ENROLLEES
Enrollee is an individual who is enrolled for coverage under a health plan contract and who is eligible on his/her own behalf (not by virtue of being an eligible dependent) to receive the health services provided under the contract.
MEMBERS or PATIENTS or CLIENTS
Persons eligible for health care coverage under MCO’s health care benefit plans and includes Enrollees. From the Providers perspective, these persons comprise a part of, or all, of their volume of patients.
NETWORK OF PROVIDERS
MCO’s contract with providers for special rates for services to be rendered to their Members. This group of contracted providers are considered a network of providers.
OUT OF PLAN
If a member of a health care plan is “out of plan” that means the member does not receive any coverage from the plan for those specific services. Accordingly, medical services rendered out of plan are not covered and the member is held personally responsible for payment for those services.
POOL (RISK POOL)
A defined account (ex. defined by size, geographic location, claim dollars that exceed “x” level per individual, etc.” to which revenue and expenses are posted. A risk pool attempts to define expected claim liabilities of a given defined account as well as required funding to support the claim liability.
POOLING
The process of combining risk for all groups or a number of groups into one risk pool.
POINT OF SERVICE (POS)
A type of health plan allowing the covered person to choose to receive a service from a participating or a non-participating provider, with different benefit levels associated with the use of participating providers. Essentially, Point- of-service is where the members of that plan can choose to go outside of the normal plan and those members pay more. Point-of-Service can be provided in several ways: an HMO may allow members to obtain limited services from non-participating providers:
- an HMO may provide non-participating benefits through a supplemental major medical policy;
- a PPO may be used to provide both participating and non-participating levels of coverage and access;
- various combinations of the above may be used.
REFERRALS
The recommendation by a physician and/ or health plan for a member to receive care from a different physician or facility. MCO’s typically have various requirements authorizing payment for certain services. These requirements may include certain referral procedures to specialists by PCP’s for non-emergency services. Members may be required to comply with such referral rules to secure payment for medical services by MCO’s.
REFERRAL PROVIDER
A provider that renders a service to a patient who has been sent to him/her by a participating provider in the health plan.
REINSURANCE
Insurance purchased by an HMO, insurance company, self-funded employer, or other entity from another insurance company to protect itself against all or part of the losses that may be incurred in the process of honoring claims. Insurance purchased to protect against extremely high-cost cases. See “Stop-Loss” definition.
RISK-SHARING POOLS
Risk-Sharing Pools consist of money set aside by MCO’s to cover designated medical costs. These Risk-Sharing Pools may be structured in various ways. Subject to the terms of the agreement between the Providers and MCO’s, money in the Risk-Sharing Pools, if any, left after a specified time frame may be distributed in a designated manner among the Providers. See definition of “Withholds or Bonus” under Chapter Two.
SELF PAY
A situation under which a patient is responsible for payment of medical services rendered.
SPECIALIST
A physician with greater training and expertise in a specific area – held to the standard of care of a specialist in that area.
STOP-LOSS
The practice by MCO’s of protecting itself or its contracted medical groups against part or all losses above a specified dollar amount incurred in the process of caring for its policyholders. MCO’s may purchase insurance from another company to protect itself. Also, referred to as Reinsurance.
STOP-LOSS INSURANCE
Insurance coverage taken out by a health plan or self funded employer to provide protection from losses resulting from claims over a specific dollar amount per member per year (calendar year or illness to illness). Types of stoop-loss insurance:
- Specific or individual – reimbursement is given for claims on any covered individual which exceed a predetermined deductible, such as $25,000 or $50,000.
- Aggregate – reimbursement is given for claims which in total exceed a predetermined level, such as 125% of the amount expected in an average year. See also reinsurance.
SUBSCRIBERS
The individual or member who has health plan coverage by virtue of being eligible on his or her own behalf rather than as a dependent. Employees or other qualified persons who have entered into health care benefits plans. The subscriber’s spouse and children are typically considered “Dependants” if covered under the health care benefits plan. Subscribers and Dependants are collectively referred to as “Members” or “Enrollees” of the health care benefits plan. These Members are the providers “patients.”
UNIFORM BILLING SYSTEM
Most MCO’s require providers to submit claims using a uniform billing system. For example, Current Procedures and Terminology -4 (CPT-4), commonly known as CPT -4 is mainly office based and procedures oriented. International Classification of Disease, 9th Edition, United States version commonly known as ICD-9-CM is primarily oriented toward inpatient care.
VARIABLE INCENTIVE COMPENSATION
MCO’s use incentive compensation most often to motivate physicians toward agreed-on objectives. These variable incentive compensation methods are used by MCO’s to reward physicians for practicing cost-effectively and decreasing the variability in patient outcome.
AFFORDABLE CARE ACT:
ACCOUNTABLE CARE ORGANIZATION
Accountable Care Organizations (ACOs) create incentives for health care providers to work together to treat an individual patient across care settings—including doctor’s offices, hospitals, and long-term care facilities.
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