By Leroy Jones, Jr. on September 3, 2009 9:41 AM
Definition: A pool of money that is at risk for being used for defined expenses. Commonly, if the pool money that is put at risk is not expended by the end of the year, some or all of it is returned to those managing the risk.
Two different definitions are in use:
1) A pool of funds set aside as reserves to be used for defined expenses. Under capitation, if all of the risk pool is not used by the end of the contract year, it is usually disseminated to participating providers, and,
2) Legislatively created programs that group individuals who cannot secure coverage in the private market. Funding comes from government or assessment on insurers.
By Leroy Jones, Jr. on September 1, 2009 8:58 AM
Long-Term Care (LTC)
Definition: A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis.
The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals.
Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care.
Medicare doesn't pay for this type of care if this is the only kind of care a person needs.
However, Medicaid and long-term care insurance plans do provide some coverage for long-term care.
Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.
By Leroy Jones, Jr. on August 28, 2009 8:00 AM
Definition: A medical condition developed prior to issuance of a health insurance policy that may result in the limitation in the contract on coverage or benefits.
Normally this is defined as a health problem for which the new enrollee received health care services before the date that the new health plan benefit begins.
Some policies exclude coverage of
such conditions and the exclusion may continue for a specific period of
time or indefinitely. Federally qualified HMOs cannot limit coverage
for pre-existing conditions.
New statutes in 1997 and 1998 altered the freedom other health plans have enjoyed in setting preexisting time limits. Certification of prior coverage may mean new insurers would need to waive preexisting clauses for some subscribers.