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
Appeal
A formal request to have a health insurance company or government program review a decision regarding coverage or services, such as a denial of payment for a medical service.
A formal request to have a health insurance company or government program review a decision regarding coverage or services, such as a denial of payment for a medical service.
Asset Test
A financial assessment used by Medicaid and certain other programs to determine eligibility based on the value of an individual’s or family’s assets, such as savings and property.
A financial assessment used by Medicaid and certain other programs to determine eligibility based on the value of an individual’s or family’s assets, such as savings and property.
Buy-In Program
A Medicaid program that allows certain individuals, such as people with disabilities or those with higher incomes, to "buy into" Medicaid by paying a premium. It provides Medicaid coverage without meeting traditional income or asset limits.
A Medicaid program that allows certain individuals, such as people with disabilities or those with higher incomes, to "buy into" Medicaid by paying a premium. It provides Medicaid coverage without meeting traditional income or asset limits.
Benefit Verification
The process of confirming an individual’s eligibility and benefits for health services through Medicaid, Medicare, or private insurance. This ensures coverage and payment for services.
The process of confirming an individual’s eligibility and benefits for health services through Medicaid, Medicare, or private insurance. This ensures coverage and payment for services.
CHIP (Children’s Health Insurance Program)
A joint federal-state program providing low-cost health insurance for children in families that earn too much to qualify for Medicaid but cannot afford private insurance. CHIP covers a wide range of health services including doctor visits, immunizations, and prescription drugs.
A joint federal-state program providing low-cost health insurance for children in families that earn too much to qualify for Medicaid but cannot afford private insurance. CHIP covers a wide range of health services including doctor visits, immunizations, and prescription drugs.
Disenrollment
The process of voluntarily or involuntarily terminating coverage under a health insurance plan, such as Medicare, Medicaid, or CHIP. Disenrollment may occur if a beneficiary no longer meets eligibility requirements or chooses to switch plans.
The process of voluntarily or involuntarily terminating coverage under a health insurance plan, such as Medicare, Medicaid, or CHIP. Disenrollment may occur if a beneficiary no longer meets eligibility requirements or chooses to switch plans.
Eligibility
The criteria that individuals must meet to qualify for healthcare programs such as Medicare, Medicaid, CHIP, or ACA Marketplace plans. Eligibility is typically based on factors such as age, income, residency, and health status.
The criteria that individuals must meet to qualify for healthcare programs such as Medicare, Medicaid, CHIP, or ACA Marketplace plans. Eligibility is typically based on factors such as age, income, residency, and health status.
End-Stage Renal Disease (ESRD)
A medical condition in which a person’s kidneys stop functioning permanently, requiring dialysis or a kidney transplant. Individuals with ESRD are eligible for Medicare regardless of age.
A medical condition in which a person’s kidneys stop functioning permanently, requiring dialysis or a kidney transplant. Individuals with ESRD are eligible for Medicare regardless of age.
Federal Poverty Level (FPL)
A measure of income issued annually by the Department of Health and Human Services (HHS) to determine eligibility for various government assistance programs, including Medicaid, CHIP, and ACA subsidies. The FPL varies based on household size and geographic location.
A measure of income issued annually by the Department of Health and Human Services (HHS) to determine eligibility for various government assistance programs, including Medicaid, CHIP, and ACA subsidies. The FPL varies based on household size and geographic location.
Full Medicaid Benefits
Comprehensive healthcare services provided to individuals who qualify for Medicaid based on income, age, disability, or other criteria. Full Medicaid benefits include hospital care, doctor visits, preventive services, prescription drugs, and long-term care, among others.
Comprehensive healthcare services provided to individuals who qualify for Medicaid based on income, age, disability, or other criteria. Full Medicaid benefits include hospital care, doctor visits, preventive services, prescription drugs, and long-term care, among others.
Guaranteed Issue
A requirement under the ACA that insurance companies must offer health insurance to any applicant regardless of health status, age, or gender, and cannot deny coverage based on pre-existing conditions.
A requirement under the ACA that insurance companies must offer health insurance to any applicant regardless of health status, age, or gender, and cannot deny coverage based on pre-existing conditions.
Gross Income
The total income earned before any deductions, such as taxes or retirement contributions, are taken out. Gross income is used to determine eligibility for programs like Medicaid, CHIP, and ACA Marketplace subsidies.
The total income earned before any deductions, such as taxes or retirement contributions, are taken out. Gross income is used to determine eligibility for programs like Medicaid, CHIP, and ACA Marketplace subsidies.
Income Limits
The maximum income level a household can earn and still qualify for government programs like Medicaid, CHIP, and ACA subsidies. Income limits are typically based on a percentage of the Federal Poverty Level (FPL).
The maximum income level a household can earn and still qualify for government programs like Medicaid, CHIP, and ACA subsidies. Income limits are typically based on a percentage of the Federal Poverty Level (FPL).
Initial Enrollment Period (IEP)
The seven-month window when an individual is first eligible to sign up for Medicare Part A and Part B. This period begins three months before the individual turns 65, includes their birthday month, and extends three months after.
The seven-month window when an individual is first eligible to sign up for Medicare Part A and Part B. This period begins three months before the individual turns 65, includes their birthday month, and extends three months after.
Judicial Review
A legal process in which courts review decisions made by federal or state agencies regarding healthcare programs like Medicare or Medicaid. Beneficiaries may request judicial review if they disagree with a ruling on coverage or eligibility.
A legal process in which courts review decisions made by federal or state agencies regarding healthcare programs like Medicare or Medicaid. Beneficiaries may request judicial review if they disagree with a ruling on coverage or eligibility.
Look-Back Period (Medicaid)
A period of time (usually five years) during which Medicaid reviews an applicant’s financial transactions to determine if assets were transferred to meet Medicaid eligibility. Transferring assets during the look-back period may result in penalties or ineligibility for Medicaid long-term care.
A period of time (usually five years) during which Medicaid reviews an applicant’s financial transactions to determine if assets were transferred to meet Medicaid eligibility. Transferring assets during the look-back period may result in penalties or ineligibility for Medicaid long-term care.
Level of Care (LOC)
A term used in Medicaid to determine the intensity of care required by an individual. LOC assessments are used to establish eligibility for long-term care services, such as nursing home care or home and community-based services.
A term used in Medicaid to determine the intensity of care required by an individual. LOC assessments are used to establish eligibility for long-term care services, such as nursing home care or home and community-based services.
Medicaid
A joint federal and state program that provides healthcare coverage to low-income individuals, families, seniors, and people with disabilities. Medicaid covers a wide range of services, including doctor visits, hospital stays, long-term care, and preventive care.
A joint federal and state program that provides healthcare coverage to low-income individuals, families, seniors, and people with disabilities. Medicaid covers a wide range of services, including doctor visits, hospital stays, long-term care, and preventive care.
Medicaid Expansion
A provision of the ACA that allows states to expand Medicaid eligibility to adults with incomes up to 138% of the Federal Poverty Level (FPL). Expansion states offer coverage to a broader range of low-income adults, including those without children.
A provision of the ACA that allows states to expand Medicaid eligibility to adults with incomes up to 138% of the Federal Poverty Level (FPL). Expansion states offer coverage to a broader range of low-income adults, including those without children.
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.