3-Tier

Capitation
A method of paying for health care services on the basis of the number of enrollees who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided.

Care manager — see Primary care provider

Case management
A process of identifying plan members with special health care needs, developing a healthcare strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum health care outcome in an efficient and cost-effective manner.

Claims administration
The process of receiving, reviewing, adjudicating, and processing claims.

Co-insurance
A fixed percentage amount, such as 10 percent, paid by the enrollee time a certain covered service is received. In most cases, if deductible applies, the remaining charge is subject to coinsurance.

Co-payment
A fixed dollar amount paid by the enrollee each time certain covered services are received.

Deductible
A flat amount the enrollee must pay before the payer will make any benefit payments for selected covered benefits.

Fee-for-service
A system in which reimbursement is made according to a fee schedule for each service provided.

Medically necessary
A covered procedure, service, or supply that is considered eligible for benefits under this plan. All covered services must be medically necessary.

Network
The group of physicians, hospitals, and other medical care providers with whom a specific managed care plan has contracted to deliver medical services to its members.

Out-of-pocket maximum
A specified amount that the enrollee must pay out-of-pocket for covered services in a benefit period.

Primary care provider/care manager
A designated family practitioner, general internist or pediatrician who is responsible for managing and overseeing the enrollee's health care needs and who refers to specialists as necessary.