Medicare Platino definition

Medicare Platino. A program administered by ASES for Dual Eligible Beneficiaries, in which managed care organizations or other insurers under contract with ASES function as Part C plans to provide services covered by Medicare, and also to provide a “wraparound” benefit of Covered Services and Benefits under MiSalud. MiSalud (or “the MiSalud Program”): The government health services program (formerly referred to as “La Reforma”) offered by the Government of Puerto Rico, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated delivery of physical and behavioral health services. MiSalud Plan or Plan: The physical health component of the MiSalud Program offered to Eligible Persons in the Service Regions covered by this Contract, and with respect to which the Contractor shall provide Administrative Services under this Contract.
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Medicare Platino. A program administered by ASES for Dual Eligible Beneficiaries, in which MCOs or other insurers under contract with ASES function as Medicare Part C plans to provide services covered by Medicare, and also to provide a “wrap-around” Benefit of Covered Services and Benefits under the GHP. National Provider Identifier (“NPI”): The 10-digit unique-identifier numbering system for Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System. Negative Determination or Redetermination Decision: The decision by the Puerto Rico Medicaid Program that a person is not initially eligible or no longer eligible for services under the GHP Program (because the person no longer meets the eligibility requirements for Medicaid, CHIP, or Puerto Rico’s government health assistance program). Network Adequacy Standards: Provider-to-Enrollee Ratios and Time and Distance requirements, as defined by ASES in Section 9.4 and developed in accordance with 42 CFR 438.68, to measure the adequacy and appropriateness of the Contractor’s established Network Providers to meet the needs of the enrolled population.
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Medicare Platino. A program administered by ASES for Dual Eligible Beneficiaries, in which managed care organizations or other insurers under contract with ASES function as Part C plans to provide services covered by Medicare, and also to provide a "wraparound" benefit of Covered Services and Benefits under MiSalud. MiSalud (or "the MiSalud Program"): The government health services program (formerly referred to as "La Reforma") offered by the Government of Puerto Rico, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated delivery of physical and behavioral health services. MiSalud Plan: A Managed Care Organization under contract with ASES that offers services under the MiSalud Program. National Provider Identifier: The unique identifying number system for health care Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System. Negative Redetermination Decision: A decision by the Puerto Rico Medicaid Program that a person is no longer eligible for services under the MiSalud Program (because the person no longer meets the eligibility standards for Medicaid, CHIP, or Puerto Rico's government health assistance program).
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Examples of Medicare Platino in a sentence

  • That the Dual Eligible Beneficiary may not be simultaneously enrolled in the GHP and in a Medicare Platino plan, for the reason that the Platino plan already includes GHP Benefits; and That as an Enrollee in the Contractor’s Plan, the Dual Eligible Beneficiary may access Covered Services only through the PMG, not through the Medicare Provider List.

  • As a requisite to participate in the Medicare Platino program, PROVIDER agrees to be a participating provider and accept GHP enrollees.

  • The Contractor shall submit that the providers list executed an agreement with the Contractor to serve the Medicare Platino Enrollees.

  • The Contractor and the PRHIA shall each have the right to terminate this Agreement in the event the Contractor terminates or fails to renew its contract with CMS to offer the Medicare Platino Product, as defined in this Agreement, to Eligible Persons in the service area as specified in Appendix A.

  • The Medicare Platino Benefit Package and Non-Covered Services agreed to by the Contractor and the PRHIA are contained in: Appendix C-1 (13) • Appendix C-2 (13) • Appendix C-3 (13)- Appendix C-4 (13) Medicare Advantage Product (PBP) submitted toCMS Medicaid Wraparound Services not covered by Medicare Platino but provided by the Department of Health which are hereby made a part of this agreement as if set forth fully herein.

  • The Contractor must submit quarterly, the number of complaints of fraud, waste or abuse made to the Contractor related to Medicare Platino Covered Services that warrant preliminary investigation by the Contractor.

  • An Eligible Person's decision to enroll in the Contractor's Medicare Platino Product shall be voluntary.

  • The Contractor agrees that an Enrollee who is disenrolled from the Contractor's Medicare Platino Product due to loss of Medicaid eligibility and who regains eligibility within three (3) months will automatically be prospectively re-enrolled with the Contractor's Medicare Platino Product.

  • As of the Effective Date of Enrollment, and until the Effective Date of Disenrollment from Contractor's product, the Contractor shall be responsible for the provision and cost of the Medicare Platino Benefit Package as described in Appendix C-4 Summary of Benefits Report.

  • Due to the fact that at the time of the execution of this Agreement PRHIA has not received the approved PBP from CMS, all the terms and conditions of this Agreement are subject to PRIHA determination (at its sole discretion) that the PBP complies with all the requirements of Medicare Platino 2012 adopted by PRHIA.


More Definitions of Medicare Platino

Medicare Platino. A program administered by ASES for Dual Eligible Beneficiaries, in which managed care organizations or other insurers under contract with ASES function as Part C plans to provide services covered by Medicare, and also to provide a “wraparound” benefit of Covered Services and Benefits under MI Salud. MI Salud (or “the MI Salud Program”): The government health services program (formerly referred to as “La Reforma”) offered by the Commonwealth, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated delivery of physical and behavioral health services.
Sample 1
Medicare Platino. A program administered by ASES for Dual Eligible Beneficiaries, in which MCOs or other insurers under contract with ASES function as Medicare Part C plans to provide services covered by Medicare, and also to provide a “wrap-around” Benefit of Covered Services and Benefits under the GHP. National Provider Identifier (“NPI”): The 10-digit unique-identifier numbering system for Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System. Negative Determination or Redetermination Decision: The decision by the Puerto Rico Medicaid Program that a person is not initially eligible or no longer eligible for services under the GHP Program (because the person no longer meets the eligibility requirements for Medicaid, CHIP, or Puerto Rico’s government health assistance program).
Sample 1

Related to Medicare Platino

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

  • 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 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.

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

  • Health care practitioner means an individual licensed

  • Managed care plan means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier.

  • Health care organization ’ means any person or en-

  • Hospital pharmacy means a pharmacy providing pharmaceutical care to

  • Organ procurement organization means a person designated by the Secretary of the United States Department of Health and Human Services as an organ procurement organization.

  • Hospice patient s family" means a hospice patient's immediate family members, including a spouse, brother, sister, child, or parent, and any other relative or individual who has significant personal ties to the patient and who is designated as a member of the patient's family by mutual agreement of the patient, the relative or individual, and the patient's interdisciplinary team.

  • 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.

  • Licensed health care practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the Secretary of the Treasury.

  • Nursing Care Plan means a plan of care developed by a nurse that describes the medical, nursing, psychosocial, and other needs of a child and how those needs shall be met. The Nursing Care Plan includes which tasks shall be taught, assigned, or delegated to the qualified provider or family.

  • 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;

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

  • Specialty drug means a prescription drug that:

  • Care Plan means a licensee's written description of a resident's needs, preferences, and capabilities, including by whom, when, and how often care and services are to be provided.

  • Health care insurer means a disability insurer, group

  • Health care provider or "provider" means:

  • Specialty Drugs means drugs listed on the Approved Drug List meeting certain criteria, such as:

  • Health practitioner means a registered health practitioner registered or licensed as a health practitioner under an appropriate law of the State of Tasmania.

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

  • In Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

  • Health Care Operations shall have the meaning given to such term under the HIPAA 2 Privacy Rule in 45 CFR § 164.501.

  • Emergency medical care provider means an individual who has been trained to provide emergency and nonemergency medical care at the first responder, EMT-basic, EMT-intermediate, EMT-paramedic, paramedic specialist or other certification levels recognized by the department before 1984 and who has been issued a certificate by the department.

  • State health plan means the employee and retiree insurance program provided for in Article 5, Chapter 11, Title 1.