Health Insurance Glossary
- POS:
- POS stands for "Point of Service." POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, and may not be covered at all.
- A POS plan may be right for you if:
-
- You're willing to play by the rules and possibly coordinate your care through a primary care physician
- Your favorite doctor already participates in the network (use our
- Doctor Finder
- tool to find out)
- PPO:
- PPO means "Preferred Provider Organization." Like the name implies, with a PPO plan you'll need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the PPO. Services rendered by out of network providers may not be covered or may be paid at a lower level. A broad variety of PPO plans are available, many with low monthly premiums.
- A PPO may be right for you if:
-
- Your favorite doctor already participates in the PPO (use our
- Doctor Finder
- tool to find out)
- You want some freedom to direct your own health care but don't mind working within a list of preferred providers
- Your favorite doctor already participates in the PPO (use our
- Part-Time Employee:
- For the purposes of qualifying for group health insurance, a part-time employee is one working between 20-29 hours per week.
- Partial Disability:
- A condition in which, as the result of an illness or injury, a group health insurance member cannot perform all the duties of his or her occupation, but can perform some. Exact definitions differ between health insurance plans.
- Partial Hospitalization Services:
- Also referred to as "partial hospital days," this is a healthcare term used to refer to outpatient services performed in a hospital setting as an alternative or follow-up to inpatient mental health or substance abuse treatment.
- Participating Provider:
- Generally, this term is used in a sense synonymous with Network Provider. However, not all healthcare providers contract with health insurance companies at the same level. Some providers contracting with insurers at lower levels may sometimes be referred to as "participating providers" as opposed to "preferred providers."
- Peer Review:
- This term refers to the process by which a physician or team of healthcare specialists review the services, course of medical treatment, or the conclusions of a scientific medical study conducted by another physician or group of medical experts. Peer review must be provided by a physician or team of medical experts with training and expertise equal to the physician or team conducting the treatment or research in question.
- Periodic Health Exam:
- Typically, a periodic health exam is an exam that is occurs on a regular basis for preventative purposes, like a routine physical or annual check-up.
- Periodic OB-GYN Exam:
- Typically, a periodic OB-GYN exam is a routine OB-GYN exam that occurs on a regular basis, typically for preventative purposes, like a PAP smear.
- Physical Therapy:
- Typically, physical therapy services include rehabilitative services provided by a licensed physical therapist to help restore bodily functions such as walking, speech, the use of limbs, etc.
- Place of Service:
- The type of facility in which healthcare services were provided, whether it be the home, hospital, clinic, office, etc..
- Plan Name:
- The name of the health plan offered by the insurance company.
- Plan Type:PPO
-
PPO means "Preferred Provider Organization." Like the name implies, with a PPO plan you'll need to get your medical care from doctors or hospitals on the insurance company's list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the PPO. Services rendered by out of network providers may not be covered or may be paid at a lower level. A broad variety of PPO plans are available, many with low monthly premiums.
- A PPO may be right for you if:
-
- Your favorite doctor already participates in the PPO (use our
- Doctor Finder
- tool to find out)
- You want some freedom to direct your own health care but don't mind working within a list of preferred providers
- Your favorite doctor already participates in the PPO (use our
- HMO
-
HMO means "Health Maintenance Organization." HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician ("PCP") who will provide most of your health care and refer you to HMO specialists as needed. Some HMO plans require that you fulfill a deductible before services are covered. Others only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency.
- An HMO may be right for you if:
-
- You're willing to play by the rules and coordinate your care through a primary care physician
- You're looking for comprehensive benefits at a reasonable monthly premium
- You value preventive care services: coverage for checkups, immunizations and similar services are often emphasized by HMOs
- Network
-
A "Network" plan is a variation on a PPO plan. With a Network plan you'll need to get your medical care from doctors or hospitals in the insurance company's network if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it's up to you to make sure that the health care providers you visit participate in the network. Services rendered by out of network providers may not be covered or may be paid at a lower level.
- A Network plan may be right for you if:
-
- Your favorite doctor already participates in the network (use our
- Doctor Finder
- tool to find out)
- You want some freedom to direct your own health care but don't mind working within a network of preferred providers
- Your favorite doctor already participates in the network (use our
- POS
-
POS stands for "Point of Service." POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company's network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, and may not be covered at all.
- A POS plan may be right for you if:
-
- You're willing to play by the rules and possibly coordinate your care through a primary care physician
- Your favorite doctor already participates in the network (use our
- Doctor Finder
- tool to find out)
- Indemnity
-
Also called "fee-for-service" plans, Indemnity plans typically allow you to direct your own health care and visit whatever doctors or hospitals you like. The insurance company then pays a set portion of your total charges. You may be required to pay for some services up front and then apply to the insurance company for reimbursement. Indemnity plans typically require that you fulfill an annual deductible. Because of the freedom they allow members, Indemnity plans are sometimes more expensive than other types of plans.
- An Indemnity plan may be right for you if:
-
- You want the greatest level of freedom possible in choosing which doctors or hospitals to visit
- You don't mind coordinating the billing and reimbursement of your claims yourself
- EPO (Exclusive Provider Organization).
-
An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.
- Policy Form Number:
- A unique number that identifies each health insurance policy filed with a state's department of insurance.
- Policy Term:
- The period of time for which a health insurance policy provides coverage.
- PPACA:
- On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. Legislation (Public Law 111-148), commonly referred to as the health reform law. Among other things, the new law requires that all Americans maintain minimum essential coverage starting in 2014. At that time, health insurance companies will not be able to deny insurance coverage to individuals based on a pre-existing condition.
- Practical Nurse:
- A licensed nurse who provides "custodial" care services, such as assistance in walking, bathing, feeding, etc.. Practical nurses do not administer medications or perform other strictly medical services.
- Pre-Admission Authorization:
- -see Preauthorization/Precertification #2.
-
These are terms that are often used interchangeably, but which may also refer to specific processes in a health insurance or healthcare context.
1) Most commonly, "preauthorization" and "precertification" refer to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some surgeries or for certain drugs. In order to pre-approve such a drug or service, the insurance company will generally require that the patient's doctor submit notes and/or lab results documenting the patient's condition and treatment history.
2) The term "precertification" may also be used to the process by which a hospital notifies a health insurance company of a patient's inpatient admission. This may also be referred to as "pre-admission authorization."
- Pre-existing Condition:
- A health problem that existed or was treated before the effective date of your health insurance coverage. Most health insurance contracts have a pre-existing condition clause that describes conditions under which the health insurance company will cover medical expenses related to a pre-existing condition. For more information, see also Pre-existing Condition Exclusion.
- Pre-existing Condition Exclusion:
- see Pre-existing Condition. In some cases, a health insurance company may exclude a patient's pre-existing conditions from coverage under a new health insurance plan. This is more typical with individual and family health insurance plans and less common with group health insurance plans. HIPAA legislation imposes certain limitations on when a health insurance company can exclude coverage for a pre-existing condition. PPACA prohibits pre-existing condition exclusions for all plans beginning January 2014 and prohibits pre-existing condition exclusions for all children under the age of 19 in new policies sold on or after September 23, 2010.
- Premium:
- The total amount paid to the insurance company for health insurance coverage. This is typically a monthly charge. Within the context of group health insurance coverage, the premium is paid in whole or in part by the employer on behalf of the employee or the employee's dependents.
- Prescription Medication:
- A drug that may be obtained only with a doctor's prescription and which has been approved by the Food and Drug Administration.
- Prescription Drug Coverage:
-
Prescription drug coverage varies by carrier and plan type. Typically, prescription drugs are covered in one of the two ways below:
- Insurance covers a percentage after plan deductible is met.
- Insurance covers cost of the drug but a copay is required with prescription.
- Preventive benefits:
- Covered services that are intended to prevent disease or to identify disease while it is more easily treatable. PPACA requires insurers to provide coverage for certain preventive benefits without deductibles, co-payments, or coinsurance. This rule does not apply to Grandfathered Plans. HHS is continuing to update what it defines as Preventative Benefits.
- Preventive Care:
- Medical care rendered not for a specific complaint but focused on prevention and early-detection of disease. This type of care is best exemplified by routine examinations and immunizations. Some health insurance plans limit coverage for preventive care services, while others encourage such services. Note that well-baby care, immunizations, periodic prostate exams, pap smears and mammograms, though considered preventive care, may be covered even if your health insurance plan limits coverage for other preventive care services.
- Primary Care:
- Basic healthcare services, generally rendered by those who practice family medicine, pediatrics or internal medicine.
- Primary Care Physician (PCP):
- A patient may be required to choose a primary care physician (PCP). A primary care physician usually serves as a patient's main healthcare provider. The PCP serves as a first point of contact for healthcare and may refer a patient to specialists for additional services.
- Primary Coverage:
- If a person is covered under more than one health insurance plan, primary coverage is the coverage provided by the health insurance plan that pays on claims first. See also, COB.
- Prior Authorization:
- -see Preauthorization/Precertification #1.
- Probationary Period:
- A waiting period determined by the health insurance company during which coverage for certain pre-existing conditions may be excluded.
- Provider:
- A term commonly used by health insurance companies to designate any healthcare provider, whether a doctor or nurse, a hospital or clinic.
- Provider Write-off:
- The difference between the actual charge and the allowable charge, which a network provider cannot charge to a patient who belongs to a health insurance plan that utilizes the provider network. See Allowable Charge for more information.
please note, however, that definitions of certain terms may vary across insurance companies.
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