Glossary

The X12 Referral Certification and Authorization transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

There are four periods during which you can enroll in premium Part A: Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), and Transfer Enrollment Period (TEP).

• Initial Enrollment Period: The IEP is the first chance you have to enroll in premium Part A. Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months.
• General Enrollment Period: January 1 through March 31 of each year. Your premium Part A coverage is effective July 1 after the GEP in which you enroll.
• Special Enrollment Period: The SEP is for people who did not take premium Part A during their IEP because you or your spouse currently work and have group health plan coverage through your current employer or union. You can sign up for premium Part A at any time you are covered under the Group Health Plan based on current employment. If the employment or group health coverage ends, you have 8 months to sign up. The 8 months start the month after the employment ends or the group health coverage ends, whichever comes first.
• Transfer Enrollment Period: The TEP is for people age 65 or older who have Part B only and are enrolled in a Medicare managed care plan. You can sign up for premium Part A during any month in which you are enrolled in a Medicare managed care plan. If you leave the plan or if the plan coverage ends, you have 8 months to sign up. The 8 months start the month after the month you leave the plan or the plan coverage ends. If you enroll in Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, your coverage starts on July 1. (See Enrollment.)

There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay Medicare deductibles and coinsurance.You can apply for these programs if:You have Medicare Part A (Hospital Insurance). (If you are eligible for Medicare Part A but don’t think you can afford it, there is a program that may pay the Medicare Part A premium for you.),you are an individual with resources of $4,000 or less, or are a couple with resources of $6,000 or less. Resources include money in a savings or checking account, stocks, or bonds and You are an individual with a monthly income of less than $1,031, or a couple with a monthly income of less than $1,384. Income limits will change slightly in 2004. If you live in Hawaii or Alaska, income limits are slightly higher.Note: If your income is less than the amounts listed above, you may qualify for Medicaid.

These are eligibles who have not received any services through the managed care plan, as evidenced by the absence of a medical record and any encounter data. True negatives signify potential access problems, and should be investigated by the managed care plan.

These are entities, which contract between an MCO or one of its subcontractors and a physician or physician group, other than physician groups themselves. An IPA is considered to be an intermediate entity if it contracts with one or more physician groups in addition to contracting with individual physicians.

These are standards that States set for plan structure, operations, and the internal quality improvement/assurance system that each MCO/PHP must have in order to participate in the Medicaid program.

These include differentials between hospital labor and non-labor indices compared with general economy labor and non-labor indices; rates of admission incidence; the trend toward treating less complicated cases in outpatient settings; and continued improvement in DRG coding.

These services include bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.

This is a healthcare-specific lane on the Information Superhighway, as described in the National Information Infrastructure (NII) initiative. Conceptually, this includes the HIPAA A/S initiatives.

This is a Medicaid program for beneficiaries who need help in paying for Medicare Part B premiums. The beneficiary must have Medicare Part A and limited income and resources and not be otherwise eligible for Medicaid. For those who qualify, Medicaid pays a percentage of Medicare Part B premiums only.