MEDICAL, US: 1. Individuals who comprise an insured group based on health status, age, sex, and future health. Also called risk spread . 2. State program that groups those who cannot obtain insurance coverage. Funds for these programs come from either the state or an assessment on insurers. 3. In managed care plans, a collection of funds established by a managed care plan that uses a risk-sharing system (i.e., capitation) with providers of medical services. Funds are taken from withholding a portion of provider fees or capitation payments to make up the reserve to cover unforeseen use of services. Funds that remain at the end of a year are distributed among the providers. Also called pool . 4. Financial account to which a managed care plan’s specific income and expenses are posted.
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Also known as a pool. A group of insurers (or reinsurers) who share the premiums and losses of a risk they have written together, according to an agreement that exists between them. A pool often writes large commercial risks.
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Multiple subjects of insurance insured or reinsured by a single insurer where, to avoid risk concentration and improve risk distribution, different combinations of exposures, perils, and hazards will be underwritten.

Classification system used by the insurance industry to set premiums for health plans. Insured individuals who have a high risk pay more than others who are insured because of their health-related behaviors.

Measurement of the costs of an enrollee who has specific risks compared with the cost of care for the average beneficiary in a managed care plan.

In managed care plans, methods used in which the plan and contracted providers share the financial risks and benefits to care for the plan members in a cost-effective manner (e.g., capitation, risk pools, per diem contracts). It is a system used to control health care costs.

Type of managed care organization. After any applicable deductible or copayment, all of an enrollee’s or member’s medical care costs are paid for in return for a monthly premium. However, due to the lock-in provision, all of the enrollee’s or member’s services (except for out-of-area emergency services) must be arranged for by the risk-HMO. Should the Medicare enrollee or member choose to obtain service not arranged for by the plan, he or she will be liable for the costs. Neither the HMO nor the Medicare program will pay for services from providers who are not part of the HMO’s health care system or network.

Health plan, health insurer, or self-funded employer that takes on financial responsibility for a provision that lists specific benefits and accepts prepayment for the cost of the medical care.