Managed Care Glossary of Terms

HCFA
Health Care Financing Administration: Federal agency that administers Medicare and oversees state administration of Medicaid. HCFA resides within the Department of Health and Human Services. Now referred to as CMS Centers for Medicare and Medicaid Services. Now referred to as CMS Centers for Medicare and Medicaid Services.

HCFA 1500
The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers. HCFA is now called CMS, see CMS.

HCFA-1450
Health Care Financing Administration form 1450: Standard institutional (hospital) services claim form for the United States. Same as the UB92 (Uniform Billing 1992) form.

HCPCS
Healthcare Common Procedure Coding System Highlights: HCPCS Coding Process/Application.

Health
The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.

(HHS) Health and Human Services
The Department of Health and Human Services which is responsible for health-related programs and issues. Formerly HEW, the Department of Health, Education, and Welfare. The Office of Health Maintenance Organizations (OHMO) is part of HHS and detailed information on most companies is available here through the Freedom of Information Act.

Health Benefits Package
The services and products a health plan offers.

(HCFA) Health Care Financing Administration
The federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. It is now called CMS and generally it oversees the state's administrations of Medicaid, while directly administering Medicare. See CMS, or Center for Medicare and Medicaid Services.

Health Insurance
Financial protection against the health care costs of the insured person. May be obtained in a group or individual policy.

(HIPAA) Health Insurance Portability and Account
Sometimes referred to as the Kennedy-Kassebaum bill, this legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. As a result of this law, hospitals, doctors and insurance companies are now required to share patient medical records and personal information on a wider basis. This wide-based sharing of medical records has led to privacy rules, greater computerization of records and consumer concerns about confidentiality.

(HIPC) Health Insurance Purchasing Cooperative
Regional consumer groups that are establishes to shop for highest quality plan at lowest cost on behalf of large number of people, including employees of small businesses. Entity established to purchase bulk health insurance for businesses, groups or individuals. Was a key concept in the Clinton health plan and is not a current concept. Other cooperatives exist now, including business health action groups and health plan purchasing cooperatives. Although it may go by other names, we can expect such cooperatives to exist in the future.

(HIPCs) Health Insurance Purchasing Cooperatives
Public or private organizations which secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations.

(HL7) Health Level Seven
A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products.

(HMO) Health Maintenance Organization
HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. The HMO is paid monthly premiums or capitated rates by the payers, which include employers, insurance companies, government agencies, and other groups representing covered lives. The HMO must meet the specifications of the federal HMO act as well as meeting many rules and regulations required at the state level. There are 4 basic models: group model, individual practice association, network model and staff model. An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionals. The members of an HMO are required to use participating or approved providers for all health services and generally all services will need to meet further approval by the HMO through its utilization program. Members are enrolled for a specified period of time. HMOs may turn around and sub-capitate to other groups. For example, it may carve-out certain benefit categories, such as mental health, and subcapitate these to a mental health HMO. Or the HMO may subcapitate to a provider, provider group or provider network. HMOs are the most restrictive form of managed care benefit plans because they restrict the procedures, providers and benefits.

(HMSA) Health Manpower Shortage Area
An area or group which the U.S. Department of Health and Human Services designates as having an inadequate supply of health care providers. HMSAs can include: (1) an urban or rural geographic area, (2) a population group for which access barriers can be demonstrated to prevent members of the group from using local providers, or (3) medium and maximum-security correctional institutions and public or non-profit private residential facilities.

(HEDIS) Health Plan Employer Data and Information Set
A set of performance measures designed to standardize the way health plans report data to employers. HEDIS currently measures five major areas of health plan performance: quality, access and patient satisfaction, membership and utilization, finance, and descriptive information on health plan management.