Medicare Glossary: Simple Definitions & Terms

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.

A type of Medicare Advantage plan where you generally must use doctors, hospitals, and other providers in the plan's network, except in emergencies. You typically need a referral to see a specialist.

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.

A type of Medicare Advantage plan that allows you to see any provider who accepts Medicare, but you pay less when you use the plan's preferred (in-network) providers. Unlike HMOs, PPOs generally do not require referrals for specialists.

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.

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.