Glossary

Accreditation:

Usually a professionally sponsored, voluntary process that provides a measure of an organization's quality and performance.

Administrative Data:

Cost and utilization data collected by a health plan, hospital or medical group.

Appeal:

A process by which an individual asks his or her health plan to reconsider a decision not to pay for or provide medical services.

Benefits:

The money or health services to which an individual is entitled under his/her insurance plan.

Board-Certified:

Refers to a physician who has passed a written and oral examination given by a medical specialty board, and who has been certified as a specialist in that area (e.g. pediatrics, internal medicine).

Breast Cancer:

Growth of malignant cells in the breast.

Breast Cancer Screening:

Preventive exams to detect breast cancer. Includes breast self-exams clinical breast exams and mammograms.

California Cooperative Healthcare Reporting Initiative (CCHRI):

CCHRI is a statewide collaborative of employers, health plans, and providers dedicated to providing accurate, standardized, comparable reports on health care performance. The CCHRI commitment to precise standardization supports "apples to apples" comparison of plan performance so consumers can easily make informed choices about their health care.

Capitation:

A method of payment used in managed care in which doctors or hospitals are paid a fixed amount for each person cared for, regardless of the actual number or type of services they deliver.

Cervical Cancer:

The growth of cancerous cells in the cervix. Cervical cancer is described as noninvasive when it exists only on the surface of the cervix, while cancer that has spread into deeper layers of the cervix or to other organs is classified as invasive.

Cervical Cancer Screening:

A preventive service to detect the presence of cervical cancer. The screening procedure is called a Pap smear and is conducted during a pelvic exam.

Cervix:

The opening to the uterus (or womb).

Cholesterol Tests/Screening:

A blood test to identify people with high blood cholesterol levels. Used to identify individuals at risk for heart disease and stroke, who can then be given guidance on how to lower their risks.

Claim:

A document submitted to an insurance company by either a health care provider or a patient for payment of medical services under an insurance contract.

Consumer Assessment of Health Plans Survey (CAHPS®):

A patient survey developed with support from the Agency for Health Care Research and Quality to assess patient satisfaction with health care services. (CAHPS®) is now used by National Committee for Quality Assurance, among others, as part of it's voluntary accreditation process for health plans or HMOs. To get information on how members feel about their health plan or HMO, randomly selected people who are HMO members are asked to complete the CAHPS® survey.

Contract Provider:

Any hospital, skilled nursing facility, extended care facility, individual, organization or agency that has a contractual arrangement with an insurance company to provide services to enrollees.

Co-payment:

A cost-sharing arrangement of a health plan in which the patient pays a fixed fee for a specific service (such as $10.00 for an office visit). This fee does not vary with the cost of the service. Also referred to as co-insurance.

Cost Sharing:

A general set of financing arrangements whereby patients pay a certain amount of their own money to receive care, typically at the time that care is provided. Includes co-payments, deductibles, and the employee-paid portion of the monthly premium for health care insurance.

Coverage:

The scope of the health benefits provided by a health insurance plan.

Deductible:

The amount an individual must pay for health services each year before the individual's insurance company starts to pay. For example, a $500 deductible means that an individual must pay for the first $500 worth of health care expenses before the insurance company begins to pay for services.

Denial of Service:

When a health plan either refuses to pay for a medical procedure received by a patient or refuses to authorize a patient to receive a certain service.

Department of Health and Human Services (DHHS):

An agency of the federal government that is responsible for health-related programs and issues. DHHS oversees Medicare, Medicaid, and public health programs.

Diabetes:

A condition/disease caused by the body's inability to process sugar, usually due to a lack of insulin.

Diabetic Retinal Exam:

An eye exam which checks for diseases of the retina in diabetic patients. The patient's eyes are dilated so that the professional can examine the interior of the eyes for signs of the disease.

Disease:

Any interruption of the normal function of any body organ, part, or system that appears abnormal.

Disenroll:

When any member of a health plan decides to terminate his or her enrollment.

Enrollee:

A member of a health plan.

Evidence of Coverage (Member Handbook):

This document, often called an "Evidence of Coverage" (EOC), is your binding agreement or contract with your HMO. It explains your health care benefits, any limits to your coverage, the HMO's policies and procedures and what costs you will have to pay.

Exclusions:

Clauses in an insurance contract that deny coverage for certain individuals, groups, locations, properties, or types of risks.

Fee-for-Service Plans (FFS):

The traditional form of health care delivery. FFS providers are paid for each service they provide to a patient, as opposed to receiving a salary or fixed amount for all of the patient's expected health care needs.

Gatekeeper:

The term applied to the personal or primary care physician (see below)—such as a pediatrician, family physician,internist, or obstetrician/gynecologist—in a managed care plan. The personal or primary care physician is responsible for overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, typically the personal or primary care physician must authorize the visit, unless there is an emergency. Because the personal or primary care physician is the "gateway" to specialty services, they are sometimes called the "gatekeeper".

Grievance:

Formal complaints patients file with their health plan.

Health Maintenance Organization (HMO):

Also known a health plan or managed care organization, an HMO is a type of health insurance plan that provides health care services for members who prepay a premium that generally covers a comprehensive range of both inpatient and ambulatory care with limited co-payments. There are four types of HMOs:

• Staff model (Closed-panel):   Hires its physicians individually and pays them a salary to practice in the HMO facility or clinic.

• Group model:   The HMO contracts with a group of physicians and pays them a set amount per patient to provide a specified range of services. The group of physicians determines the compensation of each individual physician in the practice and often shares profits.

• IPA (Independent Practice Association):   The HMO contracts with individual physicians who see HMO members as well as patients covered by other types of health insurance in their own private offices. Physicians in an IPA are paid on either a capitation or a modified fee-for- service basis.

• Network:   The HMO contracts with a network of medical groups rather than individual physicians. Medical groups may see HMO patients as well as fee-for-service patients.

Health Plan and Employer Data and Information Set (HEDIS):

A set of health plan performance measures developed by National Committee for Quality Assurance. HEDIS measures show how well health plans do at providing specific preventive care services to their enrollees.

Healthy Families:

Healthy Families is low cost insurance for children and teens. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for free Medi-Cal.

Heart Attack:

A sudden decrease in the flow of blood to the heart muscle resulting in impaired heart functioning. Can result in death.

Home Health Care:

Services provided by nurses and other health professionals in patients' homes to patients who are unable to care for themselves.

Hospice:

A manner of providing care for terminally ill patients, either in their home or in special care facilities. Hospice care allows terminally ill individuals to live their final days in as natural and comfortable a setting as possible.

Hospital:

A health care organization that has an organized medical and professional staff and inpatient care facilities. There are four basic types: general medical and surgical, specialty, psychiatric, and rehabilitation and chronic disease.

Hypertension:

Also known as high blood pressure. A disease characterized by blood pressure above 140/90. Individuals with high blood pressure are at risk for kidney disease, heart disease and stroke. Hypertension can be treated with medication, exercise, and diet.

Immunization:

The process of obtaining resistance to a specific disease, typically delivered through a vaccination shot or orally or nasal spray. Using killed or weakened viruses, bacterial molecules or inactivated toxins, a vaccination will introduce harmless forms of the disease into the body. Once immunized, the body then develops antibodies to fight the foreign substance.

Indemnity Plan:

A plan which reimburses physicians for individual services performed or reimburses patients for medical expenses incurred.

Interpreter:

Individuals who are bilingual and who provide verbal translation services by telephone or face-to-face or who provide sign language interpretation services to members who do not speak English or who use American Sign Language.

IPA (Independent Practice Association) or Medical Group:

IPA stands for Independent Practice Association, which is a group of independent doctors who work together to provide care to HMO members as well as patients covered by other types of health insurance. Doctors in an IPA are paid on either a capitation or a modified fee-for-service basis that they negotiate with your HMO. Medical Groups are generally more highly structured groups of doctors, who have come together to provide care to patients and negotiate payment rates with HMOs.

Language Line:

A contracted company of telephone interpreters that your HMO uses when you call the HMO's customer service number and there is not a staff member available that speaks your language.

Language Services:

Services available from your HMO if you or a family member use American Sign Language or speak a language other than English. HMOs must provide interpreter services and some translated written materials to their members who do not speak or understand English well or who use American Sign Language. These services may assist you with obtaining medical care in your preferred language.

Mammograms:

X-ray examination of breast tissue used to detect breast cancer.

Managed Care:

Any system of delivering health services in which care is delivered by a specified network of doctors and hospitals who agree to comply with established care approaches. Providers may receive a capitated payment for providing all medically necessary care to enrollees or may be paid on a fee-for-service basis. Managed care often involves a defined delivery system of providers with some form of contractual arrangement with a health plan.

Measles:

An infectious viral disease, usually occurring in childhood, characterized by reddish skin eruptions appearing on the face and body, elevation of temperature, headache and loss of appetite. Can be prevented through immunizations.

Medicaid:

A federal and state health insurance program designed to provide access to health services for persons below a certain income level. Provides health care to women and children who qualify for Aid to Families with Dependent Children (AFDC) and the impoverished elderly who are poor.

Medi-Cal:

California's Medicaid program.

Medical Group or IPA (Independent Practice Association):

IPA stands for Independent Practice Association, which is a group of independent doctors who work together to provide care to HMO members as well as patients covered by other types of health insurance. Doctors in an IPA are paid on either a capitation or a modified fee-for-service basis that they negotiate with your HMO. Medical Groups are generally more highly structured groups of doctors, who have come together to provide care to patients and negotiate payment rates with HMOs.

Medically Necessary:

Determination by a health care provider that the physical or mental condition of a patient warrants a certain type of medical care.

Medicare:

A federal health insurance program designed to provide health care for the elderly and the disabled. People who qualify for Social Security benefits are automatically eligible for Medicare.

Mumps:

An contagious disease occurring mainly in childhood marked by swelling in front of the ears. Can be prevented through childhood immunization.

National Committee for Quality Assurance (NCQA):

A private, non-profit organization that accredits managed care health plans, and assesses and reports on their quality. The National Committee for Quality Assurance publishes the Health Plan and Employer Data and Information Set (HEDIS) measures.

Nursing Home:

A facility that provides care to a person who is not able to remain home alone due to physical health problems, mental health problems or functional disabilities. A broad term which encompasses a range of facilities from privately-owned adult residential care homes to community hospitals and government-operated institutions.

Obstetrician/gynecologist (OB/GYN):

A physician who treats women during pregnancy, labor, and immediately following childbirth as well as for diseases of the female reproductive system.

Open Enrollment:

The time period during which health plan enrollees have the opportunity to change their health plan (usually a 30 day period held once a year).

Outcome:

The consequence of a medical intervention (e.g. improved health status, death).

Out-of-Area Care:

Medical care received outside an approved network of facilities in a particular area. Can occur when a patient is traveling, has temporarily relocated, or has an emergency situation.

Over-utilization:

Excess use of health services.

Pacific Business Group on Health (PBGH):

A nonprofit coalition of 32 public and private sector purchasers of health care who are located in California. The organization aims to improve the quality of health care and moderate rising health care costs.

Pap Smears:

A preventive screening test for cervical and uterine cancer. Conducted during a pelvic exam.

Pediatric:

Pertains to the care of children.

Performance Measures:

Any measure designed to quantify how well or how poorly an organization performs. In the health care industry, performance measures are used to assess the quality of care provided by health plans, hospitals and doctors.

Personal doctor:

Also known as primary care physicians, personal doctors are physicians with special training in one of the four primary care specialties; pediatrics, family medicine, obstetrics and gynecology, and internal medicine. Most health plans or HMOs require members to sign up with a personal doctor. The personal doctor in a health plan or HMO has the responsibility for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referrals for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues. Personal doctors in a health plan or HMO should be aware of and coordinate the range of health care services you are receiving even if the personal doctor does not provide these services themselves.

Physician:

An individual qualified by education and legally authorized to practice medicine.

Point-of-Service Plan:

A health plan that combines features of prepaid and indemnity insurance. Enrollees decide whether to use network or non-network providers at the time care is needed, but are usually charged additional fees for using non-network providers.

Preferred Provider Organization (PPO):

Some combination of hospitals and physicians that agree to provide health care services to a group of people, perhaps under contract with a private insurer. The services may be furnished at discounted rates. Patients may incur expenses for covered services they receive outside the PPO, if the charge from the non-PPO provider exceeds the PPO reimbursement rate.

Premium:

The amount paid to a health plan or insurance company by an employer or beneficiary for health insurance coverage.

Prenatal Care:

Medical care provided to a pregnant woman to ensure the health of the mother and unborn child.

Prepaid Health Care:

Providers are paid a fixed fee per person to provide services for a stipulated length of time (see capitation). Payment occurs whether a patient actually uses services or not.

Prevention:

The concept of preventing or slowing the development of disease and promoting health through screening programs and lifestyle guidelines.

Preventive Care Guidelines:

Recommendations for how often individuals should receive certain preventive card services such as mammography or cholesterol screening. Guidelines are typically based on clinical research findings.

Preventive Care Services:

Services designed to promote health and prevent disease. Areas include prenatal care, childhood immunization, cholesterol screening, breast cancer screening, cervical cancer screening, and diabetic retinal exams.

Primary Care:

Basic or general health care traditionally provided by physicians who specialize in family medicine, pediatrics, internal medicine, or in some cases obstetricians/gynecologists.

Purchaser:

The buyer of health care coverage and/or services - typically employers, the government, or individuals.

Referral:

In healthcare, a process in which a doctor recommends that a patient see a medical professional with advanced knowledge of a certain medical specialty or technique (such as heart disease or dermatology). Also known as a consultation.

Report Cards:

A progress report presented periodically which evaluates the quality of health services.

Retinopathy:

Damage to the blood vessels in the retina, a part of the eye critical for vision. Often found in individual with diabetes.

Rubella:

German measles; an acute viral infection that resembles measles, but runs a shorter course. Can be prevented with immunization.

Skilled Nursing Facility (SNF):

A facility that accepts patients in need of medical care provided by skilled medical personnel and nurses. Typically provides rehabilitation and skilled medical care.

Specialist:

A medical doctor who specializes in a specific area of medicine, for example cardiology or gynecology.

Statistical Significance:

The probability that an event did not happen by chance alone. A result is deemed statistically significant if statistical methods have been used to prove that a certain event is highly unlikely.

Stroke:

Impeded blood supply to some part of the brain.

U.S. Preventive Services Task Force:

An expert panel assembled by the U.S. Department of Health and Human Services to make recommendations regarding the delivery of preventive care services.

Utilization Management:

Planning, organizing, directing, and controlling the use of medical services by a health care organization.

Vaginal Deliveries:

Delivery of a fetus through the vaginal canal as opposed to a Cesarean Section.