Commercial Plans
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 from federal sites, must have SSN to apply.
Off Exchange- purchased directly from insurance website, governed by the State. SSN may not be required to apply.)
What is Medicare Advantage plan?
(D-SNP is a dual special needs plan with Medicare and Medicaid.
C-SNP is a chronic special needs plan for individuals with certain chronic conditions.)
Type of coverage where a work injury resulted in person requiring medical care. Care can be limited or indefinite.
What is Worker's Compensation?
(If worker's comp is NOT related to ESRD then insurance will be billed and normal COB rules apply)
Most common type of Medicaid. Provides coverage to people with low-income and asset levels who meet eligibility requirements.
What is Traditional/Full Scope Medicaid?
Employer insurance- person can be actively working/not actively working. Self-funded (federally governed) or Fully-funded (stated governed).
What is an EGHP/COBRA plan?
A type of federal government program that delivers health care to American Indians and Alaska Natives. This type of coverage is not considered health insurance and is a payor of last resort.
What is I.H.S (Indian Health Services)?
What is Hospice?
(If Hospice is related to ESRD, hospice facility can be billed. If not related to ESRD, Medicare should be billed and Med Advantage can potentially be secondary)
Type of Medicaid category that 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 the few plans subject to pre-existing condition clause.
What is a Medigap plan?
Type of coverage for disabled veterans.
What is Veterans Administration?
(Person must elect VA benefits and obtain authorization for services before they can be billed, VA auth reimburses provider at 100% and will bill person directly for any OOP. This coverage is utilized instead of Medicare or Commercial insurance.)
Plan to protect the insured and their belongings during trips outside of their home country. Dialysis services may not be covered. Limitations and pre-existing conditions may apply.
What is Travel Insurance?
Type of Medicaid category that 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 for persons while studying and pursing higher education. Most often does not coordinate with Medicare and plans have very strict rules.
What is Student Health Insurance plan?
This Medicaid provides health coverage to people with low-income and asset levels who meet certain eligibility requirements, but make more that would qualify for full scope Medicaid.
What is Share of Cost (SOC) or Spend Down Medicaid?
Plan 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 services members or retired service members and their family.
What is TriCare or TriCare 4 Life?
Type of coverage for when a person 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?