1280 S Governors Avenue | Dover, DE 19904

302.674.2853

Delaware Healthcare Association Glossary of Health Care Terms and Acronyms - Terms Starting with C

If you would like to recommend additions to the Delaware Healthcare Association's Glossary, send them for consideration to Yasmine Chinoy at yasmine@deha.org

 

DISCLAIMER

The definitions listed here are intended for a general understanding of a health care term. These definitions should not be considered as the complete definition, since many are written in the simplest form to give a general understanding of the term listed.

 

Terms Starting with C:

 
 

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.

Castastrophic 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 HMO contract with the medical group.

Castastrophic Coverage

Insurance protection for extremely high health care costs.

Castastrophic Health Insurance

Health insurance which provides protection against the high cost of treating severe or lengthy illnesses or disability.  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.

Categorical Grant

Federal assistance to State and local governments, institutions, agencies, organizations, and individuals to carry out specified activities in the public's interest.  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 Related

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).  Also see categorically eligible.

Center for Health Care Strategies

Established in 1995 as a non-profit, non-partisan policy and resource center affiliated with the Woodrow Wilson School of Public and International Affairs at Princeton University.  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 see Robert 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 and Prevention (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.

Centers for Medicare and Medicaid (CMS)

US Federal agency which administers Medicare, Medicaid, and the State Children's Health Insurance Program.

Certificate of Authority

A certificate issued by a state government licensing the operation of an HMO.

Certificate of Need

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

Certification is the official authorization for use of services.

Certified Nurse Practitioner

See Nurse Practitioner.

Certified Nurses Aid

See Nurses Aid.

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 requirements.

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 Access

See Closed Panel.

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.

CMP

See Competitive Medical Plan.

Code of Federal Regulations

A publication of the Federal government that consists of all regulations of Federal departments and agencies.

Coding

A mechanism for identifying and defining physicians' and hospitals' services.  Coding provides universal definition and recognition of diagnoses, procedures and level of care.  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.

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.

Commission on Accreditation of Rehbilitation Facilities (CARF)

Nationally recognized independent review organization that accredits disability service organizations.

Commission on Health Care Quaity (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.

Community Care Networks

Systems of health care providers organized to provide access to a comprehensive range of personal health services to members of a geographic area.  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 Inclusion

See community integration.

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 up 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.

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 on day for most patients.

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 Rehbilitation Facility (CORF)

Medicare term used to designate providers that offer a defined set of outpatient rehabilitation services that can be reimbursed through Medicare.

Computerized Medical Record (CMR)

See Electronic Medical Record.

Computerized Patient Record (CPR)

See Electronic Medical Record.

Concurrent Review

A screening method by which a health care provider reviews a procedure performed or hospital admission authorized by a colleague to assess its necessity.

Congregate Housing

Housing for older and disabled people.  Provides for private living quarters and shared eating and living areas.

Congregate Meals

Program authorized under Title II-C-1 of the Older Americans Act which provides, five or more days a week, a hot or other appropriate meal per day in a group setting.  Congregate nutrition programs also include nutrition education and other appropriate services for older people.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

A Federal law that requires employers to offer continued health insurance coverage to employees who have had their health insurance coverage terminated.

Consumer Directed Care

See Participant Driven Supports.

Consumer Directed Services

See Participant Driven Supports.

Consumer Price Index (CPI)

A measure of changes in prices for various commodities.  The medical CPI analyzes price changes which have occurred in hospitals, physician services, drugs and other related items.

Continuing Care Accreditation Commission (CCAC)

The nation's only accreditation program for CCRCs.  The commission accredits communities meeting strict criteria in the areas of finance, governance and administration, resident life and health care.

Continuing Care Retirement Community (CCRC)

Prepaid long term care plan that provides a continuum of residential options from independent living to nursing home care.  Usually requires a substantial entrance fee and monthly charges.

Continuing Medical Education (CME)

The continuing education of practicing physicians through refresher courses, medical journals and texts, educational programs and self-study courses.  In some states CME is required for continued licensure.

Continuous Quality Improvement (CQI)

A process to continuously make everything better each day.  The initiative is customer focused and requires that processes be analyzed, measured, improved and evaluated on an ongoing basis.

Continuum of Care

A range of clinical services provided to a patient that may reflect the treatment rendered during a single hospitalization or may include care for multiple conditions spanning the patient's lifetime.

Contractual Allowance

A practice of setting rates that are higher than actual costs to recover unreimbursed costs from government, uninsured, underinsured, and other payers.

Contributory Program

A method of payment for group coverage in which part of the premium is paid by the employee and part is paid by the employer or union.

Convalescent Care

Term often used for short-term custodial care and refers to a "recovery" period after an illness or injury when some assistance may be needed that does not require skilled care.

Conversion

In group health insurance, the opportunity given the insured and any covered dependents to change his or her group insurance to some form of individual insurance, without medical evaluation upon termination of his or her group insurance.

Conversion Factors

The dollar amount that, when multiplied by Relative Value Scale (RVS) unit values, estimate the average cost per service.  The unit values vary by medical procedure according to the relative complexity or cognitive value of the different procedures.  Conversion factors can be ued to measure physician fee levels and they may be by area and the period being used for experience.  The term also is used for any factor which is multiplied by a standard value to adjust payments.  Also see relative value scales.

Conversion Privilege

See Conversion.

Coordination of Benefits

An insurance provision whereby responsibility for primary payment for medical services is allocated among carriers when a person is covered by more than one employer-sponsored health benefit program.  This prevents beneficiaries from being reimbursed for more than 100% of allowable charges.

Coordination of Coverage

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.

Cost Based Reimbursement

A method of paying hospitals for actual costs incurred by patients.  Those costs must conform to explicit principles defined by third-party payers.

Cost Benefit Analysis

A comparison of the cost of an action and the economic benefits it produces through elimination of other direct and indirect costs.

Cost Containment

Efforts by purchasers and by providers to control health care costs through mechanisms such as benefit design, pre-admission certification, pre-admission testing, and concurrent review programs; second opinion programs; discharge planning; claims audits, case management, and employee education.

Cost Contract

A formal agreement with the Centers for Medicare and Medicaid Services (CMS) to arrange for the provision of health services to plan members based on reasonable cost or prudent buyer concepts.  The plan receives an interim capitated amount derived from an estimated annual budget that may be periodically adjusted during the course of the contract to reflect actual cost experience.  The plan's expenses are audited at the end of the contract to determine the final rate the plan should have been paid.  The AAPCC may be a factor in establishing the final payment rate.

Cost Effectiveness

Usually considered as a ratio, the cost effectiveness of a drug or procedure, for example, relates the cost of that drug or procedure to the health benefits resulting from it.  In health terms, it is often expressed as the cost per year per life saved or as the cost per quality-adjusted life-year saved.

Cost Management

Cost Outlier

An individual whose service costs are significantly higher than the average.  In Medicare, it refers to a patient who is more costly to treat compared with other patients in a particular diagnosis related group.  Also see day outlier.

Cost Reimbursement

Method of provider reimbursement based on actual costs incurred.

Cost Sharing

Financing arrangements whereby the member of a health plan must pay some of the costs to receive care.

Cost Shifting

When rates are set higher than actual costs to recover unreimbursed costs from government, uninsured, underinsured and other payers.

Cost Shifting, Employer

Initiating or increasing employee financial participation in the health benefit cost through premium sharing, co-payments, co-insurance, or deductibles.

Cost Shifting, Medicare

A provision of COBRA, shifting primary coverage for eligible claims from Medicare to employer health plans for employees and their spouses.

Cost Shifting, Provider

Charging some patients, or classes of patients, more than others for the same services in order to recover unreimbursed costs from government and other payers.

Coverage

Promise by a third party to pay for all or a portion of expenses incurred for specified health care services.

Covered Person

An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.

Covered Service

The specified scope of services and the units of each service to be included as benefits under an insurance policy.

Credentialing

The process of reviewing a practitioner's academic, clinical and professional ability as demonstrated in the past to determine if criteria for clinical privileges are met.

Critical Pathway

Standardized specifications for care developed by a formal process that incorporates the best scientific evidence of effectiveness with expert opinion.

Current Procedural Terminology

A coding system used to determine Medicare reimbursement rates.

Custodial Care

The medical or non-medical services, which do not seek to cure, are provided during periods when the medical condition of the patient is not changing, or do not require the continued administration by medical personnel.

Cytotech

Works under the direction of a pathologist screening slides of cell samplings for clues to disease.

© 2012 Delaware Healthcare Association
1280 S Governors Avenue
Dover, DE 19904
302.674.2853