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Chapter 14
Medicare
| Question | Answer |
|---|---|
| accountable care organizations (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 noncoverage (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 for 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 |
| 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 managed care organizations that reward efficiency and encour |
| 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 |
| 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 |
| 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 |
| 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 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 suppli |
| 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 |
| 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 |
| 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 |
| 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 |
| 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. |
| 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 inpatien |
| 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 |
| spell of illness | formerly called spell of sickness; is sometimes used in place of benefit period. |
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