Managed Care An organized way to manage costs, use, and quality of the health care system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO). Medicaid A joint federal-state health insurance program that is run by the states and covers certain low-income people (especially children and pregnant women). And disabled people. Medicare The federally sponsored health insurance program of hospital and medical insurance primarily for people age 65 and over. Out-of-Pocket Maximum The most money you will be required to pay in a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums. Point-of-Service (POS) Plan A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar co-payment (say $10 for a doctor’s visit), or to an out-of-network provider and pay a deductible and/or coinsurance charge. Portability The ability for an individual to transfer from one health insurer to another health insurer with regard to pre-existing conditions or other risk factors. Pre-authorization A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for the service. Pre-existing Condition A health problem that existed before the date your insurance became effective. Many insurance plans will not cover preexisting conditions. Some will cover them only after a waiting period. Preferred Provider Organization (PPO) A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decisions generally remain with the patient as he/she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network. Premium The amount you or your employer pays in exchange for insurance coverage. Primary Care Physician Under a health maintenance organization (HMO) or point-of-service (POS) plan, usually your first contact for health care. This is often a family physician, internist, or pediatrician. A primary care physician monitors your health, treats most health problems, and refers you to specialists if necessary. Provider Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care. Third-Party Payer Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government. Usual and Customary Charge The amount a health plan will recognize for payment for a particular medical procedure. It is typically based on what is considered “reasonable” for that procedure in your service area. Utilization Review A cost control mechanism by which the appropriateness, necessity, and quality of health care services are monitored by both insurers and employers. |