OCR Text |
Show Glossary (Abstracted from "Glossary of Terms As Commonly Used in Health Care," The Alpha Center, Washington, DC) A Adjusted average per capita cost (AAPCC) The basis for HMO or CMP reimbursement under Medicare-risk contracts. The average monthly amount received per enrollee is currently calculated as 95 percent of the average costs to deliver medical care in the fee-for-service sector. Agency for Health Care Policy and Research (AHCPR) One of the newest agencies of the U.S. Public Health Service, the AHCPR was created in 1989. The Agency's primary goal is to enhance the quality, appropriateness, and effectiveness of health care services by conducting and sponsoring credible and timely research. It is the federal government's focal point for health services research, the efforts of which are built upon the work of AHCPR's predecessor, the National Center for Health Services Research and Health Care Technology Assessment. B Blue Cross Plan A nonprofit, tax-exempt insurance plan providing coverage for hospital care and related services. Historically, the plans were largely the creation of the hospital industry and designed to provide hospitals with a stable source of revenue. A Blue Cross plan should be a nonprofit community service organization with a governing body whose membership includes a majority of public representatives. Blue Shield Plan A nonprofit, tax-exempt insurance plan which provides coverage for physicians' services. Blue Shield coverage is sometimes sold in conjunction with Blue Cross coverage, although this is not always the case. Boren Amendment Part of the Medicaid law, known by the name of its principal Congressional sponsor. It provides that state payment for hospitals and nursing facilities must be reasonable and adequate to meet the costs incurred by efficiently and economically operated facilities to provide care and services meeting state and federal standards. C Capitation A method of payment for health services in which an individual or institutional provider is paid a fixed amount for each person served, without regard to the actual number or nature of services provided to each person in a set period of time. Capitation is the characteristic payment method in certain health maintenance organizations. It also refers to a method of Federal support of health professional schools. Carve Out Regarding health insurance, an arrangement whereby an employer eliminates coverage for a specific category of services (e.g., vision care, mental health/psychological services and prescription drugs) and contracts with a separate set of providers for those services according to a predetermined fee schedule or capitation arrangement. Carve out may also refer to a method of coordinating dual coverage for an individual. Case Management The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. Certificate of Need (CON) A certificate issued by a governmental body to an individual or organization proposing to construct or modify a health facility, acquire major new medical equipment, modify a health facility, or offer a new or different health service. Such issuance recognizes that a facility or service, when available, will meet the needs of those for whom it is intended. CIN is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services. 122 Glossary |