Glossary beginning with M
- Managed Care
Programs where a health plan manages the care needs of its enrollees and a pool of money to pay for those needs. The health plan is paid on a capitated (or per capita) basis for the people in its program, and then provides services directly, or contracts for them using third parties. Contracts with other providers may include capitated payments, or may be fee-for-service payments. Both Medicare and Medicaid include expanded managed care alternatives to fee for service programs.
The U.S. national entitlement program for certain needy and low income people. Medicaid is jointly funded by the federal and state governments, and is run, under broad national guidelines, by each state. Program eligibility, services offered, and financing varies widely from state to state. Generally, Medicaid covers anyone eligible for Supplemental Security Income (SSI), and may cover other Medically Needy or Categorically Needy individuals. The program goes by other names in various states. For instance, in California it is called Medi-Cal and in Tennessee it is TennCare.
The Medicaid program has become the insurer of last resort for about 70% of nursing home residents. These residents exhaust their own assets prior to or during an expensive nursing home stay.
- Medically Needy
An optional Medicaid program which covers the cost of medical care for persons who would qualify for Medicaid on the basis of the services they require, but who have too much income to qualify for the program and too little to pay for the medical services they need. Not all states have ?medically needy? programs.
The national health insurance program for people age 65 or older in the United States. Medicare pays for acute medical care services under either Part A Hospital Insurance (HI) or Part B Supplementary Medical Insurance (SMI). Medicare is not a needs-based program, but provides coverage for acute care services to most people age 65 or over. Most chronic care services, including many nursing home stays, are not covered under the Medicare program.
Private insurance which covers some of the gaps in Medicare coverage, such as the deductibles and coinsurance.
- Minimum Data Set
A federally-mandated resident assessment which must be done for every resident in a nursing home. The MDS must be completed within a certain period of time from admission to the facility, and must be reviewed on a scheduled basis or whenever there is a significant change in the residentÂ’s condition. In the MDS, the residentÂ’s needs are scored in a variety of areas, and the results of those scores trigger treatment protocols which should be addressed in the care plan. The MDS data are transmitted electronically to a designated state agency, and are accumulated at the federal level. In some states, the MDS is used as a tool to set the Medicaid reimbursement rate for the resident, based on the level of care needed as reflected in the MDS instrument. The MDS is also used in setting Medicare rates, under the Prospective Payment System.
A limit on the number of healthcare facilities or services which can be built in a state or a geographic area, by restricting permission for a Certificate of Need (CON) needed to start new facilities or services. The stipulated reason for establishing moratoriums is usually to control healthcare costs by preventing overbuilding and excess capacity in the system.