A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z

Sanction- warning that gives binding force to a law or rule, or secures obedience to it, as the penalty for breaking it, or a return for carrying it out. The government and its agencies can authorize hospitals, providers and health plans. Health plans sometimes look for to sanction hospitals and physicians.

Back to top

Secondary Care - Services provided by medical specialists who usually do not have first contact with patients. In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than transfer by primary care providers.

Back to top

Secondary Coverage - Health plan that pays costs not enclosed by primary coverage under coordination of benefits rules. Any insurance that supplements Medicare treatment. There are three main sources for secondary insurance are employers, privately used to purchase Medigap plans, and Medicaid.

Back to top

Secondary Payer - An insurance policy, plan, or program that pays second on a assert for medical care. This could be Medicare, Medicaid, or other insurance that depend on the circumstances and may or may not be Supplemental Insurance.

Back to top

Second Opinion - This is when another doctor gives his or her vision about what another doctor has said a patient has and how it should be treat.

Back to top

Self-Funding or Self-Funded Plan - Employer or organization assumes total liability for health care losses of its covered employees. This usually includes setting up a fund against which claim payments are drawn and claims dispensation is often handled through a managerial services contract with an independent organization.

Back to top

Self-Insurance or Self-Insured - An individual or organization that assumes the monetary risk of paying for health care. This term is usually used to explain the type of insurance that an employer provides. When an employer is self-insured, this means that the payer or managed care company manages the employer's funds whether it require the employer to pay premiums.

Back to top

Sentinel Event - Adverse health events that may have been avoided through suitable care or alternate interventions. Providers are necessary to alert JCAHO and frequently state licensing authorities of all guard events, including a review of risk factors, preventative measures and case analysis.

Back to top

Service Area - The region where a health plan accepts members. For plans that need enrollees to use convinced doctors and hospitals, it is also the area where services are provided. Service area is also a word used by hospitals to explain the geographic or catchment area from which the hospital may be given referrals or admissions.

Back to top

Service Category Definition - A broad description of the types of services provided below the service and/or the characteristics that define the service category.

Back to top

Shadow Pricing - Inside a given employer group, pricing of premiums by HMO based upon the cost of indemnity insurance coverage, rather than severe adherence to community rating or knowledge rating criteria.

Back to top

Shared Savings - A stipulation of most prepaid health care plans where at least part of the providers' income is directly connected to the financial performance of the plan. If costs are lower than projections, a proportion of these savings are referred to the providers.

Back to top

Single-Stream Funding - The consolidation of multiple sources of financial support into a single stream. For example, this is a key move toward used in some progressive mental health systems to ensure that "funds follow consumers."

Back to top

Site Appropriateness Listings - A resource for the appraisal of surgery and certain no surgical interventions that indicates the most appropriate settings for ordinary procedures.

Back to top

Site-of-Service Differential - The difference in the monies paid when the same service is used to perform in different practice setting or by a different provider.

Back to top

Skilled Care - A type of health care given when a patient needs accomplished nursing or treatment staffs to manage, observe, and evaluate care. Usually refers to a level of care that is lower, or less intense, than inpatient hospital care.

Back to top

Skilled Nursing Care - A level of care that includes services that can only be performed securely and properly by a licensed nurse.

Back to top

Small Group Market - The insurance market for products sold to groups that are lesser than a specified size, classically employer groups. The size of groups incorporated usually depends on state insurance laws and thus differ from state to state, with 50 employees the most ordinary size, and normally ranging from 2 to 99 members.

Back to top

Solo Practice, Solo Practitioner - A physician who practices only or with others but does not pool income or expenses. This form of practice is becoming increasingly less frequent as physicians band together for constricting, overhead costs and risk sharing.

Back to top

Special Election Period - A term used by CMS to explain a set time that a beneficiary can alter health plans or return to the Original Medicare Plan, such as the citizen moves outside the service area, Medicare Choice organization violates its contract with the citizen, organization does not renew its agreement with CMS, or other exceptional conditions resolute by CMS.

Back to top

Special Enrollment Period - A set time when a senior citizen can sign up for Medicare Part B, without punishment. If the citizen did not take Medicare Part B throughout the Initial Enrollment Period because the citizen or the citizen's spouse were working and had group health plan coverage during an employer or union. The citizen can sign up at anytime while he or she is covered under the group plan based on present employment position.

Back to top

Specialist- A doctor who treats only convinced parts of the body, certain health problems, or certain age groups. Usually, a specialist has received advanced training in a specialty field. Some health plans need enrollees to obtain a referral from a primary care provider previous to seeing a specialist in order for the specialist care to be reimbursed.

Back to top

Special Needs Plan - A special type of plan that provides more alert health care for specific groups of people, such as those who have both Medicare and Medicaid, who exist in a nursing home, or who have sure chronic medical conditions.

Back to top

Spend Down - A term used in Medicaid for persons whose income and assets are over the threshold for the state's designated medically deprived criteria, but are below this doorstep when medical expenses are factored in. The amount of expenditures for health care services, relative to income, that qualifies an individual for Medicaid in States that cover firmly eligible, medically indigent individuals.

Back to top

Spider Graphs/Charts - A technique or tool developed by Ernst & Young, to unite analyses of a market's level of managed care evolution with an internal willingness review.

Back to top

Staff Model HMO - A closed-panel HMO whose general practitioners are employees of the HMO. All premiums and other revenues accumulate to the HMO, which, in twist, compensates physicians. Very much like the group representation, except the doctors are employees of the HMO. Normally, all ambulatory health services are provided less than one roof in the staff model.

Back to top

Standard Class Rate (SCR) - Base revenue obligation per member multiplied by demographic information to decide monthly premium rates.

Back to top

Standard Community Rating - A type of community ranking in which an MCO considers only community-wide data and establishes the same financial presentation goals for all risk classes.

Back to top

Standard of Care - An analytic and treatment process that a clinician should pursue for a certain type of patient, illness, or clinical circumstance.

Back to top

Standards- According to the Institute of Medicine, Standards are reliable statements of Minimum levels of acceptable performance or results, excellent levels of presentation or results and the range of satisfactory performance or results.

Back to top

Statutory Solvency - An MCO's capability to maintain at least the minimum amount of capital and surplus specific by state insurance regulators.

Back to top

Structural Integration - The unification of before separate providers under ordinary ownership or control.

Back to top

Subscriber- Employment group or person that contracts with an insurer for medical services. Person or group accountable for payment of premiums, or person whose employment is the foundation for membership in a health plan.

Back to top

Subsidy- A monetary grant paid by the government to a private person or company to help an enterprise deemed beneficial to the public.

Back to top

Subrogation- Procedure where insurance company recovers from a third party when the act resulting in medical expense was the responsibility of another person. The revival of the cost of services and benefits provided to the insured of one health plan when other parties are legally responsible.

Back to top

Supplemental Insurance - Any private health insurance plan detained by a Medicare beneficiary or profitable beneficiary, including Medigap policies and post-retirement health benefits. Supplemental frequently pays the deductible or co-pay and sometimes will pay the whole bill when the primary carrier's benefits are tired.

Back to top

Supplemental Medical Insurance (SMI) - Part B normally covers the outpatient services, as different to Part A that covers inpatient. This charitable program requires payment of a monthly premium, which covers 25 percent of pro-ram costs. Beneficiaries are liable for a deductible and coinsurance payments for most covered services.

Back to top

Supplier- Normally, any company, person, or agency that provides supplies to medical providers or that provides medical items or services, like wheelchair or walkers, straight to patients.

Back to top

Surplus Lines Tax - A tax compulsory by state law when coverage is placed with an insurer not licensed or admitted to manage business in the state where the risk is located. Unlike premium tax for admitted insurers, the surplus lines tax is not incorporated in the premium and must be composed from the policyholder and remitted to the state.

Back to top