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Glossary

Please note that the definitions included in this Glossary reflect the manner in which these terms are used on Medicare in general.

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Initial appeal process when you disagree about your care at a hospital, skilled nursing facility (SNF), or home health agency being terminated by a provider or Medicare health plan.
A part of the Medicare Savings Program (MSP) that allows qualified individuals to get help from your state Medicaid program to help pay your Medicare Part A premium.
The Affordable Care Act (ACA) sets protections and requirements for health insurance plans that meet them. QHPs are sold in places called Marketplaces or Exchanges that are state-run or by the federal government. People who don’t have employer coverage or not eligible for Medicare and Medicaid are eligible for a QHP.
An independent organization that Medicare contracts with to handle the reconsideration, second level of an Original Medicare (Part A or Part B) appeal.
A part of the Medicare Savings Program (MSP), that allows qualified individuals to get help from your state Medicaid program pay for your Medicare Part A premium, Part B premiums, deductibles, coinsurances and copayments.
A part of the Medicare Savings Program (MSP), that allows qualified individuals to get help from your state Medicaid program to help pay your Medicare Part B premium.
A group of doctors and other health care experts who work together to improve the care that Medicare recipients receive. QIOs handle complaints about the quality of care and review appeals for both Original Medicare and Medicare Advantage beneficiaries regarding services at a hospital, skilled nursing facility (SNF) or a home health agency.
The extent to which healthcare services for individuals and populations will increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
A limitation applied to a medication by Medicare Advantage Plans and Part D Plans. The restriction may limit the amount of medication dispensed or the length of time that a drug can be covered for to promote safety and cost effectiveness.

Disclaimer

This glossary explains terms in the Medicare program, but it isn't a legal document. The official Medicare program provisions are found in the relevant laws, regulations, and rulings.

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