Qualifying Event: An event that enables an individual to make a change to their health plan outside of the enrollment period. Examples include divorce, termination of employment, or birth of a child.
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.
Provider: A supplier of healthcare services like a hospital, nursing home, lab, or physician.
Primary Care Physician (PCP): A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.
Preventive Care: Care received to help prevent or detect illness before it occurs, such as routine physicals, well baby care, annual gynecological exams, etc.
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): 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-Existing Condition: A health condition (except pregnancy) that was diagnosed and/or treated within six months prior to enrolling in a health plan.
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.
Pre-admission Review: Review of an elective hospitalization prior to a patient’s admission in order to ensure that the services are necessary and that they should be provided in an inpatient hospital setting.
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.
Physician Services: Healthcare services a licensed medical physician (M.D.-Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
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.
Per Diem Cost: Cost per day; hospital or other institutional cost for a day of care.
Patient Protection and Affordable Care Act (PPACA): A law with a series of statues that go into effect beginning March 23, 2010 aimed at increasing access to affordable healthcare for most Americans. Health insurers, healthcare facilities, physicians, individuals, small and large businesses, Medicare, and Medicaid are all impacted by the law.
Patient Centered Medical Home (PCMH): A team-based healthcare delivery model led by a physician that provides comprehensive and continuous medical care to patients. Some goals of a PCMH are better access to healthcare, increased satisfaction with care, and overall improved health.
Participating Provider: Any physician, hospital, pharmacy, laboratory, or other diagnostic centerunder contract with the health plan to provide services to members at a specified cost.
Outpatient Care: Care in a hospital that usually does not require an overnight stay.
Out-of-Pocket Maximum (OOP max or MOOP): The maximum amount that an insured person will have to pay for covered expenses under the plan, usually within the plan effective dates.
Out-of-Pocket Costs: Healthcare costs that are not covered by insurance, such as Copayments, Coinsurance, and Deductibles.
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: 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: 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).
Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide healthcare services.