Glossary

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

EPSDT program covers screening and diagnostic services to determine physical or mental defects in recipients under age 21, as well as health care and other measures to correct or ameliorate any defects and chronic conditions discovered.

Economic Credentialing

The use of economic criteria unrelated to quality of care or professional competency in determining an individual’s qualifications for initial or continuing hospital medical staff membership or privileges. Economic credentialling has become a controversial topic involving much concern about ethics, yet, economic credentialing remains the most powerful form of controlling the behavior of doctors. Other forms of control include utilization review, certification, exclusive provider panels and more.

Effective Date

The date on which a policy’s coverage of a risk goes into effect.

Electronic Claim

A digital representation of a medical bill generated by a provider or by the provider’s billing agent for submission using telecommunications to a health insurance payer.

Electronic Data Interchange (EDI)

The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization.

Electronic Medical Record (EMR)

This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entities to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans.

Eligible Dependent

Person entitled to receive health benefits from someone else’s plan. See also Dependent.

Eligible Employee

Employee who qualifies to receive benefits.

Elimination Period

Most often used to designate the waiting period in a health insurance policy.

Emergency

Sudden unexpected onset of illness or injury which requires the immediate care and attention of a qualified physician, and which, if not treated immediately, would jeopardize or impair the health of the Member, as determined by the payer’s Medical Staff. Significant in that Emergency may be the only acceptable reason for admission without pre-certification.

Emergency Center, Emergi-Center

Non-hospital affiliated health facility that provides short-term care for minor medical emergencies or procedures needing immediate treatment; also called urgi-center, urgent center or free standing emergency medical service center.

Employee Assistance Program (EAP)

A service, plan or set of benefits which are designed for personal or family problems, including mental health, substance abuse, gambling addiction, marital problems, parenting problems, emotional problems or financial pressures. This is usually a service provided by an employer to the employees, designed to assist employees in getting help for these problems so that they may remain on the job. EAP began with a primary drug and alcohol focus with an emphasis on rehabilitating valued employees rather than terminating them for their substance problems. It is sometimes implemented with a disciplinary program which requires that the impaired employee participate in EAP in order to retain employment. With the advent of managed care, EAP has sometimes evolved to include case management, utilization review and gatekeeping functions for the psychiatric and substance abuse health benefits.

Employee Retirement Income Security Act (ERISA)

Also called the Pension Reform Act, this act regulates the majority of private pension and welfare group benefit plans in the U.S.. It sets forth requirements governing, among many areas, participation, crediting of service, vesting, communication and disclosure, funding, and fiduciary conduct. Key legislative battleground now, because ERISA exempts most large self-funded plans from State regulation and, hence, from any reform activities undertaken at state level–which is now the arena for much healthcare reform.

Employer Mandate

Option that federally qualified HMOs have to exercise over employees, requiring them to have available one or more types of HMOs per plan.

Encounter

A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.

Encounter Data

Data relating to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis. Used in determining the level of service.

Enrolled Group

Persons with the same employer or with membership in an organization in common, who are enrolled collectively in a health plan. Often, there are stipulations regarding the minimum size of the group and the minimum percentage of the group that must enroll before the coverage is available. Same as Contract group.

Enrollee ( Also beneficiary; individual; member)

Any person eligible as either a subscriber or a dependent for service in accordance with a contract.

Enrollment

Initial process whereby new individuals apply and are accepted as members of a prepayment plan.

Episode of Care

A term used to describe and measure the various health care services and encounters rendered in connection with identified injury or period of illness.

EPO

Exclusive Provider Organization: A type of HMO that provides an exclusive hospital and physician network that members must use. A member incurs the entire cost if they use services outside their network.

Essential Community Providers

Providers such as community health centers that have traditionally served low-income populations.

Evidence of Insurability (E of I)

Proof of a person’s physical condition that affects acceptibility for insurance or a health care contract

Evidence or Explanation of Coverage or Evidence or Explanation of Benefits (EOC, EOB)

A booklet provided by the carrier to the insured summarizing benefits under an insurance plan.

Excess Risk

Either specific or aggregate stop loss coverage.

Excluded Hospitals and Distinct-Part Uni

Hospitals and hospital units that are specifically excluded from Medicare’s prospective pay system. These commonly include children’s, cancer, hospital based outpatient care, long-term care, rehabilitation inpatient and psychiatric hospitals or units. Rehabilitation or psychiatric units of acute care hospitals are exempt if they meet certain criteria specified by HHS and are referred to as “DRG exempted”. Excluded facilities are paid through submission of cost reports and TEFRA limits.

Exclusions

Conditions or situations not considered covered under contract or plan. Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks. Providers will negotiate for exclusions for outliers and carve-out of certain high cost procedures, while payers will negotiate for exclusions to avoid payment of higher cost care.

Exclusive Provider Arrangement (EPA)

An indemnity or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts (with some exceptions for emergency and out-of-area services).

Exclusive Provider Organization (EPO)

A plan which limits coverage of non-emergency care to contracted health care providers. Operates similar to an HMO plan but is usually offered as an insured or self-funded product. Sometimes looks like a managed care organization that is organized similarly to a PPO in that physicians do not receive capitated payments, but the plan only allows patients to choose medical care from network providers. If a patient elects to seek care outside of the network, then he or she will usually not be reimbursed for the cost of the treatment. Uses a small network of providers and has primary care physicians serving as care coordinators (or gatekeepers). Typically, an EPO has financial incentives for physicians to practice cost-effective medicine by using either a prepaid per-capita rate or a discounted fee schedule, plus a bonus if cost targets are met. Most EPOs are forms of POS plans because they pay for some out-of-network care.

Exclusivity Clause

A part of a contract which prohibits physicians, providers or other care entities from contracting with more than one managed care organization. Exclusive contracts are common in staff model HMOs and IPAs but becoming less common in other health plan contracting.

Expansion

Some HMOs compute Plan expansion as part of the capitation rate in order to provide the necessary capital for growth.

Experience

A term used to describe the relationship of premium to claims for a plan, coverage, or benefits for a stated time period. Usually expressed as a ratio or percent. See also Medical Loss Ratio.

Experience Rating

The process of setting rates partially or in whole on evaluating previous claims experience for a specific group or pool of groups. The rating system by which the Plan determines the capitation rate or premium rate is determined by the experience of the individual group enrolled, based on actual or anticipated health care use by the specific group of insureds. Each group will have a different rate based on utilization. This system tends to penalize small groups with high utilization. A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group, such as determining the premium based on a group’s claims experience, age, sex or health status. Experience rating is not allowed for federally-qualified HMOs.

Experience-Rated Premium

A premium with is based upon the anticipated claims experience of, or utilization of service by, a contract group according to its age, sex, constitution, and any other attributes expected to affect its health service utilization, and which is subject to periodic adjustment in line with actual claims or utilization experience.

Explanation of Benefits (EOB)

A statement sent to covered individuals explaining services provided, amount to be billed, and payments made. A summary of benefits provided subscribers by the carrier.

Extended Care Facility (ECF)

A nursing or convalescent home offering skilled nursing care and rehabilitation services on a 24 hour basis.

Extension of Benefits

Insurance policy provision that allows medical coverage to continue past termination of employments. See also COBRA.