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Here we list definitions for some terminology you may come across in the context of healthcare plans.

blanket insurance
Blanket health insurance is different from normal group insurance, which is generally more comprehensive. Blanket health insurance often establishes caps on coverage to reduce certain kinds of medical costs. Blanket health insurance typically provides more coverage for catastrophic or urgent conditions, and does not generally cover routine care or the treatment of elective conditions. These restrictions reduce the cost of the plan. Blanket insurance is geared toward a specific market in order to provide maximum benefit at the best overall price. Laws pertaining to group health insurance may, or may not, apply to blanket insurance, although generally they do.
copay or copayment
Healthcare plans sometimes charge a fixed dollar amount each time certain services are received. This amount you pay is called a copayment. As an example, each time you visit the doctor or fill a prescription, they might charge you $10.
deductible
Before some insurance plans will begin to cover medical expenses, the insured person must pay a certain dollar amount of their own medical costs. As an example, an insurance policy may require the policy holder to pay $200 of hospital costs--once the policy holder has paid this much is hospital expenses, the insurance will cover the rest of hospital costs (at whatever rate they specify).

Deductibles are usually for one year, meaning that meeting a deductible for one year only lasts for that policy year--the deductible will be reset for the next policy year. Deductibles vary from policy to policy. Some have no deductible, some have a deductible applied to all medical services, just to some medical services, to all family members, or a per-individual deductible.

Some insurance plans allow you to choose a higher deductible with the benefit that you have a lower premium.

dependent
A dependent can be a spouse/partner, a child under a certain age (often under 18), or a child who is attending school and is supported by the family.

Each insurance plan will define more precisely what kinds of dependents can be covered.

family medicine
The branch of medicine that provides comprehensive medical care for all members of a family, including adults and children.
general practitioner
A doctor with general training in medicine (not trained in a medical specialty). When you have a medical condition, you usually go to a general practitioner who evaluates your condition. For simple conditions, they may treat you themselves, but for more complicated conditions they will refer you to a specialist.
HMO or Health Maintenance Organization
A medical insurance provider under which services are obtained via a network of participating doctors and facilities. Usually, you receive no benefits if you obtain services from doctors or facilities outside their network. See a comparison between HMOs and PPOs.
in-network
Some insurance plans require that you receive most or all medical services from a certain set (or network) of doctors and facilities. When you do so, such services are called in-network and are usually coverage better than for out-of-network services.
inpatient
Refers to medical services provided while admitted to a hospital. Often, insurance plans cover inpatient and outpatient services differently. Be aware that insurance companies may have their own definition of what constitutes inpatient services.
internal medicine
The diagnosis and non-surgical treatment of general medical diseases and conditions in adults.
managed care
A general term for organizing doctors, hospitals, and other providers into groups under the claim that doing so improves the quality of care for patients and provides better control over the costs of healthcare. Managed care organizations include things like HMOs and PPOs.
nurse practitioner
A registered nurse with advanced education, who is skilled in physical exams, treatment of common health problems, preventive care and counseling in an emotional crisis. Nurse practitioners work together as a team with doctors and are authorized to write prescriptions.
out-of-network
Some insurance plans require that you receive most or all medical services from a certain set (or network) of doctors and facilities. When you obtain services with doctors or facilities outside of this network, these services are referred to as out-of-network. Coverage of out-of-network services is often lower than for in-network services. In the extreme case, there may be no coverage for out-of-network services.
outpatient
Refers to medical services provided while not admitted to a hospital. Often, insurance plans cover inpatient and outpatient services differently. Be aware that insurance companies may have their own definition of what constitutes outpatient services.
pediatrics
The medical specialty that is concerned with the care and development of children, and the treatment of childhood diseases.
PPO or Preferred Provider Organization
A medical insurance provider under which services are obtained via a network of preferred doctors and facilities. Usually, you receive lower benefits if you obtain services from non-preferred doctors or facilities. See a comparison between HMOs and PPOs.
premium
There is usually a fixed, yearly fee for enrolling in an insurance plan. This fee is paid whether medical services are rendered or not and is called the premium.
primary care provider
The doctor or nurse that you first see when you have a medical condition. After they evaluate you, they may prescribe medicine, tests, other treatments or refer you to a specialist (e.g., eye doctor, neurologist) if necessary.

HMO/PPO Comparison

The following table provides a general comparison between HMO and PPO coverage. The bottom line is that you pay more for a PPO in order to have greater flexibility in your healthcare choices. "HMO's are the most restrictive form of managed care benefit plans because they restrict the procedures, providers and benefits."

HMOPPO
Enrollment Enroll for specific period of time. Costs and coverage may change at each new enrollment period.
Premium, Copayments & Deductibles Fixed, pre-paid premium. A small additional copayment may be required for some services. In addition to a premium, copayments and deductibles must be met for services rendered.
In-Network Benefits Required to use participating (or approved) providers for all services. Receive services at discounted rates.
Out-of-Network Benefits None except in life or death emergency circumstances. May go to any out-of-network doctors or facilities, but pay more than for in-network services.
Authorization Pre-approval by the HMO is likely to be required to receive most services, including specialty care, hospitalizations and many procedures. Pre-approval required for hospitalizations.


To contact the Graduate Student Organization on healthcare issues, send mail to healthcare@gso.bu.edu.
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