Medical Insurance Flashcards
Access
A person’s ability to obtain affordable medical care on a timely basis.
accreditation
An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
ACF
Ambulatory Care Facility - Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedures even when provided outside of hospitals. (A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.)
acquisition
The purchase of one organization by another organization.
ACR
Adjusted Community Rating - laws will not allow the use of actual or expected health status or claims experience to set group premiums. Other factors such as age, geographic area and tobacco use may be used to vary premiums, within certain limits. (A rating method under which a health plan or MCO divides its members into classes or groups based on demographic factors such as geography, family composition, and age, and then charges all members of a class or group the same premium. The plan cannot consider the experience of a class, group, or tier in developing premium rates. Also known as modified community rating or community rating by class.)
actuaries
The insurance professionals who perform the mathematical analysis necessary for setting insurance premium rates.
administrative services only (ASO) contract
The contract between an employer and a third party administrator.
Agent
A person who is authorized by an MCO or an insurer to act on its behalf to negotiate, sell, and service managed care contracts.
MCO
managed care organization (MCO) A healthcare provider whose goal it is to provide appropriate, cost-effective medical treatment. Two types of these providers are the health maintenance organization (HMO) and the preferred provider organization (PPO).
aggregate stop-loss coverage
A type of stop-loss insurance that provides benefits when a group’s total claims during a specified period exceed a stated amount.
ancillary services
Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient’s condition.
annual maximum benefit amount
The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all healthcare services provided to a subscriber in a year.
antitrust laws
Legislation designed to protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies. See also Sherman Antitrust Act, Clayton Act, and Federal Trade Commission Act.
appropriate care
A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.
appropriateness review
An analysis of healthcare services with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided.
associate medical director
Manager whose duties are often defined as a subset of the overall duties of the medical director.
at-risk
Term used to describe a provider organization that bears the insurance risk associated with the healthcare it provides.
autonomy
An ethical principle which, when applied to managed care, states that managed care organizations and their providers have a duty to respect the right of their members to make decisions about the course of their lives.
behavioral healthcare
The provision of mental health and substance abuse services.
beneficence
An ethical principle which, when applied to managed care, states that each member should be treated in a manner that respects his or her own goals and values and that managed care organizations and their providers have a duty to promote the good of the members as a group.
benefit design
The process an MCO uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan.
blended rating
For groups with limited recorded claim experience, a method of forecasting a group’s cost of benefits based partly on an MCO’s manual rates and partly on the group’s experience.
brand
A name, number, term, sign, symbol, design, or combination of these elements that an organization uses to identify one or more products.
broker
A salesperson who has obtained a state license to sell and service contracts of multiple health plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the health plan or insurer.
business integration
The unification of one or more separate business (nonclinical) functions into a single function.
capitation
A method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided.
