Lien Resolution Glossary
When a Final Demand, Final Determination, or Final Compromise has been reached, but there are errors in the calculation of the lien on the part of the lien holder, an appeal is submitted, identifying the error and requesting a correction. In most cases, an appeal request is submitted only after the Final Determination has been made if there are unrelated claims or an incorrect calculation of the final lien. Appeal decision timeframes can vary by lien holder; Medicare requests a minimum of 60 days for a response to any appeal requests.
When a lien has been established by Medicare or Medicaid, a compromise can be proposed in an attempt to reduce the lien beyond the standard reduction for procurement costs (Medicare). A compromise may be granted if the case meets the consideration requirements by CMS.
Need-based health insurance plans administered by state and funded federally. Eligibility and income requirements vary by state, and sometimes by county. Generally, Medicaid recipients are all ages, with some programs developed specifically for children of low income families. Medicaid programs cover both hospital and outpatient care, and may offer prescription drug discounts or benefits. Medicaid Institutional Care Program (“ICP”) provides benefits for those in nursing homes.
A health benefit plan for the aged and disabled administered by the Centers of Medicare and Medicaid Services (CMS). To qualify for Medicare, a beneficiary needs to be 65 and older, disabled (if under age 65), or suffering from End Stage Renal Disease (permanent kidney failure). Medicare consists of Part A – Inpatient Hospital / Skilled Nursing Facility benefits, Part B – Outpatient care, doctor visits, and supplies and Part D Prescription Drug benefit. Part C plans are Medicare Advantage HMO policies that are fee for service plans.
An employee benefit plan where the employer is providing health care benefits out of pocket. Larger companies are often self-funded; some may hire an insurance company in an administrative only capacity – to handle claim processing and related functions. A Form 5500 can identify if a plan is self-funded.
Military Heath System administers military healthcare coverage for uniformed soldiers and their dependent families. Tricare beneficiaries include active duty, National Guard, Reserve, and retirees (Tricare for Life for those with Medicare benefits). Tricare allows beneficiaries to receive care and services through civilian providers and facilities.
Department of Veteran’s Affairs administers benefits to those who were enlisted in any U.S. Military branch and have served during wartime. VA health benefits extend coverage to beneficiaries who receive care in a VA hospital or facility, or for VA authorized services in a civilian facility. VA benefits cannot be used in conjunction with Medicare benefits; they can only be used one at a time, though a beneficiary may have both. For more information, go to www.va.gov.
In very special cases where a Medicare lien cannot be repaid by a beneficiary, a waiver request can be submitted to Medicare. This request is made by using form SSA-632-BK, and describing the financial situation along with the reason for the inability to reimburse Medicare after an overpayment.