Biomed Chapter 3 Vocab

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

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 - for example, hip replacement surgery and home care after discharge from the hospital

Capitation

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

Centers for Medicare and Medicaid Services (CMS)

Agency of the U.S. Department of Health and Human Services (HHS) that manages Medicare and Medicaid and strives to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries

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 allowed states to target Medicaid recipients to complete work or work equivalent activities such as caregiving or being enrolled as a student as a condition of eligibility for Medicaid

Copayment

The share of a cost (fixed amount) of healthcare services (for example, a doctor’s visit) not covered by insurance

Coinsurance

The percentage of the cost of Medical Services paid by the consumer of the total cost of the service for example, amount for those enrolled in Medicare is 20%

Cost-sharing subsidy

A provision of the Affordable Care Act includes subsidies for those enrolling in the silver Health Plan; these subsidies can be used to pay for healthcare expenses not covered by health insurance such as deductibles and co-payments for clinic visits or prescription drugs

Deductible

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

Department of Health and Human Services (HHS)

The U.S. government's principal agency for protecting the health of all Americans and providing essential 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 the 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 who is eligible for both Medicare and Medicaid services based on age and/or disability and income

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

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.

Exclusive provider organization (EPO)

Health plan that only covers the cost of providers inside the network

Fee-for-service payment

Payment to a healthcare provider for each medical service rendered to a patient

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

Hospital Readmission Reduction Program (HRRP)

A program under the Affordable Care Act to improve quality and reduce cost 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 (HDHP/SO)

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 services and supports (LTSS)

System of providing healthcare 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 (MCOs)

Healthcare plan with established cost controls and designed to improve quality of care

Marketplace Subsidies

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

Medicaid

Healthcare program for low-income pregnant women, seniors at 100% and adults at $133% of the federal poverty level, and a visual individuals with disabilities; jointly funded by 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 (CHIP)

Medicare

Provides healthcare to the disabled and those over 65 years of age

Medicare Advantage Plan

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

Network

Groups of hospitals, physicians, and other healthcare providers as well as insurers and community agencies that deliver health services within a geographic area

Preferred provider organizations (PPOs)

Health insurance plan that covers the cost of providers within a network and outside of the network although co-payments by the patient are higher for out-of-network providers

Premium tax credit

Also premium subsidies; allowed by the Affordable Care Act for those who earn 400% or less of the federal poverty level. It reduces the cost of the health insurance premiums purchased through the federal marketplace

Private health insurance

Health insurance provided 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 employee or purchased through a Health Exchange

Out-of-pocket

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

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

Managed care plan with…

• low premiums and overall cost

• PCP, gatekeeper, and referrals required

• out-of-network not covered

HMO

Managed care plan with…

• High premiums, higher overall cost

• No gatekeeper

• PCP and referrals not required

• Out-of-network covered for a higher cost

PPO

Managed care plan with…

• Mid-range cost

• PCP required, referrals usually required

• out-of-network care depends

POS

Managed care plan with…

• Mid-range price

• PCP and referrals not required

• Out-of-network care not covered unless emergency

EPO