 |
|
|
Directory
of 1,000 Healthcare Recruiters Calendar of Health Observance Dates Recommended
Reading Lists & Healthcare Bookstore Glossary of Managed Care Terms Health Care Companies & Hospitals Tools for Physician Executives Tools for Traveling Executives
To search this site, click here.
"This time, like all times, is a very
good one, if we but know what
to do with it."
(Ralph Waldo Emerson)
|
You are here > Home > Managed Care Terminology > S Words Glossary of Terms in Managed Health Care
This glossary can also be purchased
in printed book format if you would like to have it nearby and accessible.
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | Search | S Sanction - Reprimand
that gives
binding force to a law or rule, or secures obedience to it, as the penalty for
breaking it, or a reward for carrying it out. The government and its agencies
can sanction hospitals, providers and health plans. Health plans sometimes seek
to sanction hospitals and physicians. Medical staffs sometimes seek sanctions
against its members. SCH - See Sole Community Hospital. SCHIP - See State Children's Health Insurance Program, below. SCR - See Standard Class Rate. Secondary Care - Services provided by medical specialists
who generally do not have first contact with patients (e.g., cardiologist,
urologists, dermatologists). In the U.S., however, there has been a trend toward
self-referral by patients for these services, rather than referral by primary
care providers. This is quite different from the practice in England, for
example, where all patients must first seek care from primary care providers and
are then referred to secondary and/or tertiary providers, as needed. Secondary Coverage - Health plan that pays costs not covered by primary coverage under coordination of benefits rules. Any insurance that supplements Medicare coverage. The three main sources for secondary insurance are employers, privately purchased Medigap plans, and Medicaid. See Secondary Payer. Secondary Payer - An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation and may or may not be Supplemental Insurance. Second Opinion - This is when another doctor gives his or her view about what another doctor has said a patient has and how it should be treated. Section 1115
Medicaid Waiver - The Social
Security Act grants the secretary of HHS broad authority to waive certain laws
relating to Medicaid for the purpose of conducting pilot, experimental or
demonstration projects which are "likely to promote the objectives" of
the program. Section 1115 demonstration waivers allow states to change
provisions of their Medicaid programs, including: eligibility requirements, the
scope of services available, the freedom to choose a provider, a provider's
choice to participate in a plan, the method of reimbursing providers, and the
statewide application of the program. Health plans and capitated providers can
seek waivers through their state intermediaries. Section 1915(b)
Medicaid Waiver - Section
1915(b) waivers allow states to require Medicaid recipients to enroll in HMOs or
other managed care plans in an effort to control costs. The waivers allow states
to: implement a primary care case-management system; require Medicaid recipients
to choose from a number of competing health plans; provide additional benefits
in exchange for savings resulting from recipients' use of cost-effective
providers; and limit the providers from which beneficiaries can receive
non-emergency treatment. The waivers are granted for two years, with two-year
renewals. Often referred to as a "freedom-of-choice waiver" Self-Funding
or Self-Funded Plan - Employer or organization assumes complete
responsibility for health care losses of its covered employees. This usually
includes setting up a fund against which claim payments are drawn and claims
processing is often handled through an administrative services contract with an
independent organization. In this case, the employer does not pay premiums to an
insurance carrier, but, rather pays administrative costs to the insurance
company or health plan, and, in essence, treats them as a third party
administrator (TPA) only. However, the employee may not be able to detect any
difference because the plan description and membership card may carry the name
of the insurance company not the employer. Same as Self-Insured, see below. Self-Insurance or
Self-Insured - An individual
or organization that assumes the financial risk of paying for health care. This term is
usually used to describe the type of insurance that an employer provides. When
an employer is self-insured, this means that the payer or managed care company
manages the employer's funds whether than requiring the employer to pay
premiums. Many employers choose to self-insure because they are then exempted
from certain insurance laws and also think that they will spend less money in
the short run. Employers assume the risks involved and also have full rights to
all insurance claim information. Typically, the self-insured employer is a large
employer. The employees or patients will not be able to discern if their
employer is self-insured easily since all paperwork or benefits cards usually
contain the name of the insurance company. Sentinel Event - Adverse health events that may have been avoided through appropriate care or alternate interventions. Providers are required to alert JCAHO and often state licensing authorities of all sentinel events, including a review of risk factors, preventative measures and case analysis. Service Area - The area where a health plan accepts members. For plans that require enrollees to use certain doctors and hospitals, it is also the area where services are provided. The plan may disenroll a member who moves out of the plan's service area. Service area is also a term used by hospitals to describe the geographic or catchment area from which the hospital may receive referrals or admissions. Also see Disenrollment. Service Category Definition - A general description of the types of services provided under the service and/or the characteristics that define the service category. Shadow Pricing - Within a given employer group, pricing of
premiums by HMO based upon the cost of indemnity insurance coverage, rather than
strict adherence to community rating or experience rating criteria. Shared Risk Pool
for Referral Services - In
capitation, the pool established for the purpose of sharing the risk of costs
for referral services among all participating providers. Commonly, this involves
a group or specialty category of physicians and is based on utilization.
Sometimes, risk pools are established in partnered or limited partner or
foundation capitation systems, whereby both providers share risk in a limited
way and health plans. Shared Savings - A provision of most prepaid health care
plans where at least part of the providers' income is directly linked to the
financial performance of the plan. If costs are lower than projections, a
percentage of these savings are referred to the providers. SHIP - See State Health Insurance Assistance Program. SHMO - See Social Health Maintenance Organization. Significant Break in Coverage - Generally, a significant break in coverage is a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual’s coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage. This definition relates to Creditable Coverage and Pre-Existing Illnesses that are considered when an individual enrolls in a new health plan. See also Creditable Coverage. Single-Stream
Funding - The consolidation
of multiple sources of funding into a single stream. For example, this is a key approach used
in some progressive mental health systems to ensure that "funds follow
consumers." Site Appropriateness Listings - A resource for the review of surgery and certain nonsurgical interventions that indicates the most appropriate settings for common procedures. Site-of-Service Differential - The difference in the monies paid when the same service is performed in different practice setting or by a different provider. One example would be an examination in an ER versus in a family doctor's office. Skilled Care - A type of health care given when a patient needs skilled nursing or rehabilitation staff to manage, observe, and evaluate care. Generally refers to a level of care that is lower, or less intense, than inpatient hospital care. Skilled Nursing Care - A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse). Skilled Nursing
Facility (SNF) - A licensed
institution, as defined by Medicare, which is primarily engaged in the provision
of skilled nursing care. SNFs are usually DRG or PPS exempt and are located
within hospitals, but sometimes are located in rehab facilities or nursing
homes. Small Group - Although each MCO's size limit may vary, generally a group composed of 1 to 99 members for which the group sponsor provides health coverage. Small Group Market - The insurance market for products sold to groups that are smaller than a specified size, typically employer groups. The size of groups included usually depends on state insurance laws and thus varies from state to state, with 50 employees the most common size, and typically ranging from 2 to 99 members. SMI - See Supplemental Medical Insurance. SNF - See Skilled Nursing Facility. Sole Community
Hospital (SCH) - A hospital
which (1) is more than 50 miles from any similar hospital, (2) is 25 to 50 miles
from a similar hospital and isolated from it at least one month a year as by
snow, or is the exclusive provider of services to at least 75 percent of its
service area populations, (3) is 15 to 25 miles from any similar hospital and is
isolated from it at least one month a year, or (4) has been designated as an SCH
under previous rules. The Medicare DRG program makes special optional payment
provisions for SCHs, most of which are rural, including providing that their
rates are set permanently so that 75 percent of their payment is
hospital-specific and only 25 percent is based on regional DRG rates. Solo Practice, Solo Practitioner - A physician who practices alone or with others but does not pool income or expenses. This form of practice is becoming increasingly less common as physicians band together for contracting, overhead costs and risk sharing. Social Health Maintenance Organization (SHMO) - A special type of health plan that provides the full range of Medicare benefits offered by standard Medicare HMOs, plus other services that include the following: prescription drug and chronic care benefits, respite care, and short-term nursing home care; homemaker, personal care services, and medical transportation; eyeglasses, hearing aids, and dental benefits. SLMB - See Specified Low-Income Medicare Beneficiaries. SPD - See Summary Plan Description. Special Election Period - A term used by CMS to describe a set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: when the citizen moves outside the service area, if a Medicare+Choice organization violates its contract with the citizen, if the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). See Election Periods, Enrollment, Penalty, or Special Enrollment Period. Special Enrollment Period - A set time when a senior citizen can sign up for Medicare Part B, without penalty, if the citizen did not take Medicare Part B during the Initial Enrollment Period - because the citizen or the citizen's spouse were working and had group health plan coverage through an employer or union. The citizen can sign up at anytime while he or she is covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment ends or the group health coverage ends, whichever comes first. See also Penalty. Specialist - A doctor who treats only certain parts of the body, certain health problems, or certain age groups. Normally, a specialist has received advanced training in a specialty field. For example, some doctors treat only heart problems. Some health plans require enrollees to obtain a referral from a primary care provider prior to seeing a specialist in order for the specialist care to be reimbursed. Also see Referral or Primary Care Physician. Special Needs Plan - A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions. 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. Also see Carve-Out. Specific Stop Loss Coverage - The form of excess risk coverage that provides protection for the employer against high claim on any one individual. This is protection against abnormal severity of a single claim rather than abnormal frequency of claims in total. Also see Reinsurance, Stop Loss, and Individual Stop-Loss Coverage. Specified Disease Insurance - This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn't fill gaps in Medicare coverage but may do so when combined with other types of health plan coverage. Specified Low-Income Medicare Beneficiaries (SLMB) - A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources. Spend Down - A term used in Medicaid for persons whose
income and assets are above the threshold for the state's designated medically
needy criteria, but are below this threshold when medical expenses are factored
in. The amount of expenditures for health care services, relative to income,
that qualifies an individual for Medicaid in States that cover categorically
eligible, medically indigent individuals. Eligibility is determined on a
case-by-case basis. Spider Graphs/Charts - A technique or tool developed by Ernst & Young, to combine analyses of a market's level of managed care evolution with an internal readiness review. Sponsor - An entity that sponsors a health plan or makes one available to members of a group. This can be an employer, a union, or some other entity. SSI - See Supplemental Security Income. Staff Model HMO -
A closed-panel HMO whose physicians are employees of the HMO. A model in which the HMO hires its own
physicians. All premiums and other revenues accrue to the HMO, which, in turn,
compensates physicians. Very much like the group model, except the doctors are
employees of the HMO. Generally, all ambulatory health services are provided
under one roof in the staff model. Standard Class Rate (SCR) - Base revenue requirement per member multiplied by demographic information to determine monthly premium rates. 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 Standard of Care - A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. Standards - According to the Institute of Medicine, Standards are authoritative statements of: (1) minimum levels of acceptable performance or results, (2) excellent levels of performance or results, or (3) the range of acceptable performance or results. Standing Referral - A referral to a specialist provider that
covers routine visits to that provider. It is a common practice to permit the
gatekeeper to make referrals for only a limited number of visits (often 3 or
fewer). In cases where the medical condition requires regular visits to a
specialist, this type of referral eliminates the need to return to the
gatekeeper each time the initial referral expires. State Children's
Health Insurance Program (SCHIP) -
Under Title XXI of the Balanced Budget Act of 1997, the availability of health
insurance for children with no insurance or for children from low-income
families was expanded by the creation of SCHIP. SCHIPs operate as part of a
state's Medicaid program. State Health Insurance Assistance Program (SHIP) - A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare. State Insurance Department - A state agency that regulates insurance and can provide information about Medigap policies and other private insurance. HMOs and other managed care entities may require permission from this department in order to operate in a given state. State Medical Assistance Office - A state agency that is in charge of the state’s Medicaid program and can give information about programs that helps pay medical bills for people with low incomes. State Pharmacy Assistance Program - A state program that provides people assistance in paying for drug coverage, based on financial need, age or medical condition and not based on current or former employment status. These programs are run and funded by the states. State Survey - A process that varies by state and is responsible for assuring that hospitals or other health providers comply with Medicare, Medicaid, fire safety or other rules and regulations. Statutory Solvency - An MCO's ability to maintain at least the minimum amount of capital and surplus specified by state insurance regulators. Step Protocol – see Step Therapy below. Step Therapy (and Fail First Requirements) - Drug plans may require an enrollee to try one drug before the plan will pay for another drug. Step therapy aims to control costs by requiring that enrollees use more common drugs which are usually less expensive. The process of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapy is called Step Therapy or Fail First Requirement. Progression to a new medication is predicated on the former medication failing to provide symptomatic relief or cure; hence “fail first.” Physicians and drug plans may disagree on the proper Step Therapy and patients are encouraged to become knowledgeable and decisive in agreeing to protocols. Also called “step protocol.” Stop Loss
Insurance - Insurance
purchased by an insurance company or health plan from another insurance company
to protect itself against losses. 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 insurance to
reimburse the insured organization for claims paid in excess of a specified
yearly maximum. Reinsurance purchased to protect against
the single overly large claim or the excessively high aggregated claim during a
set period.
Providers when
purchasing Malpractice, Workers Comp and Liability coverages, may also use Stop
Loss. Also see Reinsurance and Specific Stop
Loss. Structural Integration - The unification of previously separate providers under common ownership or control. Sub-Capitation,
Subcap or Subcapitation - An arrangement whereby a capitated health
plan pays its contracted providers on a capitated basis. Subscriber - Employment group or individual that contracts with an insurer for medical services. Person or group responsible for payment of premiums, or person whose employment is the basis for membership in a health plan. Usually synonymous with enrollee, covered individual or member. Subscriber
Contract - A written
agreement that describes the individual's health care policy. Also called
subscribe certificate or member certificate. Subsidy - A monetary grant paid by the government to a private person or company to assist an enterprise deemed advantageous to the public. Subrogation - Procedure where insurance company recovers
from a third party when the action resulting in medical expense (e.g. auto
accident) was the fault of another person. The recovery of the cost of services
and benefits provided to the insured of one health plan when other parties are
liable. Summary Plan Description (SPD) - In self-funded plans, a written explanation of the eligibility for and benefits available to employees required by ERISA. Supplemental
Insurance - Any private
health insurance plan held by a Medicare beneficiary or commercial beneficiary,
including Medigap policies and post-retirement health benefits. Supplemental
usually pays the deductible or co-pay and sometimes will pay the entire bill
when the primary carrier's benefits are exhausted. Supplemental Medical Insurance (SMI) - Part B of the Medicare program. Part B normally covers the outpatient services, as opposed to Part A that covers inpatient. This voluntary program requires payment of a monthly premium, which covers 25 percent of pro-ram costs. Beneficiaries are responsible for a deductible and coinsurance payments for most covered services. See also Part B. Supplemental
Payer - Any private
health insurance plan held by a Medicare beneficiary or commercial beneficiary,
including Medigap policies and post-retirement health benefits. Supplemental
usually pays the deductible or co-pay and sometimes will pay the entire bill
when the primary carrier's benefits are exhausted. Supplemental
Security Income (SSI) - A
federal cash assistance program for low-income aged, blind and disabled
individuals established by Title XVI of the Social Security Act. States may use
SSI income limits to establish Medicaid eligibility. Supplemental
Services - Optional services
a health plan covers or provides. Supplier - Generally, any company, person, or agency that provides supplies (such as medicines, linens or prostheses) to medical providers or that provides medical items or services, like wheelchair or walkers, directly to patients. Surplus - The amount that remains when an insurer subtracts its liabilities and capital from its assets. Surplus Lines Tax - A tax imposed by state law when coverage
is placed with an insurer not licensed or admitted to transact business in the
state where the risk is located. Unlike premium tax for admitted insurers, the
surplus lines tax is not included in the premium and must be collected from the
policyholder and remitted to the state. A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | Home This glossary can also be purchased in printed book format if you would like to have a copy for your briefcase or desk. Copyright© 1997 - Present Date, Pam Pohly, All Rights Reserved. |
