Health Insurance Glossary
Health / Health Insurance Glossary
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 a . . . View Full Definition
Acquisition: The purchase of one organization by another organization.
Actuaries: The insurance professionals who perform the mathematical analysis necessary for setting insurance premium rates.
Actuary: A mathematician working for a health insurance company responsible for determining what premiums the company needs to charge based in large part on claims paid verses amounts of premium gene . . . View Full Definition
Adjusted Community Rating (ACR): 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 . . . View Full Definition
Administrative Services Only (ASO) Contract: The contract between an employer and a third party administrator.
Admitting Privileges: The right granted to a doctor to admit patients to a particular hospital.
Advocacy: Any activity done to help a person or group to get something the person or group needs or wants.
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.
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.
Ambulatory Care Facility (ACF): 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 medic . . . View Full Definition
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 Ac . . . View Full Definition
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.
Association: A group. Often, associations can offer individual health insurance plans specially designed for their members.
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 . . . View Full Definition
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 organizati . . . View Full Definition
Benefit: Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
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 bene . . . View Full Definition
Word of the Day:
Malty: An aromatic sensation created by a moderately volatile set of aldehydes and ketones that produces sensations reminiscent of toasted grains.