Understanding Health Insurance: Chapter 14-Medicare Key Terms

ACCOUNTABLE CARE ORGANIZATION (ACOs)

Groups of physicians, hospitals, and other health care providers, such as DME suppliers, all of whom come together voluntarily to provide coordinated high-quality care to Medicare traditional fee-for-service patients and to control health care costs

ADVANCE BENEFICIARY NOTICE OF NON-COVERAGE (ABN)

Document that acknowledges patient responsibility for payment if Medicare denies the claim

BENEFIT PERIOD

Begins with the first day of inpatient hospitalization and ends when the Medicare patient has been out of the hospital fro 60 consecutive days

CONDITIONAL PRIMARY PAYER STATUS

Medicare claim process that includes the following circumstances: a plan that is normally considered to be primary to Medicare issues a denial of payment that is under appeal; a patient who is physically or mentally impaired failed to file a claim to the primary payer; a worker’s compensation claim has been denied and the case is slowly moving through the appeal process; or there is no response from a liability payer within 120 days of filing the claim

DEMONSTRATION/ PILOT PROGRAM

Special project that tests improvements in Medicare coverage, payment, and quality of care

DIAGNOSTIC COST GROUP HIERARCHICAL CONDITION CATEGORY (DCG/HCC) RISK ADJUSTMENT MODEL

CMS model implemented for Medicare risk-adjustment purposes and results in more accurate predictions of medical costs for Medicare Advantage enrollees; its purpose is to promote fair payments to manage care organizations that reward efficiency and encourage excellent care for the chronically ill

DRUG FORMULARY

List of brand name and generic prescription drugs covered by a health plan

EMPLOYER-SPONSORED GROUP HEALTH PLAN (EGHP)

Provides coverage to employees and dependents without regard to the enrollee’s employment status (e.g., full-time, part-time, or retired)

GENERAL ENROLLMENT PERIOD (GEP)

Enrollment period for Medicare Part A and Part B held January 1 through March 31 of each year.

INITIAL ENROLLMENT PERIOD (IEP)

Seven-month period prior to turning age 65 that provides an opportunity for the individual to enroll in Medicare Part A and Part B

LIFETIME RESERVE DAYS

May be used only once during a patient’s lifetime and are usually reserved for use during the patient’s final, terminal hospital stay

MASS IMMUNIZER

Traditional Medicare-enrolled provider/supplier or a non-traditional provider that offers influenza virus and/or pneumococcal vaccinations to a large number of individuals

MEDICAL NECESSITY DENIAL

Denial of otherwise covered services that were found to be not “reasonable and necessary.”

MEDICARE

Federal health insurance program, authorized by Congress and administered by CMS, for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD)

MEDICARE ADVANTAGE

An alternative to the Original Medicare Plan that bundles Medicare Part A, Part B, and Part D coverage, and may offer extra benefits such as dental, hearing, vision; formerly called Medicare+Choice; currently also called Medicare Advantage

MEDICARE BENEFICIARY IDENTIFIER (MBI)

Replaces SSN as health insurance claim number on new Medicare cards for transactions such as billing, eligibility status, and claim status

MEDICARE COST PLAN

Type of Medicare health plan available in certain areas of the country, which works similarly to a Medicare Advantage plan; if the beneficiary receives health care services from a non-network provider, Original Medicare provides coverage, and the beneficiary pays Medicare Part A and Part B coinsurance and deductibles

MEDICARE HOSPITAL INSURANCE

Helps cover inpatient hospital care, skilled nursing facility care, hospice care, and home health care; the UB-04 (CMS-1450) claim is submitted for services

MEDICARE-MEDICAID (MEDI-MEDI) CROSSOVER

Combination of Medicare and Medicaid programs available to Medicare-eligible persons with incomes below the federal poverty level

MEDICARE MEDICAL INSURANCE

Helps cover physician and other qualified health care practitioner services, outpatient care, durable medical equipment, and preventive services; the CMS-1500 claim is submitted for services

MEDICARE MEDICAL SAVINGS ACCOUNT (MSA)

Used by a Medicare beneficiary who is enrolled in Medicare Part C (Medicare Advantage) pay for health care services; Medicare pays the cost of a special health care policy that has a high deductible, and Medicare annually deposits into an account the difference between policy costs and what Medicare pays for an average enrollee in the patient’s region; money deposited by Medicare is managed by a Medicare-approved insurance company or other qualified company, and it is not taxed if the beneficiary uses it to pay for qualified health care expenses

MEDICARE OUTPATIENT OBSERVATION NOTICE (MOON)

Standardized notice provided to Medicare beneficiaries that they are outpatients receiving observation services and are not inpatients of a hospital or a critical access hospital (CAH)

MEDICARE PART A

Helps cover inpatient hospital care, skilled nursing facility care, hospice care, and home health care; the UB-04 (CMS-1450) claim is submitted for services

MEDICARE PART B

Helps cover physician and other qualified health care practitioner services, outpatient care, durable medical equipment, and preventive services; the CMS-1500 claim is submitted for services.

MEDICARE PART C

Helps cover physician and other qualified health care practitioner services, outpatient care, durable medical equipment, and preventive services; the CMS-1500 claim is submitted for services

MEDICARE PART D

Helps cover the cost of band name and generic prescription drugs according to a drug formulary

MEDICARE PART D COVERAGE GAP

The difference between the initial coverage limit and the catastrophic coverage threshold as described in the Medicare Part D plan purchased by a Medicare beneficiary; a Medicare beneficiary who surpasses the prescription drug coverage limit is financially responsible for the entire cost of prescription drugs until expenses reach the catastrophic coverage threshold; also called Medicare Part D “donut hole.”

MEDICARE PART D “DONUT HOLE”

See Medicare Part D coverage gap

MEDICARE PART D SPONSOR

Organization (e.g., health insurance company) that has one or more contract(s) with CMS to provide Part D benefits to Medicare beneficiaries

MEDICARE PRESCRIPTION DRUG COVERAGE

See Medicare Part D

MEDICARE PRIVATE CONTRACT

Agreement between Medicare beneficiary and physician or other practitioner who has “opted out” of Medicare for two years for all covered items and services furnished to Medicare beneficiaries; physician/practitioner will not bill for any service or supplies provided to any Medicare beneficiary for at least two years

MEDICARE SAVINGS PROGRAM (MSP)

Implemented as part of the Medicare Catastrophic Coverage Act of 1988 and later expanded by other legislation to provide relief for individuals who have limited income and resources so that the federal and state (and even some county) governments help pay for Medicare costs (when certain conditions are met)

MEDICARE SECONDARY PAYER (MSP)

Situations in which the Medicare program does not have primary responsibility for paying a beneficiary’s medical expenses

MEDICARE SELECT

Type of Medigap policy available in some states where beneficiaries choose from a standardized Medigap plan

MEDICARE SHARED SAVINGS PROGRAM (MSSP)

Mandated by the Patient Protection and Portable Care Act (PPACA) to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary costs through the creation of accountable care organizations (ACOs)

MEDICARE SPECIAL NEEDS PLANS (SNP)

Covers Medicare Part?A and/or Part B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management; such plans may limit membership to individuals who are eligible for both Medicare and Medicaid, have certain chronic or disabling conditions, and reside in certain institutions (e.g., nursing facility)

MEDICARE SUPPLEMENTARY INSURANCE [MSI]

See Medigap

MEDICATION THERAPY MANAGEMENT PROGRAMS

Available to Medicare beneficiaries who participate in a drug plan so they can learn how to manage medications through a free Medication Therapy Management (MTM)program; the MTM provides a list of a beneficiary’s medications, reasons why beneficiaries take them, an action plan to help beneficiaries make the best use of medications, and a summary of medication review with the beneficiary’s physician or pharmacist

MEDIGAP

Supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the costs of Medicare deductibles, copayments, and coinsurance, which are considered “gaps” in Medicare coverage

OPT-OUT PROVIDER

Provider who does not accept Medicare and has signed an agreement to be excluded from the Medicare program

ORIGINAL MEDICARE

Includes Medicare Part A and Medicare Part B

PRIVATE FEE-FOR-SERVICE (PFFS)

Health care plan offered by private insurance companies; not available in all areas of the country

PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

Provides a comprehensive package of community-based medical and social services as an alternative to institutional care for persons aged 55 or older who require a nursing home-level of care (e.g., adult day health center, home health care, and/or inpatient facilities)

RISK ADJUSTMENT

Method of adjusting managed care capitation payments to health plans, accounting for differences in expected health costs of enrollees

RISK ADJUSTMENT DATA VALIDATION (RADV)

Process of verifying that diagnosis codes submitted for payment by a Medicare Advantage organization are supported by patient record documentation for an enrollee

ROSTER BILLING

Streamlines the process for submitting health care claims for a large group of beneficiaries for influenza virus or pneumococcal vaccinations

SPECIAL ENROLLMENT PERIOD (SEP)

Enrollment in Medicare Part A and Part B available outside of the general enrollment period due to special circumstances, such as individuals covered by a group health plan based on current employment as long as the individual or spouse (or family member if the individual is disabled) is working, and the individual is covered by a group health plan through the employer or union based on that work; individuals covered by a group health plan based on current employment whose employment ends or group health plan insurance based on current employment ends, whichever occurs first; or individuals who serve as international volunteers for at least 12 months and who volunteer for a tax-exempt non-profit organization and have health insurance during that time when volunteer work stops or health insurance outside of the United States ends, which occurs first; usually there is no late enrollment penalty if individuals enroll during a special enrollment period

SPELL OF ILLNESS

Formerly called spell of sickness; is sometimes used in place of benefit period