Toolkit: Glossary of Terms
The following list of terms related to EPSDT and overall pediatric preventive health care as practiced in pediatric settings is not meant to be comprehensive, but to serve as an introductory quick-reference. Not all of these terms are covered in the Well-Child Care curriculum.
For more information, see (1) the Glossary of the Title V Guidance; (2) the Medicaid Glossary (available in English and Spanish).
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.
Assessment (see also Risk Assessment): A formal, diagnostic evaluation based on all available subjective and objective data obtained through comprehensive history, physical examination, observations, and validated screening tests. Note: In the context of well-child care, this curriculum generally uses the term "assessment" to mean risk assessment (such as a nutritional or developmental assessment.
Beneficiary: A person who is eligible for and enrolled in a Medicaid or similar program.
Centers for Medicare & Medicaid Services (CMS): Formerly known as the Health Care Financing Administration (HCFA), this US DHHS 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. Online at http://www.cms.hhs.gov.
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.
Children with Special Health Care Needs (CSHCN): Individuals from birth through age 21 who have health problems requiring more than routine and basic care.
Children's Health Insurance Program: See State Children's Health Insurance Program.
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. See the National Center for Cultural Competence for a more complete definition and resources.
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. State Title V and Medicaid agencies are required to participate in coordination of EPSDT services.
Federally Qualified Health-Center (FQHC) and Ambulatory Services: States must provide services (primary and other ambulatory care) through FQHCs (community and migrant health centers as well as other clinics that, while eligible, do not receive Federal funds) in their basic Medicaid package.
Financial Eligibility: Medicaid's policy of providing services to individuals with limited income. Financial eligibility varies by State and category.
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 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.
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.
Interperiodic Screens: Health screenings performed outside of and in addition to the timing and frequency listed in the Periodicity Schedule.
Managed Care Organization (MCO): An organization or network of healthcare providers who contract to provide a wide variety of healthcare services to enrolled members through participating providers.
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 Assistance: Payment for services covered under a State's Medicaid program.
Medical Home: Comprehensive individualized health supervision that includes all components of preventive health 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 Needy: Beneficiaries who qualify for Medicaid coverage because of high medical expenses.
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.
Prepaid Inpatient Health Plan (PIHP): A health plan that provides less than comprehensive inpatient services on an at-risk reimbursement basis.
Presumptive Eligibility Period: The time period between when a provider determines that a beneficiary's income does not exceed the eligibility threshold until a formal eligibility determination is made by the State Medicaid agency.
Preventive Care: Comprehensive care emphasizing health promotion, illness or injury prevention, and early detection and intervention. Preventive care services include a health history; physical exam; developmental and nutritional assessments of health status and risk; dental, vision, and hearing screenings; immunizations; laboratory tests and other screenings; and health education and guidance. Content of care is based primarily on the AAP's Recommendations for Preventive Pediatric Care.
Risk Assessment: A process that enables health providers 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. Risk is assessed through health history, physical examination, observations, and screening tests if indicated.
Risk Factors: A factor that increases one's chances of developing specific illness or condition. Scientifically established direct and indirect causes of morbidity and mortality.
Screening: In this curriculum, the term "screening" generally indicates objective testing or examination methods that can identify health conditions.
Screening Tests: Those preventive services in which a standardized, validated testing method is used to help identify children or teens requiring further diagnostic assessment, treatment services, and/or special intervention.
Supplemental Security Income (SSI): A Federal entitlement program that provides monetary assistance to specific beneficiaries. In most States (with the exception of Section 209(b) States), SSI beneficiaries are also eligible for Medicaid.
State Children's Health Insurance Program (SCHIP): A Federal-State matching health care block grant program for uninsured low-income children. Children who are eligible for Medicaid are not eligible for SCHIP, although States can administer SCHIP through their Medicaid programs.
TANF: Children are eligible for Temporary Assistance for Needy Families (TANF), formerly known as Aid to Families with Dependent Children, based on criteria for assistance to low-income families.
Title V: Enacted by Congress in 1935 as part of the Social Security Act, the only legislation to promote and improve the health of all mothers and children. Title V authorized the creation of the MCH programs, providing the infrastructure to achieve this mission.
Title XIX: Enacted by Congress in 1965 as part of the Social Security Act, the legislation that authorizes the Medicaid program that pays for medical assistance for certain individuals and families with low incomes who meet defined eligibility requirements.
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.