Health / Health Insurance Glossary

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

Blended Rating: For groups with limited recorded claim experience, a method of forecasting a group's cost of benefits based partly on an MCO's manual rates and partly on the group's experience.

Brand: A name, number, term, sign, symbol, design, or combination of these elements that an organization uses to identify one or more products.

Brand-Name Drug: Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many . . . View Full Definition

Broker: A salesperson who has obtained a state license to sell and service contracts of multiple health plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the healt . . . View Full Definition

Business Integration: The unification of one or more separate business (nonclinical) functions into a single function.

Capitation: A method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of serv . . . View Full Definition

Captive Agents: Agents that represent only one health plan or insurer.

Carrier: The insurance company or HMO offering a health plan.

Carve-Out: Specialty health service that an MCO obtains for members by contracting with a company that specializes in that service. See also carve-out companies.

Carve-Out Companies: Organizations that have specialized provider networks and are paid on a capitation or other basis for a specific service, such as mental health, chiropractic, and dental. See also carve-out.

Case Management: A process of identifying plan members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goa . . . View Full Definition

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