Anticipatory Guidance: Information that helps families prepare for expected physical and behavioral changes during their child's or teen's current and approaching stage of development.
Centers for Medicare & Medicaid Services (CMS): Formerly known as HCFA, this USDHHS agency is responsible for providing oversight and coordination in working with states to administer the Medicaid program, including EPSDT . CMS is also responsible for maintaining certain HIPPA code sets.
Child and Adolescent Supplemental Security Income (SSI) and SSI-Related Plan (CASSIP): Children with Special Health Care Needs are children who, because of a disability, are eligible to receive Supplemental Security Income (SSI). They receive services beyond mandated provisions. These children are not included in the TANF DC Medicaid Managed Care Program and represent less than 5 percent of Medicaid children in DC. HealthCheck screens and services are provided to all children enrolled in this program under age 22.
Cultural Competence: The knowledge, interpersonal skills, and behaviors that enable a person or program to work effectively cross-culturally by understanding, appreciating, and respecting differences and similarities in beliefs, values, and practices within and between cultures.
DC Healthy Families Program: Children in the DC Healthy Families Program (DCHFP) (Appendix II) are eligible for HealthCheck/Medicaid services because they qualify for the Temporary Assistance For Needy Families (TANF), TANF-related programs, or the State Children's Health Insurance Program (SCHIP).
Durable Medical Equipment (DME): Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds.
Early and Periodic Screening, Diagnostic, and Treatment ( EPSDT ): Medicaid's comprehensive preventive child health program for infants, children, and adolescents, ages newborn through 20 years. Federal legislation requires states to make available to all Medicaid-eligible children under age 21 comprehensive periodic health assessments; dental, vision, and hearing services; and “medically necessary” (see below) follow-up diagnostic and treatment services. The program emphasizes preventive and primary care, early detection, and early intervention.
Foster Children: Foster children are those who are placed in protective services because they cannot remain at home. These children may have experienced neglect or abuse in the home and are generally placed with a substitute family.
Health Supervision: A comprehensive approach to providing individualized health care over time. Major components include the health history and interview questions; assessment of physical, mental, developmental, nutritional, and behavioral health; physical exam; laboratory tests and other screening procedures; immunizations; and anticipatory guidance. Includes measures that promote health, prevent illness and injury, and enhance subsequent development and maturation.
HealthCheck: The District of Columbia's EPSDT benefit for eligible low-income children and teens. Formerly known as the DC Well-Child Program or the Healthy Tots and Teens Program, HealthCheck is administered through the DC Department of Health Care Finance.
HealthCheck Provider Education System: A structured online training resource for DC primary care providers of EPSDT services. The system comprises (1) the pediatric preventive care curriculum; (2) the DC HealthCheck Program Manual and Periodicity Schedule; and (3) basic health supervision tools, such as the ACIP Immunization Schedule and the CDC growth charts.
Health Insurance Portability and Accountability Act (HIPAA): A federal law that guarantees consumers certain rights to continued or comparable health care coverage when their employment status changes. Title II of HIPAA gives USDHHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.
HIPAA Code Sets (select):
Current Procedural Terminology (CPT) codes: A medical code set adopted by USDHHS as the standard for reporting physician and other services on standard transactions. This code set is maintained and copyrighted by the American Medical Association.
Healthcare Common Procedural Coding System (HCPCS): A medical code set, selected for use in HIPAA transactions, that identifies health care procedures, equipment, and supplies for claim submissions.
- HCPCS Level I: Numeric CPT codes maintained by the AMA.
- HCPCS Level II: Alphanumeric codes used to identify various items and services not included in the CPT medical code set. These are maintained by CMS and others.
- HCPCS Level III ("local codes"): Alphanumeric codes assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These "local codes" must have "W", "X", "Y", or "Z" in the first position.
ICD-9-CM codes: International Classification of Diseases, Ninth Edition, Clinical Modification. A listing of diagnoses and identifying codes used to report diagnoses on claims. CDC maintains several code sets included in HIPAA standards, including ICD-9-CM codes.
Interperiodic Screens: Health screenings performed outside of and in addition to the timing and frequency listed in the Periodicity Schedule.
Managed Care Organization (MCO): a prepaid, capitated plan.
Medicaid: A joint federal-state program, administered by the Centers for Medicare & Medicaid Services, that helps states in supporting medical costs for eligible persons with low incomes and limited resources.
Medical Home: Comprehensive individualized health supervision that includes all components of HealthCheck preventive visits; assurance of ambulatory and in-patient care on a 24-hour basis; continuity of care from infancy through adolescence; appropriate referrals to subspecialty services; interaction with school and community agencies; and a central record and database with important health information.
Medically Necessary: A covered service or item can be defined as medically necessary if it will do, or is reasonably expected to do, one or more of the following: (a) arrive at a correct medical diagnosis; (b) prevent the onset of an illness, condition or injury or disability in the individual or in covered relatives, as appropriate; (c) reduce, correct, or ameliorate the physical, mental, developmental, or behavioral effects of an illness, condition, injury or disability; (d) assist the individual to achieve or maintain sufficient functional capacity to perform age appropriate or developmentally appropriate daily activities.
Medically Necessary Case Management: A HealthCheck service for children under age 21 who require assistance with identification, implementation, and coordination of a variety of medically necessary services but do not qualify for DC's Supplemental Security Income (SSI) childrens program / HSCSN, Inc.
Newborn Eligibility: An infant is eligible for HealthCheck if the mother qualifies for and is receiving medical assistance under a plan in which the mother is enrolled. The infant is a member as long as the mother is a plan member or the infant is officially enrolled in the plan by the DHCF. (For a detailed explanation, refer to DC Medicaid Managed Care Transmittal No. 95-09).
Partial Screens: Incomplete screens that occur when the provider is able to perform only part of the required screening during the health visit.
Periodicity (Periodicity Schedule): The frequency, timing, and content of preventive health visits scheduled at key developmental ages. Although states have flexibility in developing periodicity schedules, they are generally based on recognized medical standards, such as those of the American Academy of Pediatrics.
Preventive Care: Comprehensive care emphasizing health promotion, illness or injury prevention, and early detection and intervention. Preventive care includes health history; physical exam; developmental and nutritional assessments; dental, vision, and hearing screenings; immunizations; laboratory tests and other screenings; and health guidance. Content of care is based primarily on the AAP's Recommendations for Preventive Pediatric Care.
Primary Care Providers (PCPs): Health professionals who provide basic health care services through HealthCheck include pediatricians, family practitioners, general practitioners, internists, nurse practitioners, and gynecologists.
Risk Assessment: A diagnostic process that enables health professionals to examine the prevalence of risk and protective factors for each child or adolescent in order to determine individual susceptibility to specific diseases or conditions.
TANF: Children are eligible for Temporary Assistance for Needy Families (TANF), formerly known as Aid to Families with Dependent Children, and also qualify for HealthCheck based on criteria for assistance to low-income families.
Unclothed Physical Exam: A comprehensive examination of the body and its systems. Infants and young children must be totally unclothed. Older children and teens must be undressed and suitably draped in a light gown.