Qualified Health Plan (QHP)

Qualified Health Plan (QHP)

Qualified Health Plan (QHP): An insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like Deductibles, Copayments, and out-of-pocket maximum amounts), and meets other requirements. A QHP will have a certification by each Exchange in which it is sold.

Premium

Premium

Premium: The fee paid to a health insurance carrier by an enrolled company or individual, normally on a monthly basis, for the delivery and financing of healthcare services to the employees or the individual, and their dependents enrolled in the plan.

Preferred Provider Organization (PPO)

Preferred Provider Organization (PPO)

Preferred Provider Organization (PPO): A system in which a payer negotiates lower prices with certain doctors and hospitals. Patients who go to a preferred (or in-network) provider get a higher benefit-for example, 90 percent or 100 percent coverage of their costs-than patients who go outside the network

Pre-Authorization

Pre-Authorization

Pre-Authorization: The authorization required by an insurance carrier before the member is eligible to receive maximum benefits for hospitalization and other specific services. With some benefit plans, the member is responsible for obtaining pre-authorization prior to receiving services.

Point of Service (POS) Plan

Point of Service (POS) Plan

Point of Service (POS) Plan: An HMO plan which allows the member to pay lower Copayment or Coinsurance if they stay within the established HMO delivery system, but permits member to choose and receive services from an outside doctor, any time, if they are willing to pay higher Copayments, Deductibles, and possibly monthly premiums.

Pharmacy and Therapeutics (P&T) Committee

Pharmacy and Therapeutics (P&T) Committee

Pharmacy and Therapeutics (P&T) Committee: A group of physicians, pharmacists, and other healthcare providers who advise a managed care plan regarding safe and effective use of medications. The P&T Committee manages the prescription drug formulary and acts as the organizational line of communication between the medical and pharmacy components of the health plan.

Out-of-Network-Provider

Out-of-Network-Provider

Out-of-Network-Provider (Non-Participating Provider): Any physician, hospital, pharmacy, laboratory, or other diagnostic center not under contract with a plan to provide services to members at a specified cost. In some benefit plans, members may have reduced coverage (or NO coverage if care is received from non-participating providers).

Open Enrollment

Open Enrollment

Open Enrollment: The period (usually once a year) during which subscribers in a health plan may have an opportunity to select an alternative plan being offered to them; or a period when uninsured employees and their dependents may obtain coverage.

Non-Par (Non-Participating) Provider

Non-Par (Non-Participating) Provider

Non-Par (Non-Participating) Provider: Any physician, hospital, pharmacy, laboratory, or other diagnostic center not under contract with a plan to provide services to members at a specified cost. In some benefit plans, members may have reduced coverage (or NO coverage if care is received from non-plan providers).

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