Coinsurance - the patient portion of a medical bill. It is usually a percentage of the total claim amount. For example, in an 80/20 plan, the insurance will cover 80 percent of the charge and the patient is responsible for 20 percent of the charge.

Copayment - a type of cost sharing where the insured (patient) pays a small fixed payment determined by the insurance company at the time of services rendered (e.g., $10 per office visit, or $25 per inpatient hospital day). The insurance company pays the rest of the cost. The amount paid by the patient does not vary with the cost of the service.

Deductible - a fixed annual amount associated with indemnity plans (fee for service, PPO, POS) that is paid by the patient for services rendered before the insurance plan will pay for any expenses. For example, a plan may require you to pay the first $200 in an annual period before covering medical claims.

Fee-for-service - a system in which medical providers bill for whatever service they provide. Medicare and/or traditional insurance pay their share, and the patient pays the balance through co-payments, coinsurance and/or deductibles.

Health Maintenance Organization (HMO) - also referred to as managed care plans. The HMOs were designed to control spiraling health care costs while maintaining quality care and services. Most HMOs prepay providers for an enrolled group of members, assign members to primary care physicians, and arrange comprehensive benefits through a more limited provider panel. Copayments are often used in the HMO model as the cost- sharing method for the patient.

HIPAA - Health Insurance Portability and Accountability Act of 1996. The Act was developed by Congress to protect the confidentiality of a person's medical information. It sets boundaries on the use and release of health records and establishes safeguards to protect the privacy of health information.

Indemnity Insurance - coverage in which the insurance company reimburses the patient for his/her medical expenses. Typically, the choice of physician and hospital is completely up to the patient; there are deductibles, and there are limits to the dollar amount of coverage.

Managed care - a system of managing and financing health care delivery to reduce the cost of health care while preserving a high level of care and service. It is a combined clinical and administrative approach to health care delivery. If you choose an HMO insurance plan, you opt for managed care.

Medicare HMO - also referred to as Medicare + Choice Plan. This is an HMO for seniors (generally persons over the age of 65) and people on disability. The HMO benefits replace a patient's Medicare benefits, and often cover services that Medicare would not (e.g., pharmacy benefits). A monthly premium may be charged by the Medicare + Choice Plan to the member for these enhanced benefits.

Point of Service (POS) Plan - a health insurance benefits program in which subscribers can select between different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of medical services, rather than making the selection between delivery systems at time of open enrollment at place of employment.

Preferred Provider Organization (PPO) - a contractual arrangement between independent providers and an employer or insurance company to deliver health services to a defined population at established fees. The PPO contains a panel of physicians and health care institutions that are the preferred providers. Health care services are delivered on a fee-for-service basis at established rates, usually discounted from the physician's usual and customary rates. PPO members pay a larger coinsurance amount for using non-preferred providers.

Premium - the monthly or annual amount paid by the patient, employer or both to the insurance plan (payer) for insurance coverage.

Primary Care Physician (PCP) - a pediatrician, family or general practice physician or internist who oversees ALL your health care, from routine physical examinations to specialist and urgent/ emergent care. This allows your PCP to develop an understanding about you that is difficult for intermittent physicians to match. The close relationship you establish with him/her will enhance accurate diagnoses, preventive medicine and education. If you belong to an HMO, you must choose a primary care physician.

Provider - a medical group, Independent Practice Association (IPA), hospital, health care facility or health care professional that provides health care services to patients. This may be a single hospital, an individual such as a physician, nurse practitioner or physician assistant, or a group or organization. When you sign up for an HMO insurance plan, you are asked to select a provider from the insurance plan's provider directory. Camino Medical Group physicians can be found under the heading "Camino Medical Group." You can choose the group before choosing a primary care physician if you want to get acquainted with your physician first.

In an HMO, most primary and specialty care is provided within the provider group. Generally, this means if you see a physician outside the medical group, your insurance plan will not pay for the visit. That is why it is important to have a primary care physician to assist you in obtaining specialty care.
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