Ch. 8 Fundamentals of US Healthcare

Temporary Aid for Needy Families (TANF)

A federally funded need based grant program that allows states to administer their own assistance programs. The goal of the program is to provide families with children under the age of 18 with both financial assistance and work opportunities. The program provides cash assistance, job preparation, and support services. Recipients are required to participate in work activities for a specified period every week and be fully employed within a specified time

Great Society

A phrase coined by President Lyndon Johnson during his presidential campaign in 1964. It desribes the effort by President Lyndon Johnson to end poverty, promote equality, improve education, rejuvenate cities, and protect the environment. These efforts lead to the passage the Civil Rights Act of 1964 and the Economic Opportunity Act of 1964, the launching of Medicare and Medicaid, and initiatives to end racial injustice

preferred provider plans (PPOs)

A plan where different types of providers, physicians, hospitals, and clinics contract with a preferred provider organization to provide care to its members. Insured members pay a copayment at the time of service and a yearly deductible before the insurance begins to pay a percentage of medical fees for an in-network provider. Patients may visit out of network providers without referral and pay a higher percentage of fees

point-of-service organizations (PSOs)

A type of managed care plan with characteristics of both a health maintenance organization and a preferred provider organization. In this plan, a primary care physician is selected from participating providers, and all health care is coordinated by this physician or "point of service", Referrals by the primary care physician for specialist care are made to other-in-network physicians. When visiting an out of network specialist, the patient is responsible for submitting claims for reimbursement.

Joint Commission on Accreditation of Health Care Organizations (JCAHO)

Also referred to as the Joint Commission and founded in 1951, an umbrella organization that evaluates and accredits more than 19,000 health care organizations such as hospitals

Centers for Medicare and Medicaid Services (CMS)

Created by legislation signed into law in 1965 by President Lyndon Johnson, it is a division of the Department of Health and Human Services that administers the Medicare and Medicaid service plans. The agency was previously known as the Health Care Financing Administration (HFCA). It is also responsible for working with states to implement the State Children's Health Insurance Program (SCHIP) and portability standards for health insurance.

Social Security Act of 1935

Federal legislation that was part of Roosevelt's "New Deal" social program. It was enacted to provide retirement security for retired American workers. It created a pension system funded by taxes on employers and employees. Amendments to the Social Security Act in 1965 added health insurance benefits through the Medicare and Medicaid programs.

American Medical Association (AMA)

Founded in 1847, the professional organization for physicians that initially opposed Medicare in the 1960s, comparing it with socialized medicine. When it seemed that passage was inevitable, the AMA lobbied for the program to cover only the poor elderly

Supplemental Security Income (SSI)

Implemented in 1974, a federal program funded by general funds to provide eligible persons supplemental income to meet basic needs. Program provides assistance for the aged, blind, and disabled persons, and those with little or no income

resource based relative value scale (RBRVS)

Implemented in 1992, a method of standardized physician payment schedule that attempts to contain costs by instituting the same pay for similar services. Payment for services is based on the resource costs as measured by time, skill, and intensity needed to provide them

Medigap

Insurance purchased by Medicare beneficiaries to fill gaps in their health insurance coverage by enrolling in health maintenance organizations (HMOs) and purchasing private insurance. These policies pay most of Medicare coinsurance amounts and may provide coverage for Medicare's deductibles.

Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003

Legislation that enacted the most sweeping changes to Medicare since its inception by affording Medicare beneficiaries a prescription drug benefit. Starting in 2006, individuals who are eligible for Medicare Part A or enrolled in Medicare Part B were eligible to participate in the program, which provides a voluntary drug benefit for beneficiaries through private companies

Omnibus Budget Reconciliation Act (OBRA) of 1989

Legislation that established a new method of Medicare physician reimbursement effective in 1992, using a resource based relative value scale (RBRVS), which replaced the former method of charge based reimbursement. This legislation also prohibited physicians from referring Medicare patients to clinical laboratories in which they had financial investment

Medicare Part C

Managed care plans that provide Part A and Part B benefits, also called Medicare Advantage (MA), to enrollees. Medicare Advantage (MA) plans contract with Medicare to provide both Part A and B services to enrolled beneficiaries

dual eligibles

Medicare Part A or Part B recipients who would qualify for either the Medicare Savings Program or for Medicaid benefits. These persons qualify for programs that are part of the state Medicaid programs that pay some of the costs of Medicare; these programs may be referred to as Medicare savings programs, effectively providing full health coverage

Medicare Part D

Outpatient prescription drug benefit implemented in 2006 through the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) and funded through beneficiary premiums and general revenues.

Medicare + Choice

Plan in which enrollees can contract with other types of private health plans such as preferred provider plans (PPOs), point of service organizations (PSOSs), and medical savings accounts (MSAs). Plan members continue to pay monthly premiums but must obtain all Medicare-covered benefits through a private plan. Enrollees can choose among insurance products, such as an HMO, for their care delivery

President Harry S. Truman

Born in 1884 and the 33rd president of the U.S., he succeeded President Roosevelt upon the latter's death in 1945. As part of the Fair Deal in 1949, he proposed a comprehensive, prepaid medical insurance plan for all people through the Social Security system. His proposal was referred to as National Health Insurance, and although the legislation failed to pass the Congress, it provided the basis for President John F. Kennedy's promises of health insurance for the elderly.

President Lyndon B. Johnson

Born in 1908 and became the 36th President of the United States upon the death of President John F. Kennedy. He was president of the U.S. from 1963-1969. He signed into law the Civil Rights Act (1964) and initiated major social service programs as part of the Great Society. He signed into legislation that funded the Medicare and Medicaid programs, which, respectively, provided health benefits for the elderly and the poor

President John F. Kennedy

Born in 1917 and the 35th President of the United States from 1961-1963. He proposed legislation calling for health insurance for the elderly. The proposed legislation became the focus of debate throughout the early 1960s. President Kennedy was unable to pass health care coverage for the elderly during his presidency, but the bill was passed during the Johnson administration and was a cornerstone of his "Great Society" program

President George W. Bush

Born in 1946, served as governor of Texas (1995-2000) and was the 43rd president of the United States from 2001-2009. He supported and signed the Medicare Prescription Drug Improvement and Modernization Act of 2003, which made the most sweeping changes to Medicare by providing Medicare beneficiaries a prescription drug benefit

Children's Health Insurance Reauthorization Act of 2009 (CHIPRA)

Signed by President Barrack Obama in 2009, it increased funding by $32.8 billion to expand Children's Health Insurance Program (CHIP) to cover an additional 4 million children and pregnant women

Medicare Part B

Supplementary medical insurance that cover physician and other medical services, such as outpatient hospital care, lab tests, medical supplies, and home health. The program is funded through beneficiary premiums and general revenues.

medical savings accounts (MSAs)

Tax-deferred accounts that allow money to be saved for medical expenses

baby boomers

The generation of Americans who were born immediately following WWII, or from 1946 through 1964. Through the time from 1946 to 1964, approximately 78 million baby boomers were born in the United States

Medicare Part A

The hospital insurance program covers inpatient hospital, skilled nursing facility, hospice, and home health care. It is funded through a payroll tax paid by employees and employers

donut hole

The part of Medicare Part D reimbursement between basic services and full coverage that is the Medicare beneficiaries' responsibility to pay

State Children's Health Insurance Plan (SCHIP)

The partnership between states and the federal government that permits states either to expand Medicaid coverage or develop a proposal for a new program to be reviewed by the Centers for Medicare and Medicaid Services. In general, states are permitted to insure kids living in families whose income is up to 200% of the federal poverty level. Eligibility requirements are set so that uninsured children who are ineligible for Medicaid can still be covered under SCHIP. There are man benefits to enroll in SHCIP, including a full range of inpatient, outpatient, and physician services.

Balanced Budget Act of 1997

Through this act in 1997, Medicaid was expanded to cover additional children; however, it also resulted in reduced reimbursement to hospitals, physicians, and nurse practitioners. Some of these decreases were later restored by subsequent legislation.