Commercial Plan
Individual policies that can be purchased on government sites or directly from insurance websites. Plans do not coordinate with Medicare and can be referred to as Marketplace or QHP plans.
What is an Exchange Plan?
(On Exchange- purchased of federal site, must have SSN to apply.
Off Exchange- purchased directly off insurance website, SSN may not be required to apply.)
Federal Health Insurance w/ benefits assigned to commercial plan. Some plans may also be referred to as D-SNP or C-SNP.
What is Medicare Advantage plan?
(D-SNP is a dual special needs plan with Medicare and Medicaid.
C-SNP is a chronic specials needs plan for individuals with certain chronic conditions)
Plan where a work injury resulted in person requiring medical care. Care can be limited or indefinite and there is no COB.
What is Worker's Compensation?
(If worker's comp is not related to ESRD then normal COB rules apply)
This Medicaid provides health coverage to people with low-income and asset levels who meet eligibility requirements.
What is Full Scope Medicaid?
Employer insurance- Active working/Not Actively working. Self-funded, federally governed or Fully-funded, state governed.
What is an EGHP/COBRA plan?
A federal government program that delivers health care to American Indians and Alaska Natives. This type of plan is not considered health insurance and is a payor of last resort.
What is I.H.S (Indian Health Services)?
Plan can also be considered end-of-life care and services should be billed directly to Medicare.
What is Hospice?
(If Hospice is related to ESRD, Hospice facility can be billed. If not related to ESRD, Medicare should be billed)
This Medicaid will pay the Medicare Part B premiums for beneficiaries who already have Part A and have limited income.
What is SLMB (Specified Low Income Medicare Beneficiary)?
Plans supplement to Medicare sold by private insurance companies BUT regulated by state and federal government. One of few plans subject to pre-existing condition clause.
What is a Medigap plan?
Plan for disabled veterans, does not coordinate benefits with Medicare.
What is Veterans Administration?
(Patient must elect VA and obtain authorization for services before they can be billed, VA auth has no Deductible/OOP)
Plan to protect the insured and their belonging during trips from their home county t the USA. Dialysis services may not be covered. Limitations and pre-existing conditions may apply.
What is Travel Insurance?
This Medicaid covers all Medicare Part A/B premiums, deductible and co-insurances. Providers cannot bill these beneficiaries for services.
What is QMB (Qualified Medicare Beneficiary)?
Plans that are Medicaid like and can be purchased through Healthcare.gov, designed for low-income applicants.
What are Essential plans?
State funded programs for ESRD services ONLY, payor of last resort.
What is a State Renal Program?
(Not every state offers programs and not every program reimburses for dialysis services.)
Plan covers medical expenses while studying and living in the USA. Most often does not coordinate with Medicate and plan has very strict rules.
What is a Student Health Insurance plan?
This Medicaid provides health coverage to people with low-income and assets levels who meet certain eligibility requirements, but make more than would qualify for full scope Medicaid.
What is Share of Cost (SOC) or Spend Down Medicaid?
Plans purchased by an employer through an exchange site. Designed for employers with less than 100 employees. These plans coordinate with Medicare.
What is a SHOP plan?
Policies for active duty service members or retired service members and their family.
What is TriCare or TriCare 4 Life?
Plan when patient loses Medicare/Medicaid/Government plan due to incarceration.
What is Prison/Jail plan?
(Incarceration can be jail/prison, rehab, halfway house, etc. as long as person is court ordered)
This Medicaid provides coverage for emergencies only to low-income individuals that meet Medicaid requirements but are undocumented without citizenship.
What is Emergency (EMA) Medicaid?