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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.
|A. Managed Care Organization
|B. Competitive Medical Plan
|C. Preferred Provider Organization
|D. Primary Care Physician
|E. Utilization Review
|F. Per member Per Month
|G. Closed Panel
|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.
Last Updated 05/05/2009