Health / Health Insurance Glossary

Multiple Employer Trust (MET): A trust consisting of multiple small employers in the same industry, formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than would . . . View Full Definition

National Accounts: Large group accounts that have employees in more than one geographic area that are covered through a single national contract for health coverage. Contrast with large local groups.

National Practitioner Data Bank (NPDB): A database maintained by the federal government that contains information on physicians and other medical practitioners against whom medical malpractice claims have been settled or other dis . . . View Full Definition

Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a la . . . View Full Definition

Network Model HMO: An HMO that contracts with more than one group practice of physicians or specialty groups.

Newborns And Mothers Health Protection Act (NMHPA): A federal law which mandates that coverage for hospital stays for childbirth cannot generally be less than 48 hours for normal deliveries or 96 hours for cesarean births.

No Balance Billing Provision: A provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amount . . . View Full Definition

Non-Group Market: A market segment that consists of customers who are covered under an individual contract for health coverage or enrolled in a government program.

Non-Maleficence: An ethical principle which, when applied to managed care, states that managed care organizations and their providers are obligated not to harm their members.

Omnibus Budget Reconciliation Act (OBRA) Of 1990: A federal act which established the Medicare SELECT program, a Medicare supplement that uses a preferred provider organization to supplement Medicare Part B coverage.

Open Access: A provision that specifies that plan members may self-refer to a specialist, either in-network or out-of-network, at full benefit or at a reduced benefit, without first obtaining a referral . . . View Full Definition

Open Formulary: The provision that drugs on the preferred list and those not on the preferred list will both be covered by a PBM or MCO.

Open PHO: A type of physician-hospital organization that is available to all of a hospital's eligible medical staff.

Open-Ended Hmos: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional's services under a traditional indemnity plan.

Open-Panel HMO: An HMO in which any physician who meets the HMO's standards of care may contract with the HMO as a provider. These physicians typically operate out of their own offices and see other patient . . . View Full Definition

Operational Integration: The consolidation into a single operation of operations that were previously carried out separately by different providers.

Operations Director: Individual who typically oversees claims, management information services, enrollment, underwriting, member services, and office management.

Out-Of-Plan (Out-Of-Network): This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual . . . View Full Definition

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