A healthcare professional, facility, or organization that has a contractual agreement with an insurance plan to deliver medical services to covered individuals at negotiated rates.

In-Network:

Refers to healthcare providers or facilities that have agreements with a specific insurance plan, resulting in lower out-of-pocket costs for individuals with that insurance.

Out-of-Network:

Healthcare providers or facilities that do not have a contractual agreement with a particular insurance plan, often resulting in higher costs for individuals seeking services from them.

Preferred Provider Organization (PPO):

A type of health insurance plan that allows individuals to receive care from both in-network and out-of-network providers, though with higher costs for the latter.

Health Maintenance Organization (HMO):

A type of health insurance plan that typically requires individuals to choose a primary care physician and obtain referrals for specialized care within the network.

Exclusive Provider Organization (EPO):

A health insurance plan that only covers services provided by healthcare professionals and facilities within the designated network, except in emergencies.

Point of Service (POS):

A health insurance plan combining features of both HMO and PPO, allowing individuals to choose in-network or out-of-network providers, but with different cost-sharing arrangements.

Provider Directory:

A list of healthcare professionals and facilities included in a specific insurance plan’s network, accessible to plan members for reference.

Referral:

A recommendation from a primary care physician to see a specialist, often required in HMO plans for coverage of specialized services.

Co-payment (Co-pay):

A fixed amount individuals pay for covered services at the time of the visit, usually applied to in-network providers.

Deductible:

The amount individuals must pay out of pocket for covered services before their insurance plan begins to contribute, typically on an annual basis.