MEDICAID: Glossary of Terms
Prepared for AAFP State Government Relations By Tim M. Henderson
Capitation a method of payment for health services in which a practitioner or hospital is prepaid a fixed, per capita amount to cover a specific period of time for each person served, regardless of the actual number or nature of services provided to each person.
Care coordination, considered a managed care term, refers to primary care and coordination of health care services for all members of a Medicaid managed care plan. Care coordination procedures must meet state requirements and must do the following:
- Ensure that each enrollee has an ongoing source of primary care appropriate to his or her needs, and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee.
- Coordinate the services the managed care plan furnishes to the enrollee with the services the enrollee receives from any other managed care plan.
- Share with other managed care plans serving the enrollee with special health care needs the results of its identification and assessment of that enrollee’s needs to prevent duplication of those activities.
- Ensure that in the process of coordinating care, each enrollee’s privacy is protected.
If the State requires managed care organizations to produce a treatment plan for enrollees with special health care needs who are determined through assessment to need a course of treatment or regular care monitoring, the treatment plan must be developed by the enrollee’s primary care provider with enrollee participation, and in consultation with any specialists caring for the enrollee. For enrollees with special health care needs determined through an assessment by appropriate health care professionals to need a course of treatment or regular care monitoring, each managed care plan must have a mechanism in place to allow enrollees to directly access a specialist (for example, through a standing referral or an approved number of visits) as appropriate for the enrollee’s condition and identified needs.