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Glossary of Managed Care Terms

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S
Self-Funding
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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
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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
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A licensed institution as defined by Medicare, which is primarily engaged in the provision of skilled nursing care.
Staff Model HMO
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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
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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
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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
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The recovery of the cost of services and benefits provided to the insured of one MCO that other parties are liable.
Subscriber
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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
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Benefits contracted for by an employer group, which are outside of, or in addition to, the basic health plan.


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