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.

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