Medicare
Covers Doctor services, DME, preventive services, ambulance services, etc.
What is Part B?
These types of plans usually include prescription drug coverage at no additional premium.
What are Medicare Advantage (MAPD) plans?
This is a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.
What is Extra Help (LIS)?
This type of SEP is available each year beginning on December 8 and may be used once through November 30 of the following year.
What is 5-Star Plan SEP?
These type of Advantage plans generally make members get their care and services from doctors, other health care providers, or hospitals in the plan’s network (except for emergency care, out-of-area urgent care, or temporary out-of-area dialysis) in order for the member to be covered by the plan.
What are Health Maintenance Organization (HMO) plans?
Covers hospital stays, skilled nursing care, hospice care, etc.
What is Medicare Part A?
This is the number of consecutive days a person must go without Medicare drug coverage or other creditable prescription drug coverage after their Initial Enrollment Period to incur a late enrollment penalty.
What is 63 days?
A term for people who are eligible for both Qualified Medicare Beneficiary (QMB) and full Medicaid benefits.
What is QMB+?
This is the first opportunity the consumer will have to enroll in Medicare. It's a 7-month window of time.
What is the “Initial Enrollment Period,” or IEP?
Consumers who have specific severe or disabling chronic conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia) may benefit from enrolling in this type of plan.
What are chronic condition special needs plans or C-SNPs?
Helps pay for deductibles, copayments, and coinsurance. Policies are guaranteed renewable as long as premiums are paid.
What is a Medicare Supplement (MediGap)?
This coverage occurs when the out-of-pocket spending in 2024 reaches $8,000, the beneficiary will not have to pay a copayment or coinsurance for covered Part D drugs for the rest of the calendar year.
What is catastrophic coverage?
Consumers on Medicaid are not eligible for these type of Advantage plans since they do not pay a Part B premium.
What are giveback or Part B reimbursement plans?
This SEP code is for consumers that have both Medicare and Medicaid (or their state helps pay for their Medicare premiums) or they get Extra Help paying for their Medicare prescription drug coverage, but have not had a change.
What is MDE?
Provides the consumer details about what the plan covers, how much they will pay for certain services, and more in the next year.
What is the evidence of coverage?
The Part A deductible for each time the beneficiary is admitted to the hospital per benefit period, before Original Medicare starts to pay.
What is $1,676?
This is when the beneficiary may need to try one or more similar, lower-cost drugs before the plan will cover the prescribed drug.
What is step therapy?
Not everyone that has Medicaid will qualify for this type of Advantage plan, it is based on their level.
What is a DSNP?
Consumers enrolled in Original Medicare only can not use this SEP during 1/1 - 3/31, it is for those beneficiaries who are already in an Advantage plan and would like to make one change during this time.
What is the Open Enrollment Period (OEP)?
This report we can pull to let us know what current plan the consumer is on and if they have LIS, we must always ask permission from the consumer to access it first.
What is Marx?
The prescribers doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
What is assignment?
These certain types of Advantage plans do not include Medicare drug coverage and the beneficiary can join a separate Medicare drug plan.
What are Medical Savings Account (MSA) Plans and some Private Fee-for-Service (PFFS) Plans?
This Medicaid level has Medicaid paying only their Medicare Part B premiums (have income of greater than 100% FPL, but less than 120% FPL) and may not always qualify for a special needs plan.
What is Specified Low-Income Medicare Beneficiaries (SLMB)?
Occurs from January 1–March 31 each year.
What is the General Enrollment Period?
A Medicare and Medicaid program offered in many states that allows people who otherwise need a nursing home-level of care to remain in the community, like a home, apartment, or other appropriate setting.
What is PACE?