Provider Directory

A list of medical professionals that will be covered or considered in-network by a specific insurance plan. The directory is available online or in a patient's Summary of Benefits and Care document. Since directories are not always up-to-date, always confirm if a professional takes your insurance by calling their office directly.

Provider Network

Hospitals, physicians, imaging facilities, laboratory facilities, and other healthcare facilities that are covered by a particular plan. This means that they will offer a discounted rate on their services to those who are members of the plan, and offer full list price to those who are not.

Public Health Insurance

A branch of the state or federal government that takes on financial risk, administers benefits, and pays claims as relates to healthcare for individuals and their families.

Qualified Health Plan (QHP)

A health insurance plan offered on a marketplace that meets Affordable Care Act guidelines and is pre-approved by the state hosting the marketplace. Most comply to the Precious Metal categories (so a Silver plan purchased in California offers similar financial protection as a Silver plan purchased in New York, as an example).

Qualifying Life Event

Any change in a personal situation (loss of coverage, changes in household, changes in residence, or other similar events) that make you eligible for a Special Enrollment period outside yearly Open Enrollment.

Quote

An estimate of the cost of insurance, based on information supplied to the insurance provider by the applicant.

Referral

A physician officially directs a patient to see a specialty physician. Some plans require that a referral is placed between physicians before the patient's visit to the specialist is covered.

Reinstatement

The restoring of a lapsed policy to full force and effect. The reinstatement may be effective after the cancellation date, creating a lapse of coverage. Some companies require evidence of insurability and payment of past due premiums plus interest.

Reverse Deductible

An insurance policy in which the insurer pays an initial amount for covered care and the patient pays any additional costs above a certain value. Also called reference pricing. For example, if the insurer says they will pay $1,200 for a colonoscopy and your hospital charges $1,600 for the procedure, you would pay the $400 difference. If you went to a different hospital that only charged $900, your insurance would completely cover the procedure.

Risk Adjustment

Adjustment of payment to healthcare professionals based on the riskiness of their patients. Insurers will pay more for patients expected to cost more (ie riskier patients) and less for patients expected to cost less (ie less risky patients). Often used in a HMO insurance system.

Risk Amenable

Term used to define the preference of the minority of people who prefer not to pay any money at all in the short term and gamble that they will not experience a catastrophic bill in the future. This preference may lead people to avoid health insurance.

Risk Averse

Term used to define the preference of most people to pay a small amount monthly (a known and predictable quantity) to avoid a potentially catastrophic surprise bill (an unknown and uncertain quantity). This preference may lead people to over-insure themselves.