Basic & Supplemental Care

Basic health care services that an HMO is required to offer. They generally include:

  • Physician’s services
  • Inpatient hospital services
  • Outpatient medical services
  • Emergency health services
  • Diagnostic laboratory services and diagnostic and therapeutic radiology services
  • Preventative health services

Coordination of Benefits

The method of determining which company pays as primary insurer and which company pays as secondary or excess insurer when a working couple or their dependents have a claim covered by more than one group insurance contract.

Copayment/Out-of-Pocket Expense

The amount of dollars you must pay for a service, a minimum part of the entire charge for any given service. HMO pays the remaining charges.


The amount of dollars you must pay to the provider before a health plan is obligated to make any payment.

Primary Care Physician:

The physician who provides or authorizes all care for you. Any referrals to specialists must be authorized.

Primary Care/Specialty Care

Primary care is rendered by a physician, which is routine in nature; care that doesn’t require a specialist. Specialty care is care rendered by a specialist in a specific field (such as a cardiologist or neurologist).

Prior Authorization/PreCertification

Prior authorization is receiving permission from the HMO’s Medical Director, as required by the Evidence of Coverage, before a certain medical procedure is performed. 

Quality Assurance

An activity conducted by the HMO whereby the HMO monitors the quality of health care services rendered to its members. This activity is required by law, and the state performs quality assurance audits at least once every three years.


A referral is given by your primary care provider (PCP) when there is a need for you to see a specialist. Without a referral from the PCP, the treatment may not be covered.

Glossary of Terms