CHC Vocab (A through H) Flashcards
Question
Answer
Access
A Patient’s ability to obtain medical care. The ease of access
is determined by components such as the availability to the
patient, availability of insurance, the location of health care
facilities, transportation, hours of operation, affordability
and cost of care.
24-Hour Coverage
In general, 24-hour coverage has been proposed as a type of health care system reform that integrates the health coverage and benefits currently offered by public and
private insurance programs, state workers’ compensation
systems, and automobile insurance.
Accountable Health
Plans (AHP)
Under the Managed Care Act, providers and insurance
companies would be encouraged (through tax incentives) to
form AHPs, similar to HMOs, PPOs, and other group
practices. Accountable health plans would compete on the
basis of offering high-quality, low-cost care and would offer
insurance and health care as a single product. They would
be responsible for looking after the total health of members
and reporting medical outcomes in accordance with Federal
guidelines.
Accreditation
Approval by an authorizing agency for institutions and
programs that meet or exceed a set of pre-determined
standards.
Accredited
To meet the standards set by a non-governmental, state or
national peer group.
Accrete
The addition of new enrollee to a health plan, usually used
in reference to Medicare.
Activities of Daily
Living (ADLs)
Activities performed as part of a person’s daily routine of
self-care such as bathing, dressing, toileting and eating.
Actual Charge
The amount a physician or other provider actually bills a
patient for a particular medical service, procedure or supply
in a specific instance. The actual charge may differ from the
usual, customary, prevailing, and/or reasonable charge.
Actuarial Analysis
The statistical calculations used to determine the managed
care company’s rates and premiums charged their
customers based on projections of utilization and cost for a
defined population.
Actuarial Analysis
The statistical calculations used to determine the managed
care company’s rates and premiums charged their
customers based on projections of utilization and cost for a
defined population.
Actuarial Cost of
Coverage
The expected dollar value of a health plan’s benefits. The
method of determining this value may be based entirely on a
plan’s provisions, or may adjust for the geographic location
and demographic characteristics of enrollees, the actual
health care utilization level by plan participants, or the type
of plan under which the benefits are provided.
Actuarial Soundness
The requirement that the development of capitation rates
meet common actuarial principles and rules.
Actuary
A person in the insurance field who decides policy rates and
conducts various other statistical studies.
Acute Care
Hospital care given to patients who generally require a stay
of up to seven days and that focuses on a physical or mental
condition requiring immediate intervention and constant
medical attention, equipment and personnel.
Acute Care Bed Need Methodology
A formula used to determine hospital bed needs.
Adjusted Average Per Capita Cost (AAPCC)
A county-level estimate of the average cost incurred by
Medicare for each beneficiary in the fee-for-service system.
Adjusted Community Rating
Community rating impacted by group specific demographics.
Adjusted Payment
Rate (APR)
The Medicare capitated payment to risk-contract HMOs. For
a given plan, the APR is determined by adjusted county-level
AAPCCs to reflect the relative risks of the plan’s enrollees.
Administration on
Aging (AoA)
The AoA is the principal Federal agency responsible for
programs authorized under the Older Americans Act of
1965. The AoA serves as an advocate for older persons at
the national level, advises Congress and Federal agencies on
the characteristics and needs of older people, and develops
programs designed to promote the health and well-being of
the older population. AoA provides advice, funding, and
assistance to achieve community-based systems of
comprehensive social services for older people.
Administrative Costs
Costs related to activities such as utilization review,
marketing, medical underwriting, commissions, premium
collection, claims processing, insurer profit, quality
assurance, and risk management for purposes of insurance.
Administrative Costs
Savings
Reductions in expenditures related to changes in the
administrative costs associated with the provision of health
care coverage and services.
Administrative
Loading
The amount added to the prospective actuarial cost of the
health care services (pure premium) for administrative,
marketing expenses and profit.
Administrative Reform
Reducing paperwork though simplified universal forms or
electronic filing and processing of claims.
Administrative
Services Only
An agency that delivers administrative services to an
employer group. This type of arrangement usually requires
the employer to be at risk for the cost of health care services
provided.
Administrative
Services Organization
(ASO)
An entity which only provides administrative services
(including claims adjudication, member services, and
management information reporting).
Admissions/1000
APT
The number of hospital admissions per 1.000 health plan
members during a given period.
Adult Day Care
A program of social and health-related services provided
during the day in a community group setting. The purpose of
the program is to support frail or impaired elderly, or other
disabled adults who can benefit from care in a group setting
outside the home.
Adult Foster Care
AFC
An elderly person’s placement with another family when
independent living is no longer possible, but nursing care is
not necessary. Also see family rest residential.
Adult Protective
Services (APS)
Social service interventions for impaired adults at risk of
abuse, neglect or exploitation.
Advance Directive
A document that patients complete to direct their medical
care when they are unable to communicate their own
wishes due to a medical condition.
Advanced Practice
Nurse (APN)
A registered nurse who is approved by the Board of Nursing
to practice nursing in a specified area of advanced nursing
practice. APN is an umbrella term given to a registered
nurse who has met advanced educational and clinical
practice requirements beyond the two to four years of basic
nursing education required for all RNs. There are four types:
1. Certified Registered Nurse Anesthetist (CRNA); 2. Clinical
Nurse Specialist (CNS); 3. Certified Nurse Practitioner
(CNP); and 4. Certified Nurse Midwife (CNM).
Adverse Selection
Among applicants for a given group or individual health
insurance program, the tendency for those with an impaired
health status, or who are prone to higher-than-average
utilization of benefits, to be enrolled in disproportionate
numbers in lower deductible plans.
Aftercare
Services following hospitalization or rehabilitation
individualized for each patient’s needs. Aftercare gradually
phases the patient out of treatment while providing followup
attention to prevent relapse.
Age/Sex Factor
A measurement used in insurance underwriting. It
represents the age and sex risk of medical costs of one
population relative to another. For example, a group with an
age/sex factor of 1.05 would be expected to incur medical
costs 5% greater than the average.
Age/Sex Rates (ASR)
Set of rates for a grouping based on age and sex categories
used to calculate premiums. This type of premium structure
is often preferred over single and family rating in small
groups because it automatically adjusts to demographic
changes in the group. Also called table rates.
Agency for Health Care
Policy and Research
(AHCPR)
A Federal agency within the Public Health Service
responsible for research on quality, appropriateness,
effectiveness and cost of health care.
Aging in Place
Process allowing seniors to remain in their current
residence despite changes in their needs by adjusting the
degree and type of services provided. This can occur at
home or in a facility offering multiple levels of care.
Aging Network
A highly complex and differentiated system of Federal, State,
and local agencies, organizations and institutions which are
responsible for serving and/or representing the needs of
older persons. The network is involved in service systems
development, advocacy, planning, research, coordination,
policy development, training and education, administration,
and direct service provision. The core structures in the
network include the Administration on Aging (AoA), State
Units on Aging (SUA), Area Agencies on Aging (AAA), and
local service provider agencies.
Aid to Families with
Dependant Children
(AFDC)
A Federally supported, state-administered program
established by the Social Security Act of 1935 that provides
financial support for children under the age of 18 (and their
caretakers) who have been deprived of parental support or
care because of the parent’s death, continued absence from
the home, unemployment, or physical or mental illness.
Alien Insurance
Company
An insurance company that operates under the laws of
another country.
All Patient Diagnosis
Related Groups
(APDRG)
An enhancement of the original Diagnostic Related Groups,
designed to apply to a population broader than that of
Medicare beneficiaries, who are predominately older
individuals. The APDRG set includes groupings for pediatric
and maternity cases as well as of services for HIV-related
conditions and other special cases.
All-Payer System
A plan to impose uniform prices on medical services,
regardless of who’s paying.
Allied Health
General term referring to a variety of non-physician and
non-nursing clinicians, practitioners, therapists,
technologists and technicians working in the health field.
Allied Health
Personnel or Allied
Health Professional
Specially trained and often licensed health workers other
than physicians, dentists, optometrists, chiropractors,
podiatrists, and nurses. The term is sometimes used
synonymously with paramedical personal, all health workers who perform tasks that must otherwise be
performed by a physician, or health workers who do not
usually engage in independent practice.
Allopathic
One of two schools of medicine that treats disease by
inducing effects opposite to those produced by the disease.
The other school of medicine is osteopathic.
Allowable Costs
Charges for services rendered or supplies furnished by a
health care provider, which qualify as covered expenses for
insurance purposes.
Allowable Charge
Generic term referring to the maximum fee that a third
party will use in determining reimbursement for a given
service or supply. An allowable charge may not always be
the same as the actual charge.
Alternative Delivery
Sites
Substitute for traditional inpatient sites for care such as
ambulatory care centers, surgicenters, home care, hospice
care, or alternative delivery and financing systems such as
health maintenance organizations (HMOs), or preferred
provider arrangements.
Alternative Delivery
System (ADS)
An alternative to traditional inpatient care such as
ambulatory care, home health care and same day surgery.
Also used as an expression to describe all forms of health
care delivery systems other than traditional fee-for-service
indemnity health care.
Alternative Levels of
Care
Alternatives to traditional acute impatient care, such as
ambulatory care centers, surgicenters, home care, skilled
nursing facilities, and hospices.
Am.
Amended. A designation sometimes found before a House or
Senate bill number showing that formal changes have been
made to an introduced piece of legislation during the
legislative process.
Ambulance Restocking
The practice of hospital replenishing certain drugs and
supplies used by an ambulance service during transport of a
patient to the hospital.
Ambulatory
Able to get from one place to another independently (even if
using assistive devices such as manual wheelchairs, canes or
walkers).
Ambulatory Care
Care given to patients who do not require overnight
hospitalization.
Ambulatory Patient
Group (APGS)
A payment system that pays a fixed price for certain types of
outpatient procedures.
Ambulatory Setting
An institutional health setting in which organized health
services are provided on an outpatient basis, such as
surgery center, clinic or other outpatient facility.
Ambulatory care settings also may be mobile units of
services, e.g., mobile mammography, MRI.
Ambulatory Surgical
Center (ASC)
Freestanding centers that perform surgeries which do not
require an overnight stay.
Ambulatory Utilization
Management
Review prior to service against established standards to
determine the medical necessity and appropriateness of the
care to be provided in an ambulatory setting. The selection
of treatment plans subject to pre-service review may be
based upon criteria such as proposed care that would
require frequent visits, expensive therapy, an extended
course of therapy, or costly technology. Concurrent review
would be applied as appropriate.
Accreditation
Healthcare
Commission
(AAHC/URAC)
Formerly known as the Utilization Review Accreditation
Commission, AAHC/URAC is an independent not-for-profit
corporation which develops national standards for
utilization review and managed care organizations.
American Association
of Homes and Services
for the Aging (AAHSA)
AAHSA represents not-for-profit organizations dedicated to
providing high quality health care, housing and services to
the nation’s elderly. Its memberships consists of over 5,000
not-for-profit nursing homes, continuing care retirement
communities, senior housing facilities, assisted living and
community services. AAHSA organizations serve more than
one million older persons of all income levels, creed and
races. It serves these members by representing the concerns
of not-for-profit organizations that serve the elderly through
interaction with Congress and Federal agencies. It also
strives to enhance the professionalism of practitioners and
facilities through the Certification Program for Retirement
Housing professionals, the Continuing Care Accreditation
Commission, conferences and programs offered by the
AAHSA Professional Development Institute and publications
representing current thinking in the long-term care and
retirement housing fields.
American College of
Healthcare Executives
(ACHE)
An international professional society of nearly 30,000
healthcare executives. ACHE is known for it’s prestigious
credentialing and educational programs. ACHE is also
known for its journal and magazines as well as
groundbreaking research and career development and
public policy programs. ACHE’’ publishing division is a
major publisher of books and journals on all aspects of health services management in addition to textbooks for use
in college and university courses. Through its efforts, ACHE
works toward its goal of improving the health status of
society by advancing healthcare management excellence.
ACHE headquarters is based in Chicago, IL.
American Health Care
Association (AHCA)
A trade association representing nursing homes and long
term care facilities in the United States; based in
Washington, D.C.
American Hospital
Association (AHA)
A national association that represents allopathic and
osteopathic hospitals in the United States; based in
Washington, D.C. with operational offices in Chicago.
American Medical
Association (AMA)
A national association organized into local and regional
societies that represent over 700,000 medical doctors in the
United States; based in Chicago.
American with Disabilities Act (ADA)
A Federal law which prohibits employers of more than 25
employees from discriminating against any individual with a
disability who can perform the essential functions, with or
without accommodations, of the job that the individual
holds or wants.
Amount, Duration and
Scope
How a Medicaid benefit is defined and limited in a state’s
Medicaid plan. Each state defines these parameters, thus
state Medicaid plans vary in what is actually covered.
Ancillary Care
A term used to describe additional services performed
related to care, such as lab work, X-ray and anesthesia.
Ancillary Charge
Also referred to as hospital “extras” or miscellaneous
hospital charges. They are supplementary to a hospital’s
daily room and board charge. They include such items as
charges for drugs, medicines and dressings; laboratory
services; x-ray examinations; and use of the operating room.
Anti-Kickback Statute
A Federal law that prohibits the paying or receiving of
remuneration in exchange for the referral of patients or
businesses paid by a Federal health care program.
Antitrust
A situation in which a single entity, such as integrated
delivery system, controls enough of the practices in any one
specialty in a relevant market to have monopoly power (i.e.,
the power to increase prices).
Any Willing Provider
A term used to describe legislation that requires a health
plan to accept on its provider panels every physician,
hospital or other practitioner that wants to participate in
the health plan’s products.
Approved Charge
The maximum fee Medicare will pay in a given area for a
covered service.
Approved Health Care
Facility or Program
Facility or Program that is licensed, certified or otherwise
authorized pursuant to the laws of the state to provide
health care and which is approved by a health plan to
provide the care described in a contract.
Area Agency on Aging
AAA
A public or private nonprofit organization designated by the
state to develop and administer the area plan on aging
within a sub-state geographic planning and service area.
AAAs advocate on behalf of older people within the area and
develop community-based plans for services to meet their
needs. AAAs administer Federal, State, local and private
funds through contracts with local service providers. In
Delaware the State Unit on Aging also services as the state’s
sole Area Agency on Aging.
Asset
Medicaid term referring to resources such as savings, stocks,
bonds, and certain possessions that are considered in
determining financial eligibility.
Assignment of Benefits
A method under which a claimant requests that his/her
benefits under a claim be paid to some designated person or
institution, usually a physician or hospital.
Assisted Living Facility
ALF
Home-like residential option that provides personal care
and scheduled nursing care as needed.
Assistive Devices or
Technology
Any tools that are designed, fabricated, and/or adapted to
assist a person in performing a particular task, e.g., cane,
walker, shower chair, computer speech recognition,
communication device.
Associate Degree in
Nursing (AND)
A degree received after completing a two-year nursing
education program at a college or university.
At-Risk
Having to assume the financial liability for a loss that occurs
when premiums paid are less than the cost of services
provided.
Attendant
Term used most often by the disability community to refer
to an aide who provides personal assistance in the
community. Also see personal care.
Attrition Rate
Disenrollment or fall-out rate expressed as a percentage of
total membership. Off-open enrollment terminations are
generally due to subscriber’s employment or relocation
outside of the MCO’s service area, and cannot be controlled.
Open enrollment terminations are sometimes due to
subscriber dissatisfaction and thus may be controllable.
Audiologist
Performs duties directly related to problems and disorders
of human communication in the process of speech and
hearing
Audit of Provider
Treatment
Review of the patient’s medical record and charges and
claims for services to assure that the services provided were
consistent with the patient’s diagnosis(es) and that documentation in the medical record supports the submitted charges.
Authorization
As it applies to managed care, authorization is the approval
of care, such as hospitalization. Pre-authorization may be
required before a patient is admitted or care is given by (or
reimbursed to) non-HMO providers.
Auto-Assignment
A term used with Medicaid mandatory managed care
enrollment plans. Medicaid recipients who do not specify
their choice for a contracted plan within a specified time
frame are assigned to a plan by the state. Can also refer to
assignment to primary care physicians.
Average Adjusted Per Capita Cost (AAPCC)
Payment rates used by the Health Care Financing
Administration to reimburse managed care organizations
for care delivered to Medicare enrollees.
Average Cost (or Average Benefit)
The average cost (or benefit) for a unit of output (e.g., one
day in a hospital for one patient) is the total cost (or benefit)
of the total units of output delivered by the total units of
output.
Average Length of Stay
ALOS
A standard hospital statistic used to determine the average
amount of time between admission and discharge for
patients in a diagnosis related group (DRG), an age group, a
specific hospital or other factors.
Bachelor of Science in
Nursing (BSN)
Degree received after completing a four-year college or university program that qualifies a graduate nurse to take a national licensing exam to become a registered nurse.
Balance Bill
The fee amount remaining after patient co-payments.
Balance Billing
A provider’s billing of a covered person directly for charges above the amount reimbursed by the health plan (i.e., difference between billed charges and the amount paid). This may or may not be allowed, depending upon the contractual arrangements between the parties.
Balanced Budget Act of
1997 (BBA)
This law made sweeping changes in the Medicare and
Medicaid programs. Several of the significant provisions of the BBA were payment reductions to health care providers, new prospective payment systems for health care providers, and reduction of coverage of health care services by the Medicare and Medicaid programs.
Base
A set dollar amount to cover the cost of health care per covered person excluding mental health/substance abuse
services, pharmacy and administrative charges.
Base Capitation
A stipulated dollar amount to cover the health care per covered person less mental health/substance abuse
services, pharmacy and administrative charges.
Basic Benefits Package
A core set of health benefits that everyone in the country should have either through their employer, a government program, or a risk pool.
Bed Days/1000
The number of impatient days per 1000 health plan members for a fixed period of time.
Bed Reservation Benefit
In some long-term care policies, a benefit paid to maintain
the enrollee’s space in a nursing home facility when the
enrollee must be hospitalized temporarily
Behavioral Health Care
Mental services, including services for alcohol and substance abuse.
Benchmarks
Long-range measurable goals that speak to changing conditions. See also Performance Measures, Quality
Assurance, Key Indicators, Outcome Measures.
Beneficiary
A person designated by an insuring organization as eligible to receive insurance benefits.
Benefit
Amount payable by the insurance company to a claimant, assignee, or beneficiary, when the insured suffers a loss
covered by the policy.
Benefit Cap
The lifetime dollar or day limitation of an insurance policy.
Benefit Design
Selection of services, providers, and beneficiary obligations
to create the scope of coverage.
Benefit Level
The limit or degree of services a person is entitled to receive based on his/her contract with a health plan or insurer.
Benefit Package
Services an insurer, government agency, health plan, or an employer offers under the terms of a contract.
Benefit Payment
Schedule
List of the amounts an insurance plan will pay for covered health care services.
Benefit Period
The maximum length of time specified in an insurance product during which benefits will be paid.
Benefit Redesign
Restructuring employee health benefit plans by providing incentives for prudent consumer behavior, such as
introducing coverage for treatment in alternative settings;
establishing managed care provisions such as pre-admission testing, second surgical opinions and pre-admission
certification; establishing alternative financial
arrangements, such as creating individual health accounts; or changing employee premium contribution, co-payment, or deductible levels.
Benefits Tax
A tax all workers would be required to pay based on the value of employer-provided health benefits which exceeds a
certain level, or a limit on the tax deduction employers currently take for providing benefits.
Biased Selection
The phenomena whereby individuals or groups with atypical health risks disproportionately enroll in a specific health plan or type of health plan. Favorable selection occurs when a plan’s enrollment predominantly consists of above-average health risks, while plans that
disproportionately enroll individuals (and groups) of below- average health risks are said to experience adverse
selection. Biased selection may be influenced by individual
decisions in response to benefit design and plan characteristics as well as by insurer marketing and rating practices.
Billed Claims
The fees or costs for health care services provided to a covered person submitted by a health care provider.
Bio-Medical Engineering Technician
Inspects, repairs, maintains, calibrates and modifies
electronic, electrical, mechanical and hydraulic equipment and instruments used in medical therapy and diagnosis, according to schematic and verbal instructions
Block Grant
An intergovernmental transfer of Federal funds to states and local governments for broad purposes such as health,
education or community development in general. A block
grant holds few requirements for how the money is to be spent, instead offering state and local discretion within
general guidelines established by Congress and the
executive branch. Annual program plans or applications are normally required. Also see categorical grant or formula grant.
Blue Cross and Blue Shield Association (BC/BS)
An organization that offers information, consultation, representation and operational services for the Blue Cross
and Blue Shield plan members across the country for
purposes of providing insurance benefits.
Board and Care
Residential option providing no direct health or personal care services. Also see foster care, rest residential care,
family rest residential care, and adult foster care.
Board Certified
A clinician who has passed the national examination in a particular field. Board certification is available for most physician specialties, as well as for many allied medical professions.
Board Eligible
A term used to describe a physician who is eligible to take the specialty board examination by virtue of having
graduated from an approved medical school, completed a
specific type and length of training and practiced for a specified amount of time.
Boren Amendment
An amendment to OBRA 80 which repealed the requirement that states follow Medicare principles in reimbursing hospitals, nursing facilities and intermediate care facilities for the mentally retarded (ICF/MR) under the Medicaid program. The amendment substituted language which required states to develop payment rates which were “reasonable and adequate” to meet the costs of “efficiently and economically operated” providers (Recently repealed under the Balanced Budget Act).
Boutique Hospital
A limited service hospital designed to provide one medical specialty such as orthopedic or cardiac care.
Bundling Payment or Bundled Payment Bundled Rate
The use of a single payment for a group of related services.
Bundled Services
Payments that represent an amalgamation of services.
A single comprehensive group of related services. Payments
for bundled services have become the norm in recent years and unbundled services are investigated closely by HCFA
and other payers for evidence of fraud.
Buy-In
Refers to instances where a state Medicaid program agrees to pay the Medicare premiums and cost sharing for members of a specified group.
Cafeteria Plan
Flexible benefit plan under which the employer provides a range of taxable and nontaxable benefits options from which
each eligible employee can make a limited number of selections. Options that may be available to employees
through these plans include life insurance, health programs, retirement plans, vacation time, and stock options.
Nontaxable benefits can include group term life insurance up to a specified amount of coverage, disability benefits,
accident and health benefits, and group legal services to the extent that such benefits are excludable from gross income.
A cafeteria plan that includes taxable and nontaxable benefits must meet certain requirements under the Internal
Revenue Code. The term “Cafeteria Plan” may also describe a health benefit program that allows employees to select
among various cost, coverage, or provider options.
California Public Employees’ Retirement System (CalPERS)
A health insurance program available to California’s public employees and their dependents that focuses on the
maintenance of a large risk pool, the promotion of managed care strategies and a standard benefit package.
Canadian-Style System
A health care financing system based upon the system in place in Canada that provides tax-financed universal
coverage with the government as the sole purchaser of services.
Capital Costs
Equipment and physical plant costs, but not consumable supplies. Included in these costs can be interest, leases, rentals, taxes and insurance on physical assets like plant and equipment.
Capitation (CAP)
The payment of a per capita amount for a defined package of health care services. A specific dollar amount per member per month is paid to providers or organizations of providers for which they provide specific services, regardless of the quantity of services necessary to meet the health needs of the defined population.
Care Coordination
Benefit
A benefit in newer long-term care policies that pays consultation fees for a professional, such as a registered nurse or a medical social worker, to periodically assess and make recommendations about the enrollee’s care program. The purpose is to adjust services when and if the individual’s care needs change. Also called personal care advisor or personal care advocate benefit.
Carrier
An organization acting as an insurer for private plans or government programs.
Carryover
That provision in medical plans that allows individuals who
have not satisfied their deductible in a given calendar year to apply expenses incurred in the last quarter of that
calendar year to the next year’s deductible.
Carve Out
Accessing coverage for a specific type of service through a contract separate from that established with the primary providers.
Case Management
A system for assessing, planning treatment for, referring, and following up on patients in order to ensure the
provision of comprehensive and continuous service and the
coordination of payment and reimbursement for care.
Case Manager
An experienced health professional that works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of
medically necessary and appropriate health care. Often used for patients with specific diagnoses or who require high-cost or extensive health care services.
Case Mix (or Case Mix Index)
A measure of relative severity of medical conditions of a hospital’s patients.
Case Rate
Flat fee paid for services based on client characteristics
(such as diagnosis). For this fee the provider covers all of the services the client requires for a specific period of time.
Also called bundled rate, or flat fee-per-case. Very often
used as an intermediate step prior to capitation. Also see diagnostic related groups or risk adjustment.
Cash & Counseling
A joint Federal and Robert Wood Johnson Foundation demonstration program in which cash allowances are given to Medicaid recipients with disabilities to pay for attendants and other services.
Catastrophic Case
A catastrophic case is any medical condition where total cost of treatment (regardless of payment source) is expected to exceed an amount designated by the HMOcontract with the medical group.
Catastrophic Coverage
Insurance protection for extremely high health care costs.
Health insurance which provides protection against the high cost of treating severe or lengthy illnesses or disability.
Catastrophic Health
Insurance
Generally such policies cover all, or a specified percentage
of, medical expenses above an amount that is the responsibility of another insurance policy up to a maximum limit of liability. It is also used to describe those services covered by reinsurance in a capitated program.
Catchment Area
Geographical region where the majority of health care providers customers are located. Also see market area. Federal assistance to State and local governments,
institutions, agencies, organizations, and individuals to carry out specified activities in the public’s interest.
Categorical Grant
In contrast to
“block grants” money is to be spent for a particular purpose or for the benefit of a particular class or group of
individuals, such as older persons. Also see block grant or formula grant.
Categorically Needy
Persons who are aged, blind, or disabled (as defined under the Supplemental Security Income program - SSI) or a
member of a family with dependent children where one parent is absent, incapacitated or unemployed (as defined
under the Aid to Families with Dependent Children program
- AFDC).
Center for Health Care
Strategies
The Center serves as the National Program Office for two national initiatives of the Robert Wood Johnson Foundation: Medicaid Managed Care Program and Building Health Systems for People with Chronic Illnesses. Also seeRobert Wood Johnson Foundation.
Center for Independent Living (CIL)
Federally funded non-profit agencies at the state and community level that advocate for and provide independent
living services to persons with disabilities.
Centers for Disease
Control (CDC)
An agency within the U.S. Department of Health and Human Services that serves as the central point for consolidation of disease control data, health promotion and public health
programs. CDC is also known as the Centers for Disease
Control and Prevention, and is based in Atlanta, GA.
Certificate of Authority
A certificate issued by a state government licensing the operation of an HMO.
Certificate of Public
Review
Approval by the Delaware Health Resources Board of an application by a health care provider to undertake an activity subject to review under Delaware Statute. Replaced the former Certificate of Need Program.
Certification Certified Nurse
Certification is the official authorization for use of services.
Charity Care
Free or reduced fee care provided based on the financial situation of patients.
Cherry Picking
The practice of seeking only healthy customers.
Children’s Health Insurance Program (CHIP)
A state administered program funded partly by Federal government which allows states to expand health coverage
to uninsured low income children not previously eligible for
Medicaid.
Chronic Care
Care and treatment rendered to individuals whose health problems are of a long-term and continuing nature.
Rehabilitation facilities, nursing homes, and mental
hospitals may be considered chronic care facilities.
Chronic Disease
A disease which has one or more of the following
characteristics: (1) is permanent, leaves residual disability;
(2) is caused by nonreversible pathological alternation; (3) requires special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS
A program that provides funds to pay for the treatment in private institutions for members of the uniformed services and their families.
Claim
Information submitted by a provider or covered person to establish that medical services were provided to a covered person, from which processing for payment to the provider or covered person is made.
Claims Audit
Review of health care claims for the purpose of determining the liability of the payer, eligibility of the beneficiary and provider, and the accuracy of the amounts involved.
Claims Review
The method by which an enrollee’s health care service claims are reviewed before reimbursement is made. The
purpose of this monitoring is to validate the medical appropriateness of the provided service and to be sure the cost of the service is not excessive.
Clearinghouse
An agency that accepts claims from providers and resubmits them to the carrier in the carrier’s desired format and to meet the carrier’s data requirments.
Clinical Laboratory Improvement Act/Amendments (CLIA)
A Federal law designed to set national quality standards for laboratory testing. The law covers all laboratories that
engage in testing for assessment, diagnosis, prevention or
treatment purposes.
Closed Panel
Medical services delivered in the Health Insuring
Corporation owned health center or satellite clinic by physicians who belong to a specially formed, but legally
separate, medical group that only serves the HIC.
Co-Insurance
A cost-sharing requirement under a health insurance policy that provides that the insured will assume a portion or
percentage of the costs of covered services. After the
deductible is paid, this provision obligates the subscriber to pay a certain percentage of any remaining medical bills, usually 20 percent.
Co-Morbidity
Presence of a second disease or condition influencing the care or treatment of a patient, and in the hospital setting is
expected to increase the length of stay by at least one day for most patients.
Co-Payment
A type of cost-sharing which requires the insured or subscriber to pay a specified flat dollar amount, usually on a
per-unit-of-service basis, with the third-party payer reimbursing some portion of the remaining charges.
Code of Federal
Regulations
A publication of the Federal government that consists of all regulations of Federal departments and agencies.
A mechanism for identifying and defining physicians’ and hospitals’ services. Coding provides universal definition and
recognition of diagnoses, procedures and level of care.
Coding
Coders usually work in medical records departments and
coding is a function of billing. Medicare fraud investigators look closely at the medical record documentation which
supports codes and looks for consistency. Lack of consistency of documentation can earmark a record as “upcoded” which is considered fraud.
Cognitive Impairment
A loss of mental capacity demonstrated by a person’s inability to think, perceive, reason or remember. Such
impairment results in a person’s inability to care for him or herself without ongoing supervision from another person and is due to a mental or nervous condition with an organic cause.
Cognitive Impairment Reinstatement Provision
A provision in some long-term care policies that allows a policy that has lapsed because the enrollee did not pay the premium to be reinstated for full benefits, if the premiums are paid within six months after the lapse. Typically, the enrollee’s physician must certify that the enrollee suffered a cognitive impairment that presumably caused the individual to fail to pay the premium on time.
Commission on Accreditation of Rehabilitation Facilities (CARF)
Nationally recognized independent review organization that accredits disability service organizations.
Commission on Health Care Quality (CHCQ)
National Commission charged with improving health care quality.
Community Based Care
The blend of health and social services provided to an individual or family in their place of residence (or nearby) for the purpose of promoting, maintaining, or restoring
health or minimizing the effects of illness and disability. Systems of health care providers organized to provide access to a comprehensive range of personal health services to members of a geographic area.
Community Care
Networks
The “network” may act as a health insurance plan offering its services for a specified
premium. In this setting, primary care physicians and mid- level professionals are usually used as the entry and referral point for services and a range of services tailored to the needs of the specific community.
Community Health
Center (CHC)
An ambulatory health care program usually serving a geographic area which has scarce or nonexistent health services or a population with special health needs (sometimes known as the neighborhood health center). Community Health Centers attempt to coordinate Federal, state, and local resources into a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
Community Health Information Network (CHIN)
An information network for providers and insurers to record, access and share health information.
Community Health Purchasing Alliance (CHPA)
Established by the Health Care and Insurance Reform Act of
1993. CHPAs are responsible for assisting their members and particularly small employers to be prudent purchasers
of health care by analyzing and disseminating data on
prices, quality and patient satisfaction. CHPAs annually solicit bids for a variety of state mandated insurance products.
Community
Integration
Term used in the disability community to refer to an individual’s ability to share in community life including
physical, cultural and social integration as well as self-
determination.
Community Nursing
Organization (CNO)
A Federal demonstration program that capitates home health and durable medical equipment costs using nurses as care managers.
Community Rating
Method of establishing health insurance premiums on a communitywide rather than group-specific basis. The
premium is based on a blend of the average cost of actual
and anticipated health services use by all enrollees in a geographic area or industry and does not consider variables such as claims experience, age, sex, or health status of the covered population. Community rating spreads the cost of illness more evenly over the whole community. Federally qualified HMOs must community rate.
Community Rating by
Class
Modifies community rating principles to establish different premiums based upon the age, sex, marital status, or
industry of the individual group. The 1981 amendments to
the Federal HMO Act allowed Federally qualified HMOs to community rate by class. Defined under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), a competitive medical plan (CMP) resembles a health maintenance organization but is not qualified under the Federal HMO Act; it must be state-licensed; to be eligible to participate in Medicare, the CMP must be Federally approved.
Comparability
Requirement that the state must ensure that the same Medicaid benefits are available to all people who are
eligible. Exceptions include benefits approved under
Medicaid waiver programs for special sub populations of
Medicaid eligibles.
Competitive Bidding
Comparing one proposal to another based on price, services offered, quality, or other factors. Also refers to the process
of offering reduced rates to health plans to obtain exclusive
contracts from payers.
Competitive Medical
Plan (CMP)
A mechanism created in TEFRA to enable organized provider groups, in addition to Federally qualified HMOs, to participate in Medicare; these may be hospitals, medical group practices, PPOs, non-Federally qualified HMOs or other entities that meet certain financial solvency requirements. The CMP must be Federally approved to participate in Medicare.
Complication
A medical condition that arises during treatment and in the hospital setting that is expected to increase the length of
stay by at least one day for most patients.
Composite Rate or
Rating
Grouping covered individuals from separate health
insurance plans into a single group for medical underwriting purposes. For example, a composite rate would be
established for all those eligible to participate in a multiple
option plan regardless of the delivery and financing coverage elected by the plan participants. The number of covered individuals and the projected number and cost of claims under each plan option are considered.
Comprehensive Major
Medical Coverage
A health insurance plan that combines basic health benefits with higher benefit maximums to help cover the costs of major claims. The maximum benefit may range up to
$500,000 or have no limit. This coverage usually includes a deductible and coinsurance.
Comprehensive
Outpatient Rehabilitation Facility (CORF)
Medicare term used to designate providers that offer a defined set of outpatient rehabilitation services that can be reimbursed through Medicare.
