Health / Health Insurance Glossary

Service Quality: An MCO's success in meeting the nonclinical customer service needs and expectations of plan members.

Sherman Antitrust Act: A federal act which established as national policy the concept of a competitive marketing system by prohibiting companies from attempting to (1) monopolize any part of trade or commerce or ( . . . View Full Definition

Short-Term Disability: An injury or illness that keeps a person from working for a short time. The definition of short-term disability (and the time period over which coverage extends) differs among insurance comp . . . View Full Definition

Short-Term Health Insurance: Temporary coverage for an individual for a short period of time, usually from 30 days to six months.

Small Employer Group: Generally means groups with 1 99 employees. The definition may vary between states.

Small Group: Although each MCO's size limit may vary, generally a group composed of 2 to 99 members for which health coverage is provided by the group sponsor.

Specialty Health Maintenance Organization (Specialty HMO): An organization that uses an HMO model to provide healthcare services in a subset or single specialty of medical care.

Specialty Services: Services that are provided by independent, specialty organizations rather than by the MCO providing the basic health plan.

Staff Model HMO: A closed-panel HMO whose physicians are employees of the HMO.

Standard Community Rating: A type of community rating in which an MCO considers only community-wide data and establishes the same financial performance goals for all risk classes. Also known as pure community rating.

Standard Of Care: A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.

State Mandated Benefits: When a state passes laws requiring that health insurance plans include specific benefits.

Statutory Solvency: An insurer's ability to maintain at least the minimum amount of capital and surplus specified by state insurance regulators.

Stop-Loss: The dollar amount of claims filed for eligible expenses at which which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when . . . View Full Definition

Stop-Loss Insurance: A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insur . . . View Full Definition

Structural Integration: The unification of previously separate providers under common ownership or control.

Structure Measures: Healthcare quality indicators related to the nature and quality of the resources that a managed care organization has available for patient care.

Student Health Insurance: In recent years, many colleges have begun requiring proof of health insurance for students. Coverage options include insurance through family policies and coverage through school-sponsored s . . . View Full Definition

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