Glossary—MNO

Managed Long Term Care Plan—A plan designed for dual eligible individuals with long-term needs who prefer to live in their own homes yet require assistance with day-to-day health activities.

Medicaid—A joint federal and state program that provides health insurance to people who have incomes and resources below certain limits.

Medicaid Advantage Plan—A plan for people who have both Medicare and Medicaid.

Medicaid Surplus/Spenddown—The amount of income NYS Medicaid or NYC Department of Human Resources (HRA) determines an individual may be required to pay on a monthly basis to meet Medicaid eligibility requirements to continue their Medicaid coverage. HomeFirst is required to bill such enrollees for surplus charges if they are determined to incur a surplus by HRA.

Medical Necessity—Covered services that are necessary to prevent, diagnose, correct or cure conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person’s capacity for normal activity or threaten some significant handicap.

Medicare—The federal government’s health insurance program established by Title XVIII of the Social Security Act. Medicare has three (3) parts: Part A, hospital insurance; Part B, medical insurance; and Part D, prescription drug coverage.

Medicare Advantage—A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.

Medicare Advantage Organization—A public or private organization licensed by the state as a risk-bearing entity that is under contract with CMS to provide covered services. Medicare Advantage Organizations can offer one or more Medicare Advantage plans. Elderplan is a Medicare Advantage Organization with a contract with Medicare.

Medicare Advantage Plan—A health plan, such as a Medicare managed care plan or Private Fee-for-Service plan, offered by a private company and approved by Medicare. An alternative to the Original Medicare plan.

Medicare Advantage Prescription Drug (MA-PD) Plan—A Medicare Advantage plan, such as Elderplan, that includes Medicare’s Part D Prescription Drug Coverage benefit. With Elderplan, that means you get ALL the parts of Medicare plus prescription coverage and much more. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.

Medicare Options—The beneficiaries’ option to choose from several alternatives to Original Medicare.

Medicare Supplement Insurance (or Medigap)—Private health insurance that pays certain costs not covered by Fee-for-Service Medicare, such as Medicare co-insurance and deductibles.

MLTC PLAN (Applicable to Homefirst Users)—For NYS Medicaid insured, an MLTC Plan is defined as: A plan available to Medicaid recipients, provides health and long-term care services to adults with chronic illness or disabilities, to better address their needs and to prevent or delay nursing home placement. (EP glossary states MLTC is for “dual-eligibles”). Services include but are not limited to home health care, nursing, physical therapy, occupational therapy, speech pathology, and ancillary and ambulatory services including dentistry and medical equipment and supplies, podiatry, optometry, respiratory therapy, medical transportation and social day care. Enrollees get services from their primary care physicians and inpatient hospital services using their Medicaid and/or Medicare cards.

Multi-Specialty Group—Physicians representing various medical specialties working together in a group setting.

Network—A group of health care providers under contract with Elderplan that is licensed and/or certified by Medicare with the purpose of delivering or furnishing health care services. Generally, members must receive routine services within their designated network in order to be covered by Elderplan.

Network (Applicable to Homefirst Users)—MLTCP Contract defines “network” as those providers contracted with an MLTC plan to provide covered services. However, per Medicaid and MLTCP contract, there is not a requirement for a network vendor to be “licensed or certified by Medicare”, as defined in EP Glossary.

Out-of-Area—Outside of the geographical area defined by the plan’s service area.

Outpatient Services—Nonhospitalized treatment at a hospital, clinic or dispensary.

Over the Counter Medication—Over-the-Counter medicines are medicines you can buy at a pharmacy or store without a prescription, or an order from your doctor. Examples include cold medicine, medicines for stomach pain, or pain relievers.

Over the Counter (OTC) Value Added Program—non- prescription drug program offering everyday products to be purchased through a catalogue. Elderplan provides quarterly allowance to be applied towards the purchase for selected plans.