State and county directory that contains names, addresses, and specialties of Medicare-participating physicians who have agreed to accept assignment on all Medicare claims and covered services.

Acronym for Medicare supplement (Medsupp) policy. See Medigap (MG) policy .

Situation in which both parties agree and understand their responsibilities and rights under an insurance contract.

1. Person covered under the Blue Cross/Blue Shield subscriber’s contract including the subscriber or contract holder who is the person named on the membership identification card and in the case of (1) two-person coverage, (2) one adult–one child coverage, or (3) family coverage, eligible family dependents enrolled under the subscriber’s contract. 2. Individual who purchases health insurance coverage. Also called certificate holder, enrollee, insured, policyholder , and subscriber .

Continuation of insurance coverage without lapse when making a change from one group to another or one health plan to another.

Health insurance plan’s complex formula that measures and tracks the insured’s overall health levels such as how often they are in emergency departments, how often they receive preventive care, and whether they take needed medications.

Total managed care plan membership each month for a given time period (e.g., 200 members serviced each month for 6 months equals 1200 member months). Operating figures for managed care companies may be expressed in terms of member months (e.g., per member per month [PMPM] or per member per year [PMPY]).

Payment section of the insurance carrier that acts as a patient advocate to resolve problems and take insurance claims appeals to a committee after all other processes have been used.