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Maintenance List - A list of medications that we have recognized that may be dispensed in a quantity sufficient for a 90-day supply for 3 copayments or applicable coinsurance.

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Major Medical Expense Insurance - Policies intended to help offset the heavy medical expenses resulting from catastrophic or prolonged illness or injury. They generally provide benefits payments for 75 to 80 percent of most types of medical expenses over a deductible paid by the insured.

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Malpractice Insurance - Insurance in opposition to the risk of suffering financial damage due to professional misconduct or lack of ordinary skill. Mismanagement requires that the patient prove some injury and that the injury was the result of negligence on the part of the professional. A practitioner is responsible for damages or injuries caused by malpractice.

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Managed Behavioral Health Organization (MBHO) - An organization that provides behavioral health services by implementing managed care technique.

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Managed Behavioral Health Program - A program of managed care exact to psychiatric or behavioral health care. This usually is a result of a "carve-out" through an insurance company or managed care organization (MCO). Settlement may be in the form of sub-capitation, fee for service or capitation.

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Managed Care - Systems and techniques used to manage the use of health care services. The body of clinical, financial and organizational activities intended to ensure the provision of appropriate health care services in a cost-efficient manner. Managed care techniques are most often experienced by organizations and professionals that assume risk for a defined population but this is not always the case. Managed care is sometimes used as a common term for the activity of organizing doctors, hospitals, and other providers into groups in order to enhance the quality and cost-effectiveness of health care.

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Managed Care Organization (MCO) - A health preparation that seeks to manage care. Usually, this involves contracting with health care providers to deliver health care services on a capitated basis.

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Managed Care Plan - A health plan that uses managed care arrangements and has a distinct system of selected providers that contract with the plan. Enrollees have an economic incentive to use participating providers that agree to furnish a broad range of services to them. Providers may be paid on a pre-negotiated base.

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Managed Dental Care - Any dental plan accessible by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.

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Managed Health Care Plan - An agreement that integrates financing and management with the delivery of health care services to an enrolled population. It employs or contracts with a prepared system of providers that delivers services and frequently shares financial risk.

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Management Information System (MIS) - The frequent term for the computer hardware and software that provides the support of managing the plan.

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Management Services Organization (MSO) - Usually an entity owned by a hospital, physician group, PHO or IDS that provides management services and administrative systems to one or more medical practice. The management services organization provides administrative and perform management services to physicians.

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Manual Rates and Manual Rating - Rates based on a health plan's average claims data and attuned for certain factors, such as group demographics or industry. A rating method under which a health plan uses the plan's common experience with all groups, and sometimes the experience of other health plans, rather than a particular group's experience to calculate the group's premium. An MCO frequently lists manual rates in an underwriting or rating manual.

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Market Basket Index - A common word in the field of economics. In healthcare business, this refers to a percentage or index of the annual change in the prices of goods and services providers used to produce health services. Different market baskets are for PPS based hospital inputs and capital inputs, DRG exempt facility operating inputs.

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Master Patient / Member Index - An index or file with a unique identifier for every patient or member that serves as a key to a patient's or member's health record.

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Maximum Allowable Actual Charge (MAAC) - A restriction on billed charges for Medicare services provided by nonparticipating physicians. For physicians with charges more than 115 percent of the prevailing charge for nonparticipating physicians, MAACs limit increase in actual charges to 1 percent a year.

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Maximum Defined Data Set - Under HIPAA, this is all of the necessary data elements for a particular standard based on a specific implementation specification. An entity creating a deal is free to include whatever data any receiver might want or need. The recipient is free to ignore any piece of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is desirable for coordination of benefits.

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Maximum Out-of-Pocket Expenses - Limit on total number of co-payments or limit on total cost of deductibles and co-insurance below a benefit plan.

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McCarran-Ferguson Act - A 1945 Act of Congress exempting insurance businesses from federal commerce laws and delegating narrow authority to the states. A federal act that located the primary responsibility for regulating health insurance companies and HMOs that service private sector plan members at the state level.

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Medicaid - A joint federal and state program that helps with medical costs for some people with low incomes and restricted possessions. Medicaid serves the poor, blind, aged, disable or members of families with dependent children. Each state has its own standards for requirements. A Federally aided, state-operated and administered program that provides medical benefits for certain needy or low-income persons in need of health and medical care.

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Medical Advisory Committee - The MCO committee that evaluates projected policies and action plans related to clinical practice management, including changes in provider contracts, compensation, and changes in authorization procedures, reviews data regarding new medical technology, and examines planned medical policies.

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Medical Allied Manpower - This category includes some sixty occupations or specialties that can be separated into two large categories based on time required for occupational training. The first category includes those occupations that require at least a baccalaureate quantity, for example, clinical laboratory scientists and technologists, dietitians and nutritionists, health educators, medical record librarians, and occupational speech and rehabilitation therapists. The second group includes those occupations that need less than a baccalaureate degree, such as aides for each of the above categories as well as physician assistants and radiological technicians.

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Medical Care Evaluation Studies (MCE) - The name given to a general form of health care review in which problems in the quality of the delivery and organization of health care services are addressed and monitored. A program suggested as a way of meeting the federal government's requirements for an internal quality assurance program for federally qualified HMOs.

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Medical Loss Ratio (MLR) - Cost ratio of total benefits used compared to revenues established. Generally referred to by a ratio, such as 0.96 which means that 96% of premiums were spent on purchasing medical services. The goal is to keep this ratio below 1.00--preferably in the 0.80 ranges, because the MCO's or insurance company's profit comes from premiums. At present, successful HMOs do have MLRs in the 0.70-0.80 range.

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Medically Appropriate Services - Diagnostic or treatment measures for which the predictable health benefits exceed the expected risks by a margin wide enough to justify the measures.

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Medically Necessary, Medical Necessity, Medical Necessary Services - Services or supplies which congregate the following tests: They are suitable and necessary for the symptoms, diagnosis, or treatment of the medical condition. They are provided for the analysis or direct care and treatment of the medical condition. They meet the standards of good medical practice within the medical society in the service area. They are not mainly for the convenience of the plan member or a plan provider and they are the most appropriate level or supply of service which can safely be provided.

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Medically Needy - Individuals who meet the financial source requirements of categorically needy individuals, but whose monthly income exceeds particular maximums. Persons who are categorically qualified for Medicaid and whose income, less accumulated medical bills, are below state income limits for the Medicaid program. Frequently seen as a problem among the "working poor" or among the senior population.

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Medical Management Information System (MMIS) - A data scheme that allows payers and purchasers to track health care expenditure and utilization patterns. May possibly also be referred to as Health Information System (HIS), Health Information Management (HIM) or Information System (IS).

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Medical Review, Medical Review Criteria - Screening of healthcare use and the criteria used for this screening. Medical reviews are generally conducted by insurance companies, third-party payers, review organizations and case managers. This is the fundamental basis for reviewing the quality and appropriateness of care provided to selected cases. Insurance companies rely heavily on medical appraisal and their own criteria as cost control.

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Medical Savings Account (MSA) - An account in which individuals can build up contributions to pay for medical care or insurance. Some states offer tax-preferred status to MSA contributions, but such contributions is still subject to federal income taxation. MSAs vary from medical reimbursement accounts, sometimes called flexible benefits or Section 115 accounts, in that they need not be associated with an employer. Frequently, MSA specially refers to the Medicare and Choice delivery option that consists of a high-deductible catastrophic insurance policy and a tax-preferred medical savings account established for individual Medicare beneficiaries.

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Medical Services Organization (MSO) - A planned group of physicians, usually from one hospital, into an entity able to contract with others for the provision of services.

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Medicare- A federal program for the elderly and disabled, regardless of financial position. It is not necessary, as with Medicaid, for Medicare recipients to be poor. A U.S. health insurance program for people aged 65 and over, for persons eligible for social safety disability payments for two years or longer, and for sure workers and their dependents that need kidney transplantation or dialysis. Assessment from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured.

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Medicare Advantage Plan - A plan obtainable by a private company that contract with Medicare to provide an enrollee with all your Medicare Part A and Part B benefits. When an individual is enrolled in a Medicare Advantage Plan, Medicare services are covered throughout the plans, and are not paid for under Original Medicare.

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Medicare Advantage Prescription Drug Plan (MA-PD) - A Medicare Advantage plan that offers Medicare Prescription Drug treatment and Part A and Part B benefits in one plan.

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Medicare Cost Plans - Medicare cost plans are a kind of HMO that contracts as a Medicare Health Plan. As with other HMOs, the plan only pays for services outer its service area when they are emergency or urgently needed services. However, when enrolled in a Medicare Cost Plan, if an enrollee gets schedule services outside of the plan's network without a referral, the Medicare-covered services will be paid for under the Original Medicare Plan, and the plan enrollee will be accountable for the Original Medicare deductibles and coinsurance.

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Medicare Cost Report (MCR) - An annual report required of institutions to participate in the Medicare program. The MCR records each institution's total costs and charges connected with providing services to all patients, the portion of those costs and charges allocated to Medicare patients, and the Medicare payments received.

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Medicare Health Plans - A plan offered by a private company that contracts with Medicare to provide the enrollee with Medicare Part A and Part B benefits. Medicare Health Plans include Medicare Advantage plans Medicare Cost Plans are PACE plans and special needs plans.

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Medicare Managed Care Plan - A type of Medicare Advantage Plan that is obtainable in some areas of the country. In the majority managed care plans, enrollees can only go to doctors, specialists, or hospitals on the plan's list. Plans must envelop all Medicare Part A and Part B health care.

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Medicare Part A - The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, detention in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospital care.

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Medicare Part B - The Medicare constituent that provides benefits to cover the costs of physician's professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home, or an insured's home.

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Medicare+Choice - The Medicare component that addresses how covered services are delivered to enrollees and increase the numbers and types of healthcare organizations allowed to participate in Medicare.

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Medicare Prescription Drug Plan (PDP or MPDP) - A stand-alone drug plan, accessible by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan. Medicare Private Fee-for-Service Plans that don't offer prescription drug coverage and Medicare Cost Plans contributing Medicare prescription drug coverage. These stand-alone plans add prescription drug coverage to the Original Medicare Plan and to a few Medicare Cost Plans and Medicare Private Fee-for-Service Plans.

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Medicare Provider Analysis and Review (MedPAR) File - A CMS data file that contains charge data and scientific characteristics, such as diagnoses and procedures, for every hospital inpatient bill submitted to Medicare for payment.

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Medicare Remittance Advice Remark Codes - A national managerial code set for providing either claim-level or service-level Medicare-related messages that cannot be articulated with a Claim Adjustment Reason Code. This code set is used in the X12 835 Claim Payment & Remittance Advice transactions.

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Medicare Summary Notice (MSN) - A notice that the patients obtain after the doctors or providers file claims for Part A and Part B services in the Original Medicare Plan. It explains what the provider's payable for, the Medicare-approved amounts, how much Medicare paid, and what the citizen must pay.

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Medicare Supplement or Medicare Supplemental Policy - A private medical cost insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and coinsurance payments, or benefits for some medical expenses specifically expelled from Medicare coverage.

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Medigap- Individual medical expenditure insurance policies sold by state-licensed private insurance companies. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 consistent plans labeled Plan a through Plan L. Medigap policies only work with the Original Medicare Plan. Medigap plans vary from state to state standardized Medigap plans also may be recognized as Medicare Select plans.

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Member- Used synonymously by the terms enrollee and insured. A member is any individual or reliant who is enrolled in and covered by a managed health care plan.

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Member Advocate - An individual employed by Gundersen Lutheran Health Plan, Inc. specializing in the complaint process. The Member Advocate will get and record all grievances submitted in writing and interview the member who filed the grievance. This person will investigate grievances, assist the member during the grievance process and work with the appropriate department manager to affect resolution. This person will advise the member of the character of the grievance and the action taken.

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Member Services - The broad variety of activities that an MCO and its employees undertake to support the delivery of the promised benefits to members and to keep members satisfied with the company.

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Mental Health Parity and Mental Health Parity Act - Mental health parity refers to providing the same insurance coverage for mental health treatment as that obtainable for medical and surgical treatments. The Mental Health Parity Act was passed in 1996 and recognized parity in lifetime benefit limits and annual limits. A law which prohibits group health plans to apply more restrictive annual and lifetime limits on coverage for mental illness than for physical illness.

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Mental Health Provider - Psychiatrist, social worker, hospital or other facility approved to provide mental health services.

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Messenger Model - A type of independent practice association (IPA) that simply negotiates contract terms with MCOs on behalf of member physicians, who then agreement directly with MCOs using the terms negotiated by the IPA. This type of IPA is most frequently used with fee-for-service or discounted fee-for-service compensation arrangements.

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Midlevel Practitioner - Nurse practitioners, certified nurse-midwives and physicians' assistant who have been trained to provide medical services that otherwise might be performed by a physician. Depending upon state rules and regulations, midlevel practitioners may put into practice under the supervision of a doctor of medicine or osteopathy who takes responsibility for the care the midlevels provide.

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Military Health System (MHS) and Military Treatment Facilities (MTFs) - A worldwide healthcare system operated by the U.S. Department of Defense that focuses its efforts on population health improvement to integrate the delivery of healthcare services for active-duty personnel, retirees, and the families of active-duty personnel and retirees.

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Morbidity- The extent of illness, injury, or disability in a distinct population. It is typically expressed in general or specific rates of incidence or prevalence.

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Mortality- Used to describe the relation of deaths to the population in which they happen. The mortality rate expresses the number of deaths in a unit of population within a prescribed time and may be expressed as crude death rates or as death rates specific for diseases and, sometimes, for age, sex, or other attributes.

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Multiple Employer Trust (MET) - A legal trust recognized by a plan sponsor that brings together a number of small, unrelated employers for the reason of providing group medical coverage on an insured or self-funded basis. Not quite a Health Plan Purchasing Cooperative, but all along the same lines.

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Multiple Employer Welfare Arrangement (MEWA) - As defined in 1983 Erlenborn ERISA Amendment, an employee welfare benefit plan or any other understanding providing any of the benefits of an employee welfare profit plan to the employees of two or more employers. MEWAs that do not meet the ERISA definition of employee benefit plan and are not specialized by the U.S. Department of Labor may be regulated by states.

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