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Commonly Used Terms

HMO (Health Maintenance Organization)
A type of health insurance in which you must get your services from the doctors, labs and hospitals that have contracts with the HMO or work for it. Not All HMO’S offer the same range of services. Within an HMO, there can be different benefit packages that cover different services, or have different copay requirements for service. Examples of HMO’s are Kaiser, and SF Health Plan
Medi-Cal
A public health insurance benefit based on economic need that covers preventive care, doctor visits and medication. Medi-Cal benefits are linked to SSI (Supplemental Security Income) and TANf, and are available to people with disabilities and those age 65 and over. People can have Fee for Service Medi-Cal, which allows them to go to any provider who accepts Medi-Cal, or a Medi-Cal HMO such as Kaiser, SF Health Plan, and Blue Cross
Medicare
A public health insurance benefit for individuals eligible for SSDI (Social Security Disability Insurance), or who qualify for Social Security Retirement benefits. It includes Part A – inpatient, and Part B, outpatient services. People can have Fee for Service Medicare, which allows them to go to any provider who accepts MediCare, or a Medicare HMO.
Copayment/Copay
A fee that you pay for using covered benefits, such as each doctor visit, lab work or prescriptions
Benefits Package
The services covered by your health insurance
COBRA/Cal-COBRA
Laws that help employees keep their group health insurance if their job ends or their hours are cut
Evidence of Coverage (EOC)
Your contract with your HMO. The EOC tells you what your HMO will and will not pay for
Covered benefit
A service your HMO will pay for if you need it
Formulary
A list of the prescription drugs covered by your HMO
Primary Care Provider (PCP)
Your main doctor, who provides most of your care and coordinates your other health care services, including making referrals to other doctors and services within the HMO
Provider
Any person, clinic or group that provides your health care services
Specialist
A doctor with extra training in a special field, such as HIV, Cancer, Psychiatry
Network
All the doctors, labs and hospitals that have contracts with your HMO or work for it

What Can ILRCSF do to assist and support you? We can help clarify these terms, and others that we haven’t mentioned here.