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AAP |
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American Academy of Pediatrics |
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AMA |
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American Medical Association |
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Ancillary Services |
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Health care services provided by professionals other than primary care physicians. |
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BMT |
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Bone Marrow Transplant |
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Cal-Optima |
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Cal-Optima is Orange County's Medi-Cal managed care program. It is a locally based system to manage the financing and delivery of health care services to residents who do not exceed a certain income level. Please visit www.caloptima.org for more information. |
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California Kids |
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California Kids provides outpatient health insurance to children, two to 18 years old, in families with an income below 250% of the Federal Poverty Level who are not US citizens and do not qualify for Medi-Cal and Healthy Families. Inpatient care is not covered. If inpatient treatment is needed, the program coordinates with Medi-Cal (ie. Emergency Medi-Cal) to obtain care. |
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CALS |
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Consolidated Accreditation and Licensing Survey |
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Capitation |
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A set dollar payment per beneficiary, per unit of time (usually a month) that is paid to cover a specified set of services and administrative costs without regard to the actual number or the cost of services provided. (See dual-risk capitation, full-risk capitation, and shared-risk capitation). |
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CCS (California Children's Services) |
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CCS is a state-funded program for children under the age of 21 with chronic medical conditions such as: Cystic Fibrosis, Hemophilia, Cerebral Palsy, Heart Disease, Cancer and Traumatic Injuries. CCS is a need-based program and eligibility is depends on income. |
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Healthy Families |
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Healthy Families is a state-funded program that provides health care to children of working parents who earn too much to qualify for Medi-Cal, but cannot affort private insurance. Please visit www.healthyfamilies.ca.gov, or call CHOC's Healthy Families program at (714) 289-4569, for more information. |
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HMO (Health Maintenance Organization) |
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An HMO is a managed health care plan that provides, or arranges, for the delivery of comprehensive, coordinated medical services to voluntarily enrolled member on a prepaid basis. |
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In-network |
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A Service provided by a doctor, dentist or other provider who has a contract with a members insurance plan. |
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Medi-Cal |
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Medi-Cal is a need-based, state program that pays the cost of medical care. Eligibility is determined by level of income and other resources. Please visit www.medi-cal.ca.gov for more information. |
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Open Enrollment |
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Open Enrollment is your opportunity to choose a different health plan offering, dental plan or add eligible family members to their current plan. |
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POS |
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(Point of Service) - An HMO plan combined with a PPO plan - you have the option to go either way. Also called an open-ended plan. Permits members to use their HMO plan with the benefit of a lower copayment or member may choose to go out of their plan and pay the higher copayment. |
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PPO (Preferred Provider Organization) |
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A PPO is an arrangement where providers (ie. Hospitals, physicians, surgery centers) contract with a health plan to provide services at a discounted rate to members, thus forming the PPO network. Members may use any provider in the PPO or outside the PPO, but have a financial incentive to use the preferred providers within the PPO. |
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Preferred Provider Network (PPN) |
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A network of hospitals and physicians who have agreed to participate with a health insurance company, usually for discounted rates. |
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Primary Care Physician |
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A primary care physician is one who practices in basic or general healthcare (ie. Family practice, pediatrician, internal medicine) |
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Self-refer |
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When and individual makes an appointment to be cared for by a specialist without prior authorization from their primary care physician. |
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Specialist/Sub-specialist |
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A specialist is a physician who practices in a certain specialty field such as oncology, cardiology or orthopedics. A sub-specialist is a physician specialist who only treats a certain age group such as pediatrics. |
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Tricare/Champus |
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TriCare, formerly known as CHAMPUS, is the Department of Defense health benefits program. TriCare is administered through Health Net Federal Services and the program is provided to all uniformed services personnel. Please visit www.healthnetfederal.com for more information. |
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