BioMed-chap 3

Accountable Care Organization (ACO)

Healthcare delivery model that ties provider reimbursement payment to the quality and cost of care for a patient population

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 cost.

American Medical Association (AMA)

A professional medical organization that represent physicians nationwide and seeks to address the 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 field amount per person for health services without regard for 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 efficient and up to date healthcare coverage and to promote quality care for beneficiaries.

Children's Health Insurance Program (CHIP)

health insurrance 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, coinsurance 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 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)

responsible for implementing Medicaid. The program is jointly funded by the federal and state governments and is administered by individual states.

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-eligable

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 (EPDST)

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 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, CHIP, and the cost of premiums for health insurance purchased through health insurance purchased through health insurance.

Health Insurance Marketplace

Also health exchange. Federally funded clearing house for enrolling in health insurance.

Health maintenance organization (HMO)

Insurance provider that administrates basic and supplemental health maintenance and treatment services to enrollees who pay fixed fees.

Home and community based services (HCBS)

Option for state medicaid programs to cover the cost of providing health and personal care services for the elderly or disabled at home.

Hospital Readmission Reduction Program (HRRP)

A program under (ACA) to improve quality and reduce costs 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 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 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 (MCOs)

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

Marketplace subsidies

The (ACA) allows subsidies or tax credits for those who earn 400% or less of 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 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.

Medicare

Provides health care for 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.