Ch 8 Health Insurance Key Terms
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19 terms
Terms | Definitions |
|---|---|
 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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