Politics of Medicaid by Laura Katz Olson

Author:Laura Katz Olson [Olson, Laura Katz]
Language: eng
Format: epub
Tags: Public Policy, American Government, National, United States, Social Services & Welfare, Political Science, Americas (North; Central; South; West Indies), History, General
ISBN: 9780231521598
Google: -2T8eNCgYvUC
Goodreads: 17269183
Publisher: Columbia University Press
Published: 2010-05-31T00:00:00+00:00

GLOSSARY

AVERAGE MANUFACTURER PRICE: The average price that wholesalers pay in the United States for drugs distributed to retail pharmacies.

AVERAGE WHOLESALE PRICE: The average price at which wholesalers sell drugs to physicians, pharmacies, and other customers.

BOREN AMENDMENT: As part of the Omnibus Budget Reconciliation Act of 1980, this amendment required that Medicaid nursing home rates be “reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities in order to provide care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards.” The federal Balanced Budget Act of 1997 repealed the Boren amendment, giving states far greater freedom in setting nursing home payment rates.

CAPITATED PLANS: See managed-care plans.

CATEGORICALLY ELIGIBLE GROUPS: Five specific population groups that states are allowed to cover under federal law: children up to age nineteen; pregnant women; parents (and other caretakers of children) in families with dependent children; individuals with severe and permanent disabilities; and the elderly.

CENTERS FOR MEDICARE AND MEDICAID SERVICES: Federal agency under the U.S. Department of Health and Human Services that administers Medicare, Medicaid, and the State Children’s Health Insurance Program.

CERTIFIED NURSE’S AIDE: A person certified by a state agency who assists individuals with activities of daily living and provides bedside care—including basic nursing procedures—all under the supervision of a registered nurse or licensed practical nurse.

COINSURANCE: A medical insurance policy provision under which the insurer and the insured share costs incurred after the deductible is met, according to a specific formula.

COPAYMENT: See coinsurance.

COMMUNITY HEALTH CENTERS: Facilities that provide comprehensive primary health care and supportive services to medically underserved communities and low-income and uninsured people, either without charge or with fees based on ability to pay.

CORPORATE INTEGRITY AGREEMENTS: Agreements, usually lasting four to five years, imposed on providers by the Office of Inspector General when serious misconduct (fraudulent or abusive activities) is discovered through an audit or self-disclosure. They include instituting training requirements, designating a compliance officer, and implementing a communications hotline or other initiatives that are designed to ensure that the wrongful behavior does not occur again.

DIAGNOSIS-RELATED GROUPS: Medical claims reimbursements developed by Medicare for hospitals as part of its prospective payment system developed in the mid-1980s, whereby predetermined fees are set for roughly 500 listed procedures.

DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS: Special funding to hospitals that serve a significant percentage of indigent patients, as determined by special formulas under both Medicare and Medicaid. Under federal law, “A hospital is deemed to be a DSH hospital if its Medicaid utilization rate is at least one standard deviation above the mean rate for hospitals receiving Medicaid payments in the state or if the hospital’s low-income utilization rate exceeds 25 percent” (U.S.C. §1396r-4 [b] [2000]).

DUAL ELIGIBLES: Individuals who are entitled to Medicare Part A or Part B or both and are also eligible for full Medicaid benefits.

EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT: A required benefit for all “categorically needy” children younger than age twenty-one (e.g., those who have poverty-level income, receive Supplemental Security Income, or receive federal foster care or adoption assistance).

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