Glossary Section 3-Understanding Your Network and Providers

Navigating the healthcare system can feel like learning a new language. Knowing the right terms matters. It can help you

• Understand what your insurance will and won't cover.
• Know what questions to ask about your health insurance, financial assistance, or income.
• Avoid unexpected costs.
• Get financial help.
• Advocate for yourself or your patients when insurance companies deny coverage or when bills don't add up.

This glossary is a tool you can use whenever you aren't sure about a word or term. It covers health insurance basics, prescription drug coverage, billing, the approvals and appeals process, financial assistance, and income support.

Remember, health policy, program eligibility, and insurance rules change all the time. It is a good idea to check with your insurance company, job, healthcare providers, or other federal/state agencies about your specific needs or questions about your coverage.

Key Terms

In-network: Doctors, hospitals, and providers that work with your insurance plan to provide services at a negotiated rate. Using in-network providers usually costs less than using an out-of-network provider. Check to see if your provider is in-network before you have care. In-network providers can change from year to year. You can check by calling your insurance company or the provider’s office. You can also check your insurance company’s website, but online directories are not always up to date.

Network: The group of doctors, hospitals, and providers that your insurance plan works with to provide services at negotiated rates. Your network can vary based on your plan type (HMO, EPO, PPO).

Out-of-Network: Doctors, hospitals, and other providers that do not have an agreement with your health insurance plan. Using out-of-network providers usually costs more, and in some plans, like HMOs, EPOs, and some Medicare Advantage plans, may not be covered at all. Out-of-network costs do not always count toward your deductible or MOOP. Medical emergencies are always covered, even if the provider is out-of-network.

Primary Care Provider(PCP): a doctor, nurse practitioner, or physician assistant who provides your general health care needs and is the main point of contact for most of your medical care. They treat common illnesses, manage ongoing medical issues, provide preventive care, and can refer you to a specialist when needed. Some plans require you to have a PCP. An in-network PCP can help keep your costs down.

Referral: A written order or request from your PCP that lets you get care from a specialist or get certain services. Some insurance plans require a referral before you can see a specialist. Always check to see if you need a referral before your visit. Referrals can also take time to coordinate with your provider, so planning in advance is important.

Specialist: A doctor or other provider who has more training in specific areas of care, like cardiology, oncology, orthopedics, and physical therapy. Depending on the type of insurance you have, you may need a referral from your PCP to see a specialist. Specialists may also have higher co-pays than PCP visits. It is also important to be sure your specialist is in-network before your visit.