Glossary of Terms

 

California Children’s Services (CCS): The California Children’s Services program covers medical care services for children with certain disabling and chronic health conditions whose families are unable to bear the tremendous health care costs of the most painful and debilitating child illnesses.  CCS covers specialty and subspecialty care, outpatient and inpatient care, occupational and physical therapies, oral health services, pharmaceuticals, and medical equipment supplies.

 

CCS Carve-Out: Due to the urgency and high cost of specialized treatment for children with potentially life-threatening conditions, CCS was “carved out” or removed from most Medi-Cal managed care under state legislation enacted in 1994.  The CCS carve-out was needed to ensure California’s sickest children continue to receive regular access to care.

 

County Organized Health Systems (COHS): County Organized Health Systems are a type of Medi-Cal managed care plan accessed by more than a half-million Californians in eight counties.  COHS offer a local, community-governed health care program for Medi-Cal beneficiaries, including disadvantaged young families and aged, blind disabled individuals.

 

Health Maintenance Organization (HMO): HMOs are a type of prepaid medical service in which members pay a monthly or yearly fee for all health care, including hospitalization.  Because costs to patients are fixed in advance, preventive medicine is stressed to avoid costly hospitalization.  Most HMOs require patients use only doctors and specialists who are associated with the organizations.  “Open-ended” HMOs offer members the option of seeing a doctor who is not part of the HMO, but the patient must pay additional costs.

 

Managed Care: A system of health payment or delivery arrangements where the plan attempts to control or coordinate use of health services by its enrolled members in order to contain health expenditures, improve quality, or both.

 

Medi-Cal: California’s health program for low-income families and children.  It’s the state’s equivalent of the federal Medicaid program.  The children’s portion of the Medi-Cal program is called the EPSDT program (Early and Periodic Screening, Diagnosis, and Treatment Program).

 

Medi-Cal Managed Care: Under regular Medi-Cal, consumers can choose their doctor and they can go directly to the particular kind of doctor they want or need.  Under the managed care system, consumers can only go to those doctors who are a part of their plan and they must either choose or be assigned to one main doctor.  This doctor, called a primary care physician, must approve all treatment and referrals to any other doctors.  Additionally, under regular Medi-Cal, doctors are paid per doctor visit or per service.  Under the managed care system, health plans are paid a flat rate.

 

Medicare: A federal health insurance program for people age 65 and older as well as some younger, disabled individuals with certain conditions.

 

Pediatric Specialist: Pediatricians often refer their patients to pediatric specialists to care for children with chronic, more serious illnesses that require treatment beyond preventive or primary care.  Pediatric specialists are board certified in a pediatrics subspecialty, such as endocrinology, neurology, gastroenterology, pulmonology, oncology, and other pediatric subspecialty care.  Pediatric subspecialists are trained to care for the pediatric spectrum of diseases and conditions which is different from adult-related diseases and conditions.

 

Primary Care: Basic or general health care traditionally provided by doctors trained in family practice, pediatrics, or internal medicine.

 

Regional Care Centers: In order to provide the best and most efficient care for children in the CCS program, pediatric subspecialists provide centralized care in multi-disciplinary centers to children with chronic or life-threatening conditions that require constant monitoring.  These groups are usually affiliated with large hospitals and academic medical centers, often children’s hospitals and UC Medical Centers.  These regional care centers provide coordinated services for families who reside in counties, which lack pediatric medical institutions or a broad range of pediatric subspecialists.

 

Secondary Care: The medical care provided by a physician who acts as a consultant at the request of the primary physician.

 

Specialty Care: Specialized health care provided by physicians who training focused primarily in a specific field, such as neurology, cardiology, rheumatology, dermatology, oncology, orthopedics, ophthalmology, and other specialized fields.

 

Tertiary Care: Specialized consultative care, usually on referral from primary or secondary medical care staff, by specialists working in a center that has personnel and facilities for special investigation and treatment.

 

Triage: The process of prioritizing injured people based on need for medical treatment.  Due to the fact there are not enough pediatric specialists to see the sickest children with life-threatening illnesses, kids in CCS are often “triaged” based on medical immediacy.