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Last week we shared definitions of terminology used in the health insurance industry. This week we will continue where we left off.
MEDICAID – State programs of public assistance to persons, regardless of age, whose income and resources are insufficient to pay for health care. Both the State and Federal government fund this program.
OFF-LABEL USE – a drug not approved by the FDA for treatment of the condition in question or prescribed at a different dosage than the approved dosage.
OVER-THE-COUNTER-DRUGS – medicines you can purchase “over the counter” without a prescription from your physician. These are not covered by health insurance plans.
OUT-OF-NETWORK BENEFITS – benefits provided by providers who are not in the network of your health insurance plan. It is always more costly to use out-of-network providers than if you stay within your network.
POINT OF SERVICE – a plan that provides managed care to its members through its own network of providers (like an HMO) but you also have the opportunity to use providers who are not in the network. You must choose a PCP (primary care physician) to manage your health care within the network.
PARTICIPATING PROVIDER – a doctor or hospital, which has a written agreement with an insurance company to provide care to that plan’s members.
PRIMARY CARE PHYSICIAN – a participating provider who provides basic healthcare services to, and arranges specialized services for, those members who select that provider as their Primary Care Physician (PCP).
PREFERRED PROVIDER ORGANIZATION (PPO) – A group of providers participating in a particular network of providers and offering their services to insurance companies at a discounted rate. You get advantage of the “discount” when you use providers in the network but you also have the option of using providers out of the network. You always spend more money out of your pocket when you use providers out of network.
SUBSTANCE ABUSE – the abuse or addiction to drugs or controlled substances, not including alcohol.
Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.
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