Glossary
Tags
- ACA
- ACA Marketplace
- ACA subsidies
- CHIP
- CMS
- ESRD
- Extra Help
- FMAP
- FPL
- FQHC
- FSA
- HCBS
- HMO
- HRA
- HSA
- IEP
- IRMAA
- Joint Commision
- KFF
- LCD
- LIS
- Marketplace
- Medicaid
- Medicaid (rare)
- Medicaid expansion
- Medicare
- Medicare Advantage
- Medicare Part A
- Medicare Part B
- Medicare Part D
- Medicare coordination
- Medigap
- NCD
- NEMT
- NOMNC
- Original Medicare
- PCP
- Part A
- Part B
- Part C
- Part D
- QLE
- QMB
- SEP
- SNF
- SNP
- SSI
- Section 1115
- Silver Plan
- Silver plan
Medicare Supplement Insurance (Medigap)
Private health insurance that helps cover the out-of-pocket costs associated with Original Medicare (Parts A and B), such as copayments, coinsurance, and deductibles. Medigap plans are standardized and regulated by federal and state laws.
Private health insurance that helps cover the out-of-pocket costs associated with Original Medicare (Parts A and B), such as copayments, coinsurance, and deductibles. Medigap plans are standardized and regulated by federal and state laws.
Medically Needy
A category of Medicaid eligibility for individuals whose income is too high to qualify for traditional Medicaid but have significant medical expenses. Medically needy programs allow people to "spend down" their income on medical costs to become eligible.
A category of Medicaid eligibility for individuals whose income is too high to qualify for traditional Medicaid but have significant medical expenses. Medically needy programs allow people to "spend down" their income on medical costs to become eligible.
Mental Health Services
Services that focus on the diagnosis, treatment, and management of mental health conditions, such as therapy, counseling, and psychiatric care. Medicaid, Medicare, and CHIP provide coverage for a range of mental health services.
Services that focus on the diagnosis, treatment, and management of mental health conditions, such as therapy, counseling, and psychiatric care. Medicaid, Medicare, and CHIP provide coverage for a range of mental health services.
National Coverage Determination (NCD)
A decision made by Medicare about whether a particular medical service, procedure, or device is covered nationally. NCDs apply uniformly across the country and are developed based on clinical evidence and input from healthcare experts.
A decision made by Medicare about whether a particular medical service, procedure, or device is covered nationally. NCDs apply uniformly across the country and are developed based on clinical evidence and input from healthcare experts.
Network
A group of doctors, hospitals, and other healthcare providers that have agreed to provide care to members of a health insurance plan at negotiated rates. In Medicare Advantage, Medicaid, and ACA plans, enrollees typically pay less for using in-network providers.
A group of doctors, hospitals, and other healthcare providers that have agreed to provide care to members of a health insurance plan at negotiated rates. In Medicare Advantage, Medicaid, and ACA plans, enrollees typically pay less for using in-network providers.
Non-Emergency Medical Transportation (NEMT)
Transportation services provided to individuals who need assistance getting to and from medical appointments but do not require emergency care. Medicaid often covers NEMT for eligible beneficiaries, especially those with disabilities or mobility issues.
Transportation services provided to individuals who need assistance getting to and from medical appointments but do not require emergency care. Medicaid often covers NEMT for eligible beneficiaries, especially those with disabilities or mobility issues.
Nursing Home Care
Long-term care services provided in a nursing facility for individuals who need assistance with daily activities or medical care. Medicaid is the largest payer of nursing home care, though Medicare provides limited coverage for skilled nursing facility care.
Long-term care services provided in a nursing facility for individuals who need assistance with daily activities or medical care. Medicaid is the largest payer of nursing home care, though Medicare provides limited coverage for skilled nursing facility care.
Notice of Medicare Non-Coverage (NOMNC)
A formal notice that Medicare beneficiaries receive when their care is set to end, explaining that Medicare will no longer cover certain services. Beneficiaries have the right to appeal the decision if they disagree with the termination of coverage.
A formal notice that Medicare beneficiaries receive when their care is set to end, explaining that Medicare will no longer cover certain services. Beneficiaries have the right to appeal the decision if they disagree with the termination of coverage.
Open Enrollment Period (OEP)
The yearly period during which individuals can enroll in or make changes to their ACA Marketplace, Medicare Advantage, or Medicare Part D plans. Outside of this period, enrollment is only allowed with a qualifying life event.
The yearly period during which individuals can enroll in or make changes to their ACA Marketplace, Medicare Advantage, or Medicare Part D plans. Outside of this period, enrollment is only allowed with a qualifying life event.
Out-of-Pocket Costs
Medical expenses that are not covered by insurance, such as copayments, deductibles, and coinsurance, which must be paid directly by the individual. Out-of-pocket costs apply to Medicare, Medicaid, CHIP, and ACA plans.
Medical expenses that are not covered by insurance, such as copayments, deductibles, and coinsurance, which must be paid directly by the individual. Out-of-pocket costs apply to Medicare, Medicaid, CHIP, and ACA plans.
Out-of-Pocket Maximum
The maximum amount an individual must pay for covered healthcare services in a plan year before the insurance company covers 100% of the costs. Out-of-pocket maximums apply to ACA Marketplace plans, Medicare Advantage, and some Medicaid programs.
The maximum amount an individual must pay for covered healthcare services in a plan year before the insurance company covers 100% of the costs. Out-of-pocket maximums apply to ACA Marketplace plans, Medicare Advantage, and some Medicaid programs.
Outpatient Care
Medical services or treatments that do not require an overnight hospital stay. Medicare Part B, Medicaid, and CHIP cover outpatient care, which includes doctor visits, diagnostic tests, and certain surgeries.
Medical services or treatments that do not require an overnight hospital stay. Medicare Part B, Medicaid, and CHIP cover outpatient care, which includes doctor visits, diagnostic tests, and certain surgeries.
Original Medicare
The traditional Medicare program, consisting of Part A (hospital insurance) and Part B (medical insurance). Original Medicare is a fee-for-service program, allowing beneficiaries to see any provider that accepts Medicare.
The traditional Medicare program, consisting of Part A (hospital insurance) and Part B (medical insurance). Original Medicare is a fee-for-service program, allowing beneficiaries to see any provider that accepts Medicare.
Part A (Medicare)
The hospital insurance part of Medicare, covering inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most individuals qualify for premium-free Part A if they or their spouse paid Medicare taxes while working.
The hospital insurance part of Medicare, covering inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most individuals qualify for premium-free Part A if they or their spouse paid Medicare taxes while working.
Part B (Medicare)
The medical insurance part of Medicare, which covers outpatient services, doctor visits, preventive care, and certain home health services. Part B requires a monthly premium, which is income-based.
The medical insurance part of Medicare, which covers outpatient services, doctor visits, preventive care, and certain home health services. Part B requires a monthly premium, which is income-based.
Part C (Medicare Advantage)
A Medicare-approved plan offered by private insurance companies that includes all the benefits of Medicare Part A and Part B, often with additional benefits like dental, vision, and prescription drug coverage.
A Medicare-approved plan offered by private insurance companies that includes all the benefits of Medicare Part A and Part B, often with additional benefits like dental, vision, and prescription drug coverage.
Part D (Medicare)
Prescription drug coverage for Medicare beneficiaries, offered by private insurance plans. Part D helps cover the cost of prescription drugs and has a formulary, or list of covered medications, categorized by cost tiers.
Prescription drug coverage for Medicare beneficiaries, offered by private insurance plans. Part D helps cover the cost of prescription drugs and has a formulary, or list of covered medications, categorized by cost tiers.
Pre-Existing Condition
A health condition that existed before the start of an individual's health insurance coverage. Under the ACA, insurers cannot deny coverage or charge higher premiums based on pre-existing conditions.
A health condition that existed before the start of an individual's health insurance coverage. Under the ACA, insurers cannot deny coverage or charge higher premiums based on pre-existing conditions.
Premium
The monthly amount paid for health insurance coverage. Premiums are required for plans offered under the ACA Marketplace, Medicare, Medicaid (in some states), and CHIP.
The monthly amount paid for health insurance coverage. Premiums are required for plans offered under the ACA Marketplace, Medicare, Medicaid (in some states), and CHIP.
Premium Tax Credit
A subsidy provided under the ACA to help eligible individuals and families pay for health insurance premiums. Premium tax credits are based on income and are available to those purchasing coverage through the ACA Marketplace.
A subsidy provided under the ACA to help eligible individuals and families pay for health insurance premiums. Premium tax credits are based on income and are available to those purchasing coverage through the ACA Marketplace.