A listing of the providers and facilities that have contracted with your health insurer to provide services at a discount to members.
Healthcare and health insurance definitions.
Abbreviation for pharmacy benefit manager.
See primary care provider.
See preferred drug list.
See protected health information.
A person who is licensed and qualified to practice medicine in the state where their practice is located.
Services performed, facilitated, or provided by a licensed medical doctor. See ACA Uniform Glossary
The structure of an insurance benefit that helps you pay for your healthcare services. See ACA Uniform Glossary
Management of a health plan, including accounting, billing, personnel, marketing, and legal services.
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.
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.
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.
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).
See point of service.
Patient Protection and Affordable Care Act, federal legislation enacted in 2010. This is also referred to as ACA or Obamacare.
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.
This is an approval given in advance by an insurance company to a doctor for certain types of care. See ACA Uniform Glossary
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.
A provider who has a contract with your health plan to provide services to you at a reduced rate. See ACA Uniform Glossary
The fixed monthly fee you pay your insurer to keep your health insurance plan. See ACA Uniform Glossary
Health insurance or plan that helps pay for prescription drugs and medications. See ACA Uniform Glossary
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.”
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.
A physician who directly provides or coordinates a range of healthcare services for a patient. See ACA Uniform Glossary
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
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.