A payer strategy in which an insurerisolates (“carves out”) a benefit and hires another organization to provide this service. Common carve-outs include behavioral health and prescription drugs. The technique is intended to allow the insurer to better...

case management

A process in which a health plan identifies covered persons with specific health care needs, then devises and carries out a plan to achieve the best patient outcome in the most cost-effective manner.

case mix

The mix of patients treated within a particular institutional setting, such as a hospital or within a particular health plan. Case mix may be measured by the severity of patients’ illnesses or the prospective use of care resources.

case mix adjustment

Change in payment to a health plan or provider to avoid overpaying or underpaying when health status or likely use of services varies from average.

Cash and Counseling

A former Medicaid program in some states that allowed certain Medicaid beneficiaries, frail elders and adults with disabilities to purchase their own personal care and related services. Medicaid provided a monthly allowance, the amount of which is determined after...