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.

In medical care, physical examination performed on an annual (regular) basis.

Under the Health Insurance Portability and Accountability Act (HIPAA), release of protected health information for treatment, payment, or other health care operations that does not require the patient to sign a consent form.

Days in which a hospice patient and member of an insurance plan who is not receiving continuous medical care has chosen to receive hospice care at home.

First inpatient examination of a newborn infant done by a doctor but not done by the physician who delivered the baby or the doctor who gave anesthetics during delivery.

Annual physical examination made in the absence of definite symptoms of disease or injury. Sometimes an electrocardiogram, laboratory tests, and a chest x-ray may be done. Also see physical examination (PE or PX) .

With respect to individually identifiable health information, the sharing, employment, applica- tion, utilization, examination, or analysis of such information within an entity that maintains such information.