Access

Individual’s ability to obtain appropriate health care services.

Agency for Health Care Policy and Research (AHCPR) 

Public Health Service agency responsible for enhancing the quality, appropriateness and effectiveness of health care services.

Ancillary Services

Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy that are provided in conjunction with medical or hospital care.

Assessment

Collection, analysis and sharing of information about health conditions, risks, and resources in a community.

Benefit Period

Begins the day the patient goes to a hospital or skilled nursing facility (SNF) and ends when the patient hasn't’t received any hospital care (or skilled care in a SNF) for 60 days in a row.

Case Management

Monitoring and coordination of treatment to ensure continuity of services and accessibility to overcome fragmented services, in a cost effective manner.

Charges

Published prices of services provided by a facility.

Chronic Care

Care and treatment rendered to individuals whose health problems are of a long-term and continuing nature.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Federal law that allows workers and their families to continue their employer-sponsored health insurance for a certain amount of time after terminating employment.

Coding

Mechanism for identifying and defining physicians’ and hospitals’ services, diagnoses, procedures, and levels of care.

Community-Based Care

Health and social services provided to an individual or family in their place of residence (or nearby) for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability.

Co-Payment

Cost-sharing arrangement in which the health plan enrollee pays a specified flat amount for a specific service (such as $10 for an office visit or $5 for each prescription drug).

Cost Shifting

Charging one group of patients more in order to make up for underpayment by Medicaid or Medicare.

Deductibles

Amount required to be paid by a subscriber before health plan benefits will begin to reimburse for services. It is usually an annual amount of all healthcare costs that is not covered by your insurance plan.

Diagnosis-Related Groups (DRGs)

System of classifying patients on the basis of diagnoses for purposes of payment to hospitals.

Disproportionate Share (DSH) Adjustment

Special government funding to hospitals who treat significant populations of Medicaid, Medicare and uninsured patients

Doughnut Hole

Gap in coverage for seniors on Medicare which requires them to pay full cost for drug prescriptions after they reach a spending limit.

Evidence-Based Medicine (EBM)

Conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services.

Federal Poverty Level (FPL)

Standard family income threshold set by the government below which the family is officially classified as poor and entitled to welfare and other public assistance programs.

Federally Qualified Health Center (FQHC)

Grant-supported public and private non-profit healthcare organizations that meet certain criteria under the Medicare and Medicaid programs and receive funds under the Health Center Program (Section 330 of the Public Health Service Act).

Formulary

List of prescription medications covered by drug health plans.

Tool used by more than 90 percent of America's health plans to measure quality performance based on dimensions of care and service such as:

• improving the health status of Medicaid beneficiaries
• promoting standardization of managed care reporting across public and private sectors

Health Promotion

Process of fostering awareness, influencing attitudes, and identifying alternatives so that individuals can make informed choices and modify their behavior in order to achieve an optimum level of physical and mental health.

Medicaid

Assistance program for the financially needy. Also referred to as Title XIX of the Social Security Act, is a joint federal-state program that provides medical assistance for the aged, blind, and disabled, and families with dependent children who cannot pay for such assistance themselves. Benefits vary widely among the states.

Medicare

National health insurance program authorized by Title XVIII of the Social Security Act to address the medical needs of older American citizens. Medicare is available to U.S. citizens 65 years of age and older and some people with disabilities under age 65.

Medicare Part A

Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.

Medicare Part B

Medicare component that provides benefits to cover the costs of physicians’ professional services, whether the services are provided in a hospital, a physician’s office, an extended-care facility, a nursing home, or an insured’s home.

Medicare Part D

A stand-alone drug plan, offered by insurers and other private companies to beneficiaries that have Parts A and B.

Medicare Supplement or Medigap

A private medical expense insurance policy that provides reimbursement for out-of-pocket expenses, such as deductibles and co-insurance payments, or benefits for some medical expenses specifically excluded from Medicare coverage.

Outcome

The consequence of a medical intervention on a patient.

Primary Care

Basic or general healthcare services usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians -- who are often referred to as primary care providers or PCPs.

Primary Care Provider (PCP)

Healthcare provider who serves as the initial interface between the patient and the medical care system.

Referral

Process of directing or redirecting a medical case or a patient to an appropriate specialist or agency.

Resource-Based Relative Value Scale (RBRVS)

Medicare weighting system that assigns value to each procedural code performed by physicians and other providers. This payment methodology has three components:

• a relative value for each procedure,
• a geographic adjustment factor, and
• a dollar conversion factor.

Spend Down

Process that uses medical bills as income deductions, allowing to reduce or "spend down" excess income to bring it under the medically needy income limit, therefore making patient eligible for Medicaid and any further medical expenses covered by Medicaid.

State Children’s Health Insurance Program (SCHIP)

Provides health insurance for children, up to age 19, who are not already insured.

SCHIP is a state administered program and each state sets its own guidelines regarding eligibility and services.

Supplemental Security Income (SSI)

A federal cash assistance program for low-income aged, blind and disabled individuals established by Title XVI of the Social Security Act.

Tort Reform

Legislative limits or changes or judicial reform of the rules governing medical malpractice lawsuits and other lawsuits.

Reform implies that limits can be placed on individual rights to sue or on the amounts or situations for which they can seek relief.

Triage

Act of categorizing patients according to acuity, to maximize and create the most efficient use of scarce resources of medical personnel and facilities.

TRICARE
(formerly CHAMPUS)

Insurance program for Veterans and civilian dependents of members of the military.

Uncompensated Care

Care rendered by hospitals or other providers without payment from the patient or a government-sponsored or private insurance program. It includes both charity care, which is provided without the expectation of payment, and bad debts, for which the provider has made an unsuccessful effort to collect payment due from the patient.

Workers’ Compensation

State-mandated program providing insurance coverage for work-related injuries and disabilities.