Medicaid: Federal program, created by Public Law 89-97, Title XIX, a 1965 amendment to the Social Security Act, administered by the states, that provides health care benefits to indigent and medically indigent persons.Centers for Medicare and Medicaid Services (U.S.): A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.State Health Plans: State plans prepared by the State Health Planning and Development Agencies which are made up from plans submitted by the Health Systems Agencies and subject to review and revision by the Statewide Health Coordinating Council.United StatesEligibility Determination: Criteria to determine eligibility of patients for medical care programs and services.Managed Care Programs: Health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as HEALTH MAINTENANCE ORGANIZATIONS and PREFERRED PROVIDER ORGANIZATIONS.Insurance, Health, Reimbursement: Payment by a third-party payer in a sum equal to the amount expended by a health care provider or facility for health services rendered to an insured or program beneficiary. (From Facts on File Dictionary of Health Care Management, 1988)State Government: The level of governmental organization and function below that of the national or country-wide government.Medically Uninsured: Individuals or groups with no or inadequate health insurance coverage. Those falling into this category usually comprise three primary groups: the medically indigent (MEDICAL INDIGENCY); those whose clinical condition makes them medically uninsurable; and the working uninsured.Medicare: Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)Insurance Coverage: Generally refers to the amount of protection available and the kind of loss which would be paid for under an insurance contract with an insurer. (Slee & Slee, Health Care Terms, 2d ed)Reimbursement Mechanisms: Processes or methods of reimbursement for services rendered or equipment.Health Services Accessibility: The degree to which individuals are inhibited or facilitated in their ability to gain entry to and to receive care and services from the health care system. Factors influencing this ability include geographic, architectural, transportational, and financial considerations, among others.Capitation Fee: A method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount without regard to the actual number or nature of services provided to each patient.Insurance, Health: Insurance providing coverage of medical, surgical, or hospital care in general or for which there is no specific heading.Insurance Claim Review: Review of claims by insurance companies to determine liability and amount of payment for various services. The review may also include determination of eligibility of the claimant or beneficiary or of the provider of the benefit; determination that the benefit is covered or not payable under another policy; or determination that the service was necessary and of reasonable cost and quality.Health Expenditures: The amounts spent by individuals, groups, nations, or private or public organizations for total health care and/or its various components. These amounts may or may not be equivalent to the actual costs (HEALTH CARE COSTS) and may or may not be shared among the patient, insurers, and/or employers.Cost Control: The containment, regulation, or restraint of costs. Costs are said to be contained when the value of resources committed to an activity is not considered excessive. This determination is frequently subjective and dependent upon the specific geographic area of the activity being measured. (From Dictionary of Health Services Management, 2d ed)Rate Setting and Review: A method of examining and setting levels of payments.Child Health Services: Organized services to provide health care for children.Fees, Medical: Amounts charged to the patient as payer for medical services.Reimbursement, Disproportionate Share: Payments that include adjustments to reflect the costs of uncompensated care and higher costs for inpatient care for certain populations receiving mandated services. MEDICARE and MEDICAID include provisions for this type of reimbursement.Insurance Claim Reporting: The design, completion, and filing of forms with the insurer.Personal Health Services: Health care provided to individuals.Patient Protection and Affordable Care Act: An Act prohibiting a health plan from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary after January 1, 2014. It permits a restricted annual limit for plan years beginning prior to January 1, 2014. It provides that a health plan shall not be prevented from placing annual or lifetime per-beneficiary limits on covered benefits. The Act sets up a competitive health insurance market.Health Services Research: The integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between need, demand, supply, use, and outcome of health services. The aim of the research is evaluation, particularly in terms of structure, process, output, and outcome. (From Last, Dictionary of Epidemiology, 2d ed)Uncompensated Care: Medical services for which no payment is received. Uncompensated care includes charity care and bad debts.Cost Savings: Reductions in all or any portion of the costs of providing goods or services. Savings may be incurred by the provider or the consumer.Poverty: A situation in which the level of living of an individual, family, or group is below the standard of the community. It is often related to a specific income level.Formularies as Topic: Works about lists of drugs or collections of recipes, formulas, and prescriptions for the compounding of medicinal preparations. Formularies differ from PHARMACOPOEIAS in that they are less complete, lacking full descriptions of the drugs, their formulations, analytic composition, chemical properties, etc. In hospitals, formularies list all drugs commonly stocked in the hospital pharmacy.Health Maintenance Organizations: Organized systems for providing comprehensive prepaid health care that have five basic attributes: (1) provide care in a defined geographic area; (2) provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; (3) provide care to a voluntarily enrolled group of persons; (4) require their enrollees to use the services of designated providers; and (5) receive reimbursement through a predetermined, fixed, periodic prepayment made by the enrollee without regard to the degree of services provided. (From Facts on File Dictionary of Health Care Management, 1988)Federal Government: The level of governmental organization and function at the national or country-wide level.Health Care Reform: Innovation and improvement of the health care system by reappraisal, amendment of services, and removal of faults and abuses in providing and distributing health services to patients. It includes a re-alignment of health services and health insurance to maximum demographic elements (the unemployed, indigent, uninsured, elderly, inner cities, rural areas) with reference to coverage, hospitalization, pricing and cost containment, insurers' and employers' costs, pre-existing medical conditions, prescribed drugs, equipment, and services.OregonTennesseeFloridaMarylandNursing Homes: Facilities which provide nursing supervision and limited medical care to persons who do not require hospitalization.Health Care Surveys: Statistical measures of utilization and other aspects of the provision of health care services including hospitalization and ambulatory care.Budgets: Detailed financial plans for carrying out specific activities for a certain period of time. They include proposed income and expenditures.Health Policy: Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health care system.ArkansasHealth Care Costs: The actual costs of providing services related to the delivery of health care, including the costs of procedures, therapies, and medications. It is differentiated from HEALTH EXPENDITURES, which refers to the amount of money paid for the services, and from fees, which refers to the amount charged, regardless of cost.Insurance, Pharmaceutical Services: Insurance providing for payment of services rendered by the pharmacist. Services include the preparation and distribution of medical products.Economics, Hospital: Economic aspects related to the management and operation of a hospital.New JerseyDrug Costs: The amount that a health care institution or organization pays for its drugs. It is one component of the final price that is charged to the consumer (FEES, PHARMACEUTICAL or PRESCRIPTION FEES).North CarolinaNew YorkDental Care for Children: The giving of attention to the special dental needs of children, including the prevention of tooth diseases and instruction in dental hygiene and dental health. The dental care may include the services provided by dental specialists.Insurance Benefits: Payments or services provided under stated circumstances under the terms of an insurance policy. In prepayment programs, benefits are the services the programs will provide at defined locations and to the extent needed.MichiganCaliforniaInflation, Economic: An increase in the volume of money and credit relative to available goods resulting in a substantial and continuing rise in the general price level.Medicare Assignment: Concept referring to the standardized fees for services rendered by health care providers, e.g., laboratories and physicians, and reimbursement for those services under Medicare Part B. It includes acceptance by the physician.Reimbursement, Incentive: A scheme which provides reimbursement for the health services rendered, generally by an institution, and which provides added financial rewards if certain conditions are met. Such a scheme is intended to promote and reward increased efficiency and cost containment, with better care, or at least without adverse effect on the quality of the care rendered.MaineRisk Sharing, Financial: Any system which allows payors to share some of the financial risk associated with a particular patient population with providers. Providers agree to adhere to fixed fee schedules in exchange for an increase in their payor base and a chance to benefit from cost containment measures. Common risk-sharing methods are prospective payment schedules (PROSPECTIVE PAYMENT SYSTEM), capitation (CAPITATION FEES), diagnosis-related fees (DIAGNOSIS-RELATED GROUPS), and pre-negotiated fees.Fraud: Exploitation through misrepresentation of the facts or concealment of the purposes of the exploiter.Social Welfare: Organized institutions which provide services to ameliorate conditions of need or social pathology in the community.Medical Assistance: Financing of medical care provided to public assistance recipients.Drug Utilization Review: Formal programs for assessing drug prescription against some standard. Drug utilization review may consider clinical appropriateness, cost effectiveness, and, in some cases, outcomes. Review is usually retrospective, but some analysis may be done before drugs are dispensed (as in computer systems which advise physicians when prescriptions are entered). Drug utilization review is mandated for Medicaid programs beginning in 1993.Contract Services: Outside services provided to an institution under a formal financial agreement.Fee Schedules: A listing of established professional service charges, for specified dental and medical procedures.Cost Sharing: Provisions of an insurance policy that require the insured to pay some portion of covered expenses. Several forms of sharing are in use, e.g., deductibles, coinsurance, and copayments. Cost sharing does not refer to or include amounts paid in premiums for the coverage. (From Dictionary of Health Services Management, 2d ed)Long-Term Care: Care over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care.OhioInsurance, Physician Services: Insurance providing benefits for the costs of care by a physician which can be comprehensive or limited to surgical expenses or for care provided only in the hospital. It is frequently called "regular medical expense" or "surgical expense".Legislation, Hospital: Laws and regulations concerning hospitals, which are proposed for enactment or enacted by a legislative body.Public Assistance: Financial assistance to impoverished persons for the essentials of living through federal, state or local government programs.Quality of Health Care: The levels of excellence which characterize the health service or health care provided based on accepted standards of quality.Data Collection: Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data.KentuckyFinancing, Government: Federal, state, or local government organized methods of financial assistance.Utilization Review: An organized procedure carried out through committees to review admissions, duration of stay, professional services furnished, and to evaluate the medical necessity of those services and promote their most efficient use.Cost Allocation: The assignment, to each of several particular cost-centers, of an equitable proportion of the costs of activities that serve all of them. Cost-center usually refers to institutional departments or services.Drug Utilization: The utilization of drugs as reported in individual hospital studies, FDA studies, marketing, or consumption, etc. This includes drug stockpiling, and patient drug profiles.Health Services Needs and Demand: Health services required by a population or community as well as the health services that the population or community is able and willing to pay for.South CarolinaDiagnosis-Related Groups: A system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system.Case Management: A traditional term for all the activities which a physician or other health care professional normally performs to insure the coordination of the medical services required by a patient. It also, when used in connection with managed care, covers all the activities of evaluating the patient, planning treatment, referral, and follow-up so that care is continuous and comprehensive and payment for the care is obtained. (From Slee & Slee, Health Care Terms, 2nd ed)Prenatal Care: Care provided the pregnant woman in order to prevent complications, and decrease the incidence of maternal and prenatal mortality.Disabled Persons: Persons with physical or mental disabilities that affect or limit their activities of daily living and that may require special accommodations.Costs and Cost Analysis: Absolute, comparative, or differential costs pertaining to services, institutions, resources, etc., or the analysis and study of these costs.Drug Prescriptions: Directions written for the obtaining and use of DRUGS.Retrospective Studies: Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.Health Care Sector: Economic sector concerned with the provision, distribution, and consumption of health care services and related products.Ownership: The legal relation between an entity (individual, group, corporation, or-profit, secular, government) and an object. The object may be corporeal, such as equipment, or completely a creature of law, such as a patent; it may be movable, such as an animal, or immovable, such as a building.Models, Econometric: The application of mathematical formulas and statistical techniques to the testing and quantifying of economic theories and the solution of economic problems.MassachusettsHealthcare Disparities: Differences in access to or availability of medical facilities and services.Legislation, Medical: Laws and regulations, pertaining to the field of medicine, proposed for enactment or enacted by a legislative body.MissouriUnited States Dept. of Health and Human Services: A cabinet department in the Executive Branch of the United States Government concerned with administering those agencies and offices having programs pertaining to health and human services.Skilled Nursing Facilities: Extended care facilities which provide skilled nursing care or rehabilitation services for inpatients on a daily basis.Home Care Services: Community health and NURSING SERVICES providing coordinated multiple services to the patient at the patient's homes. These home-care services are provided by a visiting nurse, home health agencies, HOSPITALS, or organized community groups using professional staff for care delivery. It differs from HOME NURSING which is provided by non-professionals.Fees, Pharmaceutical: Amounts charged to the patient or third-party payer for medication. It includes the pharmacist's professional fee and cost of ingredients, containers, etc.
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