Glossary of Terms:
Washington Commercial includes both insured and self-funded coverage plans.
Health Maintenance Organizations are plans which provide health care benefits to groups and individuals for a set premium. HMOs provide both the health insurance and the delivery systems from which members receive care. Members agree to use participating providers of the HMO in exchange for lower out-of-pocket expenses. Most HMOs require that care be coordinated by a primary care physician. Physicians are often paid capitation ( a certain amount per member per month) to provide care to members in their panel. HMOs focus on coordinated care, preventive services, and early interventions for disease. Federally qualified HMOs must meet certain federal standards relating to quality of care, financial soundness, benefit packages, member services, and other areas.
STAFF MODEL HMO
Staff Model HMOs employ their providers.
GROUP MODEL HMO
Group Model HMOs contract with provider groups to provide healthcare services to their members.
Independent Practice Associations are organized groups of physicians who contract with health plans to provide services from private offices.
Health Care Service Contractors are licensed by the state of Washington to provide prepaid health care services through networks of participating providers. They are similar to insurance companies, which provide reimbursement for health care expenses, and to HMOs, in their focus on coordinated care, preventive services and disease management programs, but they are regulated by a different set of laws. Participating providers bill the HCSC for services covered by the patient's plan.
Governement Related Terms or Products
Center for Medicare and Medicaid Services, formerly HCFA (Health Care Financing Administration), is a federal agency that purchases and regulates health care for Medicare enrollees and provides federal oversight of state Medicaid programs.
Public Employee Benefits Board, administered by the Health Care Authority, purchases health care coverage for all state and higher education employees and their families.
Basic Health Plan, administered by the Health Care Authority, is a state program designed to provide affordable health coverage to state residents who do not otherwise have health insurance and do not qualify for other government programs. Subsidies are available for many state residents.
Administered by the Medical Assistance Administration, this is the state managed care Medicaid program. All Healthy Options members are enrolled with a managed care plan contracting with the state to provide service to this population. This program was started in the early 1990s to assist Medicaid enrollees with better access to health care providers, many of whom were refusing to see these patients due to low reimbursement by the state.
Medicare Supplement insurance is purchased by an individual to pay for part of the cost of services that are not covered by Medicare.
In Medicare+Choice, the Managed Care Organization has a contract with CMS and is paid a predetermined amount on a county-specific basis for every Medicare enrollee by month. The Managed Care Organization is at risk for Part A and Part B services. Individuals who choose a Medicare+Choice plan must receive all their care in accordance with Medicare+Choice plan requirements.
The Managed Care Organization has a contract with CMS and is paid up to 100% of the projected fee-for-service costs for Part B services. Individuals who join a Medicare Cost plan receive comprehensive coverage if they use the plan’s network; if they go outside the network, they must pay Medicare’s deductibles and coinsurance.
Washington Public Sector includes these programs: Medicare, Healthy Options, Basic
Health Plan, Children’s Health Insurance Program, Public Employee Benefits Board,
Federal Employees Program.
Other Various Terms
Provider networks are the physicians, clinics, hospitals, pharmacies, and other providers which health plans (HMO or HCSC) either employ or contract with to provide health care to their members.
National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization which assesses and reports on the quality of managed care plans. NCQA began the voluntary accreditation of managed care organizations in 1991 in response to the need for standardized, objective information about quality.
UTILIZATION REVIEW ACCREDITATION COMMISSION (URAC)
A Washington-based, nonprofit corporation formed in 1990 and dedicated to improving the quality of utilization review in the health care industry by providing a method of evaluation and accreditation of utilization review programs.
Joint Commision on Accreditation of Healthcare Organizations (JCAHO)
A private, nonprofit organization that evaluates and accredits health care organizations that provide acute hospital care, mental health care, ambulatory care, home care, and long-term care services.