Co-Payment: a specific dollar amount the
patient must pay to the institution or practice each time a
service or office visit is requested. Co-payments are requested
at the time of service, and are typically required as part of a
policy as set by an insurance company (usually an HMO or PPO).
Deductible: the amount a patient is
responsible for before insurance coverage takes effect.
Managed Care: a term describing programs
designed to manage the quality and cost of health care.
Preferably, managed care brings about a system where Patients
receive the care they need, including preventative care, when
they need it.
HMO (Health Maintenance Organization):
these organizations provide insurance coverage, usually through
an employee-based plan. HMOs rely on a primary care physician to
manage a person’s care. There are certain restrictions on choice
of physician, and types of specialty care that are covered, etc.
Procedures and tests must have a pre-approval from the HMO to be
covered under your plan.
Medicaid: a health insurance program for
low or no income individuals and elderly patients. Many states
have begun to introduce HMOs for this group of patients.
Medicare: A federal health insurance
program for older and eligible disabled Americans.
Medical Necessity: a determination that a
treatment, procedure, or test is necessary to a person’s health
or treating an existing medical problem. For example, cosmetic
procedures are not covered under medical necessity provisions.
Point of Service (POS): a managed care
product where enrollees have a choice of different medical
options when they need care. Patients are able to choose their
own primary care physician outside of the network, but usually
at a higher cost.
Pre-existing conditions (PEC): medical
problems that an individual already has prior to acquiring an
insurance plan. Preexisting conditions are not always covered by
insurance policies.
Preferred Provider Organization (PPO):
providers who will approve in-network and out-of-network
benefits to patients without a PCP referral. The amount a
patient will have to pay out of pocket is less when using an
in-network provider.
Primary Care Physician (PCP): a physician
whose practice is devoted to family/general practice,
pediatrics, internal medicine, and occasionally
obstetrics/gynecology.
If you have specific questions about your insurance plan or payment
options, please feel free to call our office and ask to talk with our Patient Liason or an
Account Representative. They will be more than happy to answer any
inquiries you may have.
