All Terms A-F G-MNetwork
The group of doctors, physicians, hospitals, clinics, and specialists that agree with a health plan to discount their medical services in exchange for patient referrals.
Out-Of-Pocket Maximum (Limit)
The maximum amount of health care costs that an insured must pay out of their own pocket per year. After the out-of-pocket max is met, the plan will cover 100% of any remaining costs for the year.
Care that does not require a patient to stay overnight in a medical facility.
Point of Service (POS) Plan
A managed care plan that combines the benefits of a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Like an HMO, POS plans require members choose a Primary Care Physician (PCP). Like a PPO, they provide coverage with any in or out-of-network health care providers.
Pre-Admission Review and Certification
Approval by a health care professional to be admitted into a medical facility.
Any health condition before coverage starts can be considered a pre-exiting condition. Insurance companies may require a waiting period before they cover costs related to that condition.
Preferred Provider Organizations (PPO)
A managed care plan in which members have insurance coverage with in and out-of-network doctors, hospitals, and other health care providers. Typically, members save the most on care with in-network providers.
The payment that must be made to an insurance company monthly to keep a health insurance policy in effect.
Health care intended to prevent serious (or more serious) illness through routine doctor's check-ups, physicals, well-baby care, and immunizations.
Primary Care Physician (PCP)
Can include family doctors, pediatricians, internists, general practitioners, and OB/GYNs. Members of a Health Maintenance Organization (HMO) or Point of Service (POS) plan choose a PCP as their 'first-line-of-defense' doctor. They also can provide referrals for specialist care.
Includes doctors, physicians, hospitals, clinics, specialists, or any health care professional.
Insurance plan options provided by an automated quoting service, an agent, or an insurance company.
An addition or exclusion included on an insurance policy.
An insurance company's chance of loss. Also refers to the chance of an individual becoming ill or having an accident.
An illness or injury that prevents an employee from working for a period of time.
Short-Term Medical Insurance
An insurance plan that provides insurance coverage for a designated period of time ? usually between one month and one year. Many individuals who purchase short-term coverage include recent college graduates and people in-between jobs.
Health plans that provide coverage for people while during a trip to another country.
An insurance professional that determines the premiums for applicants.
The process in which an insurance company or underwriter determines the amount the premiums will be for applicants.
Usual, Customary, and Reasonable Fees
The standard amount that is usually covered or charged for medical services and supplies, as recommended by health care professionals.
The process in which the care of patients are monitored for cost-effectiveness, efficiency, and quality.
Also known as the elimination period, it refers to the temporary amount of time an insured will not be covered for certain health care costs.
Waiver of Premium
An additional insurance policy that can be purchased. It waives premiums for a period of time if the insured becomes totally disabled and cannot make monthly payments.