See Medicare Advantage.
An outpatient prescription drug benefit available to Medicare beneficiaries. For those who enroll, this benefit helps pay for drug costs, with catastrophic coverage for very high drug costs, and additional financial assistance through the Low-Income Subsidy (LIS) program for beneficiaries with low incomes and modest assets. Funding for Part D comes from general federal government revenue (76 percent), beneficiary premiums (14 percent), and contributions from the states for people who qualify for both Medicare and Medicaid (10 percent).
Established by the Balanced Budget Act of 1997, it is an independent congressional agency that advises Congress on issues affecting the Medicare program and, in particular, Medicare payment policy.
Legislation signed into law in December 2003 that provides seniors and disabled individuals on Medicare with a prescription drug benefit (Part D), delivered through private stand-alone prescription drug plans or managed care plans integrating Part A and Part B benefits (Medicare Advantage). The law expanded the array of Medicare managed care plans and changed payment methodologies.
The program provides assistance through Medicaid with Medicare premiums — and sometimes cost-sharing requirements — to Medicare beneficiaries of limited income and resources who do not qualify for full Medicaid benefits. The program encompasses qualified Medicare beneficiaries (QMBs), specified low-income Medicare beneficiaries (SLMBs) and other groups of beneficiaries who need help with cost-sharing to access services.
See Medigap Insurance.
Also known as the Federal Coordinated Health Care Office, this office serves people who are enrolled in both Medicare and Medicaid to ensure full access to seamless, cost-effective, high quality health care. The MMCO works with the Medicaid and Medicare programs, across federal agencies, states and stakeholders to align and coordinate benefits between the two programs effectively and efficiently. The MMCO partners with states to develop new care models and improve the way Medicare-Medicaid enrollees receive health care.
Originated from passage of the Balanced Budget Act of 1997 (BBA), Medicare+Choice offered Medicare beneficiaries the option to receive their benefits through a private insurer. The 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) overhauled the Medicare program, and Medicare Advantage replaced Medicare+Choice.
Medigap insurance policies are sold by private insurance companies to fill “gaps” in fee-for-service Medicare. Except in Minnesota, Massachusetts and Wisconsin, there are 10 standardized policy designs, known as Plans A through J. Plans H, I and J include limited prescription drug coverage. No new Medigap policies that include drug coverage are now sold. Beneficiaries with existing Medigap policies that include drug coverage may maintain them if they wish. However, they may be subject to late enrollment penalties if they later want Part D drug benefits.
A state of well-being in which the individual can cope with daily stresses, can work productively, and able to make community contributions.
Formerly known as the Mental Health Parity Act (MHPA), an act requiring group health plans with more than 50 employees to ensure that financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than the predominant requirements and limitations placed on substantially all medical/surgical benefits. (See Mental Health chapter.)
One of two value-based payment programs created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). There are four categories that were built from existing quality-reporting programs: quality (based on the Physician Quality Reporting System), resource use (based on the Value-based Payment Modifier), advancing care information (based on meaningful use), and clinical practice improvement activities (new category). The four categories establish a composite performance score (0-100) that will be compared against a threshold and then used to determine physician payment adjustments. (See Medicare and Delivery System Reform chapters.)
A national initiative, launched by the Department of Health and Human Services, to prevent 1 million heart attacks and strokes by 2017.
Describes care that is provided poorly or erroneously, such as wrong-site surgery.
A method for setting health insurance premiums for everyone in a state taking into account demographic variables, but not the applicant’s medical history. (Contrast with community rating and experience rating.)
Grants to assist states in their efforts to reduce reliance on institutional care, while developing community-based long-term care opportunities that enable the elderly and people with disabilities to transition back into their communities. Initially enacted in 2006, the Affordable Care Act (ACA) extended these grants through the end of 2016.
A determination of the incidence and severity of sicknesses and accidents in a well-defined class of persons.
An actuarial determination of the death rate at each age as determined from prior experience.
A group of employers who band together for purposes of purchasing group health insurance, often through a self-funded approach. MEWAs are sometimes exempt from state benefit mandates, taxes and other regulations.