Accreditation Association for Ambulatory Health Care; One of the organizations approved by the Pennsylvania Department of Health for external quality review of HMOs, as well as outpatient surgical centers and clinics.
Certificate of Authority
The equivalent of a "license" for HMOs and PPOs to operate in Pennsylvania. The Pennsylvania Insurance Department and Department of Health share responsibility for ensuring compliance with the requirements for a Certificate of Authority.
DOH
Department of Health; Together with the Pennsylvania Insurance Department, issues the Certificate of Authority that allows HMOs to operate in Pennsylvania.
ERISA
Employee Retirement and Income Security Act; Broad ranging Federal legislation passed in 1973 directed primarily to employee retirement plans. Allows some large employers to operate benefit plans exempt from state government regulations.
Gatekeeper
A primary care physician within an HMO who is responsible for managing all clinical aspects of a patient's care, including all referrals to specialty and hospital care. Also see PCP.
Grievance
A formal complaint.
HCFA
Health Care Financing Administration; Division of the U.S. Department of Health and Human Services which monitors quality and cost effectiveness of Medicare HMOs and others.
Health Plan
Health maintenance organizations, preferred provider organizations, insured plans, self-insured plans, and other plans that cover health care services.
HEDIS
Healthplan Employer Data and Information Set; Developed by NCQA as a report card that profiles the performance of the managed care organizations.
HMO
Health Maintenance Organization; Integrates financing and delivery of health care into a single system. Manages the utilization and assumes financial responsibility to deliver care within a fixed price.
JCAHO
Joint Commission for the Accreditation of Healthcare Organizations; Reviews and accredits hospitals and other healthcare organizations.
KePRO
Keystone Peer Review Organization; A Pennsylvania health care information company that provides quality and utilization review services to the federal, state, and private sector.
Managed Indemnity Plan
A traditional insurance plan with some structures to manage utilization such as pre-surgical authorization or case management.
MCO
Managed Care Organization; A term that includes health maintenance organizations, preferred provider organizations, integrated delivery systems, and others.
Medical Loss Ratio
The ratio of premium income an HMO expends for delivery of health care services to its enrollees.
MSO
Medical Service Organization; An integrated health care delivery network that contracts with payors to provide a comprehensive array of benefits. Also see PHO.
NCQA
National Committee for Quality Assurance; Has two primary functions in regulation of MCOs: Accreditation and producing report cards, i.e., HEDIS.
PCP
Primary Care Physician; A generalist physician (family practice, general internal medicine, and general pediatrics) who provides primary care services to a group of patients. The primary care physician is the patient's first point of entry into the health care system and the continuing focal point for all needed health care services.
PHC4
Pennsylvania Health Care Cost Containment Council; An independent state agency with the legislative mandate to report on the cost and quality of health care services in Pennsylvania.
PHO
Physician Hospital Organization; A type of medical service organization that integrates hospitals and physician practice groups and provides services to a group of members by contracting either with an HMO or directly with employers.
PO
Physician Organization; A type of medical service organization that integrates physician practice groups and provides services to a group of members by contracting either with an HMO or directly with employers.
POS
Point of Service; Combines features of an HMO and a PPO. It allows members to make the decision at the time they seek health care services whether or not to use network providers. A POS retains the primary care physician gatekeeper of an HMO, but, as in a PPO, members must pay higher co-payments and deductibles for out-of-network services.
PPO
Preferred Provider Organization; A network of providers that have agreed to provide services at a reduced rate. PPOs do not require an enrollee to choose a single primary care physician.
>URAC
Utilization Review Accreditation Committee; Reviews and accredits those utilization review firms which wish to demonstrate conformance to recognized standards.
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