What is an HMO An organization which provides  comprehensive healthcare coverage to its members through a network of doctors,  hospitals and other healthcare providers (may require a referral).

What is a POS A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do (may require a referral).

What is a PPO A healthcare benefit arrangement  designed to supply services at a lower cost to use in-network healthcare  providers (who contract with the PPO at a discount). The PPO also provides coverage for services rendered by healthcare providers who are not part of the  PPO network at a higher out-of-pocket cost to the member (no referrals).

What is an EPO A healthcare benefit arrangement that is simliar  to a preferred provider organization (PPO) in administration, structure and  operation but which does not cover out-of-network care (no referrals).

What does Participating Provider mean? A healthcare  provider such as a physician, skilled nursing facility, home health agency, laboratory etc, who has an agreement with an insurance carrier to provide  covered services to its members.

What is a deductible? Dollar  amount that an insured person or family must pay each year before an insurer  will assume any liability for the remaining cost of covered services.

What is a Gated plan? A plan that requires referrals from your  Primary Care Physician in order to see specialists.

What is a Non  Gated plan? A plan that does not require referrals from a Primary Care  Physician in order to see specialists. A PCP is involved in overseeing and  coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone (EAP, employer based case manager, UR entity, etc.) which makes the decision of where a patient will receive services.

What is a Drug Formulary? A list of preferred pharmaceutical products that health plans, working with pharmacists and  physicians, have developed to encourage greater efficiency in the dispensing of  prescription drugs.

What is a PCP (Primary Care Physician)? A PCP is a family physician, family practitioner, general practitioner, internist or pediatrician that is responsible for delivering or coordinating care.

What is coinsurance? Cost-sharing requirement that the insured pay a designated percentage of the allowed amount for covered services (usually  applied when utilizing a non participating provider).

What is a Copay  (Copayment)? The fixed dollar amount that your policy requires you to pay as your share of the cost of certain services each time you receive care from a participating provider.

What is COBRA/NYS Continuation? A federal act which requires each group's health plan to allow employees and certain dependents to continue their group coverage for a stated period of time  following a qualifying event that causes the loss of group health coverage. Qualifying events include termination of employment, reduced work hours, death and divorce.