GLOSSARY OF HEALTH INSURANCE TERMS

P

Participating Provider — simply refers to a provider under a contract with a health plan. A physician or hospital that has agreed to provide services for a set payment provided by a payer, or who agrees to other arrangements, or who agrees to provide services to a set of covered lives or defined patients.

Patient Liability — the dollar amount that an insured is legally obligated to pay for services rendered by a provider. These may include copayments, deductibles and payments for uncovered services.

Payer (usually Third-Party Payer) — the public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies or self-insured employers.

Pediatrician — a physician who specializes in children's health (up to age 18).

PCP (Primary Care Physician) — the physician who often acts as the primary gatekeeper in health plans. Often the PCP must approval referrals to specialists. Particularly in HMOs and some PPOs, all members must choose or are assigned a PCP.

Peer Review — the mechanism used by the medical staff to evaluate the quality of total health care provided by the managed care organization. The evaluation covers how well all health personnel perform services and how appropriate the services are to meet the patients' needs. Evaluation of health care services by medical personnel with similar training.

Penalty (on Medicare Premium) — an amount added to a senior citizen's monthly premium for Medicare Part B, or for a Medicare Prescription Drug Plan, if they do not join the Medicare Plan(s) when first able to. The senior citizen pays this higher amount as long as they have Medicare. There are some exceptions.

Pharmacy Benefit Management (PBM) Plan — a type of managed care specialty service organization that seeks to contain the costs of prescription drugs or pharmaceuticals while promoting more efficient and safer drug use. Also known as a prescription benefit management plan.

Physician's Assistant (PA) — a licensed allied health professional who works under the supervision of a doctor and is trained to perform certain medial procedures previously reserved for physicians.

Physical Therapist — a licensed allied health professional who treats diseases or injuries by physical means; exercise, manipulation, electricity, heat, cold and water.

Plastic Surgeon — a physician who specializes in the repair, restoration or improvement of lost, injured or defective body parts.

Podiatrist (doctor of podiatry) — a licensed health professional (not a physician) who specializes in treatment of the feet.

Portability — requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans. The ability for an individual to transfer from one health insurer to another health insurer with regard to pre-existing conditions or other risk factors. This is a new protection for beneficiaries involving the issuance of a certificate of coverage from previous health plan to be given to new health plan. Under this requirement, a beneficiary who changes jobs is guaranteed coverage with the new plan, without a waiting period or having to meet additional deductible requirements.

POS (Point-of-service) Plan — a health plan that allows members to choose to receive services from a participating or nonparticipating network provider, usually with a financial disincentive for going outside the network. Generally the level of coverage is reduced for services associated with the use of nonparticipating providers.

Pre-admission Review, Pre-Admission Certification, Pre-Certification, or Pre-Authorization — review of "need" for inpatient care or other care before admission. This refers to a decision made by the payer, MCO or insurance company before admission. The payer determines whether or not the payer will pay for the service. Most managed care plans require pre-certification. This is a method of controlling and monitoring utilization by evaluating the need for service prior to the service being rendered. Failure to obtain pre-certification often results in a financial penalty or denial of payment for the admission or procedure.

Pre-existing Condition — a physical and/or mental condition of an insured person that existed prior to the issuance of his or her policy. Some plans may cover these conditions after a waiting period of six months to a year.

Preferred Provider Organization (PPO) — some combination of hospitals and physicians agreeing to offer particular services to a group of people, perhaps under contract with a private insurer. A health care delivery system that contracts with providers of medical care to provide services at discounted fees to members. Members may seek care form nonparticipating providers but generally are financially penalized for doing so by the loss of the discount and subjection to copayments and deductibles.

Premium — amount paid to a carrier for providing coverage under a contract. A periodic payment by the insured to the health insurance company or prescription benefit manager in exchange for insurance coverage. Varies depending on health plan or drug formulary.

Prescription Drug Plan (PDP) — these plans became more commonplace with the implementation of Medicare Part D in 2006. Everyone with Medicare, regardless of income, health status, or prescription drugs used, can get some sort of prescription drug coverage. These standalone plans add prescription drug coverage to the original Medicare Plan and to some Medicare Cost Plans and Medicare Private Fee-for-Service Plans.

Preventive Care — comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunizations and well-person care.

Prior Approval — a formal process for obtaining approval from a health insurer before a specific treatment, procedure, service or supply has been provided. Completing this process ensures that the patient receives full benefits for the specified services.

Primary Care — basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians — who are often referred to as primary care practitioners or PCPs — as opposed to specialist care.

Primary Coverage — a plan that pays its expenses without consideration of other plans, under coordination of benefits rules.

Primary Care Physician (PCP) — a physician, usually a pediatrician, family practitioner or internist who oversees the total care of patients, referring the patient to other professionals as appropriate.

Proctologist — a physician who specializes in disease of the anus, rectum and sigmoid colon.

Protected Health Information — under HIPAA, this refers to individually identifiable health information transmitted or maintained in any form.

Psychiatrist — a physician who specializes mental, emotional and behavioral disorders.

Psychologist (doctor of psychology) — a health professional (not a physician) who specializes in the mental or behavioral characteristics of an individual or group. Provides psychological testing for diagnosis of mental and behavioral disorders. Psychologists are granted a Doctor of Psychology degree.