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Participating Provider

A physician, hospital, nursing facility or other health care provider that has contracted with a health plan to provide covered services for a negotiated charge. Also called "preferred care provider."

Patient Protection and Affordable Care Act

The name of the new health care reform law passed by Congress in March 2010 and signed by President Obama.


A retirement fund for employees (usually tax exempt) paid for or contributed to by an employer as part of an employee's compensation package. Many employers are replacing pensions with 401(k) plans. Pension plans vary by employer so it's important to get details in writing, such as the contribution plan, choices for receiving benefits and an explanation about spousal rights to the pension.

Personal Health Record

A Personal Health Record (PHR) stores health-related information in a password-protected online record. In many cases information such as claims submitted to your health insurer, the location of your last doctors' visit and prescribed treatment is automatically added by your insurer. Depending upon the PHR, individuals may have the opportunity to input personal information like family history of disease, blood type, diet and exercise regimens and allergies. The Privacy Rule, part of the Health Insurance Portability and Accountability Act (HIPAA), regulates how health information that can be linked to an individual may be used.

Pharmacy and Therapeutics (P&T) Committee

A group of physicians, pharmacists and other health care professionals who advise a health plan regarding prescription drug formularies and the safe and effective use of medications.

Plan Documents

Plan documents describe the details of a health plan - what services are covered, what services are not covered, and what charges the patient will be required to pay (copayments, deductibles, coinsurance). "Plan documents" may include a group agreement, group policy, Certificate of Coverage, Certificate of Insurance or Evidence of Coverage. You should read the plan documents before deciding which health plan is right for you. You may obtain a copy of the plan documents through your employer or health plan.

Point-of-Service (POS)

A health benefits plan that provides coverage for care received from both participating providers and non-participating providers. In many POS plans, patients whose care is directed through referrals from their primary care physician (PCP) receive a higher level of benefits, while patients who go directly to other physicians or facilities receive a lower level of benefits.

Practice Guidelines

Also called "clinical practice guidelines," "practice parameters" or "medical protocols." These guidelines describe optimal approaches to diagnosis and treatment of specified illnesses or injuries based on current medical research.

Pre-existing Condition

A condition, disability or illness (physical or mental) that you had before you signed up for a health plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. (Note that the definition of this term differs by state.)

Pre-existing Condition Insurance Plan

A new program that grew out of health care reform provides health coverage for anyone who has been uninsured for at least six months, has a pre-existing medical condition, and has been denied coverage (or offered insurance without covering the pre-existing condition) by a private insurance company. This program will provide coverage until 2014, when access to affordable health insurance choices is available through an exchange.


Under some health plans, individuals are required to receive advance authorization of particular medical services. Such advance authorization is called “preauthorization” or “precertification.” Depending on the type of plan you have, your physician may request this authorization or you may be required to do so. Check your plan documents to see if there are any services that require preauthorization under your plan and, if so, who is responsible for requesting it.

Preferred Care Provider

See Participating Provider

Preferred Provider Organization (PPO)

A health benefits plan that allows an individual to choose any provider without designating a primary care physician (PCP), but offers higher levels of coverage to those who choose participating or preferred physicians or hospitals.


The amount charged by a health insurer for a health insurance policy. If you have a health plan through your employer, you and your employer may share this cost. If you buy a health plan yourself, you pay the full amount.

Prescription Drugs

Medicine that requires a doctor's permission to buy. These drugs are different from over-the-counter drugs, which you can buy without a prescription.

Preventive Care

Programs or services that can help maintain good health (such as annual physical exams or immunizations) or are meant to detect early signs of disease (such as mammograms and colon cancer screenings). Check to see that these are covered under your health plan.

Primary Care Physician/Primary Care Provider (PCP)

A physician who is part of a health plan's network and serves as a patient's main point of contact for medical care. A PCP typically provides basic medical and coordinates and supervises other care received by the patient. A PCP is usually a general or family care practitioner, or in some cases, an internist, pediatrician or OB/GYN. PCPs provide patients with referrals for specialist care or other medical services. In some health plans, you must choose a PCP to coordinate your care.

Private Fee-for-Service Plan

A type of Medicare Advantage Plan through a private insurance company that charges a premium to let Medicare recipients go to any Medicare-approved doctor or hospital that accepts the plan's payment. The private company, rather than the Medicare program, decides how much it will pay and how much you pay for the services you get. This type of plan may offer extra benefits the Original Medicare Plan doesn't cover.


A licensed health care facility, program, agency, physician or other health professional that delivers health care services.

Provider Network

See Network

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