Ch 8 Health Insurance Key Terms

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Balance Billing

The practice of billing patients for any balance left after deductibles, coinsurance, and insurance oayments have been made.

Categorically needy

Typically used to describe low-income families with children, individuals receiving SSI, pregnant woman, infants, and children with incomes less that a specified percent of the federal poverty level, and Qualifies Medicare Beneficiaries.

Cost avoidance

The healthcare providers bills and collects from liable third parties before sending the cial to Medicaid.

Countable income

The amount of income left over after eliminating all items that are not considered income, and applying all appropriate exclusions to the items that are considered income.

Federal Poverty Levels

Income standards that are updated annually, and that serve as one of the eligibility factors for various state and federal assistance programs.

Fiscal Intermediary

A commercial insurer or agent that contracts with the Department of Health and Human Services for the purpose of processing and administering Part A Medicare claims for the reimbursement of healthcare coverage.

Mandated services

Certain basic services that must be offered to the categorically needy population in any state Medicaid program.

Medicaid

A combinition federal and state medical assistance program designed to provide comprehensive and quality medical care for low-income families.

Medically necessary

Medical services, procedures, or supplies that are reasonable and necessary for the diagnosis or treatment of a patient's medical condtion, in accordance with the standards of good medical practice, preformed at the proper level, and provided in the most approtriate setting.

Medicare-Medicaid crossover claims

In cases in which patients qualify for Medicare and Medicaid coverage, the claim is first submitted to Medicare, who pays its share, the the claim is crossed over to Medicaid.

Payer of last resort

After all available third party resources meet their legal obligation to pay claims, the Medicaid program pays for the care of an individual eligible for Medicaid.

PACE

A program that provides comprehensive alternative care for noninstitutionalized elderly individuals who would otherwise be in a nursing home.

Reciprocity

When one state allows Medicaid beneficiaries from other states to be treated in its medical facilities.

Remittance advice

Paper or electronic form sent by Medicare to the service provider that explains how payment was determined for a claim, aka explanation of benefits.

Specified Low Income Medicare Beneficiaries

Beneficiaries with resources similar to Qualified Medicare Beneficiaries, but with slightly high incomes.

Spend down

Depleting private or family finances to the point where the individual or family becomes eligible for Medicaid assistance.

SCHIP

Program that allows states to expand their Medicaid eligibility guidelines to cover more categories of children.

Supplemental Security Income

Program established in 1972 and controlled by the Social Security Administration that provides federally funded cash assistance to qualifying elderly and disabled poor.

Temporary Assistance for Needy Families

A federal-state cash assistance program for poor families, typically headed by a single parent.

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