Common terms to know

Authorization
Approval to allow you to see a specialist, receive specific services or be admitted to the hospital.

Covered services
The health care services your insurance company will pay for under your plan.

Fee-for-service
Indemnity, or traditional, insurance under which patients may choose any doctor, regardless of speciality, at any time. Patients are responsible for all costs beyond those covered by their insurance.

Health maintenance organization (HMO)
A managed care plan that contracts with a group of physicians, other health care professionals and hospitals (known as a network) to care for its patients (known as members). Members usually must select a primary care physician from the network and call or see this doctor first for all medical care.

Managed care organizations
Companies that oversee the cost, quality and delivery of health care services. Includes HMO, PPO and POS plans.

Network
A group of physicians, other health care professionals and hospitals that have agreed to provide services to members of specific health plans.

Open enrollment
A specified time period each year when individuals select the type of health coverage (HMO, PPO, fee-for-service, etc.) offered by an employer. Individuals may be asked to choose a primary care physician to care for them and any family members covered by their plan.

Point of service (POS)
A “tiered” health plan under which your coverage level is determined by where you receive care. You pay the least for care coordinated by your primary care doctor, a higher amount if you see a specialist in your network without a referral and even a higher cost if you go to a doctor outside the network.

Preferred provider organization (PPO)
Individuals covered by this type of managed care plan may see doctors outside the network without a referral, but at an additional cost.

Primary care physician (PCP)
A doctor specializing in internal medicine (internist), family practice or pediatrics who coordinates all health services of a managed care patient and refers that patient for specialty care. Some plans include obstetricians/gynecologists as primary care physicians.

Referral
The process of sending a patient from one doctor to another or to other health care professionals for services. Most managed care plans require the primary care physician to authorize a referral before the cost of the service will be covered.

Specialist
A doctor who has received advanced education and training in a particular area of medicine. Cardiology, dermatology and orthopedics are a few examples of medical specialties.