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Mail-Order Drug: Drugs that may be ordered via mail. Certain mail-order pharmacies will supply customers with a three-month supply of their maintenance medications.
Maintenance List: See Additional Drug Benefit List
Major Diagnostic Category (MDC): Refers to a clinical grouping of ICD-9-CM diagnoses associated with major organ system.
Major Services: Refers to major dental surgery associated with endodontics, periodontics, and prosthetics.
Managed Care: Refers to a healthcare delivery system that is associated with utilization, service costs, and quality of care. Sometimes referred to as managed healthcare.
Managed Competition: Refers to a policy approach for assessing health insurance plans based on cost and various other factors. The approach is used to foster health competition among health insurance plans.
Managed Healthcare Plan: The organization that manages and provides financing for contracted healthcare members to supply their healthcare needs. It also assesses and evaluates patterns of medical usage and cost for services.
Management Service Organization (MSO): Refers to a legal entity that offers management services, administrative services, and support services for group medical practices or individual practices. See also Integrated Delivery System.
Managing General Underwriter: An entity that takes on risks associated with an insurance company.
Mandate: A state or federal law requirement for a certain procedure or a type of coverage that a health insurance plan must offer.
Mandated Benefits: The benefits that must be provided in association with state or federals laws to policy holders as well as their dependents.
Mandated Providers: Refers to certified providers of medical care, including physicians, psychologists, chiropractors, optometrists, and more whose services are included in health insurance plan coverage.
Manual Rates: Refers to rates that are developed in accordance with a health plans average claims. These rates are then adjusted benefit variations.
Master Group Contract: See Group Policy
Maximum Allowable Cost (MAC): Refers to a list of prescription drugs that will be covered at the same cost as a generic product as stated by the health insurance plan. Participating pharmacies use the list, which is subject to regular review. In some cases, individuals may have to pay a differential cost for brand-name drugs.
Maximum Allowable Fee Schedule: Refers to a healthcare payment system. It reimburses a specified dollar amount for services.
Maximum Dollar Limit: Refers to the maximum amount that an insurer will pay. Insurance plans may either have a lifetime limit or an annual dollar limit. The most common lifetime limit is a one-million-dollar limit.
Maximum Out-of-Pocket Costs: The amount that an enrollee must pay in total for copayments, deductible costs, and co-insurance in accordance with the health insurance contract.
Medicaid: The federal program that administers medical benefits to eligible low-income people and families. The cost of the program is shared by state and federal governments.
Medical Care Plan: This type of plan provides payment to hospitals or clinical healthcare providers for medical care.
Medical Care Ratio: Refers to the cost ratio of insurance benefits used to the premium amounts received. It is also known as the medical loss ratio.
Medical Cost Ratio - See Medical Care Ratio
Medical Expense Trend: The rate by which medical costs change in accordance with various factors such as medical care costs, cost shifting, and the costs of medical technology.
Medical Foundation: Refers to a not-for-profit entity associated with a professional services contract. See also Integrated Delivery System.
Medical Loss Ratio: See Loss Ratio.
Medical Management: Refers to the coordination of healthcare services provided by medical management in conjunction with doctors and other healthcare providers to treat a patient.
Medical Necessity: Refers to healthcare service evaluation of medical-appropriate care or treatment in order to meet the basic healthcare needs of individuals associated with a medical condition or diagnosis. This evaluation must be consistent with national medical guidelines in accordance with frequency, type, and duration of treatment.
Medical Supplies: Refers to items used for their intrinsic therapeutic, diagnostic, or medical treatment. It includes but is not limited to syringes, surgical dressings, intravenous fluids, etc...
Medicare: A national, federal health insurance program that covers the costs of medical care, hospitalization, and some associated medical costs for eligible people--essentially individuals aged 65 or old and disabled individuals under age 65. According to the program: .
Part A provides coverage for hospitals stays, nursing facility care, and hospice. .
Part B provides coverage for physician services, outpatient procedures, clinic services, lab services and more.
Medicare Beneficiary: Individual designated by the Social Security Administration as entitled to Medicare benefits.
Medicare + Choice Plans: Agreement between a Medicare and Choice entity and HCFA to provide Medicare+ Choice health plans. These plans may include HMO, PSO, and PPO as well as others for a fee that is paid in part by the Medicare + Choice entity and the enrollee.
Medicare Payment Assessment Commission (MedPAC): Refers to the Congressional advisory group that advises Congress about Medicare policy issues.
Medicare Supplement Policy: A policy of insurance the pays a policyholder's Medicare deductible or co-insurance for Medicare Parts A and B. It may also offer supplemental benefits in association with the type of policy shown. This policy may also be referred to as Medigap.
Medigap - see Medicare Supplement Policy
Member: Refers to an individual enrolled in a health insurance plan. This person is also known as the plan participant or enrollee.
Member Assistance Program (MAP): Refers to the human risk management program that attempts to lower medical healthcare costs by reducing treatment system demand. The program targets covered individuals and insurance providers.
Member Category: A member group classified in order to determine appropriated healthcare provider reimbursement levels. Sometimes referred to as Member Type.
Member Certificate: See Certificate of Coverage or Member Policy
Member Month: Records one month for each month the enrollee is a member of a health insurance plan.
Members Per Year: Refers to the number of members who are active on a health plan.
Membership: Refers to the number of individuals on a managed health insurance plan for a specified reporting period.
Mental Health and Substance Abuse Treatment: Refers to the multi-type health treatments provided to individuals who abuse or are addicted to drugs or alcohol. Typically, coverage for this type of treatment is less comprehensive than treatment for other medical conditions.
Mental Health Provider: Refers to a certified provider of mental healthcare services. Providers are psychiatrists, licensed psychologists, social workers, or other certified staff.
Minimum Premium: The portion that an employer must pay to an insurer to administer its benefits program.
Modified Community Rating (MCR): See Adjusted Community Rating
Modified Fee-For-Service: Refers to a system where healthcare providers will be paid in accordance with fee-for services.
Morbidity: Refers to the actuarial determination of the severity and incidence of illnesses and injuries with defined classes of individuals.
Mortality: A determination of the death rate in accordance with death probability and survival rates for each age.
Multidisciplinary: Refers to treatment plans and medical care delivery provided by healthcare professionals who represent multiple medical specialties.
Multiple Employer Trust (MET): Refers to a trust that allows small employers in related industries band together to provide health insurance under a trust agreement.
Multiple Employer Welfare Arrangement (MEWA): This is an employee welfare plan that's designed to offer benefits to employees associated with two or more employers.
Multiple Option Plan: Refers to a healthcare plan model that gives employees the option to enroll under various types of coverage. It's usually provided by an HMO or PPO.