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HEALTH DEFINITIONS YOU NEED TO KNOW
: the availability of health care services; factors include the location of health care facilities and the hours of operation
Beneficiary: the person eligible to receive insurance benefits under a specific health plan
Contract: an agreement between a health plan and provider, or health plan and beneficiary that details such things as copayments, limitations, exclusions, and dates of coverage
Co-Payment: a flat fee paid by plan members for specific medical services. For example, a $5 or $10 "copay" is often required for prescriptions and office visits.
Contract Provider: any individual, physician, hospital, facility, or other entity that has entered into a formal agreement with a health plan to provide health care services.
Covered Benefits: medical services specified as being medically necessary and covered under the terms of the health plan contract between the beneficiary and the health plan
Eligibility: a process used by the health plan to determine if a person is a beneficiary
Formulary: a health plan's list of approved prescription medications for which it will reimburse members or pay for directly. Additional medications are usually not available to plan members.
Freedom of Choice: an option for HMOs or other perpaid health plans where the beneficiary can select the provider of choice; not limited to an established group of physicians
Gatekeeper: the primary care physician who directs the medical care of HMO members. The primary care physician determines if patients should be referred for specialty care
Grievance Procedure: the procedure outlined by the plan for resolving health plan or provider complaints
Managed Care: a type of health care delivery that emphasizes active coordination and arrangement of health services. Managed care usually involves three key components : oversight of the medical care given,
contractual relationships with the providers giving care and the covered benefits tied to regulations set in terms of managed care
Managed Care Organization: an insurance organization arranging benefits through managed care. The most common types of managed care organizations include Health Maintenance Organizations (HMOs) and Preferred
Provider Organizations (PPOs). The vast majority of Americans with private health insurance are currently enrolled in managed care plans.
Network: the grouping of providers and health care professionals that a health plan contracts with to give health care to its members
Non-Plan Provider: a provider who has not contracted with the health plan or carrier
Preferred Provider: providers contracting with health plans to provide services covered under the health plan's contract. Providers include: physicians, nurse practitioners, chiropractors, pharmacies, hospitals
etc.
Primary Care Physician: these physicians provide a full range of basic health services to their patients. General practitioners, family practice physicians are usually recognized by health plans as primary care
physicians. HMOs require that each enrollee be assigned to a primary care physician who functions as a Gatekeeper.
Traditional Care: the patient-physician relationship is the key point. It is most identified with freedom of choice between the patient and physician. Patients can choose whatever provider they want to see
and physicians can choose to order whatever services they feel are necessary.
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