Direct Care Glossary
APIs - Active Pharmaceutical Ingredients; ingredients that go into drugs that Americans take each and every day. 90% of these are manufactured in the People’s Republic of China.
Administrative Costs - A key component of your health insurance policy; the amount of money it takes to process a claim, to keep the lights on and to print ID cards.
Claims - A key component of your health insurance policy; the everyday healthcare expenses incurred from prescription drugs to an MRI.
Fully-Insured - An employer contracts an insurance company to cover the employees and dependents’ healthcare and/or disability.
Healthcare - The care we get for our health.
Health Insurance - How we pay for the healthcare we get.
Health Insurance Trend - Based on Wall Street. Health insurers take a true medical trend and compound that with layers of fat incorporated into health insurance premiums to make sure they generate more profit.
MLR - Medical Loss Ratio; a key provision found within the Affordable Care Act. Effectively the way insurance companies, under the law, are required to spend your money. The standard MLR mandate found in the Affordable Care Act said that insurance companies have to spend approximately .85 of every dollar they collect on claims. In community-rated small groups, it’s closer to 80%.
Medical Trend - Independent studies of medical inflation; the actual increase in cost. The medical trend in the United States by and large, has increased somewhere between 5-7% within the last decade.
PBM - A Pharmacy Benefit Manager is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. PBM’s contract with pharmacies, negotiate discounts and rebates with drug manufacturers and process and pay prescription drug claims.
Pools or Pooling - A key component of your health insurance policy. An effective way for insurance companies to balance the scales and manage their losses. A fundamental structure by which a group of people would pool their resources collectively to be used when needed by someone when they fell ill. It was the first official employer sponsored plan and Blue Cross was born. (Seth Denson: “...specifically, the pooling structure of health insurance is the largest legal Ponzi in the United states.”)
Pooling Point - A mathematical calculation; the amount of claims that need to be incurred before effectively the rest of those funds that are set aside to pay claims cease, and instead that claim is then paid out of the pool.
RV Units - Relative value units,--a patient’s time with a doctor. Someone calculated that a doctor should be able to see four patients in an hour.
Self-Funded Healthcare - Employer provides health or disability benefits to employees using the company’s own funds. Unless exempted, such plans create rights and obligations under the Employee Retirement Income Security Act of 1974 ("ERISA").
Administrative Costs - A key component of your health insurance policy; the amount of money it takes to process a claim, to keep the lights on and to print ID cards.
Claims - A key component of your health insurance policy; the everyday healthcare expenses incurred from prescription drugs to an MRI.
Fully-Insured - An employer contracts an insurance company to cover the employees and dependents’ healthcare and/or disability.
Healthcare - The care we get for our health.
Health Insurance - How we pay for the healthcare we get.
Health Insurance Trend - Based on Wall Street. Health insurers take a true medical trend and compound that with layers of fat incorporated into health insurance premiums to make sure they generate more profit.
MLR - Medical Loss Ratio; a key provision found within the Affordable Care Act. Effectively the way insurance companies, under the law, are required to spend your money. The standard MLR mandate found in the Affordable Care Act said that insurance companies have to spend approximately .85 of every dollar they collect on claims. In community-rated small groups, it’s closer to 80%.
Medical Trend - Independent studies of medical inflation; the actual increase in cost. The medical trend in the United States by and large, has increased somewhere between 5-7% within the last decade.
PBM - A Pharmacy Benefit Manager is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. PBM’s contract with pharmacies, negotiate discounts and rebates with drug manufacturers and process and pay prescription drug claims.
Pools or Pooling - A key component of your health insurance policy. An effective way for insurance companies to balance the scales and manage their losses. A fundamental structure by which a group of people would pool their resources collectively to be used when needed by someone when they fell ill. It was the first official employer sponsored plan and Blue Cross was born. (Seth Denson: “...specifically, the pooling structure of health insurance is the largest legal Ponzi in the United states.”)
Pooling Point - A mathematical calculation; the amount of claims that need to be incurred before effectively the rest of those funds that are set aside to pay claims cease, and instead that claim is then paid out of the pool.
RV Units - Relative value units,--a patient’s time with a doctor. Someone calculated that a doctor should be able to see four patients in an hour.
Self-Funded Healthcare - Employer provides health or disability benefits to employees using the company’s own funds. Unless exempted, such plans create rights and obligations under the Employee Retirement Income Security Act of 1974 ("ERISA").
