| E |
| Early
and Periodic Screening, Diagnosis, and Treatment
(EPSDT) |
Top |
EPSDT
program covers screening and diagnostic services
to determine physical or mental defects in
recipients under age 21, as well as health care
and other measures to correct or ameliorate any
defects and chronic conditions discovered. |
| Economic
Credentialing |
Top |
This
means taking a physician's economic behavior
into account (i.e. tests ordered, hospital bed
days, and outcomes) in deciding upon medical
staff appointment or re-appointment. |
| Effective
Date |
Top |
The
date on which the Health Plan Agreement goes
into effect. |
| Eligibility
Guarantee |
Top |
An
assurance of reimbursement to the medical group
for services/goods provided to a member who
subsequently is found ineligible for benefits. |
| Emergency |
Top |
Sudden
unexpected onset of illness or injury which
requires the immediate care and attention of a
qualified physician, and which, if not treated
immediately, would jeopardize or impair the
health of the Member, as determined by the
payer's Medical Staff. Significant in that
Emergency may be the only acceptable reason for
admission without pre-certification. |
| Employee
Retirement Income Security Act of 1974 (ERISA) |
Top |
Also
called the Pension Reform Act, this act
regulates the majority of private pension and
welfare group benefit plans in the U.S. It sets
forth requirements governing, among many areas,
participation, crediting of service, vesting,
communication and disclosure, funding, and
fiduciary conduct. Key legislative battleground
now, because ERISA exempts most large
self-funded plans from State regulation and,
hence, from any reform activities undertaken at
state level--which is now the arena for much
healthcare reform. |
| Encounter |
Top |
A
member visit to the medical group with the
intent of seeing a health care provider. There
may be a variety of services performed at an
encounter: a brief office visit, EKG, lab test,
and an immunization. |
| Enrolled
Group |
Top |
Persons
with the same employer or with membership in an
organization in common, who are enrolled
collectively in a health plan. Often, there are
stipulations regarding the minimum size of the
group and the minimum percentage of the group
that must enroll before the coverage is
available. Same as Contract group. |
| Enrollee
(Also beneficiary; individual; member) |
Top |
Any
person eligible as either a subscriber or a
dependent for services in accordance with a
contract. |
| Enrollment |
Top |
The
number of members in an HMO. The number of
members assigned to a physician or medical group
providing care under contract with an HMO. Also,
the process by which a health plan signs up
individuals or groups as subscribers. |
| Enrollment
Area |
Top |
The
geographic area within a designated radius
(varies by HMO) of the PMG (Primary Medical
Group) selected by the subscriber. |
| Enrollment
Protection |
Top |
The
practice of an HMO to protect its contracted
medical groups against part or all losses
incurred for physician services above a
specified dollar amount while caring for the
HMO's enrollees. Also referred to as stop-loss
or reinsurance. |
| Evidence
or Explanation of Coverage (EOC) or Explanation
of Benefits (EOB) |
Top |
A
booklet provided by the carrier to the insured
summarizing benefits under an insurance plan. |
| Exclusions |
Top |
Clauses
in an insurance contract that deny coverage for
select individuals, groups, locations,
properties or risks. |
| Exclusive
Provider Organization (EPO) |
Top |
A
health plan in which patients must go to a
participating provider or receive no benefit.
This is a cross between an HMO and a PPO (See
preferred provider organization). Like a PPO
doctors typically are paid on a fee-for-service
basis and aren't at risk. However, patients have
less freedom to go out of network than with a
PPO. |
| Exclusivity
Clause |
Top |
A
part of a contract which prohibits physicians
from contracting with more than one managed care
organization (HMO, PPO, IPA, etc.) |
| Expansion |
Top |
Some
HMOs compute Plan expansion as part of the
capitation rate in order to provide the
necessary capital for growth. |
| Experience
Rated Premium |
Top |
A
premium with is based upon the anticipated
claims experience of, or utilization of service
by, a contract group according to its age, sex,
constitution, and any other attributes expected
to affect its health service utilization, and
which is subject to periodic adjustment in line
with actual claims or utilization experience. |
| Experience
Rating |
Top |
(a)
The rating system by which the Plan determines
the capitation rate by the experience of the
individual group enrolled. Each group will have
a different capitation rate based on
utilization. This system tends to penalize small
groups with high utilization.
(b) A method of determining the premium based on
a group's claims experience, age, sex or health
status. Experience rating is not allowed for
federally qualified HMOs. |
| Explanation
of Benefits (EOB) |
Top |
A
summary of benefits provided subscribers by the
carrier. |
| Extended
Care Facility (ECF) |
Top |
A
nursing or convalescent home offering skilled
nursing care and rehabilitation services. |
