Kathleen G. Kane - Pennsylvania Office of Attorney General - Protecting Pennsylvanians

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Glossary of Terms

Fee-for-service:
Traditional health care coverage where the patient or insurance company is billed for services provided.

Managed care:
Treatments, as well as payments, are monitored and approved or denied by the insurance company.

Health Maintenance Organization (HMO):
An HMO is a group that contracts with medical facilities, physicians, employers and sometimes individual patients to provide medical care to a group of individuals. This care is usually paid for by an employer at a fixed price per patient. Patients generally do not have any significant "out-of-pocket" expenses. The patient must see only the doctors who are members of a particular HMO. Physicians working for HMOs often are given financial incentives to decrease medical costs by limiting expensive diagnostic tests, referrals to specialists, and hospitalizations.

Medicaid:
A program of health insurance provided by the state and federal government for the poor, elderly and disabled.

Medicare:
Health insurance provided by the federal government for the elderly and disabled.

Point of Service:
A health plan that allows the patient to choose the type of payment method (traditional, PPO or HMO) at the time service is received.

Private insurance:
Traditional health care coverage purchased from an insurance company. Gives you free choice of physicians, hospitals and other health care facilities.

Premium:
The amount paid for any insurance policy.

Pre-existing condition:
Illnesses or problems a patient had before obtaining an insurance policy. Some insurance companies may refuse to issue a policy or not pay for care for the preexisting condition or may not pay for that condition for a set period of time.

The following acronyms are often used when discussing methods of health care coverage and payment. These explanations are provided for better understanding of these terms.

HMO - Health Maintenance Organization

PPO - Preferred Provider Organization

IPA - Independent Physician Association

EPO - Employer Preferred Organization

PHO - Physician Health Organization

MSO - Medical Service Organization

POS - Point of Service

DED - Deductible

EOB - Explanation of Benefits

OOP - Out of Pocket

INS - Insurance

COP - Co-Payment

COI - Co-Insurance

OEP - Open Enrollment Period

BUO - Buy-Up Options

PCS - Prescription Card Services

You can contact the Health Care Section at 1-717-705-6938 on weekdays from 8:30 AM until 5:00 PM.  The Section also has a toll-free line, 1-877-888-4877, which operates within Pennsylvania on weekdays between the hours of 8:30 AM and 9:00 PM.