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E . . .
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
A program which covers screening and diagnostic services to determine
physical or mental defects in recipients under age 21, as well
as health care and other measures to correct or ameliorate any
defects and chronic conditions discovered.
Effective Date
The date on which a policy's coverage of a risk goes into effect.
Emergency
Sudden unexpected onset of illness or injury which requires the
immediate care and attention of a qualified physician, and which,
if not treated immediately, would jeopardize or impair the health
of the Member, as determined by the payer's Medical Staff. Significant
in that Emergency may be the only acceptable reason for admission
without pre-certification.
Employee Retirement Income Security Act of 1974 (ERISA)
Also called the Pension Reform Act, this act regulates the majority
of private pension and welfare group benefit plans in the United States.
It sets forth requirements governing, among many areas, participation,
crediting of service, vesting, communication and disclosure, funding,
and fiduciary conduct. Key legislative battleground now, because
ERISA exempts most large self-funded plans from State regulation
and, hence, from any reform activities undertaken at state level --
which is now the arena for much healthcare reform.
Enrolled Group
Persons with the same employer or with membership in an organization
in common, who are enrolled collectively in a health plan. Often,
there are stipulations regarding the minimum size of the group
and the minimum percentage of the group that must enroll before
the coverage is available. Same as Contract group.
Enrollee (or Beneficiary; Individual; Member)
Any person eligible as either a subscriber or a dependent for
service in accordance with a contract.
Evidence or Explanation of Coverage (EOC)
A booklet provided by the carrier to the insured summarizing benefits
under an insurance plan.
Exclusions
Clauses in an insurance contract that deny coverage for select
individuals, groups, locations, properties or risks.
Exclusive Provider Organization (EPO)
A managed care organization that is organized similarly to PPOs
in that physicians do not receive capitated payments, but that
only allows patients to choose medical care from network providers.
If a patient elects to seek care outside of the network, then
he or she will not be reimbursed for the cost of the treatment.
Exclusivity Clause
A part of a contract which prohibits physicians from contracting
with more than one managed care organization (HMO, PPO, IPA, etc.)
Expansion
Some HMOs compute Plan expansion as part of the capitation rate
in order to provide the necessary capital for growth.
Experience Rating
One of the following:
- The rating system by which the Plan determines the capitation
rate by the experience of the individual group enrolled. Each
group will have a different capitation rate based on utilization.
This system tends to penalize small groups with high utilization.
- A method of determining the premium based on a group's claims
experience, age, sex or health status. Experience rating is not
allowed for federally-qualified HMOs.
- A system where an insurance company evaluates the risk of an
individual or group by looking at the applicant's health history.
Experience-Rated Premium
A premium with is based upon the anticipated claims experience
of, or utilization of service by, a contract group according to
its age, sex, constitution, and any other attributes expected
to affect its health service utilization, and which is subject
to periodic adjustment in line with actual claims or utilization
experience.
Explanation of Benefits (EOB)
A summary of benefits provided subscribers by the carrier.
Extended Care Facility (ECF)
A nursing or convalescent home offering skilled nursing care and
rehabilitation services.
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