Medicaid program for beneficiaries who need help in paying for Medicare Part B premiums. The beneficiary must have Medicare Part A and limited income and resources and not be otherwise eligible for Medicaid. For those who qualify, Medicaid pays a percentage of Medicare Part B premiums only.

Measuring the presence or absence of.

Referring to a test that determines the presence of an agent within the body.

1. For health plans, the general standard or grade of how well a plan keeps its members healthy or treats them when they are sick. Good-quality health care means doing the right thing at the right time, in the right way, for the right person, and getting the best possible results. 2. As defined by the Institute of Medicine, the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge. 3. Highest degree to which a product or service meets needs and expectations.

1. Process or activity of evaluating how well a medical service is provided. Now called quality improvement (QI) . This process may include formally reviewing health care given to a person or a group of persons, locating the problem, correcting the problem, and checking to see if the action taken worked or not. 2. Formal set of quality improvement organization (QIO) activities (formerly peer review organization [PRO]) designed to ensure the quality of medical services provided. See quality improvement (QI) .

Plan that continually assesses the effectiveness of inpatient and outpatient health care in managed care plans and federal programs such as TRICARE and CHAMPVA. Also see quality assurance (QA) and quality improvement (QI) .

Created in 1993 by the Health Care Financing Administration to assist states in promoting a health care quality improvement system for Medicaid managed care plans.

Product developed by the National Committee for Quality Assurance (NCQA) that contains commercial, national, regional, and state averages and percentiles. The program contains information from all HEDIS (Health Plan Employer Data and Information Set) measures including utilization data in the Use of Services domain, as well as some selected consumer assessment of health plans survey (CAHPS) rates for plans publicly releasing data. Data are available for purchase in an online format.

Programs to promote quality of health care such as peer review components to find and solve deficiencies in quality and assessment of effectiveness. Formerly known as quality assurance (QA) . Also referred to as performance improvement (PI) and continuous performance improvement (CPI) .

Program formerly known as Utilization and Quality Control Peer Review Organization (PRO) that is designed to review cases to determine appropriateness, medical necessity, and quality of care for Medicare beneficiaries. It consists of groups of practicing doctors and other health care experts. They are paid by the federal government to check and improve the care given to Medicare patients. They must review the patients’ complaints about the quality of care given by inpatient hospitals, hospital outpatient departments, hospital emergency departments, skilled nursing facilities, home health agencies, private fee-for-service plans, and ambulatory surgical centers.