Glossary of Health Care Terms

California Advancing and Innovating Medi-Cal - CalAIM

CalAIM is a multi-year initiative by the Department of Health Care Services to reform Medi-Cal. Its proposals use Medi-Cal as a tool to address the needs of California’s most vulnerable residents, including children with complex medical conditions.

California Children’s Services - CCS

The CCS program provides services and case management to children with specific medical conditions, including cystic fibrosis, cerebral palsy, and cancer. The traditional CCS program operates as a carve out of managed care in 37 counties. In the remaining 21 counties, CCS services have been incorporated into Medi-Cal managed care plans through the Whole Child Model program.

Capitation rate

There are two types of capitation rates. The first is the flat, per member per month fee that the Department of Health Care Services pays to each plan to provide Medi-Cal through managed care. Second, plans negotiate payment rates with each of their contracted providers and most primary care physicians receive a capitated payment. This rate is a fixed fee to provide care to members regardless of the type, value, or frequency of services provided.

Carve out

A carve out refers to Medi-Cal services that are administered and accessed outside of the managed care plan. These services are “carved out” of the plan’s responsibility. Depending on the county, carved out services can include dental, specialty mental health services, and California Children’s Services (CCS).

Commercial health plans

Commercial health plans are private health plans, meaning they are not public or county organized. Every county besides County Organized Health Systems model counties has a commercial plan that provides Medi-Cal managed care. Commercial health plans can be nonprofit or for-profit organizations.

County Organized Health Systems Model – COHS

COHS is a county model of Medi-Cal managed care where the state contracts with one county-run managed care plan to serve the Medi-Cal population in the county

Department of Health Care Services - DHCS

DHCS is the state department responsible for the administration of Medi-Cal (both fee-for-service and managed care). DHCS is a department of the California Health and Human Services Agency. DHCS contracts with health plans across the state to provide Medi-Cal managed care

Dyadic care

Dyadic care is a model of treatment targeting caregiver or family well-being to support healthy child development and mental health. Dyadic care can refer to pediatric practice models like HealthySteps, or family therapy models like Parent-Child Interaction Therapy (PCIT).

Early and Periodic Screening, Diagnostic and Treatment – EPSDT

EPSDT is a comprehensive set of preventive, diagnostic, and treatment services that Medi-Cal must provide to children under federal law, and as outlined in American Academy of Pediatrics/Bright Futures guidelines. States are required to provide comprehensive services and furnish all Medicaid-coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines.

Early: Assessing and identifying concerns early

Periodic: Checking children’s health at periodic, age-appropriate intervals

Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential concerns

Diagnostic: Performing diagnostic tests to follow up when a risk is identified

Treatment: Control, correct, or reduce health concerns found

Federally Qualified Health Clinic - FQHC

FQHCs are community-based health centers that receive enhanced funding to serve underserved areas or populations. They provide services regardless of patients’ ability to pay and charge for services on a sliding fee scale. FQHCs often integrate access to pharmacy, mental health, and oral health services.

Fee-for-service- FFS

FFS is a system of health care payment and delivery in which providers are paid a set fee for each service delivered. Individuals with FFS Medi-Cal can see any provider who accepts Medi-Cal. Only 10% of children receive Medi-Cal through FFS and the rest are in managed care.

Federal medical assistance percentage - FMAP

FMAP is the percentage of a state’s Medicaid program costs that are paid for by the federal government. In California the FMAP is 50%.

Geographic Managed Care Model - GMC

GMC is a county model of Medi-Cal managed care where the state contracts with multiple commercial health plans in a single county to serve the Medi-Cal population.

Health Effectiveness Data and Information Set - HEDIS

HEDIS measures are standardized performance indicators for health plans. They are designed by the National Committee for Quality Assurance (NCQA) to measure, report, and compare quality across plans on important indicators like immunization status and well-child visit access.

Local initiative

A local initiative is another name for a “county-organized health plan” operating in a Two-Plan model county.

Medi-Cal Administrative Activities - MAA

MAA encompasses efforts to identify and enroll potential eligible individuals into Medi-Cal. The MAA program is funded by a combination of local funds and federal Medicaid funds. MAA reimburses participating counties for the federal share of costs (typically 50%) of performing administrative activities that directly support Medi-Cal member identification and enrollment.

Managed care

Managed care is a system of health care payment and delivery. The State contracts with managed care plans to provide services for people on Medi-Cal. These members enroll into a managed care plan in their county and are assigned a primary care provider, who is part of the managed care plan’s network. In managed care, members can only see doctors who are part of the plan’s network and often need referrals from their primary care provider to see specialists.

Managed Care Accountability Sets - MCAS

The MCAS is a set of performance measures that managed care plans must report on annually. They are selected by the Department of Health Care Services, and include HEDIS measures.

Mental Health Plan - MHP

EPSDT mental health services in Medi-Cal are delivered primarily through two parallel systems. MHPs are the county-run plans responsible for providing Specialty Mental Health Services (SMHS) for people on MediCal. Managed Care Plans (or fee-for-service (FFS) providers for children not enrolled in managed care) are responsible for providing non-specialty mental health services.

Network

A managed care plan network refers to all the doctors, labs, hospitals, and other providers that have contracts with the plan to provide health care services to members.

Public health plans

Public health plans are non-commercial plans run by the county.

Regional Model

The Regional Model is a county model of Medi-Cal managed care where the state contracts with two commercial health plans to serve the MediCal population in two or more contiguous counties.

Reprocurement

DHCS is in the process of entering into new contracts with health plans to deliver Medi-Cal managed care. This “reprocurement” of contracts is an important opportunity to improve the way managed care plans deliver and are held accountable for children’s health services. The Department’s request for proposals (RFP) is scheduled to be released in late 2021, and new contracts will go into effect starting January 2024.

For more information, see the First 5 Association and First 5 Center’s recommendations to the State on children’s services.

Specialty Mental Health Services – SMHS

SMHS refers to the Medi-Cal mental health services delivered by county Mental Health Plans (MHPs). Specialty mental health services are carved out of the managed care plan’s responsibility.

Targeted case management - TCM

TCM refers to services that help individuals access needed medical, social, educational, and other services. The TCM program is funded by a combination of local funds and federal Medicaid funds. The TCM program reimburses participating counties for the federal share of costs (typically 50%) of case management services provided to specific target populations (including children).

Two-Plan Model

The Two-Plan model is a county model of Medi-Cal managed care where the state contracts with two plans to serve the Medi-Cal population: one county-organized plan called the local initiative and one commercial plan.