Term
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Definition
| Refers to the ability of an individual to receive healthcare services when needed |
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Term
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Definition
| A process by which an agency or organization evaluates and recognizes a program of study or an activity of an instiution as meeting certain predetermined standards. It is usually granted by private or professional organizations and is created to assure the public of the quality of the organization or agency |
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Term
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Definition
| Short-term, intensive medical care for an illness or injury usually requiring hospitalization |
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Term
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Definition
| The number of admissions to a hospital or inpatient facility |
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Term
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Definition
| Occurs when those joining a health plan have higher medical costs than the general population; if too many enrollees have higher than average medical costs, the health plan experiences adverse selection |
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Term
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Definition
| Specially trained and licensed or certified (when necessary) health workers who do not engage independent practice. |
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Term
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Definition
| Charge determined by a plan as the max that the plan will pay for a service, regardless of the charge the provider sets for the service. If the actual charge exceeds the allowalbe charge, then the recipient of services generally pay the balance. |
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Term
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Definition
| Medical or health care services outside the traditional medical model. |
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Term
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Definition
| Outpatient medical services; medical care rendered to pts in physician's offices, outpt departments, and health centers |
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Term
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Definition
| Hospital or other inpt services other than room and board and professional medical services such as physician and nursing care. |
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Term
| Average Length of Stay (ALOS) |
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Definition
| The mean number of days admitted pts stay in an inpt facility. The formula for this measure is the total days of care incurred by all D/C pts divided by the total number of D/Cs during the period |
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Term
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Definition
| Refers to the leftover sum that a provider bills to the pt after insurance has only partially paid the charge that was initially billed |
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Term
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Definition
| List of health and related services guaranteed to be provided in a health plan |
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Term
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Definition
| Person in a workplace who develops and oversees a package of health, retirement, and other programs for employees |
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Term
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Definition
| A physician who has passed an examination by a medical specialty group and who has been certified as a specialist in that specific medical area |
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Term
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Definition
| In the strictest sense, a stipulated dollar (pre-paid) amount established to cover the health care delivered to an individual. The term usually refers to a negotiated per capita rate paid on a monthly basis to a health-care provider, and may be referred to as the "per member, per month" (PMPM) rate |
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Term
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Definition
| Amount paid to a health plan or provider for services based on a fixed monthly or annual amount per person, no matter how few or how many services and consumer uses |
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Term
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Definition
| A health professional affiliated with a health plan who is responsible for coordinating the medical care of an individual enrolled in a managed care plan |
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Term
| The Centers for Medicare and Medicaid Services (CMS) |
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Definition
| The federal agency within the Department of Health and Human Services (DHHS) responsible for administering the Medicare program and for overseeing the states' administration of the Medicaid and SCHIP programs |
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Term
| Certificate of Need (CON) |
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Definition
| Control exercised by a government planning agency over expansion of medical facilities; e.g., determination of whether a new facility should be opened in a certain location, whether an existing facility should be expanded, or whether a hospital should be allowed to purchase major equipment |
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Term
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Definition
| A process by which a governmental or non-governmental association grants recognition to an individual or entity that has met predetermined qualifications. It is voluntary and carries no legal sanctions. |
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Term
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Definition
| The amount a provider bills for rendering a service (see cost) |
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Term
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Definition
| The care guide used by health plans and providers in making decisions about medical necessity |
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Term
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Definition
| The percentage amount of money paid out of pocket by plan members for medical services. CO-INSURANCE payments usually constitute a fixed percentage of the total cost of a medical service covered by the plan. If a health plan pays 80% of a physician's bill, the remaining 20% which the member pays is referred to as co-insurance |
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Term
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Definition
| Nonfederal, short-term general or specialized hospital whose services are available to the general public |
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Term
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Definition
| A flat free paid by plan members for specific medical services. For example, a $5 or $10 "co-pay" is often required for prescriptions and office visits |
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Term
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Definition
| What it costs the provider to produce a service |
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Term
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Definition
| The degree to which a service meets a specified goal at an acceptable cost |
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Term
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Definition
| Provisions in a health insurance plan that require the insured to pay some portion of his or her covered health expenses. Includes co-insurance, co-payments, and deductibles |
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Term
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Definition
| The formal recognition of professional or technical competence; includes the licensure of individuals or organizations by the government, certification of individuals by voluntary agencies and accreditation of organizations or programs by voluntary associations. A "credential" is a statement of value that warrants confidence. It establishes that a person or institution has achieved professional recognition in a specific field. In the US, a credential in health care may take the form of one of the following: educational or institutional credential, or accreditation, certification, or licensure |
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Term
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Definition
| The sum of money that an individual must pay out pocket for medical expenses before a health plan reimburses a percentage or set amount of additional covered medical expenses |
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Term
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Definition
| Refers to those facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations or he American Osteopathic Association; signifies compliance with the Medicare Conditions of Participation for Hospitals |
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Term
| Diagnosed Related Groups (DRGs) |
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Definition
| A system of classification for inpt hospital services based on principal Dz (Dx), secondary Dz (Dx), surgical procedures, age, sex, and presence of complications or co-morbidities. This system of classification is used as a mechanism to pay hospitals and selected providers for services to Medicare beneficiaries in particular. See RBRVS for the comparable physician payment plan |
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Term
| Durable Medical Equipment (DME) |
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Definition
| Necessary medical equipment that is not disposable; for example, wheelchairs, walkers, ventilators, commodes |
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Term
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Definition
| The amount an employer pays towards the premium cost for an individual's health plan contract (health insurance) |
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Term
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Definition
| The time when you decide which MCO you will choose; "open" enrollment takes place annually |
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Term
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Definition
| A health care program to which a certain category of people is entitled. For example, almost everyone at 65yo in the US is entitled to Medicare health care coverage. Medicaid is not an entitlement program** |
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Term
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Definition
| Disorders, Dzs, or Txs listed as uncovered services (not reimbursable) in an insurance policy (for which the policy will not provide benefit payments) |
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Term
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Definition
| The traditional health care payment system, under which physicians and other providers receive a payment for each unit of service provided. The provider sets the payment level |
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Term
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Definition
| A health plan's list of approved prescription meds for whit it will reimburse members or pay for directly. Additional meds are usually not available to plan members |
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Term
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Definition
| A PCP who coordinates all diagnostic testing and specialty referrals for a patient's medical care |
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Term
| Health Maintenance Organization (HMO) |
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Definition
| Health plans that contract with medical groups to provide a full range of health services for their enrollees for a fixed pre-paid, per-member fee. There are three different kinds of HMOs: Group Model HMOs, Staff Model HMOs and IPA Model HMOs |
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Term
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Definition
| An HMO that contracts with a single multi-specialty medical group to provide a full range of health servicesto non-HMO patients as well.The HMO pays the medical group a negotiated per capita rate, which the group distributes among its physicians, usually on a salary basis. |
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Term
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Definition
| A type of HMO (where pts can receive services only throuh a limited number of providers) in which physicians are employees of the HMO. The providers see members in the HMO's own facilities. |
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Term
| Independent Practice Associations (IPA) |
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Definition
| A type of healthcare provider organization composed of a group of independent practicing physicians who maintain their own offices and band together for the purpose of contracting their services to HMOs, PPOs (preferred provider organizations), and insurance companies. An IPA may contract with and provide services to both HMO and non-HMO plan participants |
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Term
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Definition
| A growing number of HMOs now offer a Point of Service option. These "escape hatch" plans allow HMO members to seek care from non-HMO physicians, but the premiums for POS plans are much more costly than those for traditional HMOs which restrict choice of physician. Moreover, when an HMO member receives care from a non-participating physician or hospital, the HMO pays far less than its usual 100% coverage of necessary medical services. |
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Term
| Preferred Provider Organization (PPO) |
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Definition
| A health plan that encourages savings by establishing a network of preferred providers -- health professionals who agree to provide medical services to plan members for discounted rates. Plan members may go "out of network" to seek medical services from non-affiliated medical professionals. Members are charged higher co-payments for this option. |
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Term
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Definition
| An insurance program in which the insured person is reimbursed for specified covered expenses |
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Term
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Definition
| To receive health care services, patients are temporarily confined to institutions, such as a hospital or nursing home, where they stay overnight |
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Term
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Definition
| Permission granted to an individual or organization by an authoritative agent, usually governmental, to engage in a practice or activity that would be deemed illegal without a license. |
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Term
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Definition
| Extended assistance for chronically ill, mentally ill, or disabled people. Often focused on assistance with carrying out basic daily needs. |
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Term
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Definition
| A system of health care delivery that influences utilization and cost of services and performances measures as well as coordinating medical and other health-related services. The goal is a system that delivers value by giving people access to quality, cost-effective health care. |
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Term
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Definition
| A federal program administered globally by the federal government, but operated individually by participating states and territorial governments, which provides medical benefits to low income persons needing health care (the indigent) |
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Term
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Definition
| A nationwide, federally administered health insurance program which covers the cost of hospitalization, medical care, and some related services for eligible persons. Medicare beneficiaries include persons age 65 and over, disabled persons receiving Social Security benefits, and person with end-stage renal disease. |
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Term
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Definition
| The federal hospital insurance program that covers the cost of hospital and related post-hospital services for thsoe over 65 or with certain disabilities and diseases. Eligibility is normally based on prior payment of payroll taxes. Beneficiaries are responsible for an initial deductible per episode of illness and co-payments for some services. All beneficiaries must have Part A if they want to enroll in any of the other voluntary parts. |
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Term
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Definition
| The supplementary federal medical insurance program for those over 65 or with certain disabilities that covers the costs of physician services, outpatient laboratory and X-ray tests, durable medical equipment, outpatient hospital care and certain other services. Part B is voluntary, requires payment of monthly premium and beneficiaries are responsible for a deductible and co-payment for most covered services. Beneficiaries must enroll in Part A before they choose Part B. |
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Term
| Medicare Advantage (Formerly Medicare + Choice and Medicare Risk Accounts, also Medicare Part C) |
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Definition
| A contract between Medicare and a health plan under which the plan receives monthly capitated payments to provide Medicare-covered services for enrollees, and thereby assumes insurance risk for enrollees. A plan is eligible for a risk contract if it is a federally qualified HMO or a competitive medical plan. Beneficiaries must be enrolled in both Medicare Parts A and B and must still pay their Part B premiums. |
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Term
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Definition
| The voluntary Medicare prescription drug program. Beneficiaries can keep their fee-for-service medicare plans and sign up for a free standing Prescription Drug Plan (PDP) or enroll in a Medicare Advantage Prescription Drug (MA-PD) plan. Beneficiaries must be enrolled in both Medicare Part A and B before they can sign up for Medicare Part D |
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Term
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Definition
| Private insurance products that provide Medicare beneficiaries protection from the costs of services that exceed the amount Medicare will pay for the service. |
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Term
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Definition
| Medical Savings Accounts are tax-free accounts that can be used in conjunction with high-deductible indemnity plans. People set aside a certain amount each year to pay for un-reimbursed medical expenses. |
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Term
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Definition
| As a rule, having health insurance leads people to consume more health care services than they would have purchased if they had to pay for such services out-of-pocket. |
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Term
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Definition
| The National Committee for Quality Assurance. An organization that provides information to allow purchasers and consumers of managed health care to compare plans. |
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Term
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Definition
| Person designated by a health plan or Medicaid to solve problems and answer questions in an objective way. |
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Term
| Out-of-Pocket Cap/Maximum |
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Definition
| An annual limit on how much in deductibles and co-payments the patient is required/must pay. Also called a "stop loss" provision |
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Term
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Definition
| A person who receives health care services without being admitted to an inpatient facility; also referred to as an ambulatory patient |
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Term
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Definition
| Basic and routine health care that is provided in an office or clinic by a provider (physician, nurse, or other health care professional) who takes responsibility for coordination of all aspects of a patient's health care needs. |
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Term
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Definition
| An illness or condition which an individual has before he/she is covered by an insurance plan or while he/she was covered by a different insurance plan. These specific conditions may not be paid for by the insurer for a specific period of time. |
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Term
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Definition
| Any individual or organization that provides servies generally covered under health insurance (including Medicaid and Medicare) |
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Term
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Definition
| Refers to a wide variety of activities directed mainly at Dz prevention and generally undertaken by state and local governments. |
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Term
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Definition
| The amount of money insurers pay to a provider. They payment may only be a portion of the actual charge. |
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Term
| Resource Based Relative Value Scale (RBRVS) |
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Definition
| A fee schedule introduced by HCFA (now CMS) to pay physicians for services to Medicare beneficiaries based on teh amount of time and resources expended in treating patients, with adjustments for overhead costs and geographical differences in market prices |
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Term
| Risk Adjustment/Risk Sharing |
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Definition
| Occurs when two parties agree to a formula that will determine the proportion of costs they will share from any losses that result when medical costs exceed the payments |
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Term
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Definition
| An arrangement through which a health provider agrees to provide a ful range of medical services to a set population of patients for a pre-paid sum of money. They physician is responsible for managing the care of these patients and risks losing money if the total expenses exceed the pre-determined allocated funds. |
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Term
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Definition
| Refers to a system in which there is a single payer as opposed to multiple payers. The single payer is generally the government, as in the case in a national health insuracne program. |
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Term
| SNF/Skilled Nursing Facility |
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Definition
| An institution providing skilled nursing and related services to residents; a nursing home |
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Term
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Definition
| The process of using up all income and assets on medical care in order to qualify for Medicaid |
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Term
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Definition
| A form of health insurance that provides protection for medical expenses above a certain limit |
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Term
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Definition
| An intermediary between patients and providers. Third parties carry out the functions of insurance and paymetns for health care delivery. |
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Term
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Definition
| Means that all citizens have access to at least a basic package of health care services. |
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Term
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Definition
| Refers to the quantity of health care consumed |
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Term
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Definition
| The various methods used by health plans to measure the amount and appropriateness of health services used by its members. These checks can occur before, during, and after services have been sought or received from health professionals. |
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Term
1. AAPCC
2. ACA
3. ACO
4. ADA
5. ADL |
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Definition
1. Adjusted Average Per Capita Cost
2. Affordable Care Act
3. Accountable Care Organization
4. Americans with Disabilities Act of 1990
5. Activities of Daily Living |
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Term
1. AFDC/TANF
2. AHA
3. AMA
4. ANA
5. AHRQ |
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Definition
1. Aid to Families with Dependent Children (changed to Temporary Assistance for Needy Families)
2. American Hospital Association
3. American Medical Association
4. American Nurses Association
5. Agency for Healthcare Research and Quality |
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Term
1. ALOS
2. APG
3. APN
4. AWP
5. BBA |
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Definition
1. Average length of stay
2. Ambulatory Patient Groups
3. Advanced Practice Nurse
4. Any willing provider
5. Balanced Budget Act of 1997 |
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Term
1. BBRA
2. BIPA
3. CARF
4. CBO
5. CDC |
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Definition
1. Balanced Budget Refinement Act of 1999
2. Benefits Improvement and Protection Act of 2000
3. Commission on Accreditation of Rehabilitation Facilities
4. Congressional Budget Office
5. Centers for Dz Control and Prevention |
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Term
1. CMS
2. COBRA
3. CON
4. CPT
5. CQI |
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Definition
1. Consolidated Omnibus Budget Reconciliation Act of 1985
2. Certificate of Need
3. Current Procedural Terminology
4. Continuous Quality Improvement |
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Term
1. DHHS
2. DME
3. DO
4. DRG
5. DSH |
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Definition
1. Department of Health and Human Services
2. Durable Medical Equipment
3. Doctor Osteopathy
4. Diagnosis Related Group
5. Disproportionate Share Hospital |
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Term
1. DSF
2. DSM-IV
3. ED/ER
4. EMTALA
5. EOB |
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Definition
1. Disproportionate Share Funding
2. Diagnostic and Statistical Manual of Mental Disorders
3. Emergency Department
4. Emergency Medical Tx and Labor Act of 1986
5. Explanation of Benefits |
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Term
1. EPSDT
2. ERISA
3. FDA
4. GAO
5. GDP |
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Definition
1. Early Periodic Screening, Dx and Tx
2. Employee Retirement Income Security Act
3. Food and Drug Administration
4. General Accounting Office
5. Gross Domestic Product |
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Term
1. GME
2. HIPAA
3. HEDIS
4. HMO
5. HPSA |
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Definition
1. Graduate Medical Education
2. Health Insurance Portability and Accountability Act
3. Health Plan Employer Data and Information Set
4. Health Maintenance Organization
5. Health Professional Shortage Area |
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Term
1. IADL
2. ICD-9-CM
3. IDS/IDN
4. IMGs
5. IOM |
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Definition
1. Instrumental Activities of Daily Living
2. International Classification of Dzs
3. Integrated Delivery Systems/Integrated Delivery Networks
4. International Medical Graduates
5. Institute of Medicine |
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Term
1. IPA
2. JC
3. LOS
4. LPN
5. LTC |
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Definition
1. Independent Practice Association
2. Joint Commission (formerly JCAHO)
3. Length of Stay
4. Licensed Practical Nurse
5. Long Term Care |
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Term
1. MCO
2. MD
3. MedPAC
4. MMA
5. MA-PD |
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Definition
1. Managed Care Organization
2. Doctor of Medicine
3. Medicare Payment Advisory Commission
4. Medicare Prescription Drug, Improvement, and Modernization Act
5. Medicare Advantage-Prescription Drug Plan |
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Term
1. MSA
2. NCQA
3. NFP
4. NIH
5. NP |
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Definition
1. Medical Savings Account or Metropolitan Statistical Area
2. National Committee for Quality Assurance
3. Not-for-Profit
4. National Institutes of Health
5. Nurse Practitioner |
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Term
1. OBRA
2. OMB
3. OSHA
4. OT
5. PA |
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Definition
1. Omnibus Budget Reconciliation Act
2. Office of Management and Budget
3. Occupational Safety and Health Administration
4. Occupational Therapy
5. Total Badasses |
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Term
1. PACE
2. PCMH
3. PCCM
4. PCP
5. PDP |
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Definition
1. Program of All-Inclusive Care for the Elderly
2. Patient Centered Medical Home
3. Primary Care Case Management
4. Primary Care Physician
5. Prescription Drug Plan |
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Term
1. PHI
2. PHO
3. PMPM
4. POS
5. PPACA |
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Definition
1. Protected Health Information
2. Physician Hospital Organization
3. Per Member Per Month
4. Point of Service
5. Patient Protection and Affordable Care Act of 2010 |
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Term
1. PPO
2. PPS
3. PRO
4. PSRO
5. PT |
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Definition
1. Preferred Provider Organization
2. Prospective Payment System
3. Peer Review Organization
4. Professional Standards Review Organization
5. Physical Therapy |
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Term
1. QA
2. QMB
3. RBRVS
4. RN
5. RPh |
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Definition
1. Quality Assessment/Quality Assurance
2. Qualified Medicare Beneficiary
3. Resource Based Relative Value Scale
4. Registered Nurse
5. Registered Pharmacist |
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Term
1. RT
2. RUGs
3. SCHIP
4. SES
5. SLMB |
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Definition
1. Respiratory Therapist
2. Resource Utilization Groups
3. State Children's Health Insurance Program
4. Socioeconomic Status
5. Specified Low-Income Medicare Beneficiary |
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Term
1. SNF
2. SSA
3. SSI
4. SW
5. TEFRA |
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Definition
1. Skilled Nursing Facility
2. Social Security Administration
3. Supplemental Security Income
4. Social Worker
5. Tax Equity and Fiscal Responsibility Act of 1982 |
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Term
1. TQM
2. UCR
3. UR
4. VHA
5. WHO |
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Definition
1. Total Quality Management
2. Usual, customary, and reasonable
3. Utilization Review
4. Veterans Health Administration (or VA)
5. World Health Organization |
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