Glossary of health insurance terms

A plan that usually limits coverage to care from doctors who contract with the HMO. It generally will not cover out-of-network care except in an emergency. An HMO requires you to live in its service area to be eligible for coverage. HMO plans also require a referral from your primary care doctor to see a specialist.

A plan that excludes the highest cost providers, as determined by the health insurance provider. It includes only lower-cost providers that meet a certain quality threshold.

A plan in which you pay less to use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. PPO plans do not require a PCP referral for a specialist visit.

CT/PET scans, and MRIs.

The yearly period when employees and retirees can enroll in and change health insurance plans and coverage without a qualifying life event.

A fixed amount you pay for each covered healthcare service, in addition to your premium and any deductible.

A fixed amount an employee pays for certain services before the insurer begins to pay for those services.  Members pay in full for certain services until reaching the annual maximum deductible amount.

Care that you receive when admitted (acute, medical rehabilitation, and skilled nursing care). Excludes mental health and substance use disorder.

Care that you receive without being admitted or for a stay of less than 24 hours.

The percent of premium you pay for health insurance every month (from paycheck or pension). The employer pays the remaining percentage.

A physician who directly provides or coordinates a range of health care services for a patient.

A physician who focuses on a specific area of medicine or a group of patients to:

• diagnose
• manage
• prevent, or
• treat certain types of symptoms and conditions.