Medicare Glossary

Capitation

A payment method where a health plan pays a fixed monthly amount per enrolled member to a provider or group, regardless of how many services that member uses. Common in Medicare Advantage HMO plans.

Out-of-Network

Providers, facilities, or suppliers that do not have a contract with your health plan. Using out-of-network providers often costs more. Some Medicare Advantage plans (like PPOs) allow out-of-network use at higher cost; others (like HMOs) generally do not.

Primary Care Provider (PCP)

The main doctor who manages your overall health care and refers you to specialists when needed. Some Medicare Advantage HMO plans require you to choose a PCP and get referrals from them before seeing a specialist.

Also known as: PCP, Primary care doctor

Referral

A written order from your primary care provider authorizing you to see a specialist or get certain health care services. HMO-type Medicare Advantage plans typically require referrals; PPOs and Original Medicare do not.