Understanding Health Insurance h h
HealthhInsuranceh-h
Ahcontracthbetweenhahpolicyholderhandhahthird-
hhhhhhhhhhhhhh
partyhpayerhorhgovernmenthprogramhtohreimbursehthehpolicyholderhforhallhorhahportionhofhthehcosthofh
medicallyhnecessaryhtreatmenthorhpreventivehcarehprovidedhbyhhealthcarehprofessionals.
GrouphHealthhInsuranceh-h
Traditionalhhealthcarehcoveragehsubsidizedhbyhemployershandhotherhorganizationsh(e.g.,hlaborh
hhhhhhhhhhhhhh
unions,hruralhandhconsumerhhealthhcooperatives)hwherebyhparthorhallhofhpremiumhcostsharehpaidhforha
nd/orhdiscountedhgrouphratesharehofferedhtoheligiblehindividuals.
PersonalhHealthhRecordh(PHR)h-h
Ahweb-
hhhhhhhhhhhhhh
basedhapplicationhthathallowshindividualshtohmaintainhandhmanagehtheirhhealthhinformationh(andhthath
ofhothershforhwhomhtheyharehauthorized,hsuchhashfamilyhmembers)hinhahprivate,hsecure,handhconfidenti
alhenvironment.
TotalhPracticehManagementhSoftwareh(TPMS)h-h
UsedhtohgeneratehthehEMR,hautomatinghthehfollowinghmedicalhpracticehfuncitons;hregisteringh
hhhhhhhhhhhhhh
patientshschedulinghappointments,hgeneratinghinsurancehclaimshandhpatienthstatements,hprocessinghp
aymentshfromhpatientshandhthird-partyhpayers,handhproducinghadministrativehandhclinicalhreports.
ElectronichMedicalhRecordh(EMR)h-h
Hashahmorehnarrowhfocush(ashcomparedhwithhthehEHR).hThehpatienthrecordhcreatedhforhahsingl
hhhhhhhhhhhhhh
ehmedicalhpracticehandhishgeneratedhusinghtotalhpracticehmanagementhsoftwareh(TPMS).
FederalhEmployees'hCompensationhActh(FECA)h-h
Replacedhtheh1908hworkers'hcompensationhlegislation,handhcivilianhemployeeshofhthehfederalh
hhhhhhhhhhhhhh
governmenthwerehprovidedhmedicalhcare,hsurvivor'shbenefits,handhcompensationhforhlosthwages.hAdmi
nisteredhbyhthehOfficehofhWorker'shCompensationhProgramsh(OWCP).
Self-insuredh(orhself-funded)h-h
employer-
hhhhhhhhhhhhhh
sponsoredhgrouphhealthhplanshAllowshlargehemployershtohassumehthehfinancialhriskhforhprovidinghhealt
1h|hP a g e
,hcarehbenefitshtohemployees.hThehemployerhdoeshnothpayhahfixedhpremiumhtohahhealthhinsurancehpaye
r,hbuthestablisheshahtrusthfundh(ofhemployerhandhemployeehcontributions)houthofhwhichhclaimsharehpaid
.
CivilianhHealthhandhMedicalhProgramh-UniformedhServicesh(CHAMPUS)h-h
Designedhashahbenefithforhdependentshofhpersonnelhservinghinhtheharmedhforceshandhuniforme
hhhhhhhhhhhhhh
dhbrancheshofhthehPublichHealthhServicehandhthehNationalhOceanichandhAtmospherichAdministration.hT
hishprogramhishnowhcalledhTRICARE.
Medicaidh(TitlehXIXhofhthehSSAhofh1965)h-h
ishahcost-
hhhhhhhhhhhhhh
sharinghprogramhbetweenhthehfederalhandhstatehgovernmentshtohprovidehhealthcarehserviceshtohlow-
incomehAmericans.h(OriginallyhadministeredhbyhthehSocialhandhRehabilitationhServiceh[SRS]).
Medicareh(TitlehXVIIIhofhthehSSAhofh1965)h-h
provideshhealthcarehserviceshtohAmericanshoverhthehagehofh65.h(Originallyhadministeredhbyhth
hhhhhhhhhhhhhh
ehSocialhSecurityhAdministration).
LifetimehMaximumhAmounth-h
Thehmaximumhbenefitshpayablehtohahhealthhcarehparticipant.
hhhhhhhhhhhhhh
Deductibleh-h
Thehamounthforhwhichhthehpatienthishfinanciallyhresponsiblehbeforehanhinsurancehpolicyhprovid
hhhhhhhhhhhhhh
eshpayment.
MajorhMedicalhInsuranceh-h
Provideshcoveragehforhcatastrophichorhprolongedhillnesseshandhinjuries.hMosthofhthesehprogra
hhhhhhhhhhhhhh
mhincorporatehlargehdeductibleshandhlifetimehmaximumhamounts.
InternationalhClassificationhofhDiseasesh(ICD)h-h
Ahclassificationhsystemhusedhtohcollecthdatahforhstatisticalhpurposes.
hhhhhhhhhhhhhh
WorldhHealthhOrganizationh(WHO)h-h
2h|hP a g e
, DevelopedhthehInternationalhClassificationhofhDiseasesh(ICD),hahclassificationhsystemhusedhtohc
hhhhhhhhhhhhhh
ollecthdatahforhstatisticalhpurposes.
Third-partyhAdministratorshAnhindirecthresulthofhthehTaft-HartlyhActhofh1947.h-h
Administershhealthcarehplanshandhprocesshclaims,hthushservinghashahsystemhofhcheckshandhbal
hhhhhhhhhhhhhh
anceshforhlaborhandhmanagement.
Hill-BurtonhActh-h
Thishprovidedhfederalhgrantshforhmodernizinghhospitalshthathhadhbecomehobsoletehbecausehof
hhhhhhhhhhhhhh
hahlackhofhcapitalhinvestmenthduringhthehGreathDepressionhandhWWIIh(1929-
1945).hInhreturnhforhfederalhfunds,hfacilitieshwerehrequiredhtohprovidehserviceshfreehorhathreducedhrates
htohpatientshunalblehtohpayhforhcare.
OccupationalhSafetyhandhHealthhAdministrationhActhofh1970h(OSHA)h-h
Designedhtohprotecthallhemployeeshagainsthinjurieshfromhoccupationalhhazardshinhthehworkpla
hhhhhhhhhhhhhh
ce.
HealthhCarehFinancinghAdministrationh(HCFA)h-h
TohcombinehhealthcarehfinancinghandhqualityhassurancehprogramshintohahsinglehagencyhthehHC
hhhhhhhhhhhhhh
FAhwashformedhwithinhthehDepartmenthofhHealthhandhHumanhServicesh(DHHS).hThehMedicarehandhMe
dicaidhprogramshwerehalsohtransferredhtohthehnewlyhcreatedhagency.h(HCFAhishnowhcalledhthehCentershf
orhMedicarehandhMedicaidhServiceshorhCMS.)
CivilianhHealthhandhMedicalhProgramhofhthehDepartmenthofhVeteranshAffairsh(CHAMPVA)h-h
Provideshhealthcarehbenefitshforhdependentshofhveteranshratedhash100hpercenthpermanentlyha
hhhhhhhhhhhhhh
ndhtotallyhdisabledhashahresulthofhservice-
connectedhconditions,hveteranshwhohdiedhashahresulthofhservice-
connectedhconditions,handhveteranshwhohdieshonhdutyhwithhlesshandh30hdayshofhactivehservice.
MedicarehContractinghReformhinitiativeh(MCR)h-h
EstablishedhtohintegratehthehadministrationhofhMedicarehPartshAhandhBhfee-for-
hhhhhhhhhhhhhh
serviceshbenefitshwithhnewhentitieshcalledhMedicarehadministrativehcontractorsh(MACs)
RecordhLinkagehAllowsh-h
patienthinformationhtohbehcreatedhathdiffernethlocationshaccourdinghtohahuniquehpatienthidenti
hhhhhhhhhhhhhh
fierhorhidentificatonhnumber.
3h|hP a g e
, AmericanhRecoveryhandhReinvestmenthActhofh2009h(ARRA)h-h
Authorizedhanhexpenditurehofh$1.5hillionhforhgrantshforhconstruction,hrenovation,handhequipm
hhhhhhhhhhhhhh
ent,handhforhthehacquisitionhofhhealthhinformationhtechnologyhsystems.
ElectronichHealthhRecordh(EHR)h-h
Ahglobalhconcepththathincludeshthehcollectionhofhpatienthinformationhdocumentedhbyhahnumb
hhhhhhhhhhhhhh
erhofhprovidershathdifferenthfacilitieshregardinghonehpatient.
HealthhInformationhTechnologyhforhEconomichandhClinicalhHealthhActh(HITECH)h-h
IncludedhinhthehARRA,hthishacthammendedhthehPublichHealthhServiceshActhtohestablishhanhOffic
hhhhhhhhhhhhhh
ehofhNationalhCoordinatorhforhHealthhInformationhTechnologyhwithinhHHShtohimprovehhealthcarehquali
ty,hsafety,handhefficiency.
Problem-orientedhRecordh(POR)h-h
Ahsystematichmethodhofhdocumentationhthathserveshashthehtablehofhcontentshforhthehpatienthr
hhhhhhhhhhhhhh
ecord.hIthconsistshofhfourhcomponents:hDatabase,hProblemhList,hInitialhPlan,h&hProgresshNotesh(docume
ntedhusinghthehSOAPhformat).hIthincludeshthehchiefhcomplaint,hpresenthconditionshandhdiagnosis,hsocial
hdata;hpast,hpersonal,hmedical,handhsocialhhistory,hreviewhofhsystems,hphysicalhexamination,h&hbaseline
hlaboratoryhdata.
Patienthrecordh(Medicalhrecord)h-h
documentshhealthcarehserviceshprovidedhtohahpatient,handhhealthcarehprovidersharehresponsi
hhhhhhhhhhhhhh
blehforhdocumentinghandhauthenticatinghlegible,hcomplete,handhtimelyhentries,haccordinghtohfederalhre
gulationshandhaccreditationhstandards.hServeshashahcomunicationhtoolhforhphysicianshandhotherhpatient
hcarehprofessionals,handhassistshinhplanninghindividualhpatienthcarehandhdocumentinghahpatientshillnessh
andhtreatment.
ContinuityhofhCareh-h
Involveshdocumentinghpatienthcarehserviceshsohthathothershwhohtreaththehpatienthhavehahsourc
hhhhhhhhhhhhhh
ehofhinformationhtohassisthwithhadditionalhcarehandhtreatment.
HealthhMaintenancehOrganizationhAssistancehActhofh1973h-h
Authorizedhfederalhgrantshandhloanshtohprivatehorganizationshthathwishedhtohdevelophhealthh
hhhhhhhhhhhhhh
maintenancehorganizationsh(HMOs).
4h|hP a g e
HealthhInsuranceh-h
Ahcontracthbetweenhahpolicyholderhandhahthird-
hhhhhhhhhhhhhh
partyhpayerhorhgovernmenthprogramhtohreimbursehthehpolicyholderhforhallhorhahportionhofhthehcosthofh
medicallyhnecessaryhtreatmenthorhpreventivehcarehprovidedhbyhhealthcarehprofessionals.
GrouphHealthhInsuranceh-h
Traditionalhhealthcarehcoveragehsubsidizedhbyhemployershandhotherhorganizationsh(e.g.,hlaborh
hhhhhhhhhhhhhh
unions,hruralhandhconsumerhhealthhcooperatives)hwherebyhparthorhallhofhpremiumhcostsharehpaidhforha
nd/orhdiscountedhgrouphratesharehofferedhtoheligiblehindividuals.
PersonalhHealthhRecordh(PHR)h-h
Ahweb-
hhhhhhhhhhhhhh
basedhapplicationhthathallowshindividualshtohmaintainhandhmanagehtheirhhealthhinformationh(andhthath
ofhothershforhwhomhtheyharehauthorized,hsuchhashfamilyhmembers)hinhahprivate,hsecure,handhconfidenti
alhenvironment.
TotalhPracticehManagementhSoftwareh(TPMS)h-h
UsedhtohgeneratehthehEMR,hautomatinghthehfollowinghmedicalhpracticehfuncitons;hregisteringh
hhhhhhhhhhhhhh
patientshschedulinghappointments,hgeneratinghinsurancehclaimshandhpatienthstatements,hprocessinghp
aymentshfromhpatientshandhthird-partyhpayers,handhproducinghadministrativehandhclinicalhreports.
ElectronichMedicalhRecordh(EMR)h-h
Hashahmorehnarrowhfocush(ashcomparedhwithhthehEHR).hThehpatienthrecordhcreatedhforhahsingl
hhhhhhhhhhhhhh
ehmedicalhpracticehandhishgeneratedhusinghtotalhpracticehmanagementhsoftwareh(TPMS).
FederalhEmployees'hCompensationhActh(FECA)h-h
Replacedhtheh1908hworkers'hcompensationhlegislation,handhcivilianhemployeeshofhthehfederalh
hhhhhhhhhhhhhh
governmenthwerehprovidedhmedicalhcare,hsurvivor'shbenefits,handhcompensationhforhlosthwages.hAdmi
nisteredhbyhthehOfficehofhWorker'shCompensationhProgramsh(OWCP).
Self-insuredh(orhself-funded)h-h
employer-
hhhhhhhhhhhhhh
sponsoredhgrouphhealthhplanshAllowshlargehemployershtohassumehthehfinancialhriskhforhprovidinghhealt
1h|hP a g e
,hcarehbenefitshtohemployees.hThehemployerhdoeshnothpayhahfixedhpremiumhtohahhealthhinsurancehpaye
r,hbuthestablisheshahtrusthfundh(ofhemployerhandhemployeehcontributions)houthofhwhichhclaimsharehpaid
.
CivilianhHealthhandhMedicalhProgramh-UniformedhServicesh(CHAMPUS)h-h
Designedhashahbenefithforhdependentshofhpersonnelhservinghinhtheharmedhforceshandhuniforme
hhhhhhhhhhhhhh
dhbrancheshofhthehPublichHealthhServicehandhthehNationalhOceanichandhAtmospherichAdministration.hT
hishprogramhishnowhcalledhTRICARE.
Medicaidh(TitlehXIXhofhthehSSAhofh1965)h-h
ishahcost-
hhhhhhhhhhhhhh
sharinghprogramhbetweenhthehfederalhandhstatehgovernmentshtohprovidehhealthcarehserviceshtohlow-
incomehAmericans.h(OriginallyhadministeredhbyhthehSocialhandhRehabilitationhServiceh[SRS]).
Medicareh(TitlehXVIIIhofhthehSSAhofh1965)h-h
provideshhealthcarehserviceshtohAmericanshoverhthehagehofh65.h(Originallyhadministeredhbyhth
hhhhhhhhhhhhhh
ehSocialhSecurityhAdministration).
LifetimehMaximumhAmounth-h
Thehmaximumhbenefitshpayablehtohahhealthhcarehparticipant.
hhhhhhhhhhhhhh
Deductibleh-h
Thehamounthforhwhichhthehpatienthishfinanciallyhresponsiblehbeforehanhinsurancehpolicyhprovid
hhhhhhhhhhhhhh
eshpayment.
MajorhMedicalhInsuranceh-h
Provideshcoveragehforhcatastrophichorhprolongedhillnesseshandhinjuries.hMosthofhthesehprogra
hhhhhhhhhhhhhh
mhincorporatehlargehdeductibleshandhlifetimehmaximumhamounts.
InternationalhClassificationhofhDiseasesh(ICD)h-h
Ahclassificationhsystemhusedhtohcollecthdatahforhstatisticalhpurposes.
hhhhhhhhhhhhhh
WorldhHealthhOrganizationh(WHO)h-h
2h|hP a g e
, DevelopedhthehInternationalhClassificationhofhDiseasesh(ICD),hahclassificationhsystemhusedhtohc
hhhhhhhhhhhhhh
ollecthdatahforhstatisticalhpurposes.
Third-partyhAdministratorshAnhindirecthresulthofhthehTaft-HartlyhActhofh1947.h-h
Administershhealthcarehplanshandhprocesshclaims,hthushservinghashahsystemhofhcheckshandhbal
hhhhhhhhhhhhhh
anceshforhlaborhandhmanagement.
Hill-BurtonhActh-h
Thishprovidedhfederalhgrantshforhmodernizinghhospitalshthathhadhbecomehobsoletehbecausehof
hhhhhhhhhhhhhh
hahlackhofhcapitalhinvestmenthduringhthehGreathDepressionhandhWWIIh(1929-
1945).hInhreturnhforhfederalhfunds,hfacilitieshwerehrequiredhtohprovidehserviceshfreehorhathreducedhrates
htohpatientshunalblehtohpayhforhcare.
OccupationalhSafetyhandhHealthhAdministrationhActhofh1970h(OSHA)h-h
Designedhtohprotecthallhemployeeshagainsthinjurieshfromhoccupationalhhazardshinhthehworkpla
hhhhhhhhhhhhhh
ce.
HealthhCarehFinancinghAdministrationh(HCFA)h-h
TohcombinehhealthcarehfinancinghandhqualityhassurancehprogramshintohahsinglehagencyhthehHC
hhhhhhhhhhhhhh
FAhwashformedhwithinhthehDepartmenthofhHealthhandhHumanhServicesh(DHHS).hThehMedicarehandhMe
dicaidhprogramshwerehalsohtransferredhtohthehnewlyhcreatedhagency.h(HCFAhishnowhcalledhthehCentershf
orhMedicarehandhMedicaidhServiceshorhCMS.)
CivilianhHealthhandhMedicalhProgramhofhthehDepartmenthofhVeteranshAffairsh(CHAMPVA)h-h
Provideshhealthcarehbenefitshforhdependentshofhveteranshratedhash100hpercenthpermanentlyha
hhhhhhhhhhhhhh
ndhtotallyhdisabledhashahresulthofhservice-
connectedhconditions,hveteranshwhohdiedhashahresulthofhservice-
connectedhconditions,handhveteranshwhohdieshonhdutyhwithhlesshandh30hdayshofhactivehservice.
MedicarehContractinghReformhinitiativeh(MCR)h-h
EstablishedhtohintegratehthehadministrationhofhMedicarehPartshAhandhBhfee-for-
hhhhhhhhhhhhhh
serviceshbenefitshwithhnewhentitieshcalledhMedicarehadministrativehcontractorsh(MACs)
RecordhLinkagehAllowsh-h
patienthinformationhtohbehcreatedhathdiffernethlocationshaccourdinghtohahuniquehpatienthidenti
hhhhhhhhhhhhhh
fierhorhidentificatonhnumber.
3h|hP a g e
, AmericanhRecoveryhandhReinvestmenthActhofh2009h(ARRA)h-h
Authorizedhanhexpenditurehofh$1.5hillionhforhgrantshforhconstruction,hrenovation,handhequipm
hhhhhhhhhhhhhh
ent,handhforhthehacquisitionhofhhealthhinformationhtechnologyhsystems.
ElectronichHealthhRecordh(EHR)h-h
Ahglobalhconcepththathincludeshthehcollectionhofhpatienthinformationhdocumentedhbyhahnumb
hhhhhhhhhhhhhh
erhofhprovidershathdifferenthfacilitieshregardinghonehpatient.
HealthhInformationhTechnologyhforhEconomichandhClinicalhHealthhActh(HITECH)h-h
IncludedhinhthehARRA,hthishacthammendedhthehPublichHealthhServiceshActhtohestablishhanhOffic
hhhhhhhhhhhhhh
ehofhNationalhCoordinatorhforhHealthhInformationhTechnologyhwithinhHHShtohimprovehhealthcarehquali
ty,hsafety,handhefficiency.
Problem-orientedhRecordh(POR)h-h
Ahsystematichmethodhofhdocumentationhthathserveshashthehtablehofhcontentshforhthehpatienthr
hhhhhhhhhhhhhh
ecord.hIthconsistshofhfourhcomponents:hDatabase,hProblemhList,hInitialhPlan,h&hProgresshNotesh(docume
ntedhusinghthehSOAPhformat).hIthincludeshthehchiefhcomplaint,hpresenthconditionshandhdiagnosis,hsocial
hdata;hpast,hpersonal,hmedical,handhsocialhhistory,hreviewhofhsystems,hphysicalhexamination,h&hbaseline
hlaboratoryhdata.
Patienthrecordh(Medicalhrecord)h-h
documentshhealthcarehserviceshprovidedhtohahpatient,handhhealthcarehprovidersharehresponsi
hhhhhhhhhhhhhh
blehforhdocumentinghandhauthenticatinghlegible,hcomplete,handhtimelyhentries,haccordinghtohfederalhre
gulationshandhaccreditationhstandards.hServeshashahcomunicationhtoolhforhphysicianshandhotherhpatient
hcarehprofessionals,handhassistshinhplanninghindividualhpatienthcarehandhdocumentinghahpatientshillnessh
andhtreatment.
ContinuityhofhCareh-h
Involveshdocumentinghpatienthcarehserviceshsohthathothershwhohtreaththehpatienthhavehahsourc
hhhhhhhhhhhhhh
ehofhinformationhtohassisthwithhadditionalhcarehandhtreatment.
HealthhMaintenancehOrganizationhAssistancehActhofh1973h-h
Authorizedhfederalhgrantshandhloanshtohprivatehorganizationshthathwishedhtohdevelophhealthh
hhhhhhhhhhhhhh
maintenancehorganizationsh(HMOs).
4h|hP a g e
