Glossary of Commonly Used Terminology

Accreditation

A “seal of approval” given to a health plan, hospital or healthcare facility by an independent organization to certify that it meets national quality standards. 

Two examples of managed care accreditation organizations are: NQCA (National Committee for Quality Assurance) and URAC (Utilization Review Accreditation Commission). TJC (The Joint Commission) is an example of a hospital accreditation organization.

Advance Directives

A written document stating how a person wants medical decisions to be made if s/he loses the ability to make them for her/himself. It may include a Living Will and a Durable Power of Attorney for health care. 

Affordable Care Act (ACA)

The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).

The law has 3 primary goals:

• Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
• Expand the Medicaid (known as Medi-Cal in California) program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
• Support innovative medical care delivery methods designed to lower the costs of health care generally. 

Appeal

If a health insurer refuses to pay a claim, denies or modifies a service request, or ends a member's coverage, s/he has the right to appeal the decision and have it reviewed by a third party, not involved in the original decision.

The member can ask the insurer to reconsider its decision. Insurers have to tell you why they’ve denied your claim, request, or ended your coverage. And they have to let you know how you can dispute their decisions.

California Children's Services (CCS) 

CCS is a California State program for children with certain diseases or health problems. Through this program, children up to 21 years old can get the health care and services they need. CCS will connect children with doctors and trained health care people who know how to care for children with special health care needs.  The CCS program provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children under age 21 with CCS-eligible medical conditions. Examples of CCS-eligible conditions include, but are not limited to, chronic medical conditions such as cystic fibrosis, hemophilia, cerebral palsy, heart disease, cancer, traumatic injuries, and infectious diseases producing major sequelae. CCS also provides medical therapy services that are delivered at public schools. 

Please note that some Medi-Cal Managed Care Plans administer CCS benefits as part of their contract agreement with the State.

Carved Out

A term used by the California Department of Health Care Services in its Medi-Cal program to describe when a covered benefit is not accessible through a Medi-Cal Managed Care Plan but is accessed through other means, such as directly from fee-for-service Medi-Cal or through a Mental Health Plan.

Case Management

A process used by a doctor, nurse, or other health professional to manage the health care of individuals. Case managers make sure that their clients get needed services in a timely manner and track the use of facilities and resources.

Centers for Medicare and Medicaid Services (CMS) 

The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

Chronic Disease Management

An integrated care approach to managing illness which may include screenings, telephonic and/or in person check-ups, monitoring and coordinating treatment, and patient education. Disease management programs can improve quality of life while reducing health care costs by preventing or minimizing the effects of a disease. 

Coinsurance 

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. 

Coordination of Benefits

A process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over. 

Copayment

The fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. 

Creditable Coverage

Health insurance coverage under any of the following: a group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; the Federal Employees Health Benefits Program; Indian Health Service; the Peace Corps; Public Health Plan (any plan established or maintained by a State, the U.S. government, a foreign country); Children’s Health Insurance Program (CHIP); or, a state health insurance high risk pool. If a person has prior creditable coverage, it will reduce the length of a pre-existing condition exclusion period under new job-based coverage. 

Creditable coverage also applies to prescription drug coverage, that may be part of a health insurance benefit package or a separate prescription drug plan.

Current Procedural Terminology (CPT) 

A code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel.[1] The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. 

Deductible

The amount that is paid out-of-pocket for covered health care services before a health plan starts to pay. After the deductible is paid, there are typically, copayment or coinsurance for covered services but the health plan pays the rest. 

Diagnosis-Related Group (DRG)

A classification system that group patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. 

Please note that Medi-Cal Managed Care Plans typically uses APR-DRG (All Patients Refined Diagnosis-Related Group), which uses similar DRG methodology but includes newborn and children; and, accounts for severity of illness and risk of mortality.

Fee for Service (FFS)

A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits. 

Independent Review Organization (IRO)

Within the health care industry, an independent review organization (IRO) acts as a third-party medical review resource which provides objective, unbiased medical determinations that support effective decision making, based only on medical evidence. IROs deliver conflict-free decisions that help clinical and claims management professionals better allocate healthcare resources. 

Managed Care Organization (MCO) 

A system of providing health care (such as an HMO, PPO, EPO, POS, etc.) that is designed to control costs through managed programs in which providers accept constraints on the amount charged for medical care and the member has limited choices of physicians, hospitals, and ancillary service providers. 

Medi-Cal

California's version of the Medical Assistance Program, known in other States as the Medicaid Health Care Program. The Medi-Cal program pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is supported by federal and state taxes.

Medi-Cal Managed Care 

A system of care that provides Medi-Cal recipients high quality, accessible, and cost-effective health care through managed care delivery systems. 

Medi-Cal Managed Care contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care.  Managed care plans are a cost-effective use of health care resources that improve health care access and assure quality of care. 

Medically Necessary

According to CMS- Services or supplies that: are proper and needed for the diagnosis or treatment a medical condition, are provided for the diagnosis, direct care, and treatment of the medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of the patient or the doctor.  

According to California DHCS- Reasonable and necessary covered services to protect life, to prevent illness or disability, alleviate severe pain through the diagnosis or treatment of disease, illness, or injury, achieve age appropriate growth and development, and attain, maintain, or regain functional capacity. 

Medicare

The federal health insurance program for:

• People who are 65 or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

Medicare Part A- Hospital, Part B- Medical, Part D- Pharmacy. Medicare Part C is Medicare Advantage/managed care plans. 

Share of Cost

A term used in the Medi-Cal program to mean a person's or family's net income in excess of their maintenance need that must be paid or obligated toward the cost of health care services before the person or family may be certified and receive Medi-Cal coverage. 

Supplemental Security Income/State Supplemental Program (SSI/SSP)

The federal and state payments, respectively, which are based on need, and are paid to aged, blind or disabled persons. 

Telehealth

As defined by the Medi-Cal program: 

“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.