Medicare Eligibility and Enrollment
Eligibility for premium-free Medicare Part A is based on this method of measurement based on payments of payroll taxes during a beneficiary's working years.
Quarters of Coverage (QCs)
This plan helps cover home health care, hospice care, and inpatient care.
Medicare Part A
Document that acknowledges patient responsibility for treatment in the event of an anticipated Medicare denial due to lack of medical necessity.
Advanced Beneficiary Notice (ABN)
This is the basis for determining Medicaid income eligibility for most children, pregnant people, parents, and adults.
The Modified Adjusted Gross Income (MAGI)
This term is used to refer to the direct payment of claims to a provider.
Assignment of Benefits
Those who qualify for premium-based Medicare Part A must also apply for what additional coverage?
Medicare Part B
This type of plan allows people who otherwise need a nursing home level of care to remain in the community.
Programs of All-Inclusive Care for the Elderly (PACE)
This standardized notice is provided to Medicare beneficiaries to inform them that they are outpatients receiving observational services and are not inpatients of a hospital or critical access hospital.
Medicare Outpatient Observation Notice (MOON)
This term refers to individuals who are entitled to Medicare and are eligible for some type of Medicaid benefit.
dual eligibles
This entity provides comprehensive benefit packages, is organized to manage cost, utilization, and quality, and provides delivery of services through contracted arrangements with Medicaid.
Managed care organization (MCO)
Those who wish to apply for Medicare should submit an application to this government entity.
The Social Security Administration (SSA)
This is a method of adjusting managed care capitation payments to health plans, accounting for differences in expected health costs of beneficiaries.
Risk adjustment.
This is a document provided to a Medicare beneficiary prior to rendering services which informs the patient of their financial responsibility for services which are not a benefit of Medicare.
Notice of Exclusion of Medicare Benefits.
This eligibility group allows members who may have too much income to qualify for other programs to become eligible by spending down the amount of income that is above the state's eligibility standard.
Medicaid Medically Needy Program
This is the term used for the portion of Medicaid funding that is provided by the federal government, determined using a formula which compares the per capita income level of the state against the national average.
Federal Medical Assistance Percentage
Three months prior to a beneficiary's 65 birthday, they enter a seven-month application timeframe for Medicare referred to as what?
Initial Enrollment Period (IEP)
These types of Medicare plans cover all Medicare Part A and Part B health care services for individuals who can benefit the most from special care. These include plan types for chronic conditions, institutions, and dual eligible plans.
Medicare special needs plans (SNP)
This document is generated as a result of a claim that Medicaid should not have paid.
voided claim
In this eligibility group, state pays Medicare Part A and B premiums and cost sharing for individuals with low incomes.
Qualified Medicare Beneficiaries (QMB)
This program safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services.
Surveillance and utilization review subsystem (SURS)
Those who do not apply for Medicare when they qualify are subject to a penalty added to premium costs for each 12-month period the beneficiary failed to apply. What percentage is this penalty?
10%
These are plans offered by private insurance companies where Medicare pays a preestablished amount each month to the insurance company, who then decides how much it will pay for services.
Private fee-for-service (PFFS)
This Medicaid document is sent to the provider and contains the current status of all claims.
Medicaid Remittance Advice
In this eligibility group, state pays Medicare part A premiums for certain individuals with disabilities who lose Medicare coverage because of work.
Qualified working disabled individuals (QWDI)
Fee-for-service fee schedules can be based on a percentage of Medicare's fee, a state developed fee schedule using local factors, or this scale of measurement:
Resource based relative value scale (RBRVS)