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Glossary

Healthcare and health insurance definitions.

A B C D E F G H I L M N O P Q R S T U V W

P

Participating provider panel :

A listing of the providers and facilities that have contracted with your health insurer to provide services at a discount to members.

PBM :

Abbreviation for pharmacy benefit manager.

PCP :

See primary care provider.

PDL :

See preferred drug list.

PHI :

See protected health information.

Physician :

A person who is licensed and qualified to practice medicine in the state where their practice is located.

Physician services :

Services performed, facilitated, or provided by a licensed medical doctor. See ACA Uniform Glossary

Plan :

The structure of an insurance benefit that helps you pay for your healthcare services. See ACA Uniform Glossary

Plan administration :

Management of a health plan, including accounting, billing, personnel, marketing, and legal services.

Plan year :

The 12-month period on which a plan operates. Note: The plan year may or may not be the same as the benefit year. Your policy or plan description/handbook should indicate which month is the start of each plan year.

Point of service (POS) :

Type of health plan in which you may pay less (or have a higher level of benefits) if you use doctors, hospitals, and other healthcare providers that belong to a plan’s network.

Policyholder :

The employer or individual to whom the health insurance contract is issued and in whose name the policy is written. In a plan contracting directly with an individual or family, the policyholder is the individual to whom the contract is issued.

Portability :

Access to continuous health coverage so that the insured does not lose insurance coverage due to any change in health or personal status (such as employment, marriage, or divorce).

POS :

See point of service.

PPACA :

Patient Protection and Affordable Care Act, federal legislation enacted in 2010. This is also referred to as ACA or Obamacare.

Pre-existing condition :

Physical or mental condition of an insured person that existed before enrollment in a health plan. Pre-existing conditions may result in a limitation of coverage or benefits. Pregnancy is not considered a pre-existing condition.

Preauthorization :

This is an approval given in advance by an insurance company to a doctor for certain types of care. See ACA Uniform Glossary

Preferred drug list (PDL) :

A list of brand name prescription medicines that is more limited than a standard drug formulary. Drugs on the list are selected based on clinical results and economic value.

Preferred provider :

A provider who has a contract with your health plan to provide services to you at a reduced rate. See ACA Uniform Glossary

Premium :

The fixed monthly fee you pay your insurer to keep your health insurance plan. See ACA Uniform Glossary

Prescription drugs :

Drugs and medications that require a prescription. See ACA Uniform Glossary

Prescription drug coverage :

Health insurance or plan that helps pay for prescription drugs and medications. See ACA Uniform Glossary

Preventive care :

Healthcare focused on preventive measures such as routine physical exams, check-ups, immunizations, etc., and not a specific medical complaint. This type of care is also sometimes referred to as “routine,” “screening,” or “pre-care.”

Primary care :

This is routine medical care, normally provided in a doctor’s office. Services may be administered by an internist, family practitioner, obstetrician-gynecologist, pediatrician, or nurse practitioner.

Primary care physician (PCP) :

A physician who directly provides or coordinates a range of healthcare services for a patient. See ACA Uniform Glossary

Primary care provider (PCP) :

This may include a primary care physician, but its definition also includes a nurse practitioner, clinical nurse specialist or physician assistant, who provides, coordinates or helps a patient access a range of health care services. For more, view our video, What is a PCP, and why do I need one? Also see ACA Uniform Glossary

Provider :

A person licensed, certified, or otherwise authorized to administer healthcare services. Examples of providers include physicians, dentists, nurses, pharmacists, and other healthcare facilities or entities.