Glossary of Health Care Terms
Beneficiary: A person who is eligible to receive benefits under a health benefits plan. In some circumstances, the term "beneficiary" can include eligible dependents enrolled under a plan.
Clinical Practice Guidelines: General guidelines establishing an acceptable range of practices for particular diseases or medical conditions. Usually, the guidelines are developed by a consensus of doctors who practice in a specific field.
Covered Entities (in the context of HIPPA Privacy Rule): The Privacy Rule applies to health plans, health care clearinghouses, and health care providers who conduct certain health care transactions electronically.
Employee Assistance Program (EAP): an EAP is an assessment and referral program or a short-term counseling program that is pre-purchased by some employers and is available to their employees, their dependents and household members. Visits to the EAP are separate from your behavioral health care benefits plan with no co-payment required.
Extended Care Facility (ECF): A healthcare facility for patients who require long-term care, including medical care and assisted living. Patients of an ECF often suffer from chronic disease or a condition requiring prolonged rehabilitation or therapy.
Health Care Financing Administration (HCFA): The federal agency responsible for administering Medicare and federal participation in Medicaid.
Health Insurance Portability and Accountability Act of 1996 (HIPPA): Federal law that outlines requirements of employer-sponsored group insurance plans, insurance companies, and managed care organizations. HIPPA is designed to protect health insurance coverage for workers and their families when they change or lose their jobs, to reduce administrative costs of providing and paying for healthcare, and to protect the privacy of individuals' health information.
Health Maintenance Organization (HMO): An organization that arranges a wide spectrum of health care services which commonly include hospital care, physicians' services and many other kinds of health care services with an emphasis on preventive care.
Independent Practice Association (IPA): An organization of individual physicians or small group medical practices, which contracts with MCOs to provide healthcare services by its member physicians.
Integrated Delivery System (IDS): An organization that is integrated operationally and clinically to provide a full range of health-care services. (These services can include physician services, hospital services, and ancillary services).
Joint Commission on Accreditation of Healthcare Organizations (JCAHO): An independent, not-for-profit organization focusing on improving the quality of care provided to the public through evaluation and accreditation of hospitals and health care organizations. The Joint Commission facilitates improvement of organizations that provide managed care (including health plans, preferred provider organizations, and integrated delivery systems), home care, long-term care, behavioral health care, laboratory, and ambulatory care services.
Managed Care: The integration of financing and delivery of health-care within a system with the goals of managing accessibility, quality, and cost of care.
Managed Care Organization (MCO): An entity that uses specific methods or procedures to manage the quality, accessibility, and cost, of health-care.
Management Services Organization (MSO): An organization, owned by a hospital or a group of investors, which provides management and administrative support services to individual physicians and small group practices. MSOs handle the non-medical aspects of the business, which allows the physicians to focus on the clinical aspects of their practice.
Medicaid: A joint federal and state program that provides health insurance (hospital expense and medical expense) assistance to low-income, certain aged, and disabled individuals.
Medicare: Federal insurance program providing hospital expense and medical expense insurance to disabled persons and persons over the age of 65. (Title XVIII of the Social Security Act of 1965)
National Committee on Quality Assurance (NCQA): An independent, nonprofit organization that assesses the quality of managed care plans, managed behavioral health care organizations and credentials verification organizations.
Physician-Hospital Organization (PHO): An organization in which a hospital and physicians (including individual physicians and group practices) negotiate as one entity directly with insurers. Additionally, this organization may oversee utilization review, credentialing, and quality assurance.
Physician Practice Management (PPM) Company: A company that purchases physicians' practices and provides practice management services. In most cases, physicians have a long-term contract to continue working in their practice, and in some cases, have an ownership position in the company.
Preferred Provider Organization (PPO): A healthcare benefit plan that allows beneficiaries to use any health care provider, however, the cost will be greater when using a health care provider outside of the PPO network.
Protected Health Information (PHI): Individually identifiable information, which is associated with the identity of a patient and relates to medical care, services, or procedures.
State Children's Health Insurance Program (SCHIP): Established by the Balanced Budget Act, this program is designed to provide health insurance assistance to uninsured and low-income children. SCHIP operates through separate programs or through expanded eligibility under state Medicaid programs.
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