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Part I: Terminology
 > Managed Care Glossary

Glossary of Managed Care Definitions

Accreditation: a systematic review of a managed care plan by one of three private, nonprofit agencies (the National Committee for Quality Assurance, the Joint Commission on the Accreditation of Health Care Organizations, and the American Accreditation HealthCare Commission/Utilization Review Accreditation Commission). The review assesses how the plan compares to standards developed by each organization in specific areas, such as credentialing of health care providers, quality assurance programs, consumer satisfaction, etc. Plans that meet standards receive a stamp of approval called accreditation. Maintaining accreditation requires undergoing review on a periodic basis.

Actual charge: the price levied by a health care provider (for example, a hospital or physician) on a consumer or a managed care plan, for a specific medical product or service.

Actuarial: methods and calculations used to estimate the financial risk for a managed care plan of enrolling a specific consumer or group of consumers. Based on these calculations, the insurer develops eligibility criteria, as well as premiums that it will charge the consumer(s).

Acute care: short-term treatment for an illness that is limited in its duration. Examples of acute care include a physician office visit to suture a wound or hospitalization for a heart attack. The goal of acute care is to cure the illness or prevent worsening.

Acute illness: an ailment (illness or injury) that is limited in its duration and resolves before becoming chronic and requiring on-going management. Acute illnesses range from the common cold to food poisoning to heart attacks.

Administrative costs: expenses related to running an organization, such as overhead (rent, utilities, and supplies), advertising and marketing.

Adverse selection: a situation in which a managed care plan's population of consumers is older or sicker than expected and, consequently, more likely to incur higher expenses for the plan.

Allowable charge: amount that a managed care plan determines is the appropriate amount to pay health care provider for a specific product or service. The allowable charge is frequently lower than a health care provider's actual charge.

Alternative health care: products and services such as acupuncture, homeopathy, nutrition therapy, and massage, that can complement the services provided by hospitals and physicians.

American Accreditation HealthCare Commission/ Utilization Review Assessment
Commission (URAC)
: a private, nonprofit agency located in Washington, D.C., that reviews managed care plans against its own performance standards. Plans that compare favorably to the standards are accredited, or approved, for a specific period of time and are re-examined periodically to maintain their

Ancillary services: imaging (such as x-rays and CAT scans) and laboratory testing (such as blood or urine testing) that are provided to a consumer in conjunction with hospital or physician care to assist with diagnosis and

Any willing provider: laws that require managed care plans, such as health maintenance organizations, to contract with all physicians or hospitals in the area served by the plan who wish to serve the plan's members.

Appeal: review of an adverse coverage decision by a managed care plan. Appeals are typically initiated by consumers or their physicians when they and the plan disagree with a plan's decision to deny or limit care.

Assignment: process by which a health care provider, such as a physician, agrees to accept payment for a product or service directly from the managed care plan. Assignment typically also limits the amount the health care provider can collect from the consumer, in addition to the allowable charge, as determined by the managed care plan. (See balance billing below.)

At-risk: a situation that occurs when a health care provider receives a fixed, predetermined sum of money to care for a consumer (or group of consumers) and stands to lose money if total expenses for care exceed the amount paid.

Authorization: approval by a managed care plan for a consumer to receive a health care product or service, such as a specific medical treatment, surgical procedure, or diagnostic test.

Balance billing: a system in which a health care provider can collect from a consumer the difference between the provider's actual charge and the insurer's allowable charge. For example: a provider's actual charge for a service is $100, and the insurer's allowable charge is $80, of which it pays 80 percent ($64). In balance billing, the provider can collect $36 from the consumer. A provider who accepts assignment (see above) would only be able to collect $16 from the patient.

Behavioral health care: products and services intended to diagnose and treat mental and emotional illnesses, such as depression or substance abuse.

Beneficiary: a consumer, or his or her dependent, who enrolls with a managed care plan, and is entitled to receive coverage and payment for health care products and services covered by the contract with the plan.

Benefit limits: caps on how much the managed care plan will pay for specific health care products or services, or the quantity of services a consumer may receive (such as the number of visits to specialty physicians).

Benefits package: the set of health care products and services covered by the contract between a managed care plan and the purchaser of care (typically an employer or individual consumer). The benefits package can include items such as hospital and physician care, prescription drugs, diagnostic testing, and other

Board certified: describes the level of training and competency testing successfully completed by a physician. A board certified physician has completed medical school, post medical school training (known as residency), and passed an exam in one of the areas of specialization or subspecialization recognized by the American Board of Medical Specialties.

Brand-name drug: a drug that carries a specific, trademarked name and is produced by one manufacturer.

Capitation: a system managed care plans use to pay physicians or hospitals, in which the providers receive a fixed, predetermined sum of money, typically on a monthly basis, from the plan to care for plan members. Capitation places providers at-risk (see above) for financial losses.

Carve out: a product or service (such as prescription drug benefits or mental health care) provided by a managed care company that specializes in the particular service.

Case management: process managed care plans may use to review the care that patients receive. The goal of case management is to ensure that patients receive the appropriate service from the right provider, at the right time, and in the least costly setting. Case management typically is performed by physicians or nurses who are paid by the plan.

Case rate: a payment system in which the managed care plan pays health care providers an all-inclusive fee to provide care for a patient, based on the patient's diagnosis, or the medical treatments or surgical procedures provided to the patient.

Center of excellence: is a designation assigned by the managed care industry to provide hospitals or a network of hospitals selected to provide managed care plan for patients with a specific set of clinical services, such as transplants. Hospitals designated as centers of excellence may be chosen because they meet criteria developed by the plan, such as quality of care goals and competitively priced services.

Chronic care: supportive care for an ongoing or lengthy illness. The care includes diagnosis and treatment of complications and patient education, with the goals of minimizing symptoms, maintaining the maximum level possible of patient functioning, and preventing a worsening of the patient's ailment.

Chronic illness: any ailment that requires ongoing treatment and management, beyond its acute phase, sometimes for a lifetime.

Claims form: paperwork that patients and health care providers file with managed care plans in order to receive payment for services.

Clinical pathway: a medical "roadmap" that helps health care providers identify the most appropriate course of treatment for a specific patient, based on that patient's clinical situation.

Clinical trial: a medical research study in which physicians assess the effect of a new test or treatment versus an existing test or treatment or none at all. Clinical trials typically have four parts or phases. A majority of clinical trials may include the following stages: A Phase 1 trial is the first test of a new drug in humans. Phase 1 trials are intended to assess the safety of a therapy in humans, usually in a small number of patients. In cancer care, some patients who have not responded to other treatments are enrolled in Phase 1 trials to see how the new drugs work for them. A Phase 2 trial builds on information gathered in Phase 1 and assesses the effectiveness of the therapy in small groups. Treatments that show promise in Phase 2 then move to Phase 3. A Phase 3 trial compares the new treatment with therapies currently in use to see which one is more effective. Finally, a Phase 4 trial is done after the treatment is approved for patients with a particular diagnosis. A Phase 4 trial may assess how well the new therapy performs when it is used in combination with other treatments, such as surgery or other drugs. Generally, Phase 4 is used to test effectiveness on larger groups.

Closed panel: a situation in which the physicians who work for a managed care plan see and treat only patients belonging to the plan.

Coinsurance: the portion of health care costs not paid by the managed care plan, for which the consumer is responsible. Coinsurance usually is expressed as a fixed proportion of the managed care plan's allowable charge. For example, if a plan pays 80 percent of its allowable charge for a covered service, the consumer is responsible for the remaining 20 percent as coinsurance.

Contract: legal agreement between a managed care plan and either an employer or a consumer that describes the monthly premiums due to the plan, the health care services covered by the plan, and how much the plan is obligated to pay for each service. Contracts are usually renegotiated annually. Managed care
companies may also sign contracts with health care providers to care for plan members for negotiated fees.

Contract year: the 12 month period covered by the agreement between the plan and the employer, consumer, or provider.

Contracted provider: a hospital, physician, network of hospitals and physicians, or other health care providers who enter into a legal agreement with a managed care plan to care for the plan's members for negotiated prices.

Coordination of benefits: a process that takes place between two or more managed care plans that cover the same consumer, to ensure that plans do not make duplicative or unnecessary payments for services.

Copayment: a fixed sum of money that a consumer pays each time he or she receives a covered service from a plan contracted provider. For example, in many managed care plans, the copayment for a physician office visit is $5 or $10.

Cost sharing: the responsibility of a consumer in a managed care plan to pay a portion of the costs for his or her care. Cost sharing can come in three forms: copayments, deductibles, and coinsurance.

Cost-based reimbursement: a payment system in which managed care plans pay health care providers based on the actual cost of a test or treatment provided to a plan member.

Coverage: decision making process that identifies what services or products are benefits under the employer's or consumer's contract with the plan. Covered products or services are eligible to be paid for by the plan.

Covered expenses: the costs of health care products or services that are eligible for payment by the managed care plan.

Credentialing: a system used by managed care plans to assess the qualifications of physicians or other health care providers who may be offered contracts with the plan.

Customer service: a resource available to the managed care plan member to answer member's questions, help resolve disputes or complaints, and explain plan operations.

Deductible: a form of cost sharing in a managed care plan, in which a consumer pays a fixed dollar amount of covered expenses each year, before the plan begins paying its share of costs.

Denial of care: a refusal by a managed care plan to cover a specific test or treatment.

Direct contracting: the legal relationship between a managed care plan and an employer, in which the managed care plan agrees to provide a specific set of health care benefits for employees, for specified premiums.

Discounted fee-for-service: a payment system in which a managed care plan pays a health care provider a negotiated fee for each specific health care service, after the service is rendered to a plan member. The payment is usually a proportion of the provider's actual charge for a product or service.

Disease management: an organized, integrated program of health care and patient education aimed at providers or patients with a specific diagnosis, such as cancer or diabetes. The goals of disease management are to improve care,
lower costs, and measure patient outcomes or satisfaction with care.

Drug formulary: an exclusive list of drugs covered by a managed care plan.

Drug utilization review: systematic oversight of prescription medicines used by managed care plans to assess costs, prescription patterns, and the appropriateness of drug therapy.

Emergency care: urgent medical tests and treatment provided to patients with severe or life-threatening symptoms.

Employer group health plan: package of medical benefits offered to all the employees at a company, typically using one or more managed care plans.

ERISA (Employee Retirement Income Security Act): a federal law that regulates the pension, health and welfare benefits offered by employers to their employees. Under ERISA, some employer group health plans are exempt from state laws and regulation that govern insurance.

Evidence of coverage: a detailed description of the medical benefits available to a member of a managed care plan, most often provided to members after they enroll in the plan.

Exclusion: a health care product or service which a managed care plan will not cover or pay for.

Explanation of Benefits (EOB): a statement sent to some managed care plan members from the plan that shows the following information: the actual charges levied by a health care provider for health care services provided to the plan
member, the plan's allowable charge for each service, the plan's payment for each service, and the amount owed by the plan member (coinsurance or deductible).

Fee schedule: a predetermined list of prices a managed care plan will pay for specific health care products or services given to plan members by health care providers.

Fee-for-service payment: reimbursement made by a managed care plan to a health care provider after the provider renders care to a plan member.

First dollar coverage: managed care plan benefits that do not require plan members to meet an annual deductible before plan coverage and payment begin.

Gag rules: portions of contracts between managed care plans and physicians that may limit the communication between physicians and their patients. Gag rules may be intended to restrict what physicians may tell patients about the range of testing or treatment options available to them through the plan or the financial relationship between the physician and the plan.

Gatekeeper: a primary care physician who controls a patient's access to certain tests, treatments, and specialty physicians in a managed care plan.

Generic drug: a medicine that is the chemical equivalent of a brand-name drug. Generic drugs are typically less costly to consumers than equivalent brand-name drugs.

Grievance: a complaint brought to the administration of a managed care plan by a plan member. The complaint may pertain to quality of care issues, a plan coverage decision, or financial issues, such as a dispute between the plan and the member over how much the plan has paid for a particular health care
product or service.

Group model health maintenance organization(HMO): a type of managed care plan in which the plan has contracted with a multispecialty physician group to care for plan members. The physicians who treat plan members are employed by the physician group.

Health Care Financing Administration (HCFA): now called the Centers for Medicare and Medicaid Services (CMS), a federal agency that runs the Medicare and Medicaid programs.

Health care spending account: a benefit option offered by some employers that lets employees set aside a specific sum of money each year to pay for certain medical expenses, such as premiums, copayments, deductibles, and
coinsurance amounts, or services such as eyeglasses or dental care. Money not spent in any given year generally cannot be returned to the employee.

Health education: programs or classes offered by some managed care plans to their members to help plan members enhance their understanding of specific issues, such as nutrition or contraception, or meet personal goals, such as smoking cessation, weight loss, or stress management.

Health insurance purchasing cooperative: a mechanism in which individuals and small businesses join together to purchase medical benefits from managed care plans. By forming a larger group than they would constitute as individual entities, the employers try to get a lower price from managed care plans for a
specific set of benefits.

Health Plan Employer Data Information Set(HEDIS): a set of managed care plan performance measures collected, organized, and reported by the National Committee for Quality Assurance (NCQA, see below).

Hospice care: supportive services provided to patients who have reached the terminal stage of their illness when aggressive, curative therapy is no longer appropriate. Hospice care includes medical services such as pain management, as well as emotional support (for example, counseling) for both patients and their families.

Hospital privileges: permission granted by a hospital to a physician to admit patients to the institution and manage their care while hospitalized.

Indemnity insurance plan: type of health insurance that pays for care after consumers receive it, usually on a fee-for-service basis, with little oversight to assess the cost or appropriateness of care.

Independent Practice Association (IPA): a type of managed care plan which contracts with many physicians or physicians groups in an area to provide care to plan members.

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): a private, non-profit agency that evaluates and accredits managed care plans, hospitals, networks of health care providers, and other health care

Lifetime cap: maximum dollar amount of benefits available to a consumer in a managed care plan.

Major medical: health insurance benefits found most commonly in indemnity insurance plans that provide coverage and payment for services such as hospitalization, surgery, or durable medical equipment.

Malpractice: negligent care provided to a patient by a health care provider or managed care plan that results in harm to the patient.

Managed care: a broad term that describes the health insurance products available to most consumers in the health care marketplace today. Managed care more tightly integrates the payment and delivery of health care products and services to consumers to, ideally, deliver the highest quality services at the lowest possible cost.

Managed indemnity insurance: an indemnity insurance plan that incorporates some managed care features, such as utilization review, to help
control costs.

Mandated benefits: products or services offered in managed care plans that are required by either federal or state law.

Medicaid: a joint federal and state program that provides health insurance to low income persons who meet specific eligibility requirements.

Medicaid HMO: a managed care plan approved by a state government to enroll persons eligible for Medicaid.

Medical director: the chief physician in a managed care plan who is part of the plan's administration, and oversees plan coverage decisions and the performance of the physicians who work for the plan or sign contracts to serve plan members.

Medical licensing board: a state regulatory agency that authorizes physicians to practice in a state and disciplines physicians who are found to have violated the state's laws or regulations that govern the practice of

Medical loss ratio: the amount of money spent on medical care for plan members by a managed care plan. Methods of calculating medical loss ratios vary across plans.

Medical record: the official documentation of the care provided to a patient by a health care provider. The medical record includes notes from physician visits, hospitalization records, test results, and consultations by specialists. Each health care provider who treats a patient usually creates and maintains a medical record on the patient.

Medical underwriting: the process by which a managed care plan evaluates the level of risk posed by an individual consumer or group of consumers, based upon age, sex, health history, or other factors. The plan uses medical
underwriting to determine what premium it will charge the consumer(s).

Medically necessary: health care products or services covered by the managed care plan that are appropriate and indicated to assist in the diagnosis or treatment of disease.

Medicare: a federal health insurance program that provides medical benefits to all persons over age 65 who receive Social Security benefits or are disabled and meet specific eligibility requirements. Medicare has two parts: Part A, which provides coverage and payment for hospital care and Part B, which
covers physician services.

Medicare HMO: a managed care plan that meets federal standards and is eligible to enroll persons who receive Medicare benefits.

Medicare secondary payer: a circumstance in which a Medicare beneficiary has both Medicare and private insurance. Medicare pays for the portion of covered health care services that are not paid by the beneficiary's private

Medigap: Medicare supplemental health insurance that pays for some of the deductibles and coinsurance for which Medicare beneficiaries are responsible. Medigap insurance plans also may cover some additional services not covered by Medicare, such as prescription drugs. Medicare beneficiaries who desire Medigap insurance must purchase it themselves and pay a monthly premium for it.

Mental health care: medical services, such as counseling or therapy, hospitalization, and prescription drugs, used to diagnose and treat emotional and psychological illness, such as depression, bipolar disorder, or substance

Mixed model or network HMO: a managed care plan that contracts with individual physicians, as well as physicians groups to provide care for plan members.

Monthly premium: the amount paid each month to a managed care plan by an employer, employees, or individual consumers to obtain coverage from the plan.

Morbidity rates: the frequency with which an illness occurs in a given population. Morbidity is usually expressed as the number of illnesses per 100,000 population.

Mortality rates: the frequency of death from a given cause in a population. Mortality is usually expressed at the number of deaths per 100,000 population.

National Committee for Quality Assurance (NCQA): a private, nonprofit organization that evaluates and accredits managed care plans. The NCQA also gathers and reports managed care plan performance data through its Health Plan Employer Data Information Set (HEDIS) reports.

Networks of health care providers: groups of hospitals, physicians, and other providers that come together to offer managed care plans and consumers an organized, comprehensive system of care.

Ombudsman: a troubleshooter who can help managed care plan members resolve problems or complaints with the plan. The ombudsman may work for the plan or for an outside agency, such as a state or county government.

Open enrollment: a specific period of time (one or more times annually or monthly) during which consumers can select and enroll in, or disenroll from, a managed care plan.

Open panel: a situation in which physicians care for patients from many different managed care plans, as well as other insurers, such as Medicaid and Medicare.

Out-of-pocket expenses: costs of health care products or services which managed care plan members pay themselves. Out-of-pocket costs include copayments, coinsurance, and deductibles. Consumers also may incur out-ofpocket
costs for some products or services not covered by their managed care plan, such as over-the-counter drugs.

Outcome data: information that describes the result of care provided to managed care plan members. Outcome data helps identify what tests and treatments have the greatest beneficial impact on patients, as well as the complications
and problems that result from them.

Participating provider: a hospital or physician who signs a contract with a managed care plan and agrees to care for plan members for negotiated fees and conditions specified in the contract. Typically, when plan members see participating providers, they have low copayments and no paperwork to file with the plan.

Payer: another term for an insurer that covers and pays for a specific set of health care benefits for plan members.

Per member per month: refers to the incremental sum paid by a managed care plan to a health care provider who cares for plan members under a capitation arrangement. This term also is applied to the premiums paid to
managed care plans by employers or to the way Medicare pays Medicare HMOs that enroll and care for Medicare beneficiaries.

Pharmacy and therapeutics committee: a group of physicians, pharmacists, and other health care professionals within a managed care plan who review new drugs and biotechnology products to decide which ones the plan will cover, under what circumstances, and at what cost to the plan and its members.

Pharmacy Benefit Manager (PBM): a type of managed care plan that specializes in the distribution and management of prescription drugs for plan members.

Physician Hospital Organization (PHO): an entity formed by physicians and hospitals under the authority of state or federal law to negotiate and sign contracts with managed care plans or contract directly with employers to serve the health care needs of their employees.

Plan member: a consumer or his or her dependent who enrolls in a managed care plan through an employer, the Medicare or Medicaid programs, or as an individual enrollee.

Point of Service (POS): the most rapidly expanding form of managed care in the marketplace. POS plans give consumers increased flexibility by offering options: consumers can use health care providers in a plan's network at a reduced cost (the HMO option), or use providers not in the network, at higher costs to themselves (the indemnity option).

Practice guidelines: suggestions or mandates for how physicians can manage patients with a particular symptom or diagnosis to achieve the best possible outcome.

Practice profiling: also known as practice evaluation; the process by which managed care plans measure how well physicians who treat plan members are performing against plandeveloped financial and clinical criteria. The practice profiles may affect the physician's compensation by the plan or the plan's decision about whether to sign the physician to a contract in the next year.

Pre-existing condition: a medical condition, ailment, or disease for which a managed care plan member was treated during a specific period of time before joining the plan, typically one or two years. If a consumer has a condition that was treated during this time, the managed care plan, depending on applicable laws and the terms of the contract, may limit how much care it will cover and pay for related to the preexisting condition.

Preadmission certification: prior approval by a managed care plan to admit a member to hospital for medical treatment, testing, or surgery.

Preauthorization: prior approval by a managed care plan for a plan member to receive a medical treatment, test, or surgical procedure on an outpatient basis.

Preferred Provider Organization (PPO): a large group of hospitals and physicians under contract to a managed care plan. Health care providers in the PPO serve plan members for negotiated fees and copayments. Plan members who use providers not in the PPO face higher out of pocket costs.

Premature hospital discharge: termination of an inpatient hospital stay before it is medically appropriate to send the patient home.

Preventive health care: health care products and services aimed at forestalling the development of illness or injury. An example of preventive
health care is immunizations to prevent childhood illnesses.

Primary Care Physicians (PCPs): a class of physicians that typically includes internists, family physicians, pediatricians, and obstetricians/gynecologists. As PCPs, these physicians may control access that managed care plan members have to other plan services such as diagnostic testing or visits to specialists.

Provider: a qualified, licensed professional (physician, dentist, optometrist, etc.) or institution (hospital, clinic, skilled nursing facility, etc.) that renders health care services to managed care plan members under a contract with a plan.

Quality assurance: an oversight program used by health care providers and managed care plans to evaluate the care provided to plan members and identify and rectify problems in care delivery.

Referral: authorization by a managed care plan or primary care physician for a plan member to use other services in the plan, such as diagnostic tests, care from a specialist, or physical therapy.

Report card: information on how well a managed care plan performs compared to other managed care plans, or national standards, along specific clinical, financial, or consumer satisfaction criteria. Report cards can be
developed by plans themselves, private agencies such as the National Committee for Quality Assurance, employers, or government agencies.

Screening tests: health care services intended to identify diseases at an early stage of development when they are typically easier and less costly to treat. An example of a screening test is mammography to detect breast cancer.

Secondary payer: a second plan a consumer has. Through coordination of benefits (see above), the second plan will pay for covered services that are not covered and paid for by the first plan.

Shared financial risk: a concept in which health care providers, through payment arrangements with managed care plans such as capitation (see above), share risk on the health care services they provide to managed care plan members.

Specialist: a physician who has received extensive training (beyond that of a primary care physician) in a specific, often highly focused area of medicine.

Staff model HMO: a type of managed care plan in which physicians who care for plan members are employees of the plan.

State insurance commissioner: a regulatory official who enforces the state insurance laws and regulations to which managed care plans are subject.

Stop loss insurance: a type of back-up insurance that limits financial risk for physicians or hospitals who accept capitation payments to care for managed care plan members. Once expenses for a patient reach a specific point, the stop-loss insurance program starts paying bills to limit further financial losses for the capitated provider.

Symptom: manifestation of a disease or illness that a patient expresses to a physician or other health care provider, such as pain, nausea, or dizziness.

Technology assessment: process that managed care plans use to evaluate new tests, treatments, drugs, medical devices, biotechnology products, and surgical procedures, to decide what the plan will cover, for which patients, and at what costs to the plan and planmembers.

Therapeutic substitution: replacement of a drug prescribed by a physician with a similar or equivalent product, usually with permission of the prescribing physician.

Third-Party Administrator (TPA): a managed care plan or other health insurer that processes claims, pays bills, and manages contracts with health care providers for self-insured health plans.

Triage: a system by which managed care plans or health care providers prioritize patients to ensure that patients with the greatest need receive care first.

Usual, customary reasonable charges (UCR): a calculation by a managed care plan of what it believes is the appropriate fee to pay for a specific health care product or service, in the geographic area in which the plan operates.

Utilization review: a mechanism of assessing the care received by a patient in a managed care plan to assess whether the care is medically necessary and appropriate to the patient's needs.

Withhold: a portion of the fees paid to health care providers by managed care plans that are held back by the plan until the end of the contract year. Then, if the provider meets specific plan criteria (see practice profiling), the plan may pay the held back money to the provider in the form of a bonus.