Glossary of Terms from Hackley Community Care Center

2700 Baker Street,
Muskegon Heights, MI 49444
Medical: 231.737.1335
Dental: 231.737.8603
Pharmacy: 231.737.9510

Access: A person's ability to obtain affordable medical care on a timely basis.

Capitation:⁷ A method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided.

Categorically needy individuals: Enrollees in Medicaid programs who meet traditional Medicaid age and income requirements.

Children's Health Insurance Program (CHIP): A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under state Medicaid programs.

Claim: An itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

CNM (Certified Nurse-midwife): A person who is trained in both nursing and midwifery and, in the US, is certified by the American College of Nurse-Midwives (ACNM).

Coinsurance: A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.

Co-payment: A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered.

Credentialing: The process of obtaining, reviewing, and verifying a provider's credentials—the documentation related to licenses, certifications, training, and other qualifications—for the purpose of determining whether the provider meets the Managed Care Organization's pre-established criteria for participation in the network.

DDS (Doctor of Dental Surgery): The degree awarded upon graduation from dental school to become a general dentist.

Deductible: A flat amount a group member must pay before the insurer will make any benefit payments.

Disease management (DM): A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.

D.O. (Doctor of Osteopathic Medicine): A physician with training that differs slightly from that of a physician with an M.D. The DO is equally educated with four years of undergraduate training, four years of medical schools, and additional years if the DO chooses to specialize. However, the DO has a slightly different approach to treating the patient than the MD.

The DO is trained to evaluate the person in a holistic way. The goal of the DO is not simply to treat problems as they arise, but as well to prevent problems by evaluating the total health and health risks of the person. This evaluation may include not only looking at quantifiable risk factors for disease but also evaluation of the person in terms of their home life, their stress level and their work life. As well, disease is evaluated in terms of how it affects the entire body, not simply a few parts of the body.

Electronic medical record (EMR):¹⁶ An automated, on-line medical record containing clinical and demographic information about a patient that is available to providers, ancillary service departments, pharmacies, and others involved in patient treatment or care.

Fee-for-service (FFS) payment system: A system in which the insurer will either reimburse the group member or pay the provider directly for each covered medical expense after the expense has been incurred.

Formulary:²⁰ A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that are to be used by an MCO's providers in prescribing medications.

Functional status: A patient's ability to perform the activities of daily living.

⁷Capitation: Questions and Answers, (Washington, D.C.: American Association of Health Plans, 1996.

¹⁶Richard Rogenehaugh, The Managed Healthcare Dictionary (Gaithersburg, VA: Aspen Publishers, Inc., 1997),

²⁰Drug Benefit Trends [1995, 7(2): 6-10 1997, SCP Communications, Inc.]

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