Managed Care Health Plans Definitions

Case Management
A process by which a member with a serious, complicated, or chronic health condition is identified by a managed care organization and a plan of treatment is established in order to achieve optimum health in a cost-effective manner.
Closed Panel
A type of health plan that requires members to seek care from a medical provider who is either employed by or under contract to the health maintenance organization or limited service health organization.
Coinsurance
A provision in insurance policies that requires the participant to pay a percentage of all eligible medical expenses, in excess of the deductible.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Standardized surveys that measure members' experiences with their care in areas such as claims processing, rating of their own health plan, and getting needed care quickly. The CAHPS program is administered by the federal Agency for Healthcare Research and Quality.
Copayment
A provision in insurance policies that requires the participant to pay a flat fee for certain medical services.
Deductible
The portion of eligible medical expenses that the participant must pay before the plan will make any benefit payments.
Defined Network Plan
Any health benefit plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the plan. This type of plan is sometimes referred to as a managed care plan.
Drug Formulary
A list of generic and brand name prescription drugs that are covered by the health plan.
Emergency Care
A medical emergency includes severe pain, an injury, sudden illness, or suddenly worsening illness that would cause a reasonably prudent layperson to expect that delay in treatment may cause serious danger to your health if you do not get immediate medical care.
Grievance
Any written statement of dissatisfaction with a managed care plan or limited service health organization submitted by or on behalf of a plan enrollee.
Health Maintenance Organization (HMO)
A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific plan providers.
Healthcare Effectiveness Data and Information Set (HEDIS)
A standardized set of performance measures that assesses plans' performance on a number of elements, including such things as access, quality of care, and financial stability. HEDIS enables purchasers and consumers to compare the performance of managed care plans. It is sponsored by the National Committee for Quality Assurance.
Independent Review
An appeal process in which a health care professional with no connection to an enrollee's health plan reviews a dispute over whether treatment is medically necessary or experimental.
Individual Practice Association (IPA)
An association of physicians that contracts with a health maintenance organization, limited service health organization, or preferred provider plan to provide health care services.
In-Network
A provider, hospital, pharmacy, or other facility is "in-network" when it has contractually accepted the health insurance company's terms and conditions for payment of services.
Limited Service Health Organizations (LSHO)
A health care plan that makes available to its enrolled participants a limited range of health care services, such as dental or eye care, performed by providers selected by the organization.
Managed Care
A health insurance plan that makes available to its members health care services performed by providers selected by the plan and which seeks to manage the cost, accessibility, and quality of care.
Managed Care Plan
Any health plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the health benefit plan.
Medicare Advantage Plan
A federal program providing Medicare coverage through the private insurance market. These plans have a special arrangement between the federal Centers for Medicare & Medicaid Services (CMS) and certain insurance companies. Medicare Advantage plans that are HMOs or preferred provider plans have a "lock in" requirement which means that, except for emergency or urgent care situations away from home, the enrollee must receive all services, including Medicare services, from plan providers.
Medicare Appeal
A benefit appeal under Medicare or a Medicare Advantage plan subject to the Medicare grievance process and not subject to the state law.
Medicare Select
A Medicare supplement health insurance product which will pay the Medicare deductibles and copayments and some additional benefits only if the covered services are obtained through specified health care professionals.
National Committee for Quality Assurance (NCQA)
A non-profit organization that evaluates and accredits managed care plans. It is also responsible for implementing and maintaining the Healthcare Effectiveness Data and Information Set (HEDIS) data reporting system that provides standardized performance measures for managed care plans.
Open Panel
A type of health plan other than a closed panel plan that provides incentives for the member to use providers selected by the plan.
Point-of-Service
A type of managed care plan that provides financial incentives to encourage members to use network providers but allows members to choose providers outside the plan.
Preauthorization/Precertification
A provision in insurance policies that requires prior approval by a managed care plan or limited service health organization in order for services to be covered by the plan.
Preferred Provider Organization (PPO)
An organization that contracts with insurers and other organizations to provide health care services at a discounted cost by providing incentives to members to use physicians and other health care providers that contract with the PPO.
Preferred Provider Plan (PPP)
A health care plan that makes available to its members either comprehensive health care services or a limited range of health care services performed by providers selected by the plan. It allows members to use providers outside the network but enrollees may be liable for a significant portion of these claims.
Primary Care Provider
A provider selected by a managed care plan or LSHO to provide or arrange health care services for enrollee and who is designated by an enrolled participant.
Referral
A process by which the primary care physician makes a request to a managed care plan on behalf of patient/member to receive medical care from a nonparticipating provider or specialist.
Service Area
The area where a health plan accepts members. For plans that require you to use their doctors and hospital, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
Urgent Care
Medically necessary care for an accident or illness which is needed sooner than a routine doctor's visit.