary care physician (PCP) then makes referrals if additional diagnostic or treatment healthcare services are needed. If you choose to visit a provider outside the network, the benefits will be paid a reduced amount and you will have a higher co-insurance amount.
Preferred Provider Arrangement (PPA)
Preferred Provider Arrangements (PPA) are agreements and contracts between health insurance companies and healthcare providers, or groups of providers to provide healthcare services to members under their contract.
Preferred Provider Organization (PPO)
A Preferred Provider Organization (PPO) is a managed care organization (MCO) that is comprised of providers who have contracted with an insurance company to provide healthcare services at negotiated rates to the members of the health insurance plan. Preferred Provider Organizations (PPO) offer more flexibility over an Health Maintenance Organization (HMO) by allowing for visits to out-of-network providers at a greater cost to the member. There is often a deductible for out-of-network expenses and a higher co-insurance.
Pure Community Rating (PCR)
Pure community Rating is a process that requires health insurance organizations to charge the same premium to all members of a community. The health insurance plan premiums cannot vary based on demographic factors such as geography, age or family composition.
A Qualifying Event is an occurence that triggers a person's health insurance plan to be removed from a group health insurance plan. That event may be death, divorce or terminatio of employment.