chapter 3

Affordable Care Act (ACA)

Healthcare reform legislation signed into law by President Barack Obama in March 2010 with a goal of increasing access to health insurance while controlling healthcare costs.

American Medical Association (AMA)

A professional medical organization that represents physicians nationwide and seeks to address the most important professional and public health issues.

Bundled payment

Method of controlling healthcare costs by reimbursing Medicare for all services for a procedure

Capitation

Paying a fixed amount per person for health services without regard to the volume of service provided.

Centers for Medicare and Medicaid Servious (CMS)

Agency of the U.S. Departement of Health and Human Services (HHS) that manages Medicare and Medicaid and strives to ensure effective, up

Children's Health Insurance Program (CHIP)

Health insurance for children from families with incomes too high for Medicaid but too low to afford the cost of premiums for private health insurance.

Community Engagement initiative

The Centers for Medicare and Medicaid (CMS) allowed states to target Medicaid recipients to complete work or "work

Copayment

The share of the cost for healthcare services (for example, a doctor's visit) not covered by health insurance.

Coinsurance

The percentage of the cost of medical services paid by the consumer of the total cost of the service. For example, for those enrolled in Medicare is 20%.

Cost-sharing subsidy-

Silver Health Plan; these subsidies can be used to pay for healthcare expenses not covered by health insurance such as deductibles and copayments for clinic visits or prescription drugs. 

Deductible

The dollar amount paid out of pocket for healthcare services before health insurance will cover the cost.

Department of Health and Human Services (HHS)

The U.S. government’s prinicipal agency for protecting the health of all Americans and providing essiential human services, especially for those who are least able to help themselves.

Diagnosis related groups (DRGs)

A set of payment categories that are used to classify patients for the purpose of hospital reimbursement with a fixed fee regardless of the actual cost and that are based on the diagnosis, surgical procedure used, age of patient, and expected length of stay.

Dual eligible

Individual eligible for Medicare and Medicaid services based on age, disability, and income.

Early and Periodic Suning Diagnostic and Treatment (EPSOT)

Services for infants, children, and adolescents under age 21 who are enrolled in Medicaid to identify and treat physical and developmental conditions and mental illness.

Fee for service

a payment model where healthcare providers are paid a separate fee for each individual service they provide

Federal poverty level (FPL)

A measure of income level issued yearly by HHS used to determine eligibility for Medicaid, the Children's Health Insurance Program, and the cost of premiums for health insurance purchased through Health Exchanges.

Health Insurance Marketplace

Also Health Exchange. Federally funded clearing house for enrolling in health insurance.

Health maintenance organization (HMO)

Insurance provider that administers basic and supplemental health maintenance and treatment services to enrollees who pay a fixed fee.

Home-and community-based services (CBS)-

are a range of personalized health and human services that help older adults and people with disabilities live independently in their homes or communities, rather than in institutions 

Hospital Readmission Reduction Program (HRRP)

A program under the Affordable Care Act to improve quality and reduce costs of care for patients readmitted to the hospital for pneumonia, congestive heart failure, or acute myocardial infarction. Medicare reduces prospective payments to hospitals That fail to meet the criteria for readmission for these three diagnoses.

High deductible health plan with a savings option (HOHPYSO)

A health insurance plan that requires individuals to pay a set amount of healthcare costs at the beginning of each calendar year before the health plan covers the costs. Usually, premiums are lower than traditional health plans. Some plans have a savings account option.

Long_term sunvious and supports TSS)

System or providing health and personal care support for the disabled, elderly, or others with chronic health problems in people’s homes instead of an institution.

Managed care organizations (MCO)

are health insurance programs that control healthcare cost by agreeing to provide health services in exchange for a set dollar amount received from Medicare or Medicaid for each enrollee: use capitation to control healthcare cost.

Marketplace subsidies

The Affordable Care Act allows subsidies or tax credit for those who earn 400% or less of the federal poverty level; subsidies reduce the cost of health insurance premiums purchased through the federal marketplace.

Medicaid_Healthcare program for low

income pregnant women, seniors at 100% and adults at 133% of the federal poverty level, and individuals with disabilities, joinly funded federal and state governments.

Medicaid waiver

A policy that allows individual states to test new ways to deliver and pay for healthcare services for Medicaid and the children's Health insurance program (CHIIP).

Medicare

Provide health care to the disabled and those over 65 years of age.

Medicare Advantage Plan

When a private health insurance company contracts with Medicare to provide all part A (hospital) and part b (outpatient) benefits including prescription drugs

Network

Group of hospitals, physicians, and other healthcare providers, insurers and community agencies delivering health services within a geographic area.

Preferred provider organizations (PPO)

health insurance plan that covers the cost of providers within a network and outside of the network, although copayments by the patient are higher for out

Premium tax credit

Also called premium; allowed by the Affordable care Act for those who earn 400% or less the federal poverty level. The tax credit reduces the cost of health insurance premiums purchased through the federal marketplace.

Private health insurance

Health insurance provide through an employer or purchased by an individual through another group such as a professional organization

Premium

The cost of health insurance covered by an employer, shared with the employer or purchased through a Health Exchange.

Reimbursement

To make a return payment to.

Work requirement waiver

Beginning in 2018, the Centers for Medicare and Medicaid Services (CMS) established a waiver to allow states to require that recipients of Medicaid be employed or enrolled as a student to qualify for health insurance through Medicaid.

Health maintenance organization (HMO)-

Insurance provider that administers basic and supplemental health maintenance and treatment services to enrollees who pay a fixed fee. 

Out-of-pocket

Cost of healthcare services not covered by private health insurance, Medicaid or Medicare, or Children's Health Insurance Program. Includes copayments for hospital and outpatient care and may include full payment for eyeglasses, hearing aids, and dental work. 

Accountable care organization (ACO)

Healthcare delivery model that ties provider reimbursement payment to the quality and cost of care for a patient population—for example, patients on kidney dialysis.