Health Policy Glossary

Managed care organizations that provide services to Medicaid beneficiaries.  This system of health delivery and financing coordinates the use of health services by its members, designates covered health services, provides a specific provider network, and directs the use of medical care services using a monthly capitated payment. 

The federal health insurance program established in 1965 through Title XIX of the Social Security Act.  Medicaid pays for health services for low-income Americans under age 65, including children, pregnant women, and people with disabilities, and for nursing home care for low-income adults over 65.  It is financed through both federal and state funds. 

Sections 1115 and 1915 of the Social Security Act define specific circumstances under which the federal government may, at a state's request, "waive" certain provisions of federal Medicaid laws.  The "waiver" is the agreement between the federal government and the state that exempts the state from these provisions and includes special terms and conditions that define who may be covered by the state.  For example, some states use Medicaid waivers to extend Medicaid coverage to adults who do not have dependent children -- a group that does not ordinarily qualify for Medicaid under federal law. 

An approach to providing comprehensive primary care through partnerships between patients and their physicians in a accessible, coordinated, comprehensive, family-centered, and culturally effective manner.  The provision of medical homes may allow better access to health care and improve health.

The percentage of premium dollars an insurance carrier spends on expenses for medical care as compared to dollars spent on administrative costs, marketing, and profit. The Affordable Care Act sets this ratio at 80 percent in the individual and small group insurance markets and at 85 percent in the large group market. States may set rules that exceed this ratio. 

Medical underwriting is the practice that allows insurance carriers to decide whom to sell coverage to, what benefits to offer, and what premiums to charge based on a number of criteria, including health status, prior medical claims, age, gender, and other factors.  Medical underwriting is common in the individual insurance market, but is prohibited in some states.  Many states have some restrictions on medical underwriting, or provide other options, such as high risk pools, to individuals turned down for insurance.

Medicare is the health insurance program for Americans ages 65 and older, and for younger adults with permanent disabilities.  Established in 1965 under Title XVIII of the Social Security Act, Medicare was initially established to provide health insurance to individuals age 65 and older, regardless of income or medical history.  The program was expanded in 1972 to include individuals under age 65 with permanent disabilities.  Medicare has four parts, each covering different benefits.  Part A covers inpatient hospital services, skilled nursing facility, home health, and hospice care, and is funded by a dedicated tax of 2.9 percent of earnings paid by employers and workers.  Part B helps pay for physician, outpatient, home health, and preventive services, and is funded by general revenues and beneficiary premiums ($96.40 per month in 2009).  Part C, also known as the Medicare Advantage program, allows beneficiaries to enroll in a private plan, that receives payments from Medicare to provide Medicare-covered benefits.  Part D is the prescription drug benefit, delivered through private plans that contract with Medicare.  Part D is funded by general revenues, beneficiary premiums, and state payments.

Medicare Savings Programs provide eligible Medicare beneficiaries with financial assistance for Medicare premiums and cost-sharing.  There are several different programs for beneficiaries:
1) Qualified Medicare Beneficiaries (QMBs) have their Medicare Part B premiums paid through federal and state Medicaid matching funds.  In addition, if they see health providers who accept Medicaid, QMBs do not have to pay cost-sharing for Medicare services.
2) Specified Low-Income Medicare Beneficiaries (SLMBs) also have their Medicare Part B premiums paid by federal and state Medicaid-matching funds.  However, SLMBs are responsible for cost-sharing for Medicare services, which is typically 20% of charges for doctor visits.
3) Qualified Individuals (QIs) have their Medicare Part B premiums paid through a federal block grant to state Medicaid agencies.  However, QIs are responsible for cost sharing for Medicare, and if the state exhausts its funds, the state is not required to continue paying premiums for QIs.

A monthly fee per person, rather than a payment per service, paid by a managed care plan to a provider network.