Glossary of terms
We’ve provided a glossary to help readers understand key terms and acronyms related to dual-eligibility, Medicaid, Medicare, and managed care.
Term
Abbreviation
Definition
Accountable Care Organization
ACO
A network of doctors, hospitals, and healthcare providers that collaborate to improve care coordination, enhance quality, and reduce costs for Medicare beneficiaries. ACOs share in savings or losses based on their performance in value-based care models like the MSSP.
Capitation
A payment model where healthcare providers or Managed Care Organizations (MCOs) receive a fixed amount per enrollee for a defined period, regardless of the services provided.
Capitated Rate
A fixed per-member-per-month (PMPM) payment made to a Managed Care Organization (MCO) or healthcare provider to cover a defined set of services for enrolled individuals, regardless of the actual number of services used.
Dual-Eligible
Individuals who qualify for both Medicare and Medicaid benefits, often due to age, disability, and low income.
Dual-Eligible Special Needs Plans
D-SNPs
A type of Medicare Advantage plan tailored for dual-eligible individuals, integrating Medicare and Medicaid services to provide coordinated care.
Federal Poverty Level
FPL
The Federal Poverty Level (FPL) is an income measure set by HHS to determine eligibility for Medicaid, Medicare Savings Programs (MSPs), and other assistance. It varies by household size and state, with many dual-eligible programs requiring income below a certain FPL percentage.
Fee-For-Service
FFS
A traditional healthcare payment model where providers are reimbursed for each service rendered, such as tests or procedures.
Full Dual-Eligible
A full dual-eligible individual qualifies for both Medicare and full Medicaid benefits. Medicaid covers Medicare premiums, deductibles, and cost-sharing, as well as additional services that Medicare does not, such as long-term services and supports (LTSS), home and community-based services (HCBS), and certain behavioral health benefits. Full dual-eligibles may also qualify for Medicare Part D Extra Help, which reduces prescription drug costs.
Full-Benefit Dual-Eligible Medicaid Recipients
These individuals are entitled to Medicare Part A and/or entitled to Part B, and qualify for full Medicaid benefits, but not the QMB or SLMB groups. Full-benefit Medicaid coverage refers to the package of services, beyond coverage for Medicare premiums and cost-sharing, that certain individuals are entitled to under 42 CFR 440.210 and 440.330. For Medicaid-covered services (i.e., services furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not Medicare, cover), a full-benefit Medicaid beneficiary pays no more than the Medicaid coinsurance3 (if applicable). For Medicare-only covered services (i.e., services covered by Medicare, but not Medicaid), these individuals pay the Medicare cost-sharing unless the state chooses to cover Medicare cost-sharing for all Medicare covered services for this eligibility group.
Home and Community-Based Services
HCBS
Medicaid services that assist individuals with daily activities, enabling them to live independently in their communities rather than in institutional settings.
Integrated Care
A healthcare approach that combines services from multiple providers to offer seamless and coordinated care, particularly beneficial for individuals with complex health needs.
Intellectual and Developmental Disability
IDD
An Intellectual and Developmental Disability is a lifelong condition that affects a person’s cognitive, adaptive, or social functioning. IDDs include conditions such as Down syndrome, autism spectrum disorder, cerebral palsy, and intellectual disabilities diagnosed before adulthood. Individuals with IDD may require specialized healthcare, supportive services, assistive technology, and HCBS to promote independence and quality of life.
Long-Term Services and Supports
LTSS
A range of medical and personal care services assisting individuals with chronic illnesses or disabilities in performing daily activities over an extended period.
Managed Care
A healthcare delivery system where organizations manage cost, utilization, and quality by providing a network of contracted providers and services.
Managed Care Organization
MCO
Entities that deliver managed care services by contracting with healthcare providers to offer a comprehensive set of services to enrolled members.
Medicaid
A joint federal and state program offering health coverage to eligible low-income individuals, including children, pregnant women, seniors, and people with disabilities.
Medical Assistance
MA
Pennsylvania’s Medicaid program that provides healthcare coverage to low-income individuals, including children, pregnant women, seniors, and individuals with disabilities. It is administered by the Pennsylvania Department of Human Services (DHS), providing comprehensive benefits like hospital care, physician services, prescription drugs, and long-term care.
Medicare
A federal health insurance program primarily for individuals aged 65 and older, as well as some younger individuals with disabilities. Coverage has four parts, Part A, B, C, and D.
Medicare Advantage
MA
Medicare Advantage plans are approved by Medicare but are run by private companies. These companies provide Medicare Part A and Part B covered services and may include Medicare drug coverage too. Medicare Advantage plans are sometimes called “Part C” or “MA” plans. MA plans are not supplemental insurance.
Medicare Advantage Organization
MAO
A private insurance company that contracts with the federal government to offer Medicare Advantage (Part C) plans. These plans cover all Medicare Part A and Part B benefits, and many include additional services like prescription drug coverage, dental, vision, and hearing. MAOs receive a capitated payment from Medicare to manage and deliver care and are responsible for coordinating services to improve quality, efficiency, and member satisfaction.
Medicare Part A
Part A
Medicare Part A is the hospital insurance portion of Medicare. It covers inpatient care in hospitals, skilled nursing facility care, hospice care, and some home health services. Most people do not pay a premium for Part A if they or their spouse paid Medicare taxes while working.
Medicare Part B
Part B
Medicare Part B is the medical insurance portion of Medicare. It covers outpatient services such as doctor visits, preventive care, lab tests, mental health services, durable medical equipment, and some home health care. Beneficiaries typically pay a monthly premium and are responsible for deductibles and coinsurance.
Medicare Part C
Part C
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Parts A and B) offered by private insurance companies approved by Medicare. These plans often include additional benefits such as vision, dental, hearing, and prescription drug coverage, and may feature care coordination services.
Medicare Part D
Part D
Medicare Part D provides prescription drug coverage. It is offered through standalone drug plans or included in some Medicare Advantage (Part C) plans. Part D helps cover the cost of medications, and individuals with limited income may qualify for Extra Help to reduce their out-of-pocket costs.
Medicare Savings Programs
MSP
MSPs help low-income Medicare beneficiaries by covering Medicare premiums, deductibles, and cost-sharing. There are four MSP categories: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and Qualified Disabled and Working Individual (QDWI). Eligibility is based on income and asset limits, with Medicaid administering the benefits.
Medicare Shared Savings Program
MSSP
The Medicare Shared Savings Program (MSSP) is a value-based initiative where Accountable Care Organizations (ACOs) coordinate care to improve quality and reduce costs for Medicare. ACOs share in savings or losses based on performance.
Partial Dual-Eligible
A partial dual-eligible individual qualifies for Medicare and receives limited Medicaid assistance through a Medicare Savings Program (MSP). Medicaid helps pay for some or all of their Medicare premiums, deductibles, and coinsurance but does not provide full Medicaid benefits. Partial dual-eligibles do not receive coverage for services like long-term care or HCBS unless they qualify under another program.
Program of All-Inclusive Car for the Elderly
PACE
A Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility. KSCE covers all Medicare- and Medicaid-covered care and services, and anything else the health care professionals in your KSCE team decide you need to improve and maintain your health. This includes prescription drugs and any medically necessary care.
Qualified Disabled and Working Individuals
QDWI
QDWI individuals ) became eligible for premium-free Part A by virtue of qualifying for Social Security Disability Insurance (SSDI) benefits, but lost those benefits, and subsequently premium-free Medicare Part A, after returning to work. QDWIs have income that does not exceed 200 percent of the FPL, have resources that do not exceed two times the SSI resource standard and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.
Qualifying Individuals
QI
QIs are entitled to Part A and have income of at least 120 but less than 135 percent of the FPL, resources that do not exceed three times the limit for SSI eligibility with adjustments for inflation and are not eligible for any other eligibility group under the state plan. QIs receive coverage for their Medicare Part B premiums, to the extent their state Medicaid programs have available slots. The federal government makes annual allotments to states to fund the Part B premiums. Individuals in the limited Part B-ID benefit may also qualify for the QI eligibility group with coverage limited to the Part B-ID premium and/or cost sharing.
Qualified Medicare Beneficiaries Only
QMB-Only
QMB-Only are entitled to Medicare Part A, have income up to 100 percent of the FPL and resources that do not exceed three times the limit for SSI eligibility with adjustments for inflation and are not otherwise eligible for full-benefit Medicaid coverage. Medicaid pays their Medicare Part A premiums, if any, and Medicare Part B premiums. Medicare providers may not bill QMBs for Medicare Parts A and B cost-sharing amounts, including deductibles, coinsurance, and copays. 1 Providers can bill Medicaid programs for these amounts, but states have the option to reduce or eliminate the state’s Medicare cost-sharing payments by adopting policies that limit payment to the lesser of (a) the Medicare cost-sharing amount, or (b) the difference between the Medicare payment and the Medicaid rate for the service. Individuals in the limited Part B Immunosuppressive Drug (Part B-ID) benefit may also qualify for the QMB eligibility group with coverage limited to the Part B-ID premium and/or cost-sharing, a status known as QMB-Part B-ID.
Serious Mental Illness
SMI
Refers to chronic and severe mental health conditions that significantly impair daily life and functioning. Examples include schizophrenia, bipolar disorder, major depressive disorder, and severe anxiety disorders. Individuals with SMI may require long-term treatment, crisis intervention, case management, and community-based services to manage their condition. Medicaid often provides additional behavioral health services for individuals with SMI beyond what Medicare covers.
Specified Low-Income Medicare Beneficiaries without other Medicaid
SLMB-Only
Entitled to Part A and have income between 100 and 120 percent of the FPL, and resources that do not exceed three times the limit for supplementary security income (SSI) eligibility with adjustments for inflation. Medicaid pays only the Medicare Part B premiums for this group. Individuals in the limited Part B-ID benefit may also qualify for the SLMB eligibility group with coverage limited to the Part B-ID premium and/or cost-sharing, a status known as SLMB-Part B-ID.
Specified Low-Income Medicare Beneficiaries with full-benefit Medicaid
SLMB-Plus
Individuals that meet the SLMB-related eligibility requirements described above, and the eligibility requirements for a separate categorical Medicaid eligibility group covered under the state plan. In addition to coverage for Medicare Part B premiums, these individuals receive full-benefit Medicaid coverage (i.e., the package of benefits provided to the separate Medicaid eligibility group for which they qualify). For Medicaid-covered services (i.e., services furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not Medicare, cover), an SLMB-Plus beneficiary pays no more than a nominal Medicaid copay2 (if applicable).
Value-Based Care
VBC
Value-based care is a term that Medicare, doctors and other health care professionals sometimes use to describe health care that is designed to focus on quality of care, provider performance and the patient experience. The “value” in value-based care refers to what an individual values most. In value-based care, doctors and other health care providers work together to manage a person’s overall health, while considering an individual’s personal health goals.
Value-Based Payment
VBP
Under value-based payment (VBP) models, payments to healthcare providers are tied to quality, efficiency, and positive patient experience. The purpose of value-based programs is to improve care for individuals and lower healthcare costs simultaneously.
With this delivery model, doctors, hospitals, and other health care providers are compensated based on the quality of care provided and patient outcomes.
Whole-Person Care
Whole person care is a healthcare approach that considers a patient’s physical, mental, social, and spiritual health. It aims to improve health and well-being by addressing multiple factors that affect a person’s health.
Check out the lates from DEHQ
Dual-eligible beneficiaries—individuals who qualify for both Medicare and Medicaid—represent one of the most complex patient populations in the U.S. healthcare system. They often have multiple chronic conditions, disabilities, and social determinants of health (SDOH) that make coordinating their care a significant challenge.
A study conducted by researchers from William & Mary, Virginia Commonwealth University, and the Virginia
A new Medicaid contract change in Idaho raises concerns about potential service disruptions for the
