Health Glossary: M - S

Select the first letter of the word to jump to the appropriate glossary section.

A—F | G—L | M | N | O | P | Q | R | S | T—Z

M

Managed Care. A health care plan such as a health maintenance organization (HMO), which contains costs by monitoring care to make sure it is appropriate and effective. Managed care programs include case management, incentives to use specific providers, limits on referrals to expensive specialists, and review/preauthorization of hospital care and other services for medical necessity. Most managed care plans are based on networks of doctors and hospitals which agree to provide their services at a discount to plan members.

Managed Fee-for-Service. Health care coverage in which providers are paid for each procedure or service as delivered. There may be financial incentives for members to receive care from participating providers.

Managed Health. Philosophy of health care which emphasizes a holistic approach targeted at improving the health status of plan members. Strategies include preventative efforts, reducing the cost of treatment, and facilitating the treatment process for providers and patients.

Medicaid. Form of public assistance sponsored jointly by federal and state governments providing medical assistance for eligible persons whose income falls below a certain level. The program was created by the Social Security Act of 1965.

Medicare. Federal government health insurance program established under Title XVIII of the Social Security Act for people age 65 and older and for individuals of any age entitled to monthly disability benefits under the Social Security or Railroad Retirement Program. Medicare also provides benefits for those with chronic renal disease who require hemodialysis or kidney transplant.

Medical Spending Account, also Reimbursement Account. An account into which employees can contribute pre-tax dollars to reimburse health-related expenditures not covered by insurance. Qualified expenses include copayments and deductibles as well as items like contact lenses, prescription drugs, and long-term care. Money left in the account at the end of the year is forfeited.

Medical Underwriting. Process by which the health status of individuals and groups is used to determine whether to provide coverage, under what conditions, and at what rate to charge.

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N

Newborn Care. All physician services provided to a baby during the mother’s hospitalization.

Non-Network, Non-Participating Facility. A facility not in the chosen network and which does not participate with a given health plan.

Non-Network, Non-Participating Provider. A provider who is not in the chosen provider network and who does not participate with a given health plan.

Notification Requirements. Ensuring that a patient receives the appropriate level of care by reviewing admissions and procedures before or after they are provided. Examples of notification requirements include precertification, admission review, prior approval, and continued stay review.

Nursing Facility. A facility which provides continuous skilled nursing services as ordered and certified by an attending physician. A registered nurse (R.N.) must supervise services and supplies on a 24-hour basis. A nursing facility must also be licensed under the laws of the state in which the facility is located.

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O

Obstetrical/Gynecological (OB/GYN) Care Provider. A selected gynecological and maternity health care manager. He or she will evaluate a health condition and either treat it or coordinate required gynecological or maternity services.

Open Access Models.  An open access health plan allows you to see any provider in the Wellmark Health Plan of Iowa network. If you go outside the network, benefits are not available. Preventive services are covered in full when you see a primary care–type provider from the network. Blue Access ^SM is an open access plan.

Open Enrollment. A certain period in which insurers accept all applicants, regardless of medical history or occupation.

Ophthalmologist. Physician specializing in the diagnosis and treatment of diseases and defects of the eye.

Optician. Specialist who fits, adjusts, and dispenses glasses and other optical devices based on the written prescription of a licensed physician or optometrist.

Optometrist. Specialist in the examination, diagnosis, treatment, and management of diseases and disorders of the visual system, the eye and associated structures, as well as the diagnosis of related systemic conditions.

Oral Surgeon. Provider licensed to perform diagnosis and treatment of oral conditions requiring surgical intervention.

Organ Procurement. Refers to hospital, physician, laboratory, administrative, and other miscellaneous costs related to the harvesting, preparation, preservation, and transportation of an organ for transplant. Organ procurement does not include fees for the purchase of an organ.

Other Providers. Providers other than facilities and practitioners. Examples include hospice agencies, ambulance services, and retail pharmacies.

Out-of-Pocket Maximum, also OPM. The out-of-pocket maximum is the most a member generally pays for covered services during a benefit period. The deductible and coinsurance apply toward meeting the out-of-pocket maximum. Copayments do not apply toward the OPM.

Outpatient Services. Treatment and care received in a practitioner’s office, the home, or the outpatient department of a hospital or ambulatory surgery center.

Owner (or Policyowner).  The individual(s) or entity that controls the policy benefits and is responsible for premium payments and policy maintenance.

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P

Participating Facility. A hospital or other health care facility that participates with a health plan network.

Participating Provider. A provider who participates with a network or a Blue Cross and Blue Shield Plan.

Physician. Generally, a doctor of medicine (M.D.) or a doctor of osteopathy (D.O).

Physician Assistant. A practitioner licensed by the Board of Physician Assistant Examiners to provide care under the supervision of a physician.

Plan Enrollee. The person who signs for a health plan certificate or agreement and is eligible to receive the benefits.

Planned Admission. An admission which can be scheduled in advance because the condition, illness, or injury is not immediately life-threatening.

Play or Pay, also "Employer Mandate". A plan to finance universal coverage in some health care reform proposals. Generally, this is the requirement that employers pay for all or part of the cost of basic health insurance benefits for their employees or pay a tax to a government fund to cover the uninsured.

Podiatrist. A specialist in conditions of the foot.

Portability of Coverage. A situation in which a person who changes jobs is guaranteed coverage with a new employer without a waiting period or without having to meet additional deductible requirements.

POS, also Point of Service. A health insurance plan providing various levels of benefits which differ based on how each provider enrollee chooses to receive care.  With Wellmark's Point of Service models,  you will choose a primary care provider (PCP) from the Wellmark Health Plan of Iowa network. Then, when you need medical care, you have options. You may receive care from your PCP or have your care coordinated through your PCP for the highest level benefits--the least expensive of your options. Or, you may refer yourself without consulting your PCP for a lower level of benefits--a higher co-payment and/or coinsurance. Blue Choice® is a three-level point of service plan.

Postoperative Care. Treatment given following a surgical operation.

Postpartum. The period of time following childbirth.

Practice Parameters. Strategies for patient management developed to assist physicians in clinical decision-making.

Practitioner. Any health care professional recognized by an insurer as licensed and/or accredited to provide covered services. Examples include certified nurse anesthetists, chiropractors, doctors of medicine, doctors of osteopathy, oral surgeons, physical therapists, and podiatrists.

Precertification. A process by which approval must be obtained before a planned admission, use of home health services, private duty nursing, hospice services, or home infusion therapy.

Pre-existing Condition. Any illness or injury, or any medical, surgical, or other condition (including a mental health condition, chemical dependency or pregnancy) which existed before a benefits certificate or agreement became effective.

Pre-existing Condition Limitation. The provision in insurance policies which excludes benefits for health conditions that existed before the coverage contract or agreement was signed. These limitations may be written to exclude specified conditions entirely or for a certain period of time.

Preferred Drug List.  Comparative price listing of all medications available which treat the same medical condition.

Preferred Provider Organization, also PPO.  With a preferred provider organization, you can see any provider you choose. However, you can take advantage of several benefit features, including lower out-of-pocket costs, when you see a provider who participates in the network. Alliance Select ^SM is a preferred provider organization.

Premium Caps. A way of controlling costs by limiting, or "capping", the amount which health insurance premiums can be raised each year.

Preoperative Care. Treatment occurring, performed, or administered just prior to a surgical operation.

Preventive Care. Health care which focuses on wellness, health promotion, and other activities that reduce the likelihood of illness or injury by achieving desired changes in causative factors such as smoking or nutrition.

Primary Beneficiary.  The individual(s) or entity to whom the death benefit of a life insurance policy is paid upon the death of the insured.  See Contingent Beneficiary.

Primary Care. Health care typically rendered by general practitioners, family physicians, internists, obstetricians, pediatricians, and some mid-level practitioners. This type of care emphasizes the patient’s general health needs as opposed to a specialized or fragmented approach to medical care. The care is usually rendered in an outpatient setting - in a doctor’s office or hospital.

Primary Care Models.  With a primary care model health plan, you will choose a primary care provider (PCP) to coordinate your care needs. Women may also choose a network obstetrician/gynecologist when they enroll. If your PCP thinks you need to be referred to a specialist, he or she will coordinate your care within the network. Blue Advantage®  is a primary care model plan.

Primary Care Provider, also PCP. A health care professional who acts as a member’s personal health care manager. The PCP evaluates a patient’s medical condition and either treats the condition or coordinates required health care services.

Prior Approval. A notification requirement for certain elective medical procedures such as cosmetic surgery. Receiving written prior approval will ensure receipt of full benefits.

Prior Deductible Credit. A provision which allows a member or family to apply any deductible credit from a previous health coverage, from the same benefit period, to current coverage.

Private Duty Nursing. Nursing services provided in the home by an approved registered nurse (R.N.) or a licensed practical nurse (L.P.N.) which last for extended periods of time.

Prosthetic Appliance. A device used as artificial substitutes to replace a missing natural part of the body; also a device to improve, aid, or increase the performance of a natural function. Prosthetic appliances do not include eyeglasses, hearing aids, orthopedic shoes, arch supports, orthotic devices, trusses, or examinations for their prescription or fitting.

Provider. A health care practitioner such as a doctor, dentist, or chiropractor, or a health care facility, such as a hospital, clinic, or doctor’s office.

Provider Savings. An amount of money saved due to contracts between a health plan and participating providers.

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Q

Qualified Medical Child Support Order. A document which creates or recognizes the right of persons named in order to enroll in the health benefit plan for which persons or their dependents are eligible.

Qualifying Previous Coverage.  Benefits or coverage that has been in effect for at least one year, provides benefits similar to or exceeding those of the Standard Plan (as described in Code of Iowa Chapter 513C), and is provided under: any group health insurance (excluding self insured plans); or an individual health benefit plan, including coverage issued by a health maintenance organization, a fraternal benefit society, a non-profit medical and surgical plan, or a non-profit hospital service plan; or an organized delivery system. Medicare, Medicare Supplement, and Short Term Major Medical coverages are not qualifying previous coverage.

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R

Reinsurance Pool. Common fund to help insurers mitigate expected high losses from insuring high-risk groups and individuals. A single entity, usually government-run, reimburses all medical claims. Consumers typically pay a uniform tax rather than premiums. Money goes to a single health care trust fund used only for health care expenditures.

Respite Care. Rest and relief help for families caring for terminally ill patients.

Risk Pools. Programs created by state legislatures for people who cannot get insurance in the private market. Funding for the pool is subsidized through assessments from insurers or through government revenues.

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S

Service Limitations. Dollar amounts or time limits applied to certain services.

Service Quality. Enhancing the value of a product through service which meets or exceeds customer expectations.

Single Coverage. Coverage for the plan member only.

Small-Employer Pool. Private or state-sponsored organization of small employers for the purpose of obtaining insurance.

Small-Group Reform, also Small Market Insurance Reform. Regulations for insurers who sell policies to small businesses (in most states, 50 or fewer) with the goal of making insurance available and affordable.

Spouse. Husband or wife as the result of a marriage which is legally recognized in the respective state.

State-Mandated Benefit Laws. State laws which require insurers to cover specified health services or for services from certain health care providers. ERISA exempts self-funded insurers from mandated benefits.

Subcutaneous Implant. Medication which is surgically placed beneath the skin to release a medication in the bloodstream.

Subrogation. Right of the health plan to recover settlement when a member receives benefits as the result of illness or injury and the member also has a lawful claim against another party or parties for compensation, damages, or other payment.

Supporting Service Provider. A health care professional who provides supporting or ancillary services under the direction of a primary care or referral provider.

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