Federal/State

A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.

The part of the Medicare program covering inpatient hospital services and services furnished by other healthcare providers such as nursing homes, home health agencies, and hospices. Part A coverage is automatically provided for individuals entitled to Medicare.

The part of the Medicare program that covers outpatient, physician, and medical supplier services. Part B coverage is optional and must be paid for separately through monthly premium payments.

Also referred to as “Medicare Part C” or “Medicare+Choice.” A Medicare program under which a patient enrolled in traditional Medicare and can elect to enroll either in a Medicare Advantage program (Medicare PPO or HMO) instead of traditional Medicare. Usually, enrolling in a Medicare Advantage program requires the patient to seek care within a specific provider network. Additionally, the patient retains the benefits of traditional Medicare and additional benefits not usually covered by traditional Medicare.

The optional part of the Medicare program that covers prescription drug coverage. In 2006, beneficiaries gained access to partial prescription drug coverage paid mainly through state payments, premiums and general revenue. Some assistance for low-income beneficiaries is available for premiums and co-pays.

The Medicare Part A claims processing contractor. See Medicare Administrative Contractor (MAC).

The Medicare Part B claims processing contractor. See Medicare Administrative Contractor (MAC).

Replaces Medicare Part A Fiscal Intermediaries (FIs) and Part B Carriers with 15 new regional Medicare provider bill payment and cost report intermediaries. MAC regions have the responsibility for all facility and physician Medicare bill payment operations.

An agency within the U.S. Department of Health and Human Services responsible for the administration of the Medicare and Medicaid programs. Formerly called the Healthcare Financing Administration. www.cms.gov.

[Part of CMS] A non-partisan congressional advisory body charged with providing policy advice and technical assistance concerning the Medicare program and other aspects of the health system. It conducts independent research, analyzes legislation, and makes recommendations to U.S. Congress. The Physician Payment Review Commission has been merged with the Prospective Payment Assessment Commission to create MedPAC.

Private health plan, also called Medigap insurance, is designed to supplement Medicare benefits by covering certain healthcare costs (i.e., beneficiary’s co-insurance, deductible, etc.) that are not paid for by the Medicare program.

An individual who qualifies for coverage by both Medicare and Medicaid (e.g., ≥ 65yrs. w/ low income < poverty). Medicare is always the primary payer.

Medicaid was established in 1965, at the same time as Medicare, under Title XIX of the Social Security Act. It was designed to assist low-income families in providing healthcare for themselves and their children. It also covers certain individuals who fall below the federal poverty level. It covers hospital and doctor’s visits, prenatal care, emergency room visits, drugs and other treatments.

Medicaid is a state-administered program funded partly by the federal government that provides healthcare services for certain low-income persons and certain aged, blind or disabled individuals. The program is approximately a 40/60 state/federal match.
www.ohanet.org/medicaid/

There are 50 separate Medicaid programs. While the federal government provides some basic requirements for determining eligibility for coverage and benefits to be provided, each state can expand Medicaid beyond that level. Each state’s Medicaid program covers slightly different groups of people with slightly different benefits.

Each state may have its own name for the program. Examples include “Medi-Cal” in California, “MassHealth” in Massachusetts, and “TennCare” in Tennessee. States may bundle together the administration of Medicaid with other separate programs such as the State Children’s Health Insurance Program (SCHIP), so the same organization that handles Medicaid in a state may also manage those additional programs. Separate programs may also exist in some localities that are funded by the states or their political subdivisions to provide health coverage for indigents and minors.

State participation in Medicaid is voluntary; however, all states have participated since 1982 when Arizona formed its Arizona Health Care Cost Containment System (AHCCCS) program. In some states Medicaid is subcontracted to private health plans, while other states pay providers (i.e., doctors, clinics and hospitals) directly.

Most states offer another benefit to those who are disabled, become eligible for Medicaid, and have some form of private health plan.

Each state defines their own unique payment methodology to reimburse providers for services provided.

Medicaid managed care grew rapidly in the 1990s. In 1991, 2.7 million beneficiaries were enrolled in some form of managed care. By 2004, that number had grown to 27 million, an increase of 900%. Of the total Medicaid enrollment in the United States in 2004, approximately 60% were receiving Medicaid benefits through managed care. All states except Alaska, New Hampshire and Wyoming have all, or a portion of, their Medicaid population enrolled in an MCO. States can make managed care enrollment voluntary, or seek a waiver of section 1915(b) of the Social Security Act (the Act) from CMS to require certain populations to enroll in an MCO.

This program, also known as TRICARE, provides comprehensive health benefits for families of uniformed services personnel and service retirees as a supplement to military and Public Health Service care. This program is federally funded and is administered by the Office for the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS).

A Department of Defense, regionally managed health-care program for active duty and retired members of the uniformed services and their families that combines military healthcare resources and networks of civilian healthcare professionals. Formerly known as CHAMPUS (the Civilian Health and Medical Program of the United States).

A reduced fee-for-service (FFS) plan similar to the network portion of a PPO.

An enrollment-based managed care option designed to provide coordinated care managed by a primary care manager, who is similar to a primary care provider in a commercial HMO.

A reduced fee-for-service plan that allows participants to use TRICARE authorized providers or non-network providers.

An enrollment-based managed care option designed to provide a health insurance program for federal employees, retirees, and their dependents and survivors. Usually administered by health plans located around the U.S. (for example Federal Blue Cross Blue Shield).

Q: A Medicare-only patient is interested in having the cochlear implant or Baha® surgery. Which part of the Medicare benefits will cover the surgery?

A: Medically necessary Cochlear implants and Baha are covered benefits under the Medicare Part B program.

Q: A Medicare patient needs replacement parts for a cochlear implant or Baha. Who covers this?

A: Medically necessary parts and accessories needed for cochlear implants and Baha after surgery are covered under the Medicare Part B – Durable Medical Equipment (DME) program in certain circumstances.

Q: Why do Medicare Advantage plans (HMOs, PPOs) require prior authorization?

A: Medicare Advantage must at least provide the same benefits as Medicare. However, Medicare Advanatage plans are managing a specific population of Medicare recipients for a set dollar amount. To better manage the care of their specific population, the plan requires authorizations to better determine whether the service is medically necessary. Since Medicare does not require authorizations, the provider and patient may not know until after the service has been rendered if the claim is denied.

Q: Will Medicare cover bilateral cochlear implants?

A: We do not know for certain, as Medicare's criteria does not specifically address coverage for bilateral implants. We recommend that you contact your local Medicare office to determine policy interpretation of bilateral coverage. It is important to note that Medicare will not review a predetermination or prior-authorization request prior to the service being provided.

Q: Does a Medicare HMO have to provide the same coverage as Medicare?

A: Yes, however some of these plans have enhanced benefits that cover more than what traditional Medicare covers.

Q: Will Medicaid follow the same coverage benefits as Medicare?

A: Although Medicaid is also a federal payer, each state administers its own coverage guidelines. For that reason, each state's Medicaid program will determine what individual coverage and payment is allowable for those services.

Q: Is the Federal Employee Health Benefits Program a public plan like Medicare?

A: Although funded by the federal government, the FEHBP is akin to private employer sponsored coverage, and administered by private health plans such as Blue Cross Blue Shield.

Q: When will Medicaid be billed as the primary payer?

A: Medicaid is always the payer of last resort. When Medicaid is the only health plan a patient has, it will be billed as the primary payer.

Q: Why do some patients have Medicaid plans that are affiliated with health plans?

A: Many Medicaid programs have Managed Care Medicaid plans. These plans will cover the same benefits as Medicaid; however they might have additional benefits and different prior authorization criteria for obtaining services. The payment associated with Medicaid plans may also differ from the payment established by the state Medicaid plan.

Q: Do state Medicaid plans require prior authorizations?

A: Many of the state Medicaid plans require prior authorizations for specific services such as cochlear implant parts and accessories. It is best to check with the state Medicaid plan to identify what services/procedures require prior authorizations before the time of service.

Q: Do Medicaid managed care plans work similarly to commercial managed care plans?

A: Yes, Medicaid managed care plans are usually health maintenance organizations (HMOs). The Medicaid managed care plan requires the patient to select a primary care physician (PCP) who is responsible for directing the patient’s medical care. The patient enrolled in a Medicaid HMO is limited to choosing medical providers within the specific health plan in which they are enrolled. In many cases, the patient must receive a referral from the PCP prior to accessing specialty care services.

Q: How often does the patient or their family need to reapply to Medicaid?

A: It depends. Normally, most people will need to reapply once a year. However, some individuals may be required to reapply every three months and some every six months depending on the financial situation of their family. Families with incomes that change from month to month must reapply on a monthly basis.

Q: Can Medicaid supplement a commercial health plan?

A: Yes, you can have Medicaid and a health plan. In order for the patient or their family to receive additional payment from Medicaid above and beyond what a health plan may offer, the health plan must also be contracted with Medicaid. The Medicaid enrollee will need to check with the providers in the health plan network to determine if the providers will accept Medicaid. If the providers are not Medicaid contracted, the providers are not allowed to balance bill the patient for services that would be covered by Medicaid if they were contracted. Medicaid may pay only after other health plans have paid first. If the health plan reimburses for a services or procedure at a higher rate that is covered by Medicaid, the provider will not get any additional payment from Medicaid. Providers will only receive the Medicaid rate if the health plan doesn’t cover certain benefits that Medicaid does cover.