whether the use of a particular site of care (for example, hospital) is justified.



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.


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.


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.


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).


An itemized statement of services provided to a specific patient by a health care provider. It is submitted to a health plan for payment.


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.


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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