Program in a managed care organization (MCO) under a carve-out arrangement that provides services to the members such as behavioral services, utilization management services, or organizing an employee assistance program (EAP).

MEDICAL,USA: 1. System of health care delivery designed to reduce unnecessary utilization of medical services, control costs, and measure performance while managing access and giving quality, cost-effective health care. Emphasis is placed on prevention, early intervention, and outpatient care. A variety of arrangements for health care delivery and financing includes health maintenance organizations (HMOs), preferred provider organizations (PPOs), point-of-service (POS) plans, and competitive medical plans (CMPs). The plans provide health services on prepayment terms that are based on either cost or risk. 2. Reimbursement method by third-party payers who implement some requirements to control costs of health care while retaining quality care. 3. Under Medicare, includes HMOs, CMPs, and other plans that provide health services on prepayment terms, which are based on either cost or risk, depending on the type of contract they have with Medicare. The term managed care has been replaced with Senior Advantage plans . See also Medicare Plus (+) Choice (M+C) program and Senior Advantage plans . Also called managed health care .
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US: Health care systems that integrate the financing and delivery of appropriate health care services to covered individuals by arrangements with selected providers to furnish a comprehensive set of health care services, explicit standards for selection of health care providers, formal programs for ongoing quality assurance and utilization review, and significant financial incentives for members to use providers and procedures associated with the plan.22424
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Systems designed to integrate the delivery and financing of health care of the highest possible quality at the lowest possible cost. In contrast to traditional fee for service arrangements, under managed care, health providers ,1. agree to negotiated payment levels for specified services to defined patient populations ,2. agree to more aggressive utilization and quality assurance review and ,3. assume financial risk leading to more severe restriction on patient choice to obtain services outside the network.

Individual or committee that receives managed care plan referral authorization requests and depending on precise rules can either approve or deny the request. Also may be known as managed care committee .

Principles that states set for plan structure, operations, and the internal quality improvement/assurance system that each MCO/PHP must have in order to participate in the Medicaid program.

1. Generic term applied to managed care plans such as exclusive provider organizations (EPOs), health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans. MCOs are usually prepaid group plans and physicians are typically paid by the capitation method. Also referred to as managed health care plan . 2. MCOs are entities that serve Medicare or Medicaid beneficiaries on a risk basis through a network of employed or affiliated providers. In the Medicaid program, other organizations may set up managed care programs to respond to Medicaid managed care. These organizations include federally qualified health centers, integrated delivery systems, and public health clinics.

1. Prepayment health care program in which a specified set of health benefits is provided in exchange for a yearly fee or fixed periodic payments to the provider by the plan. This category of third-party payers includes health maintenance organizations (HMOs), preferred provider organizations (PPOs), and independent or individual practice associations (IPAs). 2. Under the Medicare program, type of prepaid medical plan that must cover all Medicare Part A and Part B health care. Some managed care plans cover extra benefits such as extra days in the hospital. In most cases, a type of Medicare Advantage Plan that is available in some areas of the country. Cost to the patient may be lower than in the Original Medicare Plan.

Prepaid health plan that lets the patient use doctors and hospitals outside the plan for an additional cost.