Health Insurance Terms to know:
Benefits – Health care services provided under terms of a contract with a managed care organization.
Co-payments – A fixed payment that a patient pays (usually $5-$25) each time s/he visits a health plan doctor or receives covered services.
Coverage – The type of insurance and extent of benefits available through health insurance companies.
Deductible – A specified amount of money an insured patient must pay each year before the insurer will begin covering the cost of care.
Facilitated Enrollment – Assistance provided to families applying for Child Health Plus, Family Health Plus, and Medicaid, by representative of health plans, community-based organizations and health care providers.
Fee-for-Service – The traditional method for paying for medical services. Doctors charge a fee for each service provided and the insurer pays all or part of that fee.
Health Plan – An organization that acts as an insurer for an enrolled population.
Health Maintenance Organization (HMO) – An organization that provides health care in return for pre-set monthly payments. Most HMOs provide care through a network of doctors, hospitals, and other medical professionals that their members must use in order to receive care.
Lock In – A contractual provision by which members except in cases of urgent or emergency need, are required to receive all their care from the network health care providers.
Managed Care Organization (MCO) – These are organizations licensed by the state, which arrange primary care and other medically necessary services at a prepaid rate instead of billing each individual service. Managed care plans use a network of providers to promote timely access to medical services.
Primary Care Provider (PCP) – The PCP is an internist, pediatrician, family doctor or other health care provider who serves as the initial interface between a patient and the medical care system. The PCP services as the patient’s agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals.
Provider Network – The doctor, clinics, health centers, medical group practices, hospitals and other providers that managed care plans have selected and contracted with to provide care for their members.
Premium – The fee a policyholder pays to an insurance company for coverage. This fee is usually paid out monthly.
Recertification or Renewal – The annual verification process of a member’s eligibility (age, residency, citizenship/immigration status, income and resources) for the public health insurance program in which she or he is enrolled.
Sliding Scale – The system of charging fees based on the patients ability to pay for health care received. Often the patient’s household size and income are used to determine the amount of fees charged.