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h.elsayed@egyptre.com
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HHeeaall t thhIInnssuurraanncceeGGlloossssaarryy 
Complete Glossary of Health Insurance Terminology
 
 
A
1.
 
access
. A person's ability to obtain affordable medical care on a timely basis.2.
 
accreditation
.
1
An evaluative process in which a healthcare organizationundergoes an examination of its operating procedures to determine whether theprocedures meet designated criteria as defined by the accrediting body, and toensure that the organization meets a specified level of quality.3.
 
ACF
. See ambulatory care facility.4.
 
acquisition
. The purchase of one organization by another organization.5.
 
ACR 
. See adjusted community rating.6.
 
actuaries
. The insurance professionals who perform the mathematical analysisnecessary for setting insurance premium rates.7.
 
adjusted community rating (ACR)
. A rating method under which a health planor MCO divides its members into classes or groups based on demographic factorssuch as geography, family composition, and age, and then charges all members of a class or group the same premium. The plan cannot consider the experience of aclass, group, or tier in developing premium rates. Also known as modifiedcommunity rating or community rating by class.8.
 
administrative services only (ASO) contract
. The contract between anemployer and a third party administrator.9.
 
adverse selection
. See antiselection.10.
 
agent
. A person who is authorized by an MCO or an insurer to act on its behalf tonegotiate, sell, and service managed care contracts.11.
 
aggregate stop-loss coverage
. A type of stop-loss insurance that providesbenefits when a group's total claims during a specified period exceed a statedamount.12.
 
ambulatory care facility (ACF)
. A medical care center that provides a widerange of healthcare services, including preventive care, acute care, surgery, andoutpatient care, in a centralized facility. Also known as a medical clinic or medicalcenter.13.
 
ancillary services.
2
Auxiliary or supplemental services, such as diagnosticservices, home health services, physical therapy, and occupational therapy, usedto support diagnosis and treatment of a patient's condition.14.
 
annual maximum benefit amount.
The maximum dollar amount set by an MCOthat limits the total amount the plan must pay for all healthcare services providedto a subscriber in a year.15.
 
antitrust laws.
Legislation designed to protect commerce from unlawful restraintof trade, price discrimination, price fixing, reduced competition, and monopolies.See also Sherman Antitrust Act, Clayton Act, and Federal Trade Commission Act.16.
 
appropriate care.
3
A diagnostic or treatment measure whose expected healthbenefits exceed its expected health risks by a wide enough margin to justify themeasure.17.
 
appropriateness review.
An analysis of healthcare services with the goal of reviewing the extent to which necessary care was provided and unnecessary carewas avoided.18.
 
ASO contract.
See administrative services only contract.19.
 
associate medical director.
4
Manager whose duties are often defined as a subsetof the overall duties of the medical director.20.
 
at-risk.
Term used to describe a provider organization that bears the insurancerisk associated with the healthcare it provides.21.
 
autonomy.
5
An ethical principle which, when applied to managed care, states thatmanaged care organizations and their providers have a duty to respect the right of their members to make decisions about the course of their lives.
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