Terms & Acronyms





Alternative Payment Model

A payment model that gives added incentive payments to healthcare providers to provide high-quality and cost-efficient care. Tied to performance outcomes. Differs from traditional fee-for-service (FFS) payment model.




A type of a healthcare payment system in which a doctor or hospital is paid a fixed amount per patient for a certain period of time, whether a patient seeks care or not.



Community-Based Care Management Program

A physical health (PH) managed care organization (MCO) program approved by the PA Department of Human Services that increases partnerships with Community-Based Organizations, encourages preventative services, addresses social determinants of health, and improves maternal/child health.



Community-Based Organization

Nonprofit organization that works at a local level to improve life for residents (example: Goodwill, United Way). A health care provider is not considered a CBO.



Community Health Worker

According to the American Public Health Association, “A CHW is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”



Centers for Medicare and Medicaid Services

Federal agency within the U.S. Department of Health and Human Services that oversees Medicaid programs.



Current Procedural Terminology

Current Procedural Terminology (CPT) is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.




A healthcare payment model in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.



Managed Care Organization

A healthcare company or health insurance plan that serves Medicare or Medicaid customers focused on reducing costs through a network of affiliated providers.



Pennsylvania Department of Human Services

The Pennsylvania Department of Human Services is a cabinet-level state agency in Pennsylvania. The Pennsylvania Department of Human Services’ seven program offices administer services that provide care and support to Pennsylvania’s most vulnerable citizens.



Pathways Community HUB

An evidence-based Community Health Worker model that is an organized, outcome focused, network of locally-based Care Coordination Agencies who hire and train CHWs who connect at-risk individuals to needed services.  CHWs meet with participants face-to-face, preferably in their homes, then guide them through one or more of 21 Pathways designed to address needs.



Patient Centered Medical Home model

An approach to delivering high-quality, cost-effective primary care. 



Physical Health Managed Care Organizations


Physical Health (PH) Managed Care Organization (MCOs) address physical health services for members; distinguished from Behavioral Health (BH) MCOs.



Per Member Per Month

Amount of money received by a Managed Care Organization (MCO) each month for each individual enrolled in the MCO (also referred to as capitation).



Return on Investment


The ratio between net income (over a period) and the number of dollars invested. A high ROI means the investment’s gains compare favorably to its cost. As a performance measure, ROI is used to evaluate the efficiency of an investment.



State Plan Amendment

An agreement between a state and the Federal government describing how that state administers its Medicaid program. When a state makes a change, the state sends it to CMS for review and approval.


Section 1115 Demonstration Waiver

Section 1115 Demonstration Waiver

Experimental or pilot projects (funded by Centers for Medicare and Medicaid Services) that are likely to assist in goals of the Medicaid program. States are given flexibility to design and improve their programs. Generally a 5 year+ program.



Value-Based Purchasing

A health care delivery model under which health care providers are paid based on the health outcomes of their patients and the quality of services rendered.