| M |
| Major
Medical Expense Insurance |
Top |
Policies
designed to help offset the heavy medical
expenses resulting from catastrophic or
prolonged illness or injury. They generally
provide benefits payments for 75 to 80 percent
of most types of medical expenses above a
deductible paid by the insured. |
| Malpractice
Insurance |
Top |
Insurance
against the risk of suffering financial damage
due to professional misconduct or lack of
ordinary skill. Malpractice requires that the
patients prove some injury and that the injury
was the result of negligence on the part of the
professional. |
| Managed
Care |
Top |
A
relatively new term coined originally to refer
to the prepaid health care sector (e.g., HMOs)
where care is provided under a fixed budget and
costs are therein capable of being
"managed". Increasingly, many analysts
to include PPOs and even forms of indemnity
insurance coverage that incorporate preadmission
certification and other utilization controls are
using the term. |
| Managed
Competition |
Top |
A
health insurance system that bands together
employers, labor groups and others to create
insurance purchasing groups; employers and other
collective purchasers would make a specified
contribution toward insurance purchase for the
individuals in their group; the employer's set
contribution acts as an incentive for insurers
and providers to compete |
| Management
Services Organization (MSO) |
Top |
A
management entity owned by a hospital, physician
organization, or third party. The MSO contracts
with payers and hospitals/physicians to provide
services such as negotiating fee schedules,
handling administrative functions, and billing
and collections. |
| Market
Area |
Top |
The
targeted geographic area or areas of greatest
market potential. The market area does not have
to be the same as the post acute facility's
catchment area. |
| Master
Patient/Member Index |
Top |
An
index or file with a unique identifier for each
patient or member that serves as a key to a
patient's or member's health record. |
| Medicaid |
| Top |
A
federal program, run and partially funded by
individual states to provide medical benefits to
certain low income people. The state, under
broad federal guidelines, determines what
benefits are covered, who is eligible and how
much providers will be paid. All states but
Arizona have Medicaid programs. |
| Medical
Allied Manpower |
Top |
This
category includes some sixty occupations or
specialties that can be divided into two large
categories based on time required for
occupational training. The first category
includes those occupations that require at least
a baccalaureate degree, for example, clinical
laboratory scientists and technologists,
dietitians and nutritionists, health educators,
medical record librarians, and occupational
speech and rehabilitation therapists. The second
group includes those occupations that require
less than a baccalaureate degree, such as aides
for each of the above categories as well as
physician assistants and radiological
technicians. |
| Medical
Care Evaluation Studies (MCE) |
Top |
The
name given to a generic form of health care
review in which problems in the quality of the
delivery and organization of health care
services are addressed and monitored. A program
based on Mk--Es is recommended as a way of
meeting the federal government's requirements
for an internal quality assurance program for
federally qualified HMOs. |
| Medical
Group Practice |
Top |
The
American Group Practice Association, the
American Medical Association, and the Medical
Group Management Association define medical
group practice as: "provision of health
care services by a group of at least three
licensed physicians engaged in a formally
organized and legally recognized entity sharing
equipment, facilities, common records and
personnel involved in both patient care and
business management." |
| Medical
Loss Ratio (MLR) |
Top |
The
amount of revenues from health insurance
premiums that is spent to pay for the medical
services covered by the plan. Usually referred
to by a ratio, such as 0.96--this means that 96%
of premiums were spent on purchasing medical
services. The goal is to keep this ratio below
1.00--preferably in the 0.80 range, since the
MCO's or insurance company's profit comes from
premiums. Currently, successful HMOs do have
MLRs in the 0.70-0.80 range. |
| Medical
Staff Organization |
Top |
An
organized group of physicians, usually from one
hospital, into an entity able to contract with
others for the provision of services, or
Management (or Medical) Services Organization An
entity formed by, for example, a hospital, a
group of physicians or an independent entity, to
provide business-related services such as
marketing and data collection to a grouping of
providers like an IPA, PHO or CWW. This second
definition is becoming the almost exclusive
usage. |
| Medically
Necessary |
Top |
Services
or supplies which meet the following tests:
They are appropriate and necessary for the
symptoms, diagnosis, or treatment of the medical
condition;
They are provided for the diagnosis or direct
care and treatment of the medical condition;
They meet the standards of good medical practice
within the medical community in the service
area.
They are not primarily for the convenience of
the plan member or a plan provider; and
They are the most appropriate level or supply of
service that can safely be provided. |
| Medically
Unnecessary Days - MUD |
Top |
A
term used to describe that part of a stay in a
facility, as determined by a case manager, as
excessive to diagnose and treat a medical
condition in accordance with the standards of
good medical practice and the medical community.
Excessive may be because stay was too long or
appropriate is available in a less costly or
more efficient setting. |
| Medicare |
Top |
A
nationwide, federally financed health insurance
program for people age 65 and older. It also
covers certain people under 65 who are disabled
or have chronic kidney disease. Medicare Part A
is the hospital insurance program; Part B covers
physicians' services. Created by the 1965
amendment to the Social Security Act. |
| Medicare
Select |
Top |
A
type of Medicare supplement insurance which has
lower premiums in return for a limited choice of
beneficiaries: they will use only providers who
have been selected by the insurer as
"preferred providers". Also covers
emergency care outside the preferred provider
network. |
| Medicare
Supplement Insurance or "Medigap" |
Top |
It
provides additional individual benefits under
Medicare. There are 10 standardized Medigap
plans with specific packages of benefits. |
| Member |
Top |
A
person eligible to receive, or receiving,
benefits from an HMO or insurance policy.
Includes both those who have enrolled or
"subscribed" and their eligible
dependents. |
| Messenger
Model |
Top |
A
method of setting fees for loose, non-risk
bearing MCOs such as IPAs or PHOs. A designated
agent must act as a "messenger",
shuttling individual physician information to
the payer and vice versa. This method meets the
criteria of antitrust laws that bar physicians
from sharing any practice data or fee
information. |
| Midlevel
Practitioner |
Top |
Nurse
practitioners, certified nurse-midwives and
physicians' assistants who have been trained to
provide medical services that otherwise might be
performed by a physician. Midlevel
practitioners’ practice under the supervision
of a doctor of medicine or osteopathy that takes
responsibility for the care they provide.
Physician extender is another term for these
personnel. |
| Miscellaneous
Expenses |
Top |
Hospital
charges, other than room and board, such as
those for x-rays, drugs, laboratory fees, and
other ancillary services. |
| Multiple
Employer Trust (MET) |
Top |
A
legal trust established by a plan sponsor that
brings together a number of small, unrelated
employers for the purpose of providing group
medical coverage on an insured or self-funded
basis. Not quite a Health Plan Purchasing
Cooperative, but along the same lines. More
market-oriented and usually smaller in scale. |
| Multi-specialty
Group |
Top |
A
group of doctors who represent various medical
specialties and who work together in a group
practice. |
