Health Care Vocabulary
Access - The ability to obtain desired healthcare. Access is more than having insurance coverage
or the ability to pay for services. It is also determined by the availability, acceptability, cultural
appropriateness, location, hours of operation, transportation and cost of services.
Children's Health Insurance Program (CHIP) - Enacted in the 1997 Balanced budget Act as
title XXI of the Social Security Act, CHIP is a federal-state matching program of health care
coverage for uninsured low-income children. In contrast to Medicaid, CHIP is a block grant to
the states; eligible low-income children have no individual entitlement to a minimum package of
health care benefits. Children who are eligible for Medicaid are not eligible for CHIP. States
have the option of administering CHIP through their Medicaid programs or through a separate
program (or a combination of both). The federal matching rate for CHIP services (on average,
70 percent) is higher than that for Medicaid (on average at least 57 percent), but the federal
allotment to each state for CHIP services is capped at a specified amount each year.
dlaks - Center for Medicaid and State Options (CMSO) - The agency within the Centers for
Medicare and Medicaid Services (CMS, formerly the Health Care Fina Administration
HCFA) responsible for administering Medicaid and the Children's Health Insurance Program
(CHIP).
Center for Medicare and Medicaid Services (CMS) - The federal agency in the U.S.
Department of Health and Human Services (HHS) responsible for the administration of
Medicaid, Medicare, and CHIP (formerly the Health Care Financing Administration,
HCFA. http://www.hcfa.gov).
Closed Panel - A managed healthcare arrangement in which covered persons are required to
select providers only from the plan's participating providers. Also called an Exclusive Provider
Organization (EPO).
Community Mental Health Center (CMHC) - Community-based, mental healthcare centers
that provide a variable range of services, including inpatient, outpatient, emergency, partial
hospitalization, consultation, education, case management, drop-in centers and vocational
rehabilitation programs.
Continuum of Care - The availability of a broad range of treatment services so that care can be
flexible and customized to meet a consumer's needs.
e Contract Discounts - An economic incentive offered to consumers to encourage them to use
providers belonging to a group or organization preferred by a health plan. Usually, the out-of-
pocket expenses incurred by the patient are reduced.
as Copayment - A cost-sharing arrangement in which a consumer pays a specified charge for a
specified service (e.g., $10 for an office visit). The consumer is usually responsible for payment
at the time the service is rendered.
Ole Covered Expenses - Hospital, medical and other healthcare expenses paid for under a health
insurance policy
of beneficiaries. Adjusted annually for inflation and published by the Department of Health and
Human Services in the form of Poverty Guidelines, the FPL in calendar year 2001 was $14.030
for a family of 3 in the U.S., $18, 290 in Alaska, and $16,830 in Hawaii
Financial Eligibility - In order to qualify for Medicaid, an individual must meet both
categorical and financial eligibility requirements. Financial eligibility requirements vary from
state to state and from category to category, but they generally include limits on the amount of
income and the amount of resources an individual is allowed to have in order to qualify for
coverage.
Health Professional Shortage Area (HPSA) - A geographic area, population group, or medical
facility that DHHS determines to be served by too few health professional (primary care / dental
mental health) providers. Physicians who provide services in HPSAs qualify for the Medicare
bonus payments, re-payment of medical school loans or other incentives.
TYPES OF HPSAS
Dental Geographic Single County - whole county designated as Dental HPSA. Population to
Provider Ratio: 1: 5000
Dental Population Groups - a population within an area that is designated as a Dental HPSA.
Population to Provider Ratio: 1: 4000 and 30% of population must be at or below 200% of the
FPL.
Mental Health Geographic Single County - whole county designated as Mental Health HPSA.
Population to Psychiatrist Ratio: 1:30,000, Population to Certified Mental Health Provider
including psychiatrists Ratio: 1: 9,000. 6,000:1 CMHP and = or.20,000:1 psychiatrists
Mental Health Population Groups - a population within an area that is designated as a Mental
Health HPSA. Population to Psychiatrist Ratio: 1:20,000. Population to Certified Mental Health
Provider including psychiatrists Ratio: 1:6,000. Population to CHMP 1:4,500 and > 1:15.000
psychiatrists. 305 of population must be at or below 2005 of the FPL.
Primary Care Geographic Single County - whole county designated as PC HPSA. Population to
Family Physician Ratio: 1: 3500
Primary Care Geographic Service Area - portions of a county, or portions of multiple counties.
designated as a geographic PC HPSA. Population to Family Physician Provider Ratio: 1: 3500
Primary Care Population Groups - a population within an area that is designated as a PC HPSA.
Population to Provider Ratio: 1: 3000 and 30% of population must be at or below 200% of the
FPL.
State Mental Hospitals - State run mental health inpatient facilities
Correctional Institutions - Federal and State prisons and youth detention facilities
Comprehensive Health Centers - entities receiving Section 330 funds to operate comprehensive
health centers
FQHC Look-a-Like - Federally Qualified Health Centers certified as meeting 330 requirements
but not receiving grant funds
Disproportionate Share Hospital (DSH) Payments - Payments made by a state's Medicaid
program to hospitals that the state designates as serving a "disproportionate share" of low income
or uninsured patients. These payments are in addition to the regular payments such hospitals
receive for providing inpatient care to Medicaid beneficiaries. State have some discretion in
determining which hospitals qualify for DSH payments and how much they receive. The amount
of federal matching funds that a state can use to make payments to DSH hospitals in any given
year is capped at an amount specified in statute.
Dual Eligibles - A term used to describe an individual who is eligible both for Medicare and for
full Medicaid coverage, including nursing home services and prescription drugs as well
as
payments of Medicare premiums, deductibles, and co-insurance. Some Medicare beneficiaries
are eligible for Medicaid payments for some of all of the Medicare premiums, deductibles, and
co-insurance requirements, but not for Medicaid nursing home or prescription drug benefits.
Federally Qualified Health Center (FQHC) - State are required to include services provided
by FQHCs in there basic Medicaid benefits package. FQHC services are primary care and other
ambulatory care services provided by community health center and migrant health center funded
under section 330 of the Public Health Service Act, as well as by "look alike" clinics that meet
the requirements for federal funding but not actually receive federal; grant funds. FQHC status
also applies to health programs operated by Indian tribes and tribal organizations or by urban
Indian organizations.
* A Federally Qualified Health Center (FQHC) is an American community-based health
organization. An FQHC provides comprehensive primary health, oral, and mental
health/substance abuse services to persons in all stages of the life cycle.
As an organization FQHC's operate under a consumer Board of Directors governance structure
and function under the supervision of the Bureau of Primary Health Care or BPHC. FQHC's
were originally meant to provide comprehensive health services to the medically underserved to
reduce the patient load on hospital emergency rooms.
Their mission has changed since their founding. They now bring primary health care to
the underserved, underinsured and non-insured people of the United States. These groups include
migrant workers and non-citizen visitors and guests in the United States. FQHCs are located in
or serve Federally designated Medically Underserved Area/Populations (MUA or MUP).
FQHCs provide their services to all persons regardless of ability to pay, and charge for services
on a community board approved sliding-fee scale that is based on patients' family income and
size. FQHCs must comply with Section 330 program requirements.
FQHCs are also called Community/Migrant Health Centers (C/MHC), Community Health
Centers (CHC), and 330 Funded Clinics.
Federal Poverty Level (FPL) - The federal government's working definition of poverty that is
used as the reference point for the income standard for Medicaid eligibility for certain categories
Medicare Buy-in - The informal term referring to the payment of Medicare Part B premiums on
behalf of low-income Medicare beneficiaries who qualify for full Medicaid coverage (dual
eligibles) or just for assistance with Medicare premiums and cost sharing.
Medicare+Choice - An expansion of the traditional Medicare program that will augment the
fee-for-service and HMO health plans currently available to participants to include a variety of
new managed care and fee-for-service options.
Medicare Supplement Policy (Medigap) - A policy that pays coinsurance, deductibles and
copayments for Medicare recipients. It also guarantees additional coverage for services up to a
predefined benefit limit (the portion of the cost services not covered by Medicare).
Program for All-Inclusive Care for the Elderly (PACE) - A federally initiated program for
elderly persons that is funded with both Medicaid and Medicare dollars. The program attempts to
integrate the services that are traditionally divided between these two programs and is designed
to assist elderly individuals who may qualify for nursing home placement, but who live in the
community
Qualified Medicare Beneficiary (QMB) Program - A public program that pays the premiums.
deductibles and coinsurance for individuals who are on Medicare and at or below the Federal
poverty level.
Quality Assurance - A formal methodology designed to assess the quality of services provided.
Quality assurance includes formal review of care, problem identification, corrective actions to
remedy any deficiencies and evaluation of actions taken.
Quality Improvement - Includes the functions listed under Quality Assurance, plus directs
system enhancements on an ongoing basis.
Specified Low-Income Medicare Beneficiary (SLMB) Program - A public program that pays
a portion of Medicare premiums for those whose incomes are slightly above the Federal poverty
level.
Spend-Down - For most Medicaid eligibility categories, having countable income above a
specified amount will disqualify an individual from Medicaid. However, in some eligibility
categories - most notably the medically needy" - individuals may qualify for Medicaid
coverage even though their countable incomes are higher than the specified income standard by
"spending down." Under this process, the medical expenses that an individual incurs during a
specified period are deducted from the individual's income during that period. When the
individual's incurred medical expenses have been subtracted from his or her income and the
difference is at or below the state-specified income standard, the individual.
Rural Health Clinic - certified as Rural Health Clinics by the Centers for Medicare and Medicaid
Services
American Indian - Tribal Health and Urban Indian programs serving Federally Recognized tribes
Alaska Native - sites run by and/or serving the Alaska Native populations
IHS - Indian Health Service sites serving Federally Recognized tribes
Other - public or private non-profit medical facilities demonstrated to serve a designated area or
population group
Home and Community-Based Services (HCBS) Waiver - Also known as the “1915c waiver"
after the enabling section in the Social Security Act, this waiver authorizes the Secretary of HHS
to allow a state Medicaid program to offer special services to beneficiaries at risk of
institutionalization in a nursing facility or facility for the mentally retarded. These home and
community-based services, which otherwise would not be covered with federal matching funds,
include case management, homemaker/home health aide services, personal care services, adult
day health services, habilitation services, and respite care. They also include, in the case of
individuals with chronic mental illness, day treatment and partial hospitalization, psychosocial
rehabilitation services, and clinic services.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) - A private, not-
for-profit organization that evaluates and accredits hospitals and other healthcare organizations
that provide mental healthcare, home care, ambulatory care and long-term care services.
Medicaid - A nationwide health insurance program, adopted in 1965, for eligible disabled and
low-income persons. It is administered by the Federal government and participating states. The
program's costs, paid for by general tax revenue, are shared by the Federal and state
governments.
Medical Necessity - The determination that a specific health care service is: medically
appropriate; necessary to meet a consumer's health needs; consistent with the diagnosis, the most
cost-effective option, and consistent with clinical standards of care.
Medically Needy - A term used to describe a Medicaid eligibility group that is optional and is
composed of individuals who qualify for coverage because of high medical expenses, commonly
for hospital or nursing home care. These individuals meet Medicaid's categorical requirements -
i.e., they are children or parents or aged or individuals with disabilities - but their income is too
high to enable them to qualify for "categorically needy” coverage. Instead, they qualify for
coverage by “spending down”- i.e., reducing their income by their medical expenses. States that
elect to cover the "medically needy" do not have to offer the same benefit package to them as
they offer to the "categorically needy." See Categorically Needy, Spend-Down.
Medicare - A nationwide, federally administered program that covers the costs of
hospitalization, medical care and some related services for elderly and select other individuals.
Medicare has two parts: Part A generally covers inpatient costs; and part B primarily covers
outpatient costs. Pharmaceutical benefits are excluded.
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