Health care reform system wherein health plans offer their most competitive rates to provide health insurance coverage. This system changes competition in the health insurance market from risk (insuring healthy persons instead of those with preexisting conditions) to price. Employers form large purchasing networks to obtain insurance coverage at reduced rates. The employers pay for the employees and the employees choose a health plan they want during open enrollment and pay the difference between the employer’s contribution and the cost of the plan. The insurance coverage is transferable if the employee changes jobs. Also known as managed cooperation . See also consumer health alliances .

System composed of a combination of fee-for-service (FFS) and managed care components to control inappropriate use such as precertification, second surgical opinion, and utilization review. The costs of covered services given to members are paid by the plan after the services have been used. Also referred to as managed fee-for-service product .

Standard fee-for-service (FFS) health insurance plan that uses some managed care components such as concurrent utilization review and precertification for hospital and outpatient services. This type of plan allows members freedom of choice among providers.

One of the systems approved by the Centers for Medicare and Medicaid Services (CMS) that supports the operation of the Medicaid program. MARS is a federally mandated comprehensive reporting module of the Medicaid Management Information System (MMIS) that includes data and reports as specified by federal requirements.

Type of publicly or privately held administrative group that gives strategic, financial, and operational plans needed by physicians, clinics, and ancillary service providers for a successful managed care business enterprise. The MSO contracts with payers, hospitals, and physicians to provide services such as negotiating fee schedules, handling administrative functions, billing, and collections. An MSO may own the facilities and employ nonphysician staff to deliver care or may be a direct subsidiary of a hospital or owned by investors. Sometimes referred to as medical services organization (MSO) or physician management corporation (PMC) .

1. Medical services required by state or federal statutes but not necessarily covered as an insurance benefit (e.g., medical services for child abuse or rape or mandated 48-hour maternity stays following delivery of a baby). Also referred to as mandated services . 2. Minimum insurance benefits specified under federal or state regulations (e.g., specific smallest amount of benefits that must be paid for alcoholism under all insurance contracts sold in the state). Also called state legislated benefits .

1. Health care professionals who must be state or federal licensed providers to render services under a managed care plan (e.g., chiropractors, optometrists, podiatrists, psychologists). 2. Health care suppliers whose medical services must be included in insurance coverage offered by a health plan as required by state or federal regulations.