Glossary - Know exactly like a health insurance expert!

What is open access?
A provision that specifies that plan members may self-refer to a specialist, either in-network or out-of-network, at full benefit or at a reduced benefit, without first obtaining a referral from a primary care provider.

What is open formulary?
30 The provision that drugs on the preferred list and those not on the preferred list will both be covered by a PBM or MCO.

What is open-panel HMO?
An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patients as well as HMO members.

What is open PHO?
A type of physician-hospital organization that is available to all of a hospital's eligible medical staff.

What is operational integration?
The consolidation into a single operation of operations that were previously carried out separately by different providers.

What is operations director?
Individual who typically oversees claims, management information services, enrollment, underwriting, member services, and office management.

What is outcomes measures?
Healthcare quality indicators that gauge the extent to which healthcare services succeed in improving patient health.

What is out-of-pocket maximums?
Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.

What is outpatient care?
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.