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ASSIGNMENT 7
CEBS ASSIGNMENT 7
30
Other
Not Applicable
11/08/2004

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Cards

Term
STRATEGY FOR HEALTH CARE & MEDICAL CARE BENEFITS-BROAD DECISIONS FOR PLAN SPONSOR
Definition
"3 PART PROGRAM FOR MANAGING RISKS-1-HC DELIVERY SYSTEM, 2 BENEFITS TO BE PROVIDED, 3 CONTRACTUAL-FINANCIAL OR PAYMENT ARRANGEMENT TO BE NEGOTIATED WITH INS PROVIDERS"
Term
DIRECT CONTRACTING-AS IT APPLIES TO HEALTH CARE SERVICES
Definition
ACT OF PURCHASING HEALTH CARE DIRECTLY FROM PROVIDER AS OPPOSED THROUGH AND INTERMEDIARY SUCH AS INS. CO.
Term
BUNDLED VS UNBUNDLED APPROACHES TO PURCHASING HEALTH CARE SERVICES
Definition
BUNDLED-PLAN SPONSOR RECEIVES MULTIPLE SERVICES FROM ONE VENDOR. UNBUNDLED-PURCHASES SERVICES INDIVIDUALLY FOR BEST QUALITY SERVICE BUT COMPLEX ADMIN.
Term
MULTIPLE PLAN OFFERINGS
Definition
BEST THROUGH FLEXIBLE BENEFIT PLANS-EMPLOYEES GET LIMITED CREDITS OR $ AND THEY SELECT BENEFITS.
Term
TWO HEALTH PLAN OPTION PRICING
Definition
IN A FLEXIBLE BENEFIT PLAN OPTIONS MAY BE PRICED AT PREVAILING MARKET RATES. DIRECT SUSBSIDY EMPLOYEE COSTS ARE HIDDEN-EMPLOYEES SEE ONLY THE COSTS THEY ARE REQUIRED TO PAY
Term
IMPACT OF MULTIPLE HEALTH PLAN OFFERINGS AND PRICES ON EMPLOYEE PARTICIPATION AND PLAN COSTS
Definition
IF LESS EXPENSIVE INDEMNITY PLAN OFFERED-EMPLOYEES WITH LOW UTILIZATION MIGRATE TO LESS EXPENSIVE PLANS-SPONSOR CREATES ADVERSE SELECTION AGAINST INDEMNITY PLAN BY OFFERING MANAGED CARE OPTION. COSTS FOR THE ORIGINAL PLAN RISE.
Term
STRATEGIC ISSUE FOR CHOOSING PLAN FINANCING TECHNIQUE
Definition
MUST SELECT ARRANGEMENT THAT CONTROLS COSTS AND ALLOWS IT TO ASSUME A LEVEL OF RISK IT DEEMS APPROPRIATE.
Term
STANDARDS THAT COULD BE USED TO MEASURE HEALTH PLAN PERFORMANCE FOR TRADITIONAL INSURED PLAN OR A MANAGED CARE PLAN
Definition
TRADITIONAL INSURED PLAN-REQ TO PAY A SPECIFIC % OF CLAIMS WITHIN A SPECIFIED NUMBER OF DAYS. MANAGED CARE PLAN-REQ OF CERTAIN AMT OF TIME TO REACHA DR BY PHONE OR TIME BETWEEN CALL AND APPOINTMENT.
Term
FUNCTIONAL APPROACH--PLAN SPONSOR OBJECTIVES FOR EVALUATING HEALTH CARE PLANS
Definition
"PLANNING ORIENTATION, MEMBER SATISFACTION, PROVIDER CHOICE, COST SAVINGS, COST CONTAINMENT FEATURES, FINANCIAL REPORTING-FUNDING"
Term
RFP VS RFI
Definition
"RFI IS A SHORTER LESS FORMAL THAN AN RFP, AS THE NUMBER OF VENDORS ARE NARROWED WITH AN RFI, AND RFP IS ISSUED."
Term
CREDENTIALING PROVIDERS
Definition
"HELPS INSURE THAT PROVIDERS MEET ACCEPTABLE LEVELS OF EXPERTISE-GRAD FROM ACCEPTABLE MED SCHOOL, VALID STATE LICENSE/DEA REGIS., CLINICAL PRIVILEGES AT LICENSED HOSPITAL, MALPRACTICE COVERAGE/HISTORY, NO MENTAL/PHYSICAL RESTRICTIONS, NO PRIOR DISPLINARY ACTIONS, NO INAPPROPRIATE UTILIZATION PATTERNS,"
Term
NCQA-NATIONAL COMMITTEE ON QUALITY ASSURANCE STANDARDS INCLUDE
Definition
"QUALITY MANAGEMENT AND IMPROVEMENT, UTILIZATION MANAGEMENT, MEMBOR RIGHTS AND RESPONSIBILITIES, PREVENTATIVE HEALTH, MEDICAL RECORDS"
Term
INFORMATION SYSTEMS FOR ON SITE VISIT TO MANAGED CARE VENDOR
Definition
"COMPUTER SYSTEMS USED, CLAIMS ADMIN, MEMBER SERVICES AND MEDICAL MANAGEMENT INFO SYSTEMS"
Term
CARRIERS RESPONSE TO AGGRESSIVE NEGOTIATING TECHNIQUES
Definition
"CUTTING FEES TO PROVIDERS, CUTTING UNPROFITABLE LINES AND SEEKING PREMIUM RATE INCREASES WHERE POSSIBLE"
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