This Glossary of Our Terms includes most of the useful terms relating to managed health care that can be found at the California Department of Managed Health Care (DMHC) website as follows: http://www.hmohelp.ca.gov/dmhc_consumer/fr/fr_terms.aspx.
Some of these terms have specific legal definitions, as well as the common definitions used here. Any terms specific to Arta are shown in italics for your convenience.
accusation
The official charging document which alleges violations of the Knox-Keene Act by a health plan.
acute care
Medical care that you need right away but only for a short time.
appeal
A request to your health plan to solve a problem or change a decision because you are not satisfied (an appeal can also be called a complaint or a grievance).
arbitration
A way to solve disputes between health plans and patients without filing a formal lawsuit and going to court. In an arbitration process, the health plan and the patient select an independent person to settle the dispute, instead of a judge or jury.
Arta
The term used to refer to two affiliated Independent Practice Associations (IPAs), Arta Health Network and Arta Western Medical Group, located in Orange County, California. Arta currently serves 75,000 health plan members and is one of the largest, most geographically-dispersed health care provider networks in the county.
Arta Health Network (AHN)
The Arta IPA whose provider network is dedicated to rendering health care services to Orange County enrollees of commercial and senior health plans (Aetna, Anthem Blue Cross, Arta Medicare Health Plan, Blue Shield of California, CIGNA, Health Net, and MD Care) who have selected AHN and an AHN-contracted primary care physician (PCP) as his or her preferred health care provider.
Arta Western Medical Group (AWMG)
The Arta IPA whose provider network is dedicated to rendering health care services to Orange County enrollees of CalOptima who are eligible for participation in Medi-Cal or Healthy Families programs and who have selected AWMG and an AWMG-contracted primary care physician (PCP) as his or her preferred health care provider.
authorization or pre-authorization
The process of getting approval from your health plan and/or your IPA before you obtain health care services (also called approval or prior approval).
balance billing
When a provider in your health plan's network sends you a bill for the amount that is more than that provider's contracted rate with the plan. Balance billing can also happen when a non-contracted provider who works in a hospital, such as an anesthesiologist, radiologist, pathologist, or emergency room physician, sends you a bill for the part of his or her charges that your health plan does not pay.
benefit
A service covered by your health insurance.
benefits package
All the services covered by your health insurance.
CalOptima
The County-Organized Health System in Orange County, California, that is licensed as a health plan by the California Department of Managed Health Care (DMHC) and that is contracted with the California Department of Health Care Services, Medi-Cal Managed Care Division and Managed Risk Medical Insurance Board (MRMIB) to provide or arrange for health care services to eligible beneficiaries under the state's Medi-Cal and Healthy Families programs.
capitated basis
California Health & Safety Code Regulation 1300.76(f) - the fixed per-member-per-month (PMPM) payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided. For purposes of this definition, capitated basis includes the cost associated with operating staff-model facilities.
cash-to-claims ratio
California Health & Safety Code Regulation 1300.75.4(f) - an organization's cash and readily-available marketable securities and receivables, excluding all risk pool, risk-sharing, incentive-payment program and pay-for-performance receivables, that are reasonably anticipated to be collected within 60 days, divided by the organization's unpaid claims including claims that have been received but not yet processed, and an estimate of claims that have been incurred but not yet received (IBNR).
cease and desist order
An order of the DMHC to a person or organization to refrain from any act that violates the Knox-Keene Act.
chronic care
Care for a long-term health problem, such as asthma, diabetes, or congestive heart failure.
chronic disease
A health problem that goes away and comes back, or that lasts your whole life, such as diabetes, asthma, or high blood pressure.
claim
A request to your health plan to pay a bill for a health care service. Usually your provider files the claim, however you can also file a claim yourself if you paid for the service at the time it was rendered.
COBRA/Cal-COBRA
Laws that help you and your family keep your group health insurance if your job ends or your work hours are reduced.
complaint
A request to your health plan to solve a problem or change a decision because you are not satisfied. A complaint is also called a grievance or an appeal.
consent form
A form you sign that says you agree to receive a certain health care service or treatment, and that you are aware of the side effects that you may experience as a result.
conservator
An independent consultant assigned to oversee a health plan that has been seized by the DMHC.
continuity of care
Your right to continue seeing your doctor in certain cases, even if your doctor leaves your health plan or IPA.
co-payment/co-pay
A fee you pay each time you see a doctor, obtain other health care services, or fill a prescription.
creditable coverage
The amount of time you were covered by a previous health plan. You can reduce your new plan's pre-existing condition exclusion by one month for every month you had creditable coverage, as long as the gap in coverage between your previous plan and your new plan is 62 days or less.
deductible
The amount you must pay for covered health services each year before your health plan starts to pay.
dependent
A person who is covered by another person's health insurance, such as a child or a spouse.
durable medical equipment (DME)
Medical equipment, like hospital beds and wheelchairs, which can be used over and over again.
end-stage renal disease (ESRD)
Severe kidney failure that needs lifetime dialysis or a kidney transplant.
enrollee
A person who is enrolled in a health plan, also called a member, a subscriber, or a beneficiary.
evidence of coverage (EOC)
A written guide to the services your health plan covers and does not cover, and what you pay for services. An EOC is also called a contract or letter of entitlement.
exclusions
Medical services that your health plan will not pay for, which are usually listed in your Evidence of Coverage.
expedited review
A fast review of a complaint, grievance, or appeal if your medical problem is serious or urgent. A health plan must conclude an expedited review within three days of reciept.
formulary/drug formulary
A list of the prescription drugs that your health plan covers.
gap in coverage
More than 62 days in a row without health insurance, which can affect your eligibility for obtaining new coverage.
generic drug
A drug that is no longer owned and patented by one company. A generic drug has the same active ingredients as the brand name drug, but it costs less. For example, Valium is the brand name version and Diazepam is the generic version of the same tranquilizer.
grievance
A request to your health plan to solve a problem or change a decision. A grievance is also called an appeal or a complaint.
group health insurance
Health insurance that you get through a group, such as your employer or union.
health maintenance organization (HMO)
A kind of health plan.
Health Insurance Portability and Accountability Act (HIPAA)
A law that protects your rights to obtain health insurance and to the privacy of your medical records.
Healthcare Effectiveness Data and Information Set (HEDIS)
A program of the National Committee for Quality Assurance (NCQA), the Healthcare Effectiveness Data and Information Set is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service.
home health care
Health care that you receive in your home when you need continued treatment after surgery or hospitalization for an illness or injury.
hospice care
Care to relieve the physical and emotional pain of people who are dying of terminal illnesses, and to support the person's family caregivers. Hospice care is usually provided at home, but it can also be provided in a health facility.
incurred but not reported (IBNR)
An estimation used to develop a cash reserve to cover claims obligations for medical services that have been authorized or provided, but not yet received by the risk-bearing organization (RBO).
independent medical review (IMR)
A review of your health plan's denial of your request for a certain service or treatment. The review is provided by the Department of Managed Health Care and conducted by independent medical experts, and your heath plan must pay for the service if an IMR decides you need it.
independent practice association (IPA)
An entity (usually a professional medical corporation) of contracted individual physicians and other health care providers (primary care physicians, specialists, allied health professionals, and other ancillary health care providers) that form a provider network for the purposes of contracting with health plans and other payors of health care services to render covered services, on a risk basis, to enrollees of such plans in a managed-care network model.
individual health insurance
Insurance you buy on your own, not as part of a group.
in-patient care
Care for people who are in a hospital or other health facility for at least 24 hours.
letter of agreement (LOA)
A document outlining an agreement between the health plan and the DMHC regarding findings and/or penalties of an enforcement action. Also, a document outlining an agreement between Arta and a provider of health care services for a specified period of time.
management services organization (MSO)
A management services organization that is contracted with health care provider entities to provide administrative and medical management services to such entities, including services to support compliance with regulatory and quality requirements.
Medi-Cal/Medicaid
Health care for qualifying low-income families and special-needs individuals. Medicaid is paid for by the federal government, but each state runs its own program. In California, Medicaid is called "Medi-Cal".
medical group
A group of doctors who have a business together and contract with a health plan to provide services to the plan's members.
Medicare
A federal health insurance program for people aged 65 and older and some permanently disabled persons.
Medigap Insurance Policy (Medicare Supplemental Insurance)
Private insurance that helps cover the services and costs that Medicare does not cover.
member
A person who is enrolled in a health plan, also called an enrollee, a subscriber, or a beneficiary.
network
All the doctors, labs, hospitals, and other providers that have contracts with a health plan to provide health care services to the plan's members.
open enrollment period
The time period when you must decide either to stay in your current health plan or to join another health plan that your employer offers. Many employers offer open enrollment options during one month every year.
outpatient care
Health care that does not require an overnight stay in a hospital.
pre-existing condition
A health condition for which you received medical advice, diagnosis, or care in a specific period before you joined a health plan.
preferred provider organization (PPO)
A kind of health plan that allows members to choose any doctor and see out-of-network providers (providers that are not directly contracted with your health plan).
premium
A monthly fee your health plan charges for your health insurance. You may pay part of the premium and your employer or union may pay the rest.
preventive care
Health care to help prevent illness, such as flu shots and mammograms.
primary care
General health care services, such as a check-up or treatment for a cold or an ear infection. You usually get your primary care from a family practice doctor or an internal medicine doctor who is your primary care physician (PCP). Children usually get their primary care from a pediatrician.
primary care physician (PCP)
Your main doctor, who provides most of your care. In an HMO, your PCP coordinates all of your health care services and treatments and sends you to a specialist when you need one.
prior approval/prior authorization
The process of getting approval from your health plan or IPA before you get services.
provider
A professional person, IPA, medical group, clinic, lab, hospital, or other health facility that may be licensed or certified by the state or other regulatory agency to provide health care services.
referral
An authorized referral to an approved, contracted or non-contracted provider to which a member is sent to obtain medically-necessary health care services not rendered by his or her primary care physician.
risk-bearing organization (RBO)
California Health & Safety Code 1375.4(g) - a professional medical corporation, other form of corporation controlled by physicians and surgeons, a medical partnership, a medical foundation exempt from licensure pursuant to subdivision (l) of Section 1206, or another lawfully organized group of physicians that delivers, furnishes, or otherwise arranges for or provides health care services, but does not include an individual or a health care service plan, and that does all of the following:
1) Contracts directly with a health care service plan or arranges for health care services for the health care service plan's enrollees.
2) Receives compensation for those services on any capitated or fixed periodic payment basis.
3) Is responsible for the processing and payment of claims made by providers for services rendered by those providers on behalf of a health care service plan that are covered under the capitation or fixed periodic payment made by the plan to the risk-bearing organization. Nothing in this subparagraph in any way limits, alters, or abrogates any responsibility of a health care service plan under existing law.
second opinion
Advice you get from a second doctor after the first doctor has made a diagnosis or recommended a certain treatment and you want to make sure it is the right diagnosis or decision for you.
service area
All the zip codes that a health plan serves.
specialist
A doctor who has extra training in a certain medical field, such as an orthopedist (for bones) or a cardiologist (for your heart).
sponsoring organization arrangement
California Health & Safety Code 1375.4(b)(1)(B)] - a formal arrangement whereby an RBO may reduce its liabilities for purposes of calculating tangible net equity and working capital by the amount of liabilities the payment of which is guaranteed by a sponsoring organization. A sponsoring organization is one that has a tangible net equity of a level to be established by the director [of the Department of Managed Health Care] that is in excess of all amounts that it has guaranteed to any person or entity. A qualified guarantee is one that meets all of the following: (i) It is approved by a board resolution of the sponsoring organization. (ii) The sponsoring organization agrees to submit audited annual financial statements to the plan within 120 days of the end of the sponsoring organization's fiscal year. (iii) The guarantee is unconditional except for a maximum monetary limit. (iv) The guarantee is not limited in duration with respect to liabilities arising during the term of the guarantee. (v) The guarantee provides for six months' advance notice to the plan prior to its cancellation.
standing referral
A referral to a doctor or other provider for ongoing treatment for a long-term, disabling or life-threatening illness.
step therapy
A process that some health plans have, in which you must try a lower-cost drug for your condition and if that drug does not work, then you can try a more costly drug.
stipulation
An agreement between the health plan and the DMHC that may contain promises, findings, and/or corrective actions.
subscriber
A person who is enrolled in a health plan, also called an enrollee, a member, or a beneficiary.
tangible net equity
California Health & Safety Code 1300.76(e) - net equity reduced by the value assigned to intangible assets including, but not limited to: goodwill; going concern value; organizational expense; starting-up costs; obligations of officers, directors, owners, or affiliates which are not fully secured, except short-term obligations of affiliates for goods or services arising in the normal course of business which are payable on the same terms as equivalent transactions with non-affiliates and which are not past due; long-term prepayments of deferred charges, and non-returnable deposits. An obligation is fully secured for the purposes of this subsection if it is secured by tangible collateral, other than by securities of the plan or an affiliate, with an equity of at least 110 percent of the amount owing.
underwriting
A process that a health insurance company uses to look at an applicant's health history in order to decide whether to accept the applicant and how much to charge.
urgent care
Care for a health problem that is not an emergency but needs attention quickly, before you can get in to see your doctor or if your doctor's office is closed.
waiting period
The time you must wait before your health plan covers care for a pre-existing condition. A waiting period begins on the date your benefits start.
working capital
California Health & Safety Codes1375.4(b)(iii) and 1300.75.4.2(a)(4) - current assets over current liabilities calculated in a manner consistent with generally-accepted accounting principles (GAAP).
yearly out-of-pocket maximum
The most you have to pay for covered health services in a year. Once you have paid this amount, your health plan pays all of your covered health care costs.