Medicare enrollee definition

Medicare enrollee means a Medicare beneficiary who is enrolled in a PACE program.
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Medicare enrollee means an Enrollee in any of Plan’s Medicare Advantage products.
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Medicare enrollee means an Individual who is enrolled in Company’s Medicare Product on either a Group or Individual enrollment basis according to CMS’s records and for whom CMS has paid Company the applicable monthly payment amount.
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Examples of Medicare enrollee in a sentence

  • An MA organization that offers an MA co- ordinated care plan may specify the networks of providers from whom en- rollees may obtain services if the MA organization ensures that all covered services, including supplemental serv- ices contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan.

  • An MA organization may bill a GHP or LGHP for services it fur- nishes to a Medicare enrollee who is also covered under the GHP or LGHP and may bill the Medicare enrollee to the extent that he or she has been paid by the GHP or LGHP.

  • The restriction of payments imposed by paragraph (a) of this section ends when a Medicare enrollee leaves the HMO’s or CMP’s ge- ographic area for an extended period as defined in § 471.460(a)(2) and the HMO or CMP and the enrollee make arrange- ments for enrollment to continue as provided in § 417.460(a)(2)(iv).

  • Each MA organization must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner.

  • Unless the individual chooses to disenroll from the HMO or CMP the individual’s conversion to a Medicare enrollee is ef- fective the month in which he or she is entitled to both Medicare Parts A and B or Part B only.

  • An HMO or CMP must accept as a Medicare enrollee any indi- vidual who is enrolled in the HMO or CMP for the month immediately before the month in which he or she is enti- tled to both Medicare Parts A and B or Part B only.

  • If a Medicare enrollee loses entitle- ment to Part B benefits, the HMO or CMP must disenroll him or her as a Medicare enrollee effective with the month following the last month of en- titlement to Part B benefits.

  • CMS makes payment for these services to the provider on behalf of the Medicare enrollee through the provider’s Medicare fiscal inter- mediary.

  • A risk HMO or CMP must disenroll a nonrisk Medicare enrollee who refuses to convert to the risk pro- visions of the Medicare contract after CMS determines that all of the HMO’s or CMP’s nonrisk Medicare enrollees must convert.(2) Advance notice requirement.

  • An HMO or CMP may retain a Medicare enrollee who is ab- sent from its geographic area for an ex- tended period, but who remains within the United States as defined in § 400.200 of this chapter if the enrollee agrees.

Related to Medicare enrollee

  • Medicare means the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

  • Medicaid means that government-sponsored entitlement program under Title XIX, P.L. 89-97 of the Social Security Act, which provides federal grants to states for medical assistance based on specific eligibility criteria, as set forth on Section 1396, et seq. of Title 42 of the United States Code.

  • Medicare Provider Agreement means an agreement entered into between CMS or other such entity administering the Medicare program on behalf of CMS, and a health care provider or supplier under which the health care provider or supplier agrees to provide services for Medicare patients in accordance with the terms of the agreement and Medicare Regulations.

  • Health care worker means a person other than a health care professional who provides medical, dental, or other health-related care or treatment under the direction of a health care professional with the authority to direct that individual's activities, including medical technicians, medical assistants, dental assistants, orderlies, aides, and individuals acting in similar capacities.

  • Medicare benefit means the Medicare benefit payable within the meaning of Part II of the Health Insurance Act 1973 with respect to a professional service.

  • Enrollee means any person entitled to health care services from a carrier.

  • child care element of working tax credit means the element of working tax credit prescribed under section 12 of the Tax Credits Act 2002 (child care element).

  • TRICARE means, collectively, a program of medical benefits covering former and active members of the uniformed services and certain of their dependents, financed and administered by the United States Departments of Defense, Health and Human Services and Transportation, and all laws applicable to such programs.

  • Health care entity means any health care provider, health plan or health care clearinghouse.

  • Acute care hospital means a Hospital that provides Acute Care Services. Adjudicate means to deny or pay a Clean Claim. Administrative Services see MCO Administrative Services. Administrative Services Contractor see HHSC Administrative Services Contractor.

  • Medicaid Provider Agreement means an agreement entered into between a state agency or other such entity administering the Medicaid program and a health care provider or supplier under which the health care provider or supplier agrees to provide services for Medicaid patients in accordance with the terms of the agreement and Medicaid Regulations.

  • Medicare Advantage plan means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:

  • Health care system means any public or private entity whose function or purpose is the management of, processing of, enrollment of individuals for or payment for, in full or in part, health care services or health care data or health care information for its participants;

  • Health Care Law means any Applicable Law regulating the acquisition, construction, operation, maintenance or management of a health care practice, facility, provider or payor, including without limitation, 42 U.S.C. ss.1395nn and 42 U.S.C. ss. 1320a-7b.

  • Managed Care Plans means all health maintenance organizations, preferred provider organizations, individual practice associations, competitive medical plans and similar arrangements.

  • Medicare Levy Surcharge means an extra charge payable by high income earners beyond the standard Medicare Levy if they do not have qualifying private hospital insurance coverage. This charge is assessed as part of an individual or family’s annual tax return.

  • Managed care plan means a health benefit plan that either requires a covered person to use, or

  • Health care plan means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

  • Newborn means a baby less than nine days old.

  • Health care practitioner means an individual licensed

  • Health care coverage means any plan providing hospital, medical or surgical care coverage for

  • Potential Enrollee means a Medical Assistance Recipient who may voluntarily elect to enroll in a given managed care program, but is not yet an Enrollee of an MCO.

  • Health care organization ’ means any person or en-

  • Managed care entity means either a managed care organization licensed by the department of insurance (e.g., HMO or PHP) or a primary care case management program (i.e., MediPASS).

  • Health Care Laws means: (i) the Federal Food, Drug, and Cosmetic Act (21 U.S.C. §§ 301 et seq.), the Public Health Service Act (42 U.S.C. §§ 201 et seq.), and the regulations promulgated thereunder; (ii) all applicable federal, state, local and all applicable foreign health care related fraud and abuse laws, including, without limitation, the U.S. Anti-Kickback Statute (42 U.S.C. Section 1320a-7b(b)), the U.S. Physician Payment Sunshine Act (42 U.S.C. § 1320a-7h), the U.S. Civil False Claims Act (31 U.S.C. Section 3729 et seq.), the criminal False Claims Law (42 U.S.C. § 1320a-7b(a)), all criminal laws relating to health care fraud and abuse, including but not limited to 18 U.S.C. Sections 286 and 287, and the health care fraud criminal provisions under the U.S. Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) (42 U.S.C. Section 1320d et seq.), the exclusion laws (42 U.S.C. § 1320a-7), the civil monetary penalties law (42 U.S.C. § 1320a-7a), HIPAA, as amended by the Health Information Technology for Economic and Clinical Health Act (42 U.S.C. Section 17921 et seq.), and the regulations promulgated pursuant to such statutes; (iii) Medicare (Title XVIII of the Social Security Act); (iv) Medicaid (Title XIX of the Social Security Act); (v) the Controlled Substances Act (21 U.S.C. §§ 801 et seq.) and the regulations promulgated thereunder; and (vi) any and all other applicable health care laws and regulations. Neither the Company nor, to the knowledge of the Company, any subsidiary has received notice of any claim, action, suit, proceeding, hearing, enforcement, investigation, arbitration or other action from any court or arbitrator or governmental or regulatory authority or third party alleging that any product operation or activity is in material violation of any Health Care Laws, and, to the Company’s knowledge, no such claim, action, suit, proceeding, hearing, enforcement, investigation, arbitration or other action is threatened. Neither the Company nor, to the knowledge of the Company, any subsidiary is a party to or has any ongoing reporting obligations pursuant to any corporate integrity agreements, deferred prosecution agreements, monitoring agreements, consent decrees, settlement orders, plans of correction or similar agreements with or imposed by any governmental or regulatory authority. Additionally, neither the Company, its Subsidiaries nor any of its respective employees, officers or directors has been excluded, suspended or debarred from participation in any U.S. federal health care program or human clinical research or, to the knowledge of the Company, is subject to a governmental inquiry, investigation, proceeding, or other similar action that could reasonably be expected to result in debarment, suspension, or exclusion.

  • Health care facility or "facility" means hospices licensed