Member: A person eligible to receive, or receiving, benefits from an HMO or insurance policy. Includes both those who have enrolled or “subscribed,” and their eligible dependents.
Medicare: The federally financed hospital insurance system (part A) and supplementary medical insurance (Part B) for the aged created by the 1965 amendment to the Social Security Act.
Medically Necessary: A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with the standards of good medical practice and the medical community.
Medical Loss Ratio: Insurers must spend a percentage (80 percent for individual and small groups and 85 percent for large groups) of your premium on medical costs.
Medicaid: Program administered by the state’s Department of Medical Assistance Services (DMAS) under The Centers for Medicare and Medicaid Services (CMS). Payments are made for approved healthcare services provided by hospitals, health agencies, and private practitioners for welfare recipients or persons whose income does not exceed maximum limits. Funds are derived on a state-federal shared basis.
Mandated benefit: A specific coverage that an insurer or plan sponsor is required to offer by law. Mandated benefits in insurance contracts can vary from state to state according to each state’s insurance laws.
Managed Care: A healthcare system that reduces the cost of providing health benefits and improves the quality of care.
Insurance Company: is at risk for paying the group’s medical claims, regardless of the amount. Insurance companies set the premium and determine the benefit plan coverage.
In-Network Provider: (Participating Provider): Any physician, hospital, pharmacy, laboratory, or other diagnostic center under contract with the health plan to provide services to members at a specified cost.
Individual Mandate: Law that states most individuals will be required to have health insurance or pay a penalty.
Hospitalization: Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.