Glossary

Open-ended HMOs

HMOs that allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional's services under a traditional indemnity plan.

Out-of-Plan (Out-of-Network)

This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part, by an individual's insurance company.

Out-Of-Pocket Maximum

A predetermined limited amount of money that an individual must pay out of their own savings before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.

Outpatient

An individual (patient) who receives health care services (such as surgery) on an outpatient basis; that is, they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.