members
Health Insurance Glossary
members
- Occupational Therapy
- Treatment of a physically disabled person by means of constructive activities designed and adapted to promote restoration of the person's ability to perform activities of daily living and those tasks required by the person's particular occupation or role. It is not recreational or diversionary therapy.
- Open Enrollment
- Designated period of time during which an employee may enroll in group health coverage. Also, designated period of time during the year when individuals without group coverage may enroll in health coverage without needing medical underwriting.
- Other Insurance Paid
- The amount paid by other insurance coverage for covered health care service charges.
- Out-of-Network
- The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in Preferred Provider Organizations (PPO) and Point-of-Service (POS) coverages can go out-of-network, but will pay higher out-of-pocket costs. See In-Network.
- Out-of-Pocket Limit/Out-of-Pocket Maximum
- The maximum dollar amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a calendar year for covered indemnity expenses. Once the out-of-pocket limit is met, the plan pays 100% of the allowed amount for covered services for the rest of the benefit period.
- Outpatient
- Patient who receives hospital care without being admitted as an inpatient.
- Outpatient Surgery
- Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, surgery center or physician's office.