GLOSSARY

Appeal: A request by a member to an HMO to review a noncertification decision–that is, a decision to deny or limit payment of recommended health care procedures, services, or treatments.

Care Coordinator: A person who acts as a coordinator to ensure that patients receive all needed health care services. Within governmental programs, care coordinators also help patients remove barriers to access, and help link patients to other needed services in the community (such as financial assistance, housing, social services, etc.). Sometimes plans or insurance companies use the term care coordinator for a case manager who is also concerned with controlling health care costs.

Clinical Guidelines: The criteria used that outlines the process and standard of care to be given for a specific health condition, disease or illness. Clinical guidelines are usually developed by practicing health care providers, and are an attempt to identify the best way to prevent, detect or treat a particular medical condition. Managed care organizations and other health care institutions use clinical guidelines as a way to ensure that practitioners are providing appropriate care, and to standardize care across providers. Also referred to as clinical practice guidelines, clinical protocols, treatment protocols, or medical protocols.

Clinical Trials: Clinical trials are research studies to determine whether new drugs or treatments are safe and effective. These trials are used to confirm effectiveness, monitor side effects, and compare the drug or treatment to commonly used treatments. Other studies are conducted after the drug or treatment has been marketed. These studies determine the effect of the drugs or treatments in various populations, and monitor any side effects from long-term use. For more information on clinical trials, check the National Institute of Health: http://www.niaid.nih.gov/clintrials/clinictrial.html.

Copayment (Copay): A fixed payment that must be paid out-of-pocket by a patient upon receiving health care services. In some HMOs, for instance, you pay a $10 copayment for a physician visit, or a $5 copayment for a prescription.

Deductible: The amount an insured person must pay out-of-pocket each year before the insurance plan begins to cover health care costs. A policy with an individual deductible of $250 and a family deductible of $750 means that each individual person in the family must pay $250 of medical expenses before the policy begins paying benefits for that individual. Once the out-of-pocket expenses of the family reaches $750, then the insurance company will pay benefits for all of the family members.

Department of Insurance (DOI): The NC agency charged with regulating and overseeing insurance companies and HMOs.

Durable Medical Equipment (DME): Equipment to assist individuals with injury or disease-related problems that can be used repeatedly. Examples of DME include wheelchairs, walkers, and home hospital beds.

Evidence of Coverage (EOC): The document given to HMO members that describes the covered benefits and exclusions, utilization review requirements, cost sharing, and other coverage provisions. The Evidence of Coverage is similar to a policy contract that other insurers issue.

Experimental: A new treatment developed from research that is different from the commonly provided standard of care for a given disease, illness or condition. Experimental or investigational drugs, treatments or procedures are typically not approved for use by the FDA, and may be the subject of clinical trials to test toxicity, efficacy or effectiveness.

Fee-For-Service (FFS): Payments to providers based on the specific services rendered. fee-for-service systems are typically distinguished from capitation payments, which involve a fixed periodic payment per individual regardless of what services are provided. Under a fee-for-service system, the provider is paid each time he or she provides a different service.

Formulary: List of drugs and other pharmaceuticals that the health plan will cover. A formulary may limit the type and number of medications available for a physician to select from when treating any given disease, illness or condition.

Gatekeeper: In managed care systems, a primary care provider (PCP) who is responsible for authorizing treatment by specialists or non-emergency hospitalizations. If you are in a managed care system that uses gatekeepers you must see your gatekeeper before visiting a specialist (for example, a cardiologist).

Grievance: A written complaint submitted by a member which challenges any of the following: the health plan’s decisions, policies or actions related to availability, delivery or quality of health care services; claims payment or handling; reimbursement for services; the contractual relationship between the member and the insurer; or the outcome of an appeal of a noncertification decision. NCGS 58-50-61(a)(6).

Health Maintenance Organization (HMO): A type of health care organization that manages and finances its members’ care. HMOs emphasize preventive care in order to keep their members healthy. HMOs have exclusive provider networks and often use primary care providers as "gatekeepers." Gatekeepers are responsible for arranging the patient’s referral to a specialist or admission to a hospital. While most HMOs use gatekeepers, some HMOs have "open access" plans. These plans allow the patient to choose any primary care provider or specialist in the network without a referral. HMOs also may use reimbursement systems such as fixed payments for each member (called "capitation") or performance incentives to encourage providers to be more cost conscious. HMOs may contract directly with physicians in the community, or may contract with networks of physicians. This arrangement is called a network or IPA model HMO. HMOs may have their own doctors on salary or in an exclusive contractual arrangement. This is called a (group- or staff-model HMO).

Llifetime Limits: The maximum amount of money that the insurer or HMO will pay for care over the member’s lifetime. The insurer can have a lifetime limit for all health care services, or may have separate lifetime limits for specific services. Some insurers also have annual limits, which is the maximum amount of money the insurer or HMO will pay for the member during a particular year.

Managed Care Plan: A health benefit plan that creates a financial incentive to use providers that are in the health plan’s network. Some managed care plans limit coverage to care obtained from network providers. Others pay more if the member obtains care from within the network, but will pay something for covered services obtained from non-network providers. Two of the primary components of a managed care system are systems that oversee the amount and type of health care services being used ("utilization review") and provider reimbursement methods that discourage unnecessary care.

National Committee for Quality Assurance (NCQA): A private, independent organization that reviews and assesses the quality of services provided by health plans through an accreditation process. In addition, NCQA created a uniform data collection system to compare the quality of services provided by HMOs.

Network: A group of providers (physicians, hospitals, pharmacies, and other health care providers) that contract with a managed care organization to provide health care services to its members.

Out-of-Pocket Limit: Maximum amount established by a health plan that an individual member or his or her family will have to pay toward their medical care in a given year in deductibles, coinsurance and co-payments. Once this limit is met, the plan will pay 100 percent of the costs of future covered health services until the new policy year begins. However, health plans may exclude certain costs from the out-of-pocket maximum. For example, you may not be able to count the costs of non-covered services, or any costs incurred by failing to follow the health plan’s prior approval process.

Primary Care Providers (PCP): Generally, most plans allow family physicians, pediatricians or general internists to serve as primary care providers. Often, obstetricians or gynecologists (OB-GYNs), nurse practitioners (NPs), certified nurse midwives (CNMs) or physician assistants (PAs) can be PCPs. Primary care is distinguished from specialty care, which is often concerned with a particular health condition or body organ. Examples of specialists include oncologists, who deals with cancer, or cardiologists, who specialize in hearts.

Point-of-Service Plan (POS): A type of HMO plan that gives patients the opportunity to see providers outside of the network. Patients who use the HMO network of providers pay less than patients who see providers outside the network. The HMO may still require the use of a gatekeeper to authorize in-network services, but no referral is needed for out-of-network services.

Preferred Provider Organization ( PPO): PPOs manage medical costs by creating a network of providers who are willing to accept lower reimbursement rates. The providers are often required to meet other requirements, including the insurance company’s utilization review procedures. Patients may choose any health care provider, but they will have to pay additional money if they use a provider who is not part of the PPOnetwork. PPOs are usually associated with traditional insurance companies, not HMOs.

Pre-Existing Condition: Mental or physical conditions for which an individual sought medical advice, care or treatment within six months prior to the enrollment in the health plan

Prior Authorization: The health plan’s approval that a requested hospital admission, treatment or procedure is a covered service and is medically necessary and appropriate. Also known as pre-authorization, prior approval, pre-authorization.

Quality Assurance: Refers to a health plan’s internal processes to verify that the care provided to its members meets the health plan’s or government’s quality standards.

Standing Referral: A referral from a primary care provider (PCP) to a specialist for a specified period of time (often to cover a course of illness). Health plans must have a process to allow members with chronic, degenerative, disabling or life-threatening illnesses or conditions to obtain extended or "standing" referrals to in-network specialists. The standing referrals can not exceed 12 months, and must be part of a treatment plan coordinated with the primary care physician, specialist and health plan.

Utilization Review (UR): A system designed to monitor the use of, or evaluate the medical appropriateness, efficacy or efficiency of health care services, procedures, providers or facilities. Utilization review may include ambulatory review, case management, certification, concurrent review, discharge planning, prospective review, retrospective review or second opinions. NCGS 58-50-61(a)(17).

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