Exclusion from insurance coverage or coverage after a waiting period of illness or injury received by the insured before enrollment in an insurance plan. Also called preexisting condition exclusion.

Clause in an insurance contract that states until the insured has been covered under the policy for a certain period, the insurance company will not pay benefits for any preexisting conditions.

In a life insurance policy, if no beneficiary is listed, the insurance company will pay the proceeds from the policy in a stated order to the individuals shown in the contract.

Managed care plan that requires members to receive medical services from the network’s physicians at a reduced cost instead of a doctor of their own choice at a larger cost.

Any licensed health care professional who contracts with a managed care plan such as ambulatory surgical center, dentist, hospital, physician, and podiatrist.

System in managed care, in which a limited number of providers are selectively contracted at reduced rates of payment.

Under the TRICARE program, group of civilian practitioners to supplement military direct care in TRICARE Prime and Extra. PPN members offer discounts, file patients’ claims, and must meet the same professional standards as military treatment facility providers.

1. Type of mixed health-plan model that combines managed care and traditional insurance. Enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health provider designated by their program as a “preferred provider.” They may receive substantial, though reduced, benefits or may have additional cost when they obtain care from a provider of their own choosing who is not designated as a “preferred provider” by their program. 2. A Medicare+Choice coordinated care plan that has a network of providers who have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan. It provides for payment for all covered benefits regardless of whether the benefits are given with the network of providers. It is offered by an organization that is not licensed or organized under state law as a health maintenance organization (HMO). 3. Type of Medicare Advantage Plan in which the patient uses doctors, hospitals, and providers that belong to the network. Patients can use doctors, hospitals, and providers outside of the network for an additional cost.
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An organization of health care providers and/or facilities that offers a discount on services to members of the PPO.

Category for an insured or applicant of insurance who has a lower expectation of incurring a loss and has greater life expectancy than a standard applicant and qualifies for a reduced premium rate (e.g., applicant who does not smoke, applicant who does not drink). Also called superstandard risk class.