Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 174Appendix C - DefinitionsVersion 3.0Medical Management GuideMedicaidA healthcare coverage program for certain low-income individuals and families who meet state and federaleligibility requirements. Medicaid does not pay money to patients directly; instead, it sends payments directlyto healthcare providers. Depending on a state's rules, patients may also be asked to pay a small part of the cost(co-payment) for some medical services. Medicaid is a state administered program, with each state setting itsown guidelines regarding eligibility and services. Many groups of people are covered by Medicaid, but certainrequirements must be met related to age; whether an individual is pregnant, disabled, blind, or aged; incomeand resources; and a U.S. citizenship or an immigration status. The rules for counting income and resources varyfrom state to state and from group to group. There are special rules for those who live in nursing homes and fordisabled children living at home.Resources:Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/home/medicaid.asp.Medical Department Activity (MEDDAC)The Army’s medical department.Resources:Go Army – Army Health Care: http://www.goarmy.com/amedd/.Medical Evaluation Board (MEB)The MEB is a board to identify members whose physical or mental qualification for full duty is in doubt orwhose physical or mental limitation precludes return to full duty within a reasonable period of time; speaks tothe degree to which a member can perform his or her duties.Resources:Army: AR 40-400, Patient Administration: http://www.army.mil/usapa/epubs/pdf/r40_400.pdf.Army: AR 40-501, Standards of Medical Fitness: http://www.army.mil/usapa/epubs/pdf/r40_501.pdf.AFI 36-3209, Separation and Retirement Procedures for Air Force National Guard and Air Force ReserveMembers: www.af.mil/shared/media/epubs/AFI36-3209.pdf.Navy: SECNAVINST 1850.4E — Disability and Evaluation Manual:• http://doni.daps.dla.mil/default.aspx Search for: 1850.4E• http://www-nmcphc.med.navy.mil/LGuide/Medical/Medical_Boards.htmMedical Hold• Mobilized RC soldiers who were unable to deploy with their units due to a medical condition, and werenot REFRAD within 30 days of mobilization. These soldiers remain on Active Duty awaiting medical/administrative disposition.• Redeployed/Demobilizing RC soldiers who sustained injury, disease, or aggravated pre-existing conditionsthat require medical/administrative resolution before REFRAD/ demobilization.
Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 175Medical Retention Processing (MRP) - Medical holdover soldiers mobilized under Title 10 USC 12302 ISOGWOT. All RC soldiers with medical conditions that require more than 60 days for resolution will be asked tovolunteer to transition to a Medical Retention Processing Unit (MRPU). Soldiers who do not volunteer will bereleased from active duty and briefed on follow-on medical entitlements such as VA hospitals.Resources:Fort Carson the Mountain Post: http://www.carson.army.mil/Moblas/Medical%20Hold.htm.Medical Management (MM)An integrated managed care model that promotes Utilization Management (UM), Case Management (CM),and Disease Management (DM) programs as a hybrid approach to managing patient care. It includes a shift toevidence-based, outcome-oriented UM, and a greater emphasis on integrating clinical practice guidelines intothe MM process, thereby holding the system accountable for patient outcomes.Resources: DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS)and Remote Areas (Jan. 5, 2006): http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.Medical NecessityAccepted healthcare services and supplies provided by healthcare entities, appropriate to the evaluation andtreatment of a disease, condition, illness, or injury and consistent with the applicable standard of care. Whetherservices or supplies are deemed “medically or psychologically necessary,” depends on the frequency, extent,and types of medical services or supplies which represent appropriate medical care and that are generallyaccepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness,injury, pregnancy, and mental disorders or that are reasonable and adequate for well-baby care.Resources:American College of Medical Quality (ACMQ), Policy 8: Definition and Application of Medical Necessity: http://www.acmq.org/policies/policy8.pdf.Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 2 (199.2):http://www.tricare.mil/CFR/C2.PDF. See CD-ROM Resource AppendixC-Def3MedicareA health insurance program for people age 65 or older, people under age 65 with certain disabilities, andpeople of all ages with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).Medicare has Part A (Hospital Insurance), Part B (Medical Insurance), and Prescription Drug Coverage.Resources:Centers for Medicare & Medicaid Services (CMS):• http://www.cms.hhs.gov/MedicareGenInfo/• http://www.cms.hhs.gov/home/medicare.aspMedicare: http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_alp.php.
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