Managed Care Glossary of Terms

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.

(E of I) Evidence of insurability
Proof of a person's physical condition that affects acceptibility for insurance or a health care contract

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

(EPA) Exclusive Provider Arrangement
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).

(EPO) Exclusive Provider Organization
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.

(EOB) Explanation of Benefits
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.

(ECF) Extended Care Facility
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.