Integrated Care

A coordinated approach to healthcare that involves integrating physical, behavioral, and mental health services to provide holistic care. Integrated care models are often used in Medicare, Medicaid, and CHIP programs to improve outcomes.

Income-Related Monthly Adjustment Amount (IRMAA)

An additional charge added to Medicare Part B and Part D premiums for beneficiaries with higher incomes. IRMAA is determined based on the beneficiary’s modified adjusted gross income (MAGI).

Job-Based Health Plan

Health insurance coverage provided by an employer to its employees and their dependents. Medicare beneficiaries who have job-based health plans may coordinate benefits between the employer plan and Medicare.

Joint Commission

An independent, nonprofit organization that accredits and certifies healthcare organizations and programs in the United States. Accreditation by the Joint Commission is a mark of quality and safety in healthcare, including programs funded by Medicare and Medicaid.

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.

Kidney Transplant

A surgical procedure to replace a failing kidney with a healthy one from a donor. Individuals with End-Stage Renal Disease (ESRD) are eligible for Medicare, regardless of age, and Medicare covers kidney transplants, dialysis, and related services.

Kaiser Family Foundation (KFF)

A non-profit organization focused on national health issues, including the role of Medicare, Medicaid, and the ACA. KFF provides research, analysis, and information to inform policymakers and the public about healthcare policy.

Lifetime Reserve Days (Medicare)

A set of 60 additional days that Medicare Part A beneficiaries can use during their lifetime for hospital stays beyond the standard 90 days per benefit period. These days come with a higher coinsurance cost and are only available once in a lifetime.

Low-Income Subsidy (LIS)

A federal program that helps Medicare Part D beneficiaries with limited income and resources pay for prescription drug costs. The LIS program covers premiums, deductibles, and copayments for eligible individuals, reducing out-of-pocket expenses.

Long-Term Care (LTC)

A range of services that provide medical and personal care to individuals with chronic illnesses or disabilities who cannot manage their daily activities independently. Medicaid is the primary payer for long-term care services, covering nursing homes, assisted living, and home care.

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.

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.

Local Coverage Determination (LCD)

Decisions made by Medicare Administrative Contractors (MACs) regarding whether a particular medical service or item is covered on a local basis. LCDs apply to services that may not have national coverage policies from Medicare.

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.

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.

Medicare

A federal program that provides health insurance to individuals 65 and older, as well as younger people with certain disabilities or End-Stage Renal Disease (ESRD). Medicare has different parts that cover hospital care (Part A), medical services (Part B), and prescription drugs (Part D).

Medicare Advantage (Part C)

A type of health plan offered by private insurance companies that contracts with Medicare to provide all Part A and Part B benefits. Medicare Advantage plans often include extra benefits, such as vision, dental, and prescription drug coverage.

Medicare Part A

The hospital insurance component of Medicare, which covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services. Most people do not pay a premium for Part A if they or their spouse paid Medicare taxes while working.

Medicare Part B

The medical insurance component of Medicare that covers outpatient services, doctor visits, preventive services, and some home health care. Part B requires a monthly premium, which is based on income, and there are cost-sharing requirements for services.

Medicare Part D

The prescription drug coverage component of Medicare, available through private plans. Part D helps beneficiaries pay for the cost of prescription medications, with cost-sharing determined by drug formularies and tier levels.