A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
24-hour coverage- An employer’s health plan that
merges group health insurance, disability plans, and workers' compensation
programs creating a single health benefit plan that offers employee coverage
24 hours per day.
24-hour managed care- Applying managed care principles
to 24-hour coverage plans.
A
Access- The capability to afford medical coverage in a
timely manner.
Agent- A representative of an insurer who sells managed
care contracts.Arbitration The act of disputing parties submitting their
argument to a neutral third party for resolution. Assets- The valuable items
that a person or company owns.At-risk- Used to explain the insurance risk
a health care organization faces.
B
Benefits- Provided by a health insurance policy, benefits
are the services the insured person receives.
Behavioral Healthcare- Includes substance abuse as well
as mental health services.
Broker- Considered an agent of the buyer; a broker sells
health plans.
Budgeting- A financial plan used by an organization to
reach its goals and objectives.
Business Integration- Combining a number of business functions
into one unit.
C
Calendar Year- Begins on January 1st and ends on December
31st.
Catastrophic Health Insurance- Consists of a high deductible,
Catastrophic Health Insurance covers expenses not included with basic coverage.
Claim- Submitted by the insurer or health care provider,
a claim is the bill for medical services.
COBRA: “Consolidated Omnibus Budget Reconciliation
Act” of 1985. COBRA ensures that workers have the option of continuing
their health care benefits after their employment has ended.
Co-insurance- The percentage amount that a health plan
will pay for services.
Co-payment- The dollar amount the insured will pay for
services.
D
Deductible- The dollar amount paid by the insured before
the insurance pays.
Dental Health Maintenance Organization (DHMO)- Dental services
provided by a network to paying members.
Dental Point of Service (dental POS) Option- Gives the
policyholder the option of choosing an in network or out of network dentist.
Discount Plans- Discount plans are not insurance buy discount
rates provided for its members.
Disease Management- Provides cost effective preventive
health care services for at risk groups.
E
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Services- Provides medical and dental services for those on Medicaid
who are under the age of 21.
Electronic Data Interchange (EDI)- The transfer of data
between organizations using computers.
Electronic Medical Record (EMR)- A computer-based record
that includes clinical and other pertinent information regarding the patient.
Employee Benefits Consultant- An expert who provides advice
to employees regarding their health care plan.
Employee Retirement Income Security Act (ERISA)- Law that
sets standards for pension plan holders and allows them disclosure to plan
provisions and funding options.
F
Federal Employee Health Benefits Program (FEHBP)- A health
insurance plan for retirees, federal employees, and their survivors and
dependents.
Federal Trade Commission Act- Act which established the
FTC and sets forth standards for the regulation of business practices.
Fee Schedule- Fee Allowance, Capped Fee, or Fee Maximum.
Fee-for-Service (FFS) Payment System- A system where the
insurer agrees to reimburse the group member for services rendered.
Formulary- Drug listing used by providers for prescribing
medication.
G
Generic Substitution- A generic equivalent of a drug listed
on the formulary. Prescriptions may be substituted without the approval
of a physician. Group Health Insurance- Health insurance written for a number
of people that was written under a master policy.
Group Market- A group of people that enter into a contract
where the MCO provides healthcare services to the market segment.
Group Model HMO- Group Practice Model HMO; An HMO that
contracts with physicians who are employees of the practice.
H
Health Care Quality Improvement Act (HCQIA)- Federal act
passed in 1996 that offers liability protection for HMOs, physicians, and
hospitals ho agree to peer review.
Health Care Quality Improvement Program (HCQIP)- Program
designed to improve the degree of care provided to Medicare recipients.
Health Data Network or Health Information Network- Computer
network of medical information.Health Insurance Portability and Accountability
Act (HIPAA)- Federal law passed in 1996 that protects the privacy of health
related information.
Health Insuring Organization (HIO)- Organization contracted
with a Medicaid agency.
Health Maintenance Organization (HMO)- Health care services
provided by an organization for a prepaid fee.
I
Immunization Programs- Programs initiated to prevent childhood
disease through the use of vaccines.
Incurred But Not Reported (IBNR) Claims- Claims which remain
unpaid because they have not yet been reported or submitted to the insuring
company.
Indemnity Wraparound Policy- A product offered by an HMO
due to a prearranged agreement with the insurance company.
Independent Agents- Agents that represent multiple insurers.
Independent External Review- Third party review that has
no affiliation with the insurance company.
Independent Practice Association (IPA)- Physicians that
contract with a Managed Care Organization to provide health services to
its members.
J
Joint Venture- Combination of organizations to share services
and meet a common objective.
Justice/Equity- A principle that states that Managed Care
Organizations will distribute services and benefits fairly to its members.
K
Key-Person Insurance- An insurance plan that protects a
business from the loss or death of a key person within the company.
L
Large Group- Health coverage that is sponsored for a large
group of individuals.
Large Local Groups- Contracts between local groups for
health care services as opposed to national contracts.
Length of Stay (LOS)- Determined from the day of admission
to the day of discharge in a hospital or other health care facility.
Length-of-Stay Guidelines- The guidelines that determine
the length of stay based upon a patient’s condition, recommended treatment,
and services needed for recovery.
M
Mail-Order Pharmacy Programs- Programs that allow members
to order pharmaceuticals through mail order and at discount prices.
Managed Behavioral Health Organization (MBHO)- Managed
care for behavioral health services.
Managed Care- Concepts or techniques used to manage accessibility,
cost, and quality of health care.
Managed Dental Care- A dental plan that provides benefits.
Managed Indemnity Plans- Like indemnity plans, these health
insurance plans include managed care reviews.
Medical Director- The chief medical officer responsible
for the quality of services provided by the health care plan.
Medical Error- Mistake that occurs when a procedure or
treatment is misapplied.
Medical Foundation- Non profit organization created by
a health care facility that controls and hires physician practices.
N
National Practitioner Data Bank (NPDB)- Federal based database
consisting of information regarding physicians and health care practitioners
involved in malpractice claims and other disciplinary actions.
Network- The health care professionals contracted by the
Managed Care Organization to provide health care services.Network Model
HMO- Group of physicians contracted by an HMO.
O
Open Access- Allows members to visit specialists whether
in or out of the network without needing a referral.
Open PHO- Physician hospital organization available to
eligible medical staff. Outside Directors- Directors of a company’s
board that have no other position within the company.
Outsourcing- Hiring outside of the network for a Managed
Care Organization.
P
Parent Company- The company that owns another company.
Patient Perception- Outcome measurement that determines
how a patient feels after treatment. Physician-Hospital Organization
(PHO)- Joint venture between physicians and hospitals for negotiating
contracts.
Plan Funding- Used by an employer to pay for the medical
benefits and administrative fees for the plan.
Q
Quality- The degrees in which members’ needs are
met.
Quality Improvement System for Managed Care (QISMC)- Program
designed to improve the health services provided to Medicaid and Medicare
recipients.
Quality Management (QM)- The process used to determine
the quality of health care provided by a Managed Care Organization to its
members.
Quality Management Committee- Oversees the quality of the
Managed Care Organization.
R
Rating- Process used to calculate the premium price. Factors
include the cost of medical services, marketability, and competitiveness
of the Managed Care Organizations health plan.
Reactive Change- Unexpected change that can be controlled.
Rebate- Lowered price on pharmaceuticals provided by the
manufacturer.
Risk-Adjustment- Case-Mix adjustment. Adjusting outcomes
measures due to the patient’s risk factors.
S
Screening Programs- Used to determine if a member has a
health problem, even if they are currently without symptoms.
Section 1115 waivers- Waivers that allow Medicaid recipients
to receive comprehensive services.
Section 1915(b) waivers- Waivers that allow Medicaid recipients
access to an HMO.
Segments- Groups of members in a market.
Self-Funded Plan- Self-Insured Plan. An employer or group
sponsor is financially responsible for the plan’s expenses and member’s
claims.Site Appropriateness Listings- Resource for the review of procedures
and their use.
Small Group- A small group typically consists of 2-99 members
of a group-sponsored plan.
Specialist- Healthcare professional who majors in one specific
area, branch, or types of disease.
T
Termination Provision- Determines how the parties may end
the contract.
Termination without Cause- Provision that allows the provider
or Managed Care Organization the ability to terminate the contract without
showing cause.
Turnaround Time- Time required to complete a member initiated
transaction.
Two-Tier Co-payment Structure- System where a member pays
one co-payment fee for a generic pharmaceutical and a higher co-payment
fee for a name brand pharmaceutical.
Tying Arrangements- An illegal business practice that occurs
when an organization conditions the sale of one product or service on the
sale of other products or services.
U
Underwriting Impairments- Individual’s above normal
risks that are the result of certain factors.
Utilization Guidelines- Review that ensures healthcare
services are effective and appropriate.
Utilization Management (UM)- The management of medical
services to ensure that each patient receives high quality care.
Utilization Management Committee- Committee that handles
the Managed Care Organization’s reviews, protocols, and appropriateness
of medical services.
Utilization Review (UR)- The process of evaluating health
care services and treatment provided for a patient.
V
Variances- Differences that occur from determining actual
results from those that were expected.
W
Women's Health and Cancer Rights Act (WHCRA)- Law that
ensures women who suffer from cancer will have access to coverage for reconstructive
surgery following mastectomy.
Workers' Compensation- Insurance program that ensures employees
will recover wages lost due to work related injury, illness, or disease.
Workers' Compensation Indemnity Benefits- Benefits that
supplement a worker’s wages due to injury or illness.