GLOSSARY OF HEALTH INSURANCE TERMS

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Obstetrician — a physician who specializes in delivering babies.

Occupational Therapist — a licensed allied health professional who specializes in creative activities that promote recovery and rehabilitation of patients.

Ombudsperson or Ombudsman — a person within a managed care organization or a person outside of the health care system (such as an appointee of the state) who is designated to receive and investigate complaints from beneficiaries about quality of care, inability to access care, discrimination, and other problems that beneficiaries may experience with their managed care organization.

Oncologist — a physician who specializes in treatment of tumors/cancer.

Open Access — a term describing a member's ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Describes health plan members' abilities, rights or invitation to self-refer for specialty care.

Open Enrollment Period — the period when an employee may change health plans; usually occurs once per year.

Open Formulary — the provision that drugs on the preferred list and those not on the preferred list will both be covered by a Pharmacy Benefit Management plan. See entry for PBM.

Ophthalmologist —a physician who specializes in diseases of the eye.

Optician — an licensed health professional (not a physician) who makes glasses and contacts.

Optometrist — a licensed health professional (not a physician) who specializes in examinations of the eye and prescribes eyeglasses and contacts for correction.

Orthopedist (orthopedic surgeon) — a physician who specializes in injuries and diseases of the bones.

Osteopath (DO) — a specialty that emphasizes the theory that the body can make its own remedies given normal structural relationships, environmental conditions and nutrition, Osteopathic physicians are granted the Doctor of Osteopathy (DO) degree.

Out of Network Benefits — with most HMOs, a patient cannot have any services reimbursed if provided by a hospital or doctor who is not in the network. With PPOs and other managed care organizations, there may exist a provision for reimbursement of "out of network" providers. Usually this will involve higher copay or a lower reimbursement.

Out-of-Network Provider — a health care provider with whom a managed care organization does not have a contract to provide health care services. Because the beneficiary must pay either all of the costs of care from an out-of-network provider or their cost-sharing requirements are greatly increased, depending on the particular plan a beneficiary is in, out-of-network providers are generally not financially accessible to Medicaid beneficiaries.

Out of Pocket Costs — dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period. Costs borne by the member that are not covered by health care plan.

Outpatient Care — care given a person who is not bedridden. Also called ambulatory care. Many surgeries and treatments are now provided on an outpatient basis, while previously they had been considered reason for inpatient hospitalization. Some say this is the fastest growing segment of healthcare.

Outpatient Hospital Care — medical or surgical care furnished by a hospital to a patient if that patient has not been admitted as an inpatient but is registered on hospital records as an outpatient. If a doctor orders that a patient be placed under observation, it may be considered outpatient care, even if the patient stays under observation overnight.

Outpatient Surgical Facility — a freestanding center within a hospital that is approved and licensed by the state to perform outpatient diagnostic services or surgical treatment of an illness or injury.