Terms, Acronyms, and Definitions

In Preparation for the CMS Tribal Consultation on January 23, 2013 I have started a list of "Terms, Acronyms, and Definitions" that we use that not all people involved in the Tribal consultation may know.  This list is not complete and may not include all parts of definitions but are defined as we use them in our healthcare discussion.  Please comment any additions, corrections you may spot, I will be updating this post as new information is made available.

CMS- Centers for Medicare and Medicaid;  a division of the US Health and Human Services (HHS) tasked with administering both Title 18 and 19 of the Social Security Act.

HSD- NM’s Human Services Department; is the overall umbrella organization that oversees the Medicaid program.

MAD- NMs’ Medical Assistance Division; the Department within HSD which administers the Health portion of the Medicaid Program for NM’s population

ISD- NM’s Income Support Division; the Department within HSD which makes the determination of eligibility for all social service programs administered by HSD, (Medicaid, SNAP, CHIP, MI Via, D&D waiver )

IAD- Indian Affairs Department; the State Agency tasked with maintaining working relations between All State Agencies and the Tribes and Pueblos of NM, in a culturally sensitive manner.

OMB- US Office of Management and Budget; the Department within the Executive Branch responsible for the development, management and analysis of the budget for the Executive Branch.  For our discussion it refers to the rate of reimbursement for Health Services provided at an IHS/Tribal 638 facility, usually higher than the rate at which private insurance reimburse.

FMAP- Federal Medicaid Assistance Percentage; the ratio at which Medicaid is funded by the federal Government and State Governments.  Currently for NM/Federal 31%/69% Enhanced 22%/78%.

Medicaid- Title 19 of the Social Security Act originally developed to provide healthcare for low income citizen of the US

Medicare- Title 18 of the Social Security Act developed to provide low cost Insurance for US citizens with disabilities and individuals over the age of 65.

Social Security- referred to SSI is a social insurance program available to eligible US citizens who have reached the age of 65 or are determined to be disabled.

CHIP, SCHIP- Children’s health Insurance Program or Supplemental Children’s health Insurance Program; Portion of Social Security Act that is specific to providing Children with health insurance.

MCO – Managed Care Organization, a Health Corporation specializing in Managing the cost of healthcare for enrolled individuals through care Coordination.

I/T/Us- Indian Health Service Clinics/Tribal "638" Clinics/Urban Indian provider

HIX, HIE, NMHIA- Health Insurance Exchange, NM Health Insurance Alliance.  Refers to the development of a virtual Market place of Health Insurance plans aimed at providing a broader choice of government subsidized Health Insurance for eligible US Citizens.  In NM the HIX is going to be administered by the quazi governmental organization called the NM Health Insurance Alliance.

PPACA- Patient Protection and Affordable Care Act, sometimes called “Obamacare” was passed in 2010 with the intent to reform the Health Care industry in the US.

IHCIA- Indian Health Care Improvement Act, part of the PPACA, was permanently authorized and dictates the scope of work and budget of the Indian Health Service.

ARRA- American Reinvestment and Recovery Act;  enacted to stimulate the US economy, for our conversation contains many protections for Native Americans relating to Reimbursement rates consultation practices and exclusions in mandatory enrollment in MCOs and Healthcare cost sharing.

PL 93-638- Public Law 93-638 sometimes referred to as “638” is part of the Indian Self-Determination and Education Assistance Act, and refers to the Self Governance of Federal programs by a Federally recognized Native American Tribe

Opt-out Term used to describe an individuals’ personal choice to exclude his/her own self from a State or Federal Program

Opt-In Term used to describe an individuals’ personal choice to include his/her own self into a State or Federal Program

Fee for Service Term used to describe the method of reimbursement of health care services for an individual not enrolled in an MCO.  Healthcare costs are covered on an encounter basis, a patients’ bill is paid as it is incurred.

MFP Money Follows the Person; provision in the PPACA in which as an individual accesses healthcare service providers the funding is transferred to that health care provider.

1915 Waiver Term used to identify the CMS Waiver that the state of NM uses to administer its Medicaid Program.  Authorizes the use of MCOs to Manage and administer the Medicaid program on a PMPM Capitated basis

Salud- NM’s 1915 Medicaid Waiver program for low income families, children and disabled individuals.

CoLTS Coordination of Long Term Services; NM’s 1915 Medicaid Waiver program its elderly, disabled and medically fragile population.  

1115 Waiver CMS’s Research and Demonstration project, a Waiver that allows for more state authority in how a State administers its Medicaid Program.  

PM/PM- Per member/per month, term used to describe the current Capitated reimbursement rate utilized by MCOs in the State of NM. A MCO is give a lump sum of funding determine by its total enrolled membership every month to cover its cost for its total enrolled membership.  Different from a FFS system of reimbursement.

Capitated reimbursements a payment method for health care services. A health care provider is paid a contracted rate for each member assigned, referred to as "per-member-per-month" rate, regardless of the number or nature of services provided.

Care Coordination The process in which an MCO's gatekeeper–often a primary care physician, who sends a Patient for specialist services, continues to manage the Patient, assures follow up, and continuity of care.