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Managed Care Alphabet Soup
Gail Carlson, MPH Ph.D, State Health Education Specialist, University of Missouri Extension
Managed care has created a new language. Part of our responsibility as users of this system is to learn as much as we can about how managed care works and what these new terms and abbreviations mean. Use the following matching game to become a little more familiar with a few important managed care terms and abbreviations. Match the abbreviations with the correct terms. Use the answer key to check your responses.
| ____ PCP
|
A. Managed Care Organization
|
| ____ UR
|
B. Competitive Medical Plan
|
| ____ PMPM
|
C. Preferred Provider Organization
|
| ____ POS
|
D. Primary Care Physician
|
| ____ CP
|
E. Utilization Review
|
| ____ PPO
|
F. Per member Per Month
|
| ____ MCO
|
G. Closed Panel
|
| ____ CMP
|
H. Point Of Service Plan
|
Managed Care Alphabet Soup Answer Key
D—PCP (Primary Care Physician)
In many managed-care plans the PCP is responsible for
monitoring the members care and makes necessary
referrals for specialized care.
E—UR (Utilization Review)
The process of reviewing the need for certain kinds of
care provided by a managed care plan to its members.
Included are such activities as granting prior approval
for hospitalization and certain procedures; coordinating
care after a patient has left the hospital; and making
decisions about the need for a second opinion.
F—PMPM (Per member Per Month)
Under capitation the managed care plan pays health
providers a set amount per member per month rather than
paying for the number and type of services delivered.
The capitated rate may vary by factors such as age and
sex of the enrolled member.
H—POS (Point Of Service Plan)
Generally, the plan enrolls each member in both an HMO
and a conventional insurance plan. Members do not have
to choose how they will receive services until they need
them.
G—CP (Closed Panel)
A managed care plan that contracts with physicians on an
exclusive basis. These physicians are not allowed to see
patients from other managed care organizations.
C—PPO (Preferred Provider Organization)
PPOs are networks of doctors, hospitals and other
providers that work together to provide services at
prearranged prices to plan members. PPOs often limit the
number of participating providers and provide incentives
to members to use the plan's providers instead of
others. Some PPOs require members to see their Primary
Care Physician before seeing a specialist. Others allow
the member to use any physician on the list.
A—MCO (Managed Care Organization)
A generic term applied to a managed care plan. Some
people prefer to use this term rather than HMO because
it includes other types of plans like Preferred Provider
Organizations (PPOs) and Point of Service (POS) plans.
B—CMP (Competitive Medical Plan)
A federal designation that allows a health plan to
provide Medicare services without having to obtain
qualification as an HMO. Requirements for eligibility as
an CMP are not as restrictive as those for an HMO.
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Last Updated 05/05/2009
