| S |
| Self-Funding |
Top |
The
practices of an employer or organization
assuming responsibility for health care losses
of its employees. This usually includes setting
up a fund against which claim payments are drawn
and claims processing is often handled through
an administrative service contract with an
independent organization. |
| Senior
Plan |
Top |
Refers
to a benefit package offer by an HMO or other
insurer to beneficiaries eligible for Medicare
parts A & B. |
| Service
Area |
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The
geographic area served by an insurer or health
care provider. |
| Shared
Risk Pool for Referral Services |
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In
capitation, the pool established for sharing the
risk of costs for Referral Services among all
Participating Physicians. |
| Silent
PPOs |
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You
may call these voluntary PPOs, wrap-around PPOs
or blind PPOs. They act like brokers by selling
your discounts to parties that don't guarantee
you volume. For example, a PPO that you contract
with sells your discounts to an insurer, which
applies the discounts to your bills. |
| Skilled
Nursing Facility |
Top |
A
licensed institution as defined by Medicare,
which is primarily engaged in the provision of
skilled nursing care. |
| Staff
Model HMO |
Top |
A
model in which the HMO hires its own physicians.
Very much like the group model, except the
doctors are employees of the HMO. Generally, all
ambulatory health services are provided under
one roof in the staff model. |
| Stop
Loss |
Top |
The
practice of an HMO or insurance company of
protecting itself or its contracted medical
groups against part or all losses above a
specified dollar amount incurred in the process
of caring for its policyholders. Usually
involves the HMO or insurance company purchasing
insurance from another company to protect
itself. Also refereed to as reinsurance. |
| Sub-Capitation |
Top |
An
arrangement that exists when an organization
being paid under a capitated system contracts
with other providers on a capitated basis,
sharing a portion of the original capitated
premium. Can be done under Carve Out, with the
providers being paid on a PMPM basis. |
| Subrogation |
Top |
The
recovery of the cost of services and benefits
provided to the insured of one MCO that other
parties are liable. |
| Subscriber |
Top |
An
individuals meeting the health plans'
eligibility requirement, who enrolls in the
health plan and accepts the financial
responsibility for any premiums, co-payments, or
deductibles. |
| Supplemental
Benefits |
Top |
Benefits
contracted for by an employer group, which are
outside of, or in addition to, the basic health
plan. |
