Medicare Advantage and Other Medicare Health Plans Vocabulary

Vocabulary flashcards defining primary Medicare health plan options, SNP models, dual-eligibility classifications, cost-sharing frameworks, and enrollee rights based on AHIP Module 2 lecture notes.

Medicare Advantage (MA) Plan

A Medicare Part C health plan offered by private companies that covers all Medicare Part A and Part B basic benefits, and may cover Part D prescription drugs and supplemental benefits.

Coordinated Care Plan

A type of Medicare Advantage plan that utilizes a network of preferred providers, including Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

Point of Service (POS) Option

A feature offered by some HMO plans allowing enrollees to receive certain out-of-network services without prior approval, typically subject to higher cost-sharing or coverage caps.

Preferred Provider Organization (PPO)

A Medicare Advantage coordinated care plan allowing enrollees to see any U.S. provider accepting Medicare and the plan, with lower cost-sharing for in-network care than out-of-network care.

Special Needs Plan (SNP)

A Medicare Advantage coordinated care plan specifically tailored to serve a targeted subset of Medicare beneficiaries, requiring an evidence-based model of care and included prescription drug coverage.

Chronic Condition SNP (C-SNP)

A Special Needs Plan that restricts enrollment to individuals with one or more severe or disabling chronic conditions specified by CMS regulations.

Institutional SNP (I-SNP)

A Special Needs Plan restricting enrollment to MA-eligible individuals who have needed, or are expected to need for $90$ days or longer, the level of services provided in long-term facility settings.

Institutional Equivalent SNP (IE-SNP)

A Special Needs Plan enrolling MA-eligible individuals who reside in the community but are determined by an impartial entity to require an institutional level of care.

Dual-Eligible SNP (D-SNP)

A Special Needs Plan enrolling individuals eligible for both Medicare and Medicaid to coordinate Medicare and Medicaid benefit delivery.

Qualified Medicare Beneficiary (QMB)

A dual-eligible beneficiary category where Medicaid pays Medicare Part A/B premiums and cost-sharing, and providers are prohibited by law from billing the beneficiary for cost-sharing.

Specified Low-Income Medicare Beneficiary (SLMB)

A category of dual-eligible beneficiary for whom Medicaid helps pay Medicare Part B premiums.

Qualifying Individual (QI)

A dual-eligible beneficiary category where Medicaid assists with paying Medicare Part B premiums.

Qualified Disabled Working Individual (QDWI)

A dual-eligible category for working individuals under age $65$ with disabilities, for whom Medicaid pays the Medicare Part A premium.

Full-Benefit Dual Eligible (FBDE)

A dual-eligible individual who is entitled to full Medicaid benefits, also referred to as QMB-Plus.

Fully Integrated Dual-Eligible (FIDE) SNP

A D-SNP offering integrated Medicare and Medicaid benefits under a single organization, including long-term services and supports with nursing facility coverage for at least $180$ days per plan year.

Highly Integrated Dual-Eligible (HIDE) SNP

A D-SNP covering all Medicare benefits plus long-term services and supports or behavioral health services under a capitated contract with a State Medicaid agency.

Coordination-Only D-SNP (CO D-SNP)

A D-SNP that does not qualify as HIDE or FIDE, operating under a state contract to arrange notification of hospital and skilled nursing facility admissions for high-risk dual eligibles.

Exclusively Aligned Enrollment

A mechanism where a State limits D-SNP eligibility to full-benefit dual eligibles whose Medicaid benefits are covered under an MCO contract held by the D-SNP organization or its parent entity.

Applicable Integrated Plan

A FIDE or HIDE SNP (or qualifying CO D-SNP) with exclusively aligned enrollment and its affiliated MCO, mandated to offer unified appeal and grievance processes for Medicare and Medicaid.

Private Fee-for-Service (PFFS) Plan

A Medicare Advantage plan paying providers on a fee-for-service basis without financial risk, allowing enrollees to see any U.S. provider accepting plan terms, with no prior authorization requirements.

Medical Savings Account (MSA) Plan

A high-deductible Medicare Advantage plan paired with a Medicare-funded savings account, charging no monthly premium and excluding Part D prescription drug coverage.

Employer Group Waiver Plan (EGWP)

A Medicare Advantage plan with waived regulatory requirements offered exclusively to active employees, retirees, and dependents of specific employer or union sponsors.

Maximum Out-of-Pocket (MOOP) Limit

A mandatory annual limit on enrollee cost-sharing for Part A and Part B basic benefits required for all Medicare Advantage plans.

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Non-primarily health-related extra benefits, such as groceries, non-medical transportation, or pest control, offered specifically to enrollees with qualifying chronic conditions.

Step Therapy

A utilization management protocol requiring an enrollee to try less expensive drug treatments prior to obtaining coverage for more costly Part B or Part D drugs.

Medicare Cost Plan

A non-Medicare Advantage health plan (Section 1876 cost plan) permitting enrollees to receive network services under plan rules or out-of-network services through Original Medicare.

Program of All-Inclusive Care for the Elderly (PACE)

A Medicare and Medicaid program offering comprehensive medical and social services to frail individuals age $55$ or older who require nursing facility care but reside in the community.

Grievance

A complaint filed by an enrollee regarding the operational aspects, access, quality of care, or service delivery of a Medicare health plan or provider.

Coverage Decision

A formal determination made by a Medicare health plan regarding whether a medical service, item, or drug is covered and the beneficiary's required cost-sharing.

Appeal

A formal procedure initiated by an enrollee or physician to request reconsideration of an adverse coverage decision or payment denial by a Medicare health plan.