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Definition
| Established by the 1974 National Health Planning and Resources Development Act as a capital expenditure review program for hospitals, nursing homes, and other health services facilities. If states did not implement programs theran the risk of losing federal funds. The program that was the regulatory stick that required states to act on proposals for changes in health services |
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| stays for a short period of time |
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| Medical and other services provided on an ambulatory, non-inpatient basis by a hospital or other qualified facility or supplier. Ex. Physicians offce. clinic. mental clincic. Xray mobile unit. phy. Theraphy. lab test. radiation therapy. etc. patient leaves same day |
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Term
| SNF/Skilled Nursing Facility |
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Definition
| Institutions that have a transfer agreement with one or more participating hospitals, are primarily engaged in providing skilled nursing care and rehabilitative services to inpatients, and meet specific regulatory certification requirements. |
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| Care for episodic and chronic conditions and for health maintenance. |
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| The process by which physician specialists are examined and determined to have met the academic and clinical standards of their speciality. |
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| The process by which health services facilities or health professionals are deemed to have met national standards. Is done at federal level by Medicaid and medicare services and is required to do this to get paid,, for physicians this is voluntary done by a private specialty board |
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Definition
| The process by which an institution or educational program, for example, is evaluated against standard criteria to determine the extent to which it meets or exceeds those criteria. The process is intended to ensure quality of performa,ce and outcome. It is done by a private party, but also serves as medicare and |
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| The sustematic selection by high-risk consumers of insurance plans with greater degrees of coverage. Insurers that offer these plans end up with more insured people who incur greater-than-average-costs . picking and choosing what company would be the best |
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| A flat fee that the insured person has to pay out of pocket for a particular unit of service. |
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| The percentage share of medical bills that a beneficiary must pay. The portion of the hospital visit that is not paid for the beneficiary is responsible for. |
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| A generic term that includes: copayments, co-insurances, and deductibles,also out of pocket payments. |
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| A specified amount of spending for health services for which an individual or a family is responsiblebefore their health insurance coverage becomes effective. |
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| Government established programs in which the beneficiaries are entitled to all covered services. Programs such as medicare and Medicaid. Benefits are not capped, and these programs become open-ended in terms of their cost and expenditures. |
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| Services that address the health, social, and personal care needs of individuals who have never developed or have lost the capacity for self-care on a permanent or intermittent basis. |
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| The use of income and assets to pay for health services in order to achieve a level of means that makes one eligible for certain social and health services, particularly Medicaid services. |
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| Inpatient diagnostic and short-term treatment of patients |
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| describe a variety/spectrum of approaches used to integrate the delivery and financing of health care |
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| A payment system used in managed care in which the provider is paid a fixed, predetermined, amount on a regular basis, usually monthly for all the provisions of all covered benefits to the insured individual. He would lose money if under calculated- can be done by age sex and race, Also the basis of federal governments provides support for the training of health professionals |
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Definition
| when a patient pays for one service out of pock and the insurance company or the health provider has to pay the patient baack for the certain services that was provided and paid for by the patient. |
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| - the various methods used by health plans to measure the amount and appropriateness of health services used by its members. These checks can occur before during, and after services have been sought or received from health professionals |
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Term
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Definition
| -As a rule having health insurance leads people to consume more health care services than they would have purchased if they had to pay for such services out-of-pocket. Dishonesty in an individual that increases the frequency or severity of loss, E.g., faking an accident to collect from an insurer, Carelessness or indifference to a loss because of the existence of insurance, leaving your car unlocked, going to the MD for a cold, cosmetic surgery. |
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Definition
| refers to the leftover sum that a provider bills to the patient after insurance has only partially paid the charge that was initially billed |
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| Gatekeeper—primary care physician (PCP) who must authorize all care before any care is rendered - The use of health services provider to screen access to specialists in some types of managed care plans. |
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Term
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Definition
| permission granted to an individual or organization by an authoritive agent usually governmental, to engage in a practice or activity that would be deemed illegal without a license-conducted at a state level is min req. for a hosipital to meet, for physicians is done by the state government and is mandatory |
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| refers to a wide variety of activities directed mainly at disease prevention and generally undertaken by state and local governments- vital stats, communicable disease control, sanitation, maternal and child health, health edu |
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| automatically, and some insurances companies will pay more |
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