Health Care 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.

Parity: Fair or equal treatment. In the healthcare context, parity refers to a requirement under federal and state law that individual and group health plans cover mental health and substance use disorder benefits to the same extent that they cover medical and surgical benefits for your physical health.

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.

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