Term
| STRATEGY FOR HEALTH CARE & MEDICAL CARE BENEFITS-BROAD DECISIONS FOR PLAN SPONSOR |
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Definition
| "3 PART PROGRAM FOR MANAGING RISKS-1-HC DELIVERY SYSTEM, 2 BENEFITS TO BE PROVIDED, 3 CONTRACTUAL-FINANCIAL OR PAYMENT ARRANGEMENT TO BE NEGOTIATED WITH INS PROVIDERS" |
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Term
| DIRECT CONTRACTING-AS IT APPLIES TO HEALTH CARE SERVICES |
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Definition
| ACT OF PURCHASING HEALTH CARE DIRECTLY FROM PROVIDER AS OPPOSED THROUGH AND INTERMEDIARY SUCH AS INS. CO. |
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Term
| BUNDLED VS UNBUNDLED APPROACHES TO PURCHASING HEALTH CARE SERVICES |
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Definition
| BUNDLED-PLAN SPONSOR RECEIVES MULTIPLE SERVICES FROM ONE VENDOR. UNBUNDLED-PURCHASES SERVICES INDIVIDUALLY FOR BEST QUALITY SERVICE BUT COMPLEX ADMIN. |
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Term
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Definition
| BEST THROUGH FLEXIBLE BENEFIT PLANS-EMPLOYEES GET LIMITED CREDITS OR $ AND THEY SELECT BENEFITS. |
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Term
| TWO HEALTH PLAN OPTION PRICING |
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Definition
| IN A FLEXIBLE BENEFIT PLAN OPTIONS MAY BE PRICED AT PREVAILING MARKET RATES. DIRECT SUSBSIDY EMPLOYEE COSTS ARE HIDDEN-EMPLOYEES SEE ONLY THE COSTS THEY ARE REQUIRED TO PAY |
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Term
| IMPACT OF MULTIPLE HEALTH PLAN OFFERINGS AND PRICES ON EMPLOYEE PARTICIPATION AND PLAN COSTS |
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Definition
| IF LESS EXPENSIVE INDEMNITY PLAN OFFERED-EMPLOYEES WITH LOW UTILIZATION MIGRATE TO LESS EXPENSIVE PLANS-SPONSOR CREATES ADVERSE SELECTION AGAINST INDEMNITY PLAN BY OFFERING MANAGED CARE OPTION. COSTS FOR THE ORIGINAL PLAN RISE. |
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Term
| STRATEGIC ISSUE FOR CHOOSING PLAN FINANCING TECHNIQUE |
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Definition
| MUST SELECT ARRANGEMENT THAT CONTROLS COSTS AND ALLOWS IT TO ASSUME A LEVEL OF RISK IT DEEMS APPROPRIATE. |
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Term
| STANDARDS THAT COULD BE USED TO MEASURE HEALTH PLAN PERFORMANCE FOR TRADITIONAL INSURED PLAN OR A MANAGED CARE PLAN |
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Definition
| TRADITIONAL INSURED PLAN-REQ TO PAY A SPECIFIC % OF CLAIMS WITHIN A SPECIFIED NUMBER OF DAYS. MANAGED CARE PLAN-REQ OF CERTAIN AMT OF TIME TO REACHA DR BY PHONE OR TIME BETWEEN CALL AND APPOINTMENT. |
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Term
| FUNCTIONAL APPROACH--PLAN SPONSOR OBJECTIVES FOR EVALUATING HEALTH CARE PLANS |
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Definition
| "PLANNING ORIENTATION, MEMBER SATISFACTION, PROVIDER CHOICE, COST SAVINGS, COST CONTAINMENT FEATURES, FINANCIAL REPORTING-FUNDING" |
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Term
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Definition
| "RFI IS A SHORTER LESS FORMAL THAN AN RFP, AS THE NUMBER OF VENDORS ARE NARROWED WITH AN RFI, AND RFP IS ISSUED." |
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Term
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Definition
| "HELPS INSURE THAT PROVIDERS MEET ACCEPTABLE LEVELS OF EXPERTISE-GRAD FROM ACCEPTABLE MED SCHOOL, VALID STATE LICENSE/DEA REGIS., CLINICAL PRIVILEGES AT LICENSED HOSPITAL, MALPRACTICE COVERAGE/HISTORY, NO MENTAL/PHYSICAL RESTRICTIONS, NO PRIOR DISPLINARY ACTIONS, NO INAPPROPRIATE UTILIZATION PATTERNS," |
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Term
| NCQA-NATIONAL COMMITTEE ON QUALITY ASSURANCE STANDARDS INCLUDE |
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Definition
| "QUALITY MANAGEMENT AND IMPROVEMENT, UTILIZATION MANAGEMENT, MEMBOR RIGHTS AND RESPONSIBILITIES, PREVENTATIVE HEALTH, MEDICAL RECORDS" |
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Term
| INFORMATION SYSTEMS FOR ON SITE VISIT TO MANAGED CARE VENDOR |
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Definition
| "COMPUTER SYSTEMS USED, CLAIMS ADMIN, MEMBER SERVICES AND MEDICAL MANAGEMENT INFO SYSTEMS" |
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Term
| CARRIERS RESPONSE TO AGGRESSIVE NEGOTIATING TECHNIQUES |
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Definition
| "CUTTING FEES TO PROVIDERS, CUTTING UNPROFITABLE LINES AND SEEKING PREMIUM RATE INCREASES WHERE POSSIBLE" |
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