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OCR for page 334
Employment and Health Benefits: A Connection at Risk Glossary and Acronyms A access The timely use of personal health services to achieve the best possible health outcomes. acute care Services within a hospital setting intended to maintain patients for medical and surgical episodic care over a relatively short period of time. administrative expenses For health insurance, expenses incurred in one or more of the following general categories: claims administration; general administration; interest credit; risk and profit charge; commissions; and premium taxes. administrative services only (ASO) agreement A contract for the provision of certain services to a group employer or similar entity by an insurer or its subsidiary. Such services often include actuarial services, benefit plan design, claim processing, data collection and analysis, employee benefit communications, financial advice, and stop-loss coverage. admission review Assessment of the appropriateness of urgent or emergency admissions that must occur within a limited period (e.g., 24 to 48 hours) after hospitalization. adverse selection The disproportionate enrollment of individuals with poorer-than-average health expectations in certain health plans (see biased risk selection). ambulatory care Medical services provided on an outpatient (nonhospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation. appropriate care Care that is clinically justified; sometimes used interchangeably with necessary care and sometimes used only to refer to
OCR for page 335
Employment and Health Benefits: A Connection at Risk whether the use of a particular site of care (for example, hospital) is justified. B benefit Conventionally defined as the amount payable for a loss under a specific insurance coverage (indemnity benefits) or as the guarantee that certain services will be paid for (service benefits). biased risk selection Exists (1) when the individuals or groups that purchase insurance differ in their risk of incurring health care expenses from those who do not or (2) when those who enroll in competing health plans differ in the level of risk they present to different plans. C cafeteria plan A flexible benefit plan that allows employees to choose benefits from a number of different options, such as group health insurance and dependent care assistance. capitation A fixed rate of payment, usually provided on a per member per month basis, to cover a defined set of health services for members of a health plan. carrier An entity providing insurance or administering a medical expense protection plan; under Medicare, the private organization administering claims and certain other tasks for Part B. case management A planned approach to organizing medical and other services for an individual with a serious medical problem. When applied to members of a health benefit plan, exceptions to coverage limits or exclusions may be used to permit the most cost-effective mix of services. catastrophic expense protection (or out-of-pocket limit) A health plan benefit that limits the amount the enrollee must pay out-of-pocket for coinsurance or other required cost sharing for covered services. Once the limit is reached, plans generally pay for any additional covered expenses in full. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) A government health plan for dependents of active and retired members of the uniformed services (e.g., Army, Navy). claim An itemized statement of services provided to a specific patient by a health care provider. It is submitted to a health plan for payment. coalitions Regionally based groups of employers and/or providers, insurers, and labor representatives who may disseminate information on health care issues, collect and analyze data, and provide other services for members. coinsurance The percentage of a covered medical expense that a health plan or a beneficiary must pay (after the deductible is met). collective bargaining A negotiation between organized labor and employer(s) on matters such as wages, hours, working conditions, and health and welfare programs.
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