Case Management
The process for identifying members with specific health care needs in order to help in the development and implementation of a plan that efficiently uses health care resources to achieve favorable member outcomes.
Case Manager
An individual, usually a registered nurse, who is responsible for developing and implementing a plan that takes into account the benefit structure, accepted industry and internal standards, and cost effectiveness in order to achieve favorable member outcomes.
Coinsurance
The percentage of the cost of plan benefits for which a member is responsible after any applicable deductible is met. When coinsur-ance applies as a result of the in-network level of benefit, except as otherwise required by law, the coinsurance amount shall be calculated based on the lesser of provider’s charges for health services or ConnectiCare’s negotiated amount with providers for such services. When coinsurance applies as a result of the out-of-network level of benefit, except as otherwise required by law, the coinsurance amount will be calculated based on the Maximum Allowable Amount.
Coordinated Care Plan
A plan that includes a CMS-approved network of providers that are under contract or arrangement with the M+C organization to deliver the benefit package approved by CMS. Coordinated care plans include plans offered by health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), preferred provider organizations (PPOs), as well as other types of network plans (except network MSA plans).
Copayment
A flat fee paid by a member for certain plan benefits.
Deductible
The total amount which must be paid by a member during the calendar year for certain plan benefits before ConnectiCare will begin paying for those plan benefits.
Emergency Care
Covered services that are: rendered by a provider qualified to furnish emergency services; and needed to evaluate or stabilize an emergency medical condition.
Fully-insured
A health care program in which employers or individuals contract with health maintenance organizations (HMOs) for prepaid benefit plans, funded by the HMOs.
HEDIS®
Health plan Employer Data and Information Set — Developed by NCQA with considerable input from the employers. HEDIS is designed to provide some standardization in performance reporting for membership, utilization, financial, and clinical data so that employers and others can compare performance among plans.
Medically Necessary/Medical Necessity
Term used to describe health services that are required therapeutic treatments for an illness or injury. The health care practitioner determines the medical care, but coverage of the care under ConnectiCare’s plans is subject to medical necessity as determined by ConnectiCare. We use input from local physicians, including specialists, to approve and, in some cases develop our medical necessity protocols. To be medically necessary, treatment must be:
• For illness or injury: This means treatment must be for a diagnosis that is commonly recognized as a disease or injury;
• Therapeutic: This means there must be a reasonable expectation that the
treatment will directly result in the restoration of health or function;
• Required: This means there must be no reasonable alternative treatment which is less intensive or invasive;
• Not experimental or investigational; and
• Not primarily for the convenience of the member, the member’s family or a provider rendering services.
Medicare Beneficiary (or Eligible)
Any person who is age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) are eligible to receive Medicare coverage.
Medicare Advantage Plan
A Medicare program that gives members more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.
National Committee for Quality Assurance
The National Committee for Quality Assurance (NCQA) is an independent not-for-profit organization which performs quality reviews and accredits managed care organizations. NCQA also accredits credentialing verification organizations and develops HEDIS® standards.
Non-participating Physician or Provider
A physician or health care provider that is not a participating physician or a participating provider.
Out-of-Plan Services
Health care services rendered by a non-participating provider, when members are enrolled in any of our HMO plans, where participating providers must be used.
Participating Pharmacy
A pharmacy that has entered into an agreement with ConnectiCare, an IPA or an affiliate or subcontractor of ConnectiCare to provide covered prescription drugs and supplies to members.
Participating Physician
A health care professional duly licensed to practice as a physician, who has entered into an agreement with ConnectiCare, an IPA, or a subcontractor of ConnectiCare to provide certain health services to members.
Participating Provider
A health care practitioner, including a participating physician, participating pharmacy, participating hospital, or other facility that is duly licensed to provide health care services that has entered into an agreement with ConnectiCare, an IPA, or an affiliate or a subcontractor of ConnectiCare to provide certain health services to members. Participating providers do not include hospital-based clinics, even if the hospital is a participating hospital.
Plan
The benefits program operated by ConnectiCare for arranging for health services for members upon which the employer and ConnectiCare have agreed.
Plan Benefits
Health services as specified in the Membership Agreement or other Plan document.
Pharmacy Drug Program (PDP)
A program that offers prescription drug coverage for Medicare beneficiaries. Such programs must offer drug coverage equal to or greater than the Medicare standard plan. The network of pharmacies within the PDP must meet federal standards.
Pre-authorization/Pre-authorized
The authorization, based on medical necessity, needed in advance of the member’s receipt of certain specified health services that is obtained from ConnectiCare, or in the case of mental health and alcohol and substance abuse services, from ConnectiCare’s behavioral health program.
Pre-authorization also includes the written authorization, from ConnectiCare, or in the case of mental health and alcohol and sub- stance abuse services, from ConnectiCare’s behavioral health program, needed in advance of the member’s receipt of health services from a non-participating provider (out-of-plan services).
Pre-certification/Pre-certified
The registration and approval process, based on medical necessity, needed in advance of a member’s partial hospitalization or inpatient admission to a hospital, hospice, residential treatment facility, rehabilitation facility or skilled nursing facility that is obtained from ConnectiCare, or in the case of mental health and alcohol and substance abuse services, from ConnectiCare’s behavioral health program.
Primary Care Physician (PCP)
A participating physician, selected by or assigned to the member, who maintains a general practice or who is normally engaged in one of the following specialties: family practice, internal medicine or pediatrics and who is eligible for listing as a PCP in the Provider Directory, as updated from time to time.
Specialist Physician
A participating physician other than the member’s PCP.
Urgently Needed Care
Urgently needed care refers to a non-emergency situation where the member is inside the United States, the member is temporarily absent from the Plan’s authorized service area, the member needs medical attention right away for an unforeseen illness, injury, or condition, and it isn’t reasonable given the situation for the member to obtain medical care through the Plan’s participating provider network. Note: Under unusual and extraordinary circumstances, care may be considered urgently needed when the member is in the service area, but the provider network of the Plan is temporarily unavailable or inaccessible.
