Hospital Information: Glossary of Terms

For your convenience, we've included a glossary of health insurance terms that have been used here and/or may be used in discussions you may have with your plan's customer service representatives.

Affordable Care Act

Health reform legislation signed into law in March 2010. It includes a long list of health-related provisions that began taking effect in 2010. Key provisions are intended to extend coverage to millions of uninsured Americans, lower healthcare costs and improve system efficiency, and eliminate industry practices that include rescission and denial of coverage due to preexisting conditions.

Authorization

Written approval from your insurance carrier to receive medical care at Memorial Sloan Kettering. Please note that a new authorization is needed for each type of service, such as chemotherapy, radiation therapy, MRI, CT scan, outpatient surgery, and hospital admission. We will obtain this authorization for you 24 to 48 hours prior to the scheduled service.

Cancer Resource Services (CRS)

Cancer Resource Services (CRS) is a program provided by UnitedHealthcare that offers UnitedHealthcare patients access to a network of premier cancer centers. UnitedHealthcare patients should call CRS at 866-936-6002 to verify eligibility for this specialized coverage.

Carrier

An insurance company that issues policies and makes payments to medical providers for its members.

Case Manager

A Memorial Sloan Kettering employee, usually a nurse, who will advocate on your behalf with your insurance company if the proposed treatment plan is not available within your network of providers.

Co-Insurance

The amount (usually a percentage) of the healthcare costs for which you have to pay. You pay co-insurance even if your deductible has been met. For example, you may pay 20 percent of the cost of medical services after meeting the deductible.

Co-Payment

A flat fee that you pay for healthcare services from an in-network provider for certain services such as an office visit or physical therapy. For example, you may be responsible for a $15 co-payment for each office visit.

Deductible

The annual amount you must pay for healthcare expenses before your insurance company begins to pay for covered medical services.

Exclusive Provider Organization (EPO)

A managed care organization that is similar to a preferred provider organization (PPO). If you’re a member of an EPO, you can see any doctor in the network without obtaining a referral. You do not need to choose a primary care physician, but cannot go to an out-of-network provider without an authorization. You are responsible for all charges if you receive treatment from a non-network provider and do not have an authorization.

Financial Counselor

A Memorial Sloan Kettering employee who is available to answer questions you may have or to explain billing procedures.

Health Insurance Exchange (also known as Health Insurance Marketplace)

A key provision of the Affordable Care Act, established to provide a selection of competing health insurance providers, each offering different qualified plans. All qualified plans must meet standards established and enforced by the federal government.

Health Maintenance Organization (HMO)

A managed care plan that requires its members to use the services of their network of physicians, hospitals, or other healthcare providers. If you’re a member of an HMO, you are required to choose a primary care physician who must provide you with a referral to see a specialist.

In-Network

Physicians, hospitals, or other healthcare providers who have a managed care contract with your insurance plan. The fees of these providers are covered by the plan. You may still be responsible for a co-payment.

Indemnity Health Plans

Also called a fee-for-service plan. An insurance plan that allows you to see medical providers of your choice. You are responsible for paying a percentage of total charges no matter which medical provider you see.

Managed Care

An insurance plan that contracts with a network of healthcare providers. Your financial responsibility is significantly less when provided in-network. EPOs, HMOs, POS, and PPOs are managed care plans.

Medicaid

A state program that provides medical benefits to eligible people who have a low income level as well as to people with disabilities.

Medicare

A federal health insurance program that covers the cost of hospitalization, medical care, and some related services for people 65 years or older and for people with disabilities.

Network

A group of physicians, specialists, hospitals, outpatient centers, pharmacies, and other providers who has signed a contract with an insurance company to provide healthcare services to their subscribers.

Non-Covered Procedure or Service

A medical procedure or service that an insurance plan considers medically unnecessary (or experimental) and therefore does not cover.

Out-of-Network

Physicians, hospitals, or other healthcare providers who do not have a managed care contract with an individual’s insurance company. When you receive care out-of-network, you will be financially responsible for that care.

Out-of-Pocket Costs

The amount you are responsible to pay for medical services that are not reimbursed by your insurance plan.

Point of Service (POS)

A health plan that contracts with a group of providers to offer medical services at discounted rates. When seeing an in-network specialist, such as an oncologist, you must obtain a referral from your primary care physician. POS plans allow you to seek care outside of the PPO network, but the insured party has a greater out-of-pocket expense.

Precertification

Obtaining authorization from your insurance plan for any hospital admission and those outpatient procedures specified under your policy. Memorial Sloan Kettering will handle insurance-required precertification on your behalf, no matter which insurance company you have a policy with. These services include (but are not limited to) inpatient stays, emergency admissions, outpatient surgeries, radiology procedures, and radiation therapy.

Preferred Provider Organization (PPO)

A health plan that contracts with a group of providers to offer medical services at discounted rates. Typically you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. PPOs allow you to seek care outside of the PPO network, but the insured party has a greater out-of-pocket expense.

Primary Care Physician (PCP)

A general or family practitioner who is your personal physician and first contact within a managed care system. The PCP will usually direct the course of your treatment and refer you to other doctors and/or specialists in the network if specialized care is needed.

Provider

Any medical professional (physician, nurse practitioner, etc.) or institution (hospital, clinic, etc.) that provides medical care.

Referral

The approval form you receive from your primary care physician for you to see a specialist or get certain services. In many managed care plans, you need to get a referral form before you get care from anyone except your primary care doctor. If you do not first get a referral, the plan may not pay for your care. Patients in HMO plans must also obtain authorization for treatment from the carrier prior to an appointment at an out-of-network facility.

Usual, Customary, and Reasonable (UCR), or Reasonable and Customary

Every insurance carrier has a payment rate for each test, procedure, and medical service. The rates are what the insurer has decided are appropriate for these services in New York City. Insurers have different ways of deciding what is usual and customary. Memorial Sloan Kettering’s charges may be different from an insurer’s rates due to the high level of care we provide to our patients. If you only have out-of-network benefits, you are responsible for paying the difference between Memorial Sloan Kettering’s charges and the carrier’s usual and customary rates, in addition to your co-insurance and deductible costs.