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Long Term Care Medicare Terms
 

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This glossary explains terms in the Medicare program, but it is not a legal document. The official Medicare program provisions are found in the relevant laws, regulations, and rulings.

Medicare Terms

Term

Definition


A "TIER"

is a specific list of drugs. Your plan may have several tiers, and your co-payment amount depends on which tier your drug is listed. Plans can choose their own tiers, so members should refer to their benefit booklet or contact the plan for more information.
ABUSE (PERSONAL) When another person does something on purpose that causes you mental or physical harm or pain.
ACCESS Your ability to get needed medical care and services.
ACCESSIBILITY OF SERVICES Your ability to get medical care and services when you need them.
ACCESSORY DWELLING UNIT (ADU) A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.
ACCREDITED (ACCREDITATION) Means having a seal of approval. Being accredited means that a facility or health care organization has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities and organizations. Organizations that accredit Medicare Managed Care Plans include the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and the American Accreditation HealthCare Commission/URAC.
ACT/LAW/STATUTE Term for legislation that passed through Congress and was signed by the President or passed over his veto.
ACTIVITIES OF DAILY LIVING (ADL)* Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.
ACTUAL CHARGE The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves. (See Approved Amount; Assignment.)
ADDITIONAL BENEFITS Health care services not covered by Medicare and reductions in premiums or cost sharing for Medicare-covered services. Additional benefits are specified by the MA Organization and are offered to Medicare beneficiaries at no additional premium. Those benefits must be at least equal in value to the adjusted excess amount calculated in the ACR. An excess amount is created when the average payment rate exceeds the adjusted community rate (as reduced by the actuarial value of coinsurance, co-payments, and deductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the adjusted excess, which will be used to pay for services not covered by Medicare and/or will be used to reduce charges otherwise allowed for Medicare-covered services. Additional benefits can be subject to cost sharing by plan enrollees. Additional benefits can also be different for each MA plan offered to Medicare beneficiaries.
ADJUSTED AVERAGE PER CAPITA COST (AAPCC) An estimate of how much Medicare will spend in a year for an average beneficiary. (See Risk Adjustment.)
ADJUSTED COMMUNITY RATING (ACR) How premium rates are decided based on members' use of benefits and not their individual use of benefits.
ADMINISTRATIVE LAW JUDGE (ALJ) A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors.
ADMITTING PHYSICIAN The doctor responsible for admitting a patient to a hospital or other inpatient health facility.
ADVANCE BENEFICIARY NOTICE (ABN) A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it. If the doctor or supplier does give you an ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor or supplier for it. ABN?s only apply if you are in the Original Medicare Plan. They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan.
ADVANCE COVERAGE DECISION A decision that your Private Fee-for-Service Plan makes on whether or not it will pay for a certain service.
ADVANCE DIRECTIVE (HEALTH CARE) Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.
ADVANCE DIRECTIVES A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.
ADVOCATE A person who gives you support or protects your rights.
AFFILIATED PROVIDER A health care provider or facility that is paid by a health plan to give service to plan members.
AMBULATORY CARE All types of health services that do not require an overnight hospital stay.
AMBULATORY SURGICAL CENTER A place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, you may stay for only a few hours or for one night.
ANCILLARY SERVICES Professional services by a hospital or other inpatient health program. These may include x-ray, drug, laboratory, or other services.
ANESTHESIA Drugs that a person is given before surgery so he or she will not feel pain. Anesthesia should always be given by a doctor or a specially trained nurse.
ANNUAL ELECTION PERIOD The Annual Election Period for Medicare beneficiaries is the month of November each year. Enrollment will begin the following January. Starting in 2002, this is the only time in which all Medicare + Choice health plans will be open and accepting new members. (See Election Periods.)
APPEAL An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if Medicare doesn't pay for an item or service you think you should be able to get. There is a specific process that your Medicare Advantage Plan or the Original Medicare Plan must use when you ask for an appeal.
APPEAL PROCESS The process you use if you disagree with any decision about your health care services. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can have the initial Medicare decision reviewed again. If you are in the Original Medicare Plan, your appeal rights are on the back of the Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) that is mailed to you from a company that handles bills for Medicare. If you are in a Medicare managed care plan, you can file an appeal if your plan will not pay for, or does not allow or stops a service that you think should be covered or provided. The Medicare managed care plan must tell you in writing how to appeal. See your plan's membership materials or contact your plan for details about your Medicare appeal rights. (See also Organization Determination.)
APPROVED AMOUNT The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the a true amount charged by a doctor or supplier. The approved amount is sometimes called the "Approved Charge." (See Actual Charge; Assignment.)
AREA AGENCY ON AGING (AAA) State and local programs that help older people plan and care for their life-long needs. These needs include adult day care, skilled nursing care/therapy, transportation, personal care, respite care, and meals.
ASSESSMENT The gathering of information to rate or evaluate your health and needs, such as in a nursing home.
ASSIGNED CLAIM A claim submitted for a service or supply by a provider who accepts Medicare assignment.
ASSIGNMENT In the Original Medicare Plan, this means a doctor agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.
ASSISTED LIVING A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the "assisted living" residents pay a regular monthly rent. Then, they typically pay additional fees for the services they get.
AUTHORIZATION
 
MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)
BALANCE BILLING A situation in which Private Fee-for-Service Plan providers (doctors or hospitals) can charge and bill you 15% more than the plan's payment amount for services.
BASIC BENEFITS Basic Benefits includes both Medicare-covered benefits (except hospice services) and additional benefits.
BASIC BENEFITS (MEDIGAP POLICY) Benefits provided in Medigap Plan A. They are also included in all other standardized Medigap policies. (See Medigap Policy.)
BENEFICIARY The name for a person who has health care insurance through the Medicare or Medicaid program.
BENEFIT PERIOD The way that Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins if you are in the Original Medicare Plan. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.
BENEFITS The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.
BENEFITS DESCRIPTION (PLAN) The scope, terms and/or condition (s) of coverage including any limitation (s) associated with the plan provision of the service.
BIOLOGICALS Usually a drug or vaccine made from a live product and used medically to diagnose, prevent, or treat a medical condition. For example, a flu or pneumonia shot.
BOARD AND CARE HOME A type of group living arrangement designed to meet the needs of people who cannot live on their own. These homes offer help with some personal care services.
BOARD-CERTIFIED
 
This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.
CAPITATION A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.
CAPPED RENTAL ITEM Durable medical equipment (like nebulizers or manual wheelchairs) that costs more than $150, and the supplier rents it to people with Medicare more than 25 percent of the time.
CARE PLAN A written plan for your care. It tells what services you will get to reach and keep your best physical, mental, and social well being.
CAREGIVER A person who helps care for someone who is ill, disabled, or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide care-giving services for a cost.
CARRIER A private company that has a contract with Medicare to pay your Medicare Part B bills. (See Medicare Part B.)
CASE MANAGEMENT A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.
CASE MANAGER A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.
CATASTROPHIC ILLNESS A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause you financial hardship.
CATASTROPHIC LIMIT The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges. Setting a maximum amount you will have to pay protects you.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.
CERTIFICATE OF MEDICAL NECESSITY A form required by Medicare that allows you to use certain durable medical equipment prescribed by your doctor or one of the doctor's office staff.
CERTIFIED (CERTIFICATION) This means a hospital has passed a survey done by a State government agency. Being certified is not the same as being accredited. Medicare only covers care in hospitals that are certified or accredited.
CERTIFIED NURSING ASSISTANT (CNA) CNAs are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom.
CERTIFIED REGISTERED NURSE ANESTHETIST A nurse who is trained and licensed to give anesthesia. Anesthesia is given before and during surgery so that a person does not feel pain. (See Anesthesia.)
CIVILIAN HEALTH AND MEDICAL PROGRAM (CHAMPUS) Run by the Department of Defense, in the past CHAMPUS gave medical care to active duty members of the military, military retirees, and their eligible dependents. (This program is now called "TRICARE")
CLAIM A claim is a request for payment for services and benefits you received. Claims are also called bills for all Part A and Part B services billed through Fiscal Intermediaries. "Claim" is the word used for Part B physician/supplier services billed through the Carrier. (See Carrier; Fiscal Intermediaries; Medicare Part A; Medicare Part B.)
CLINICAL BREAST EXAM An exam by your doctor/health care provider to check for breast cancer by feeling and looking at your breasts. This exam is not the same as a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.
CLINICAL PRACTICE GUIDELINES Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.
CLINICAL TRIALS Clinical trials are one of the final stages of a long and careful research process to help patients live longer, healthier lives. They help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care, like how well a new cancer drug works. The trials help doctors and researchers see if the new care works and if it is safe. They may also be used to compare different treatments for the same condition to see which treatment is better, or to test new uses for treatments already in use.
COGNITIVE IMPAIRMENT A breakdown in a person's mental state that may affect a person's moods, fears, anxieties, and ability to think clearly.
COINSURANCE (MEDICARE PRIVATE FEE-FOR-SERVICE PLAN) The percentage of the Private Fee-for-Service Plan charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).
COINSURANCE (OUTPATIENT PROSPECTIVE PAYMENT SYSTEM) The percentage of the Medicare payment rate or a hospital's billed charge that you have to pay after you pay the deductible for Medicare Part B services.
COMMUNITY MENTAL HEALTH CENTER A place where Medicare patients can go to receive partial hospitalization services.
COMPLAINT (See Grievance.)
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF) A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation.
CONDITIONAL PAYMENT A payment made by Medicare for services for which another payer is responsible.
CONFIDENTIALITY Your right to talk with your health care provider without anyone else finding out what you have said.
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)* A law that lets some people keep their employer group health plan coverage for a period of time after: the death of your spouse, losing your job, having your working hours reduced, leaving your job voluntarily, or getting a divorce. You may have to pay both your share and the employer's share of the premium. Generally, you also have to pay an administrative fee.
CONSUMER ASSESSMENT OF HEALTH PLANS STUDY (CAHPS) An annual nationwide survey that is used to report information on Medicare beneficiaries' experiences with managed care plans. The results are shared with Medicare beneficiaries and the public.
CONTINUATION OF ENROLLMENT Allows MCOs to offer enrollees the option of continued enrollment in the M+C plan when enrollees leave the plan's service area to reside elsewhere. CMS has interpreted this to be on a permanent basis. M+C Organizations that choose the continuation of enrollment option must explain it in marketing materials and make it available to all enrollees in the service area. Enrollees may choose to exercise this option when they move or they may choose to terminate enrollment.
CONTINUING CARE RETIREMENT COMMUNITY (CCRC) A housing community that provides different levels of care based on what each resident needs over time. This is sometimes called "life care" and can range from independent living in an apartment to assisted living to full-time care in a nursing home. Residents move from one setting to another based on their needs but continue to live as part of the community. Care in CCRCs is usually expensive. Generally, CCRCs require a large payment before you move in and charge monthly fees.
COORDINATION OF BENEFITS Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.
COORDINATION PERIOD A period of time when your employer group health plan will pay first on your health care bills and Medicare will pay second. If your employer group health plan doesn't pay 100% of your health care bills during the coordination period, Medicare may pay the remaining costs.
COST SHARING The cost for medical care that you pay yourself like a co-payment, coinsurance, or deductible. (See Coinsurance; Co-payment; Deductible.)
COVERAGE BASIS The M+C Plan charge schedule used to base the maximum dollar coverage or coinsurance level for a service category (e.g., a $500 annual coverage limit for a prescription drug benefit may be based on a Published Retailed Price schedule, or 20% coinsurance for DME benefit may be based on a Medicare FFS fee schedule).
COVERED BENEFIT A health service or item that is included in your health plan, and that is paid for either partially or fully.
COVERED CHARGES Services or benefits for which a health plan makes either partial or full payment.
CREDITABLE COVERAGE Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. (See Pre-existing Conditions.)
CRITICAL ACCESS HOSPITAL A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
CUSTODIAL CARE

 
Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn't pay for custodial care.
DEDUCTIBLE (MEDICARE) The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. (See Benefit Period; Medicare Part A; Medicare Part B.)
DEEMED Providers are ?deemed? when they know, before providing services, that you are in a Private Fee-for-Service Plan, and they agree to give you care. Providers that are ?deemed? agree to follow your plan's terms and conditions of payment for the services you get.
DEFICIENCY (NURSING HOME) A finding that a nursing home failed to meet one or more federal or state requirements.
DEHYDRATION A serious condition where your body's loss of fluid is more than your body's intake of fluid.
DIABETIC DURABLE MEDICAL EQUIPMENT Purchased or rented ambulatory items, such a glucose meters and insulin infusion pumps, prescribed by a health care provider for use in managing a patient's diabetes, as covered by Medicare.
DIAGNOSIS The name for the health problem that you have.
DIAGNOSIS-RELATED GROUPS A way to pay hospitals for health care based on diagnosis, age, gender, and complications.
DIALYSIS Dialysis is a treatment that cleans your blood when your kidneys don't work. It gets rid of harmful wastes and extra salt and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they are not a cure for permanent kidney failure (See hemodialysis and peritoneal dialysis.).
DIETHYLSTILBESTROL (DES) A drug given to pregnant women from the early 1940s until 1971 to help with common problems during pregnancy. The drug has been linked to cancer of the cervix or vagina in women whose mother took the drug while pregnant.
DISCHARGE PLANNING A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient's home care.
DISCOUNT DRUG LIST A list of certain drugs and their proper dosages. The discount drug list includes the drugs the company will discount.
DISENROLL Ending your health care coverage with a health plan.
DRUG TIERS Drug tiers are definable by the plan. The option “tier” was introduced in the PBP to allow plans the ability to group different drug types together (i.e., Generic, Brand, Preferred Brand). In this regard, tiers could be used to describe drug groups that are based on classes of drugs. If the “tier” option is utilized, plans should provide further clarification on the drug type (s) covered under the tier in the PBP notes section (s). This option was designed to afford users additional flexibility in defining the prescription drug benefit.
DUAL ELIGIBLES Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.
DURABLE MEDICAL EQUIPMENT Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.
DURABLE MEDICAL EQUIPMENT (DME) Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant or clinical nurse specialist) for use in the home. A hospital or nursing home that mostly provides skilled care can't qualify as a ?home? in this situation. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.
DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC) A private company that contracts with Medicare to pay bills for durable medical equipment.
DURABLE POWER OF ATTORNEY
 
A legal document that enables you to designate another person, called the attorney-in-fact, to act on your behalf, in the event you become disabled or incapacitated.
ELDERCARE Public, private, formal, and informal programs and support systems, government laws, and finding ways to meet the needs of the elderly, including: housing, home care, pensions, Social Security, long-term care, health insurance, and elder law.
ELECTION Your decision to join or leave the Original Medicare Plan or a Medicare + Choice plan.
ELECTION PERIODS Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare + Choice plan. There are four types of election periods in which you may join and leave Medicare health plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.
  • Annual Election Period: The Annual Election Period is the month of November each year. Medicare health plans enroll eligible beneficiaries into available health plans during the month of November each year. Starting in 2002, this is the only time in which all Medicare + Choice health plans will be open and accepting new members.
  • Initial Coverage Election Period: The three months immediately before you are entitled to Medicare Part A and enrolled in Part B. If you choose to join a Medicare health plan during your Initial Coverage Election Period, the plan must accept you. The only time a plan can deny your enrollment during this period is when it has reached its member limit. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP).
  • Special Election Period: You are given a Special Election Period to change Medicare +C hoice plans or to return to Original Medicare in certain situations, which include: You make a permanent move outside the service area, the Medicare + Choice organization breaks its contract with you or does not renew its contract with CMS; or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).
  • Open Enrollment Period: If the Medicare health plan is open and accepting new members, you may join or enroll in it. If a health plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.
ELIGIBILITY/MEDICARE PART A You are eligible for premium-free (no cost) Medicare Part A (Hospital Insurance) if:
  • You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retirement Board, or
  • You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or
  • You or your spouse had Medicare-covered government employment, or
  • You are under 65 and have End-Stage Renal Disease (ESRD).

If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if:

  • You are age 65 or older, and
  • You are enrolled in Part B, and
  • You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the 5 years immediately before the month in which you apply.
ELIGIBILITY/MEDICARE PART B You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the 5 years immediately before the month during which you enroll in Part B.
EMERGENCY CARE Care given for a medical emergency when you believe that your health is in serious danger when every second counts.
EMPLOYER GROUP HEALTH PLAN (GHP) A GHP is a health plan that:
  • Gives health coverage to employees, former employees, and their families, and
  • Is from an employer or employee organization.
END-STAGE RENAL DISEASE (ESRD) Permanent kidney failure requiring dialysis or a kidney transplant.
END-STAGE RENAL DISEASE NETWORK A group of private organizations that make sure you are getting the best possible care. ESRD networks also keep your facility aware of important issues about kidney dialysis and transplants.
ENHANCED BENEFITS Defined as Additional, Mandatory and Optional Supplemental benefits.
ENROLL To join a health plan.
ENROLLMENT FEE The amount you must pay every year to get a Medicare-approved drug discount card.
ENROLLMENT PERIOD A certain period of time when you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.
ENROLLMENT/PART A There are four periods during which you can enroll in premium Part A: Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), and Transfer Enrollment Period (TEP).
  • Initial Enrollment Period: The IEP is the first chance you have to enroll in premium Part A. Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months.
  • General Enrollment Period: January 1 through March 31 of each year. Your premium Part A coverage is effective July 1 after the GEP in which you enroll.
  • Special Enrollment Period: The SEP is for people who did not take premium Part A during their IEP because you or your spouse currently work and have group health plan coverage through your current employer or union. You can sign up for premium Part A at any time you are covered under the Group Health Plan based on current employment. If the employment or group health coverage ends, you have 8 months to sign up. The 8 months start the month after the employment ends or the group health coverage ends, whichever comes first.
  • Transfer Enrollment Period: The TEP is for people age 65 or older who have Part B only and are enrolled in a Medicare managed care plan. You can sign up for premium Part A during any month in which you are enrolled in a Medicare managed care plan. If you leave the plan or if the plan coverage ends, you have 8 months to sign up. The 8 months start the month after the month you leave the plan or the plan coverage ends. If you enroll in Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, your coverage starts on July 1. (See Enrollment.)
EPISODE OF CARE The health care services given during a certain period of time, usually during a hospital stay.
EVIDENCE Signs that something is true or not true. Doctors can use published studies as evidence that a treatment works or does not work.
EXCESS CHARGES If you are in the Original Medicare Plan, this is the difference between a doctor's or other health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.
EXCLUSIONS (MEDICARE) Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home.
EXPEDITED APPEAL A Medicare + Choice organization's second look at whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.
EXPEDITED ORGANIZATION DETERMINATION
 
A fast decision from the Medicare + Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.
FACILITY CHARGE Some plans may vary cost shares for services based on place of treatment; in effect, charging a cost for the facility in which the service is received.
FEDERALLY QUALIFIED HEALTH CENTER (FQHC) Health centers that have been approved by the government for a program to give low cost health care. Medicare pays for some health services in FQHCs that are not usually covered, like preventive care. FQHCs include community health centers, tribal health clinics, migrant health services, and health centers for the homeless.
FEE SCHEDULE A complete listing of fees used by health plans to pay doctors or other providers.
FISCAL INTERMEDIARY A private company that has a contract with Medicare to pay Part A and some Part B bills. (Also called "Intermediary.")
FISCAL YEAR For Medicare, a year-long period that runs from October 1st through September 30th of the next year. The government and some insurance companies follow a budget that is planned for a fiscal year.
FORMULARY A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary.
FORMULARY DRUGS Listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to covered enrollees.
FRAUD AND ABUSE Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare. This is not the same as fraud.
FREE LOOK (MEDIGAP POLICY)* A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.
FREEDOM OF INFORMATION ACT (FOIA)

 
A law that requires the U.S. Government to give out certain information to the public when it receives a written request. FOIA applies only to records of the Executive Branch of the Federal Government, not to those of the Congress or Federal courts, and does not apply to state governments, local governments, or private groups.
GAPS The costs or services that are not covered under the Original Medicare Plan.

   

HEALTH CARE PROVIDER A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.
HEALTH EMPLOYER DATA AND INFORMATION SET (HEDIS) A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare & Medicaid Services (CMS) collects HEDIS data for Medicare plans. (See Centers for Medicare & Medicaid Services.)
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) A law passed in 1996 which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also:
  • limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage;
  • usually gives you credit for health coverage you have had in the past;
  • may give you special help with group health coverage when you lose coverage or have a new dependent; and
  • generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance.
HEALTH MAINTENANCE ORGANIZATIONS (HMO) A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.
HEALTH MAINTENANCE ORGANIZATIONS (HMO) A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.
HEMODIALYSIS (HD) This treatment is usually done in a dialysis facility but can be done at home with the proper training and supplies. HD uses a special filter (called a dialyze or artificial kidney) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body (See dialysis and peritoneal dialysis.).
HOME AND COMMUNITY-BASED SERVICE WAIVER PROGRAMS (HCBS) The HCBS programs offer different choices to some people with Medicaid. If you qualify, you will get care in your home and community so you can stay independent and close to your family and friends. HCBS programs help the elderly and disabled, mentally retarded, developmentally disabled, and certain other disabled adults. These programs give quality and low-cost services.
HOME HEALTH AGENCY An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.
HOME HEALTH CARE Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
HOMEBOUND Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn't keep you from getting home health care.
HOSPICE Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital Insurance).
HOSPICE CARE A special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital Insurance).
HOSPITAL INDEMNITY INSURANCE This kind of insurance pays a certain cash amount for each day you are in the hospital up to a certain number of days. Indemnity insurance doesn't fill gaps in your Medicare coverage.
HOSPITAL INSURANCE (PART A) The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
HOSPITALIST A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over your care from your primary doctor when you are in the hospital, keep your primary doctor informed about your progress, and will return you to the care of your primary doctor when you leave the hospital.
HYDRATION 
 
This is the level of fluid in the body. The loss of fluid, or dehydration, occurs when you lose more water or fluid than you take in. Your body cannot keep adequate blood pressure, get enough oxygen and nutrients to the cells, or get rid of wastes if it has too little fluid.
IMMUNOSUPPRESSIVE DRUGS Transplant drugs used to reduce the risk of rejecting the new kidney after transplant. Transplant patients will need to take these drugs for the rest of their lives.
INFORMATION, COUNSELING, AND ASSISTANCE PROGRAM (See State Health Insurance Assistance Program.)
INFUSION PUMPS Pumps for giving fluid or medication into your vein at a specific rate or over a set amount of time.
INITIAL COVERAGE ELECTION PERIOD The 3 months immediately before you are entitled to Medicare Part A and enrolled in Part B. You may choose a Medicare health plan during your Initial Coverage Election Period. The plan must accept you unless it has reached its limit in the number of members. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP). (See Election Periods; Enrollment/Part A; Initial Enrollment Period (IEP).)
INITIAL ENROLLMENT PERIOD The Initial Enrollment Period is the first chance you have to enroll in Medicare Part B. Your Initial Enrollment Period starts three months before you first meet all the eligibility requirements for Medicare and lasts for seven months.
INITIAL ENROLLMENT QUESTIONNAIRE (IEQ) A questionnaire sent to you when you become eligible for Medicare to find out if you have other insurance that should pay your medical bills before Medicare.
INPATIENT CARE Health care that you get when you are admitted to a hospital.
INSOLVENCY When a health plan has no money or other means to stay open and give health care to patients.
INTERMEDIARY A private company that has a contract with Medicare to pay Part A and some Part B bills.
INTERNIST  
 
A doctor who finds and treats health problems in adults.
J
 
 
K 

                                                                                
LARGE GROUP HEALTH PLAN A group health plan that covers employees of either an employer or employee organization that has 100 or more employees.
LIABILITY INSURANCE Liability insurance is insurance that protects against claims for negligence or inappropriate action or inaction, which results in injury to someone or damage to property.
LICENSED (LICENSURE) This means a long-term care facility has met certain standards set by a State or local government agency.
LIFETIME RESERVE DAYS In the Original Medicare Plan, 60 days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($438 in 2004).
LIFETIME RESERVE DAYS (MEDICARE) Sixty days that Medicare will pay for when you are in a hospital for more than 90 days. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($406 in 2002).
LIMITING CHARGE In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don't accept assignment. The limiting charge is 15% over Medicare's approved amount. The limiting charge only applies to certain services and doesn't apply to supplies or equipment.
LIVING WILLS A legal document also known as a medical directive or advance directive. It states your wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent.
LONG-TERM CARE A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn't pay for this type of care if this is the only kind of care you need.
LONG-TERM CARE INSURANCE A private insurance policy to help pay for some long-term medical and non-medical care, like help with activities of daily living. Because Medicare generally does not pay for long-term care, this type of insurance policy may help provide coverage for long-term care that you may need in the future. Some long-term care insurance policies offer tax benefits; these are called "Tax-Qualified Policies."
LONG-TERM CARE OMBUDSMAN  

 
An advocate (supporter) for nursing home and assisted living facility residents who works to resolve problems between residents and nursing homes or assisted living facilities.
  

MALNUTRITION A health problem caused by the lack (or too much) of needed nutrients.
MAMMOGRAM A special x-ray of the breasts. Medicare covers the cost of a mammogram once a year for women over 40.
MANAGED CARE PLAN In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan's list except in an emergency. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extra benefits, like extra days in the hospital. In most cases, a type of Medicare Advantage Plan that is available in some areas of the country. Your costs may be lower than in the Original Medicare Plan.
MANAGED CARE PLAN WITH A POINT OF SERVICE OPTION (POS) A managed care plan that lets you use doctors and hospitals outside the plan for an additional cost. (See Medicare Managed Care Plan.)
MANDATORY SUPPLEMENTAL BENEFITS Services not covered by Medicare that enrollees must purchase as a condition of enrollment in a plan. Usually, those services are paid for by premiums and/or cost sharing. Mandatory supplemental benefits can be different for each Medicare Advantage plan. Medicare Advantage Plans must ensure that any particular group of Medicare beneficiaries does not use mandatory supplemental benefits to discourage enrollment.
MAXIMUM ENROLLEE OUT-OF-POCKET COSTS The beneficiary's maximum dollar liability amount for a specified period.
MAXIMUM PLAN BENEFIT COVERAGE The maximum dollar amount per period that a plan will insure. This is only applicable for service categories where there are enhanced benefits being offered by the plan, because Medicare coverage does not allow a Maximum Plan Benefit Coverage expenditure limit.
MEDIATE To settle differences between two parties.
MEDICAID A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
MEDICAL INSURANCE (PART B) Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.
MEDICAL UNDERWRITING The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your State law allows it), and how much to charge you for that insurance.
MEDICALLY NECESSARY Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren?t mainly for the convenience of you or your doctor.
MEDICARE The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).
MEDICARE ADVANTAGE PLAN 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 (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.
MEDICARE BENEFITS Health insurance available under Medicare Part A and Part B through the traditional fee-forservice payment system.
MEDICARE BENEFITS NOTICE A notice you get after your doctor files a claim for Part A services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN). (See Explanation of Medicare Benefits; Medicare Summary Notice.)
MEDICARE CARRIER A private company that contracts with Medicare to pay Part B bills.
MEDICARE COORDINATION OF BENEFITS CONTRACTOR A Medicare contractor who collects and manages information on other types of insurance or coverage that pay before Medicare. Some examples of other types of insurance or coverage are: Group Health Coverage, Retiree Coverage, Workers? Compensation, No-fault or Liability insurance, Veterans? benefits, TRICARE, Federal Black Lung Program, and COBRA.
MEDICARE COVERAGE Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).)
MEDICARE MANAGED CARE PLAN A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan?s list. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extras, like prescription drugs. Your costs may be lower than in the Original Medicare Plan.
MEDICARE MEDICAL SAVINGS ACCOUNT PLAN (MSA) A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Insurance Policy with a high deductible. The other part is a special savings account where Medicare deposits money to help you pay your medical bills.
MEDICARE PART A (HOSPITAL INSURANCE) Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
MEDICARE PART B (MEDICAL INSURANCE) Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.
MEDICARE PART B PREMIUM REDUCTION AMOUNT Since CY 2003, MCOs are able to use their adjusted excess to reduce the Medicare Part B premium for beneficiaries. When offering this benefit, a plan cannot reduce its payment by more than 125 percent of the Medicare Part B premium. In order to calculate the Part B premium reduction amount, the PBP system must multiply the number entered in the "indicate your MCO plan payment reduction amount, per member" field by 80 percent. The resulting number is the Part B premium reduction amount for each member in that particular plan (rounded to the nearest multiple of 10 cents).
MEDICARE PREFERRED PROVIDER ORGANIZATION (PPO) PLAN A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
MEDICARE PREMIUM COLLECTION CENTER (MPCC) The contractor that handles all Medicare direct billing payments for direct billed beneficiaries. MPCC is located in Pittsburgh, Pennsylvania.
MEDICARE PRIVATE FEE-FOR-SERVICE PLAN A type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn't cover.
MEDICARE SAVINGS PROGRAM Medicaid programs that help pay some or all Medicare premiums and deductibles.
MEDICARE SAVINGS PROGRAMS There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay Medicare deductibles and coinsurance. You can apply for these programs if: You have Medicare Part A (Hospital Insurance). (If you are eligible for Medicare Part A but don't think you can afford it, there is a program that may pay the Medicare Part A premium for you.), you are an individual with resources of $4,000 or less, or are a couple with resources of $6,000 or less. Resources include money in a savings or checking account, stocks, or bonds and You are an individual with a monthly income of less than $1,031, or a couple with a monthly income of less than $1,384. Income limits will change slightly in 2004. If you live in Hawaii or Alaska, income limits are slightly higher. Note: If your income is less than the amounts listed above, you may qualify for Medicaid.
MEDICARE SECONDARY PAYER Any situation where another payer or insurer pays your medical bills before Medicare.
MEDICARE SELECT A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.
MEDICARE SUMMARY NOTICE (MSN) A notice you get after the doctor or provider files a claim for Part A and Part B services in the Original Medicare Plan. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.
MEDICARE SUPPLEMENT INSURANCE Medicare supplement insurance is a Medigap policy. It is sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Minnesota, Massachusetts, and Wisconsin, there are 10 standardized policies labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. (See Gaps and Medigap Policy.)
MEDICARE+CHOICE 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+CHOICE 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-APPROVED AMOUNT In the Original Medicare Plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare and you for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the ?Approved Charge.?
MEDIGAP POLICY A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Massachusetts, Minnesota and Wisconsin, there are 10 standardized plans labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. (See Gaps.)
MULTI-EMPLOYER GROUP HEALTH PLAN A group health plan that is sponsored jointly by two or more employers or by employers and employee organizations.
MULTI-EMPLOYER PLAN
 
A group health plan that is sponsored jointly by two or more employers or by employers and unions.
NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) A non-profit organization that accredits and measures the quality of care in Medicare health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system. (See Health Employer Data and Information Set (HEDIS).)
NATIONAL MEDIAN CHARGE The national median charge is the exact middle amount of the amounts charged for the same service. This means that half of the hospitals and community mental health centers charged more than this amount and the other half charged less than this amount for the same service.
NEBULIZERS Equipment to give medicine in a mist form to your lungs.
NEGLECT When care takers do not give a person they care for the goods or services needed to avoid harm or illness.
NETWORK A group of doctors, hospitals, pharmacies, and other health care experts hired by a health plan to take care of its members.
NO-FAULT INSURANCE No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.
NON-FORMULARY DRUGS Drugs not on a plan-approved list.
NONPARTICIPATING PHYSICIAN A doctor or supplier who does not accept assignment on all Medicare claims. (See Assignment.)
NURSE PRACTITIONER A nurse who has 2 or more years of advanced training and has passed a special exam. A nurse practitioner often works with a doctor and can do some of the same things a doctor does.
NURSING FACILITY A facility which primarily provides skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals.
NURSING HOME A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.
NUTRITION 
 
Getting enough of the right foods with vitamins and minerals a body needs to stay healthy. Malnutrition, or the lack of proper nutrition, can be a serious problem for older people.
OCCUPATIONAL THERAPY Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness.
OMBUDSMAN An advocate (supporter) who works to solve problems between residents and nursing homes, as well as assisted living facilities. Also called "Long-term Care Ombudsman."
OPEN ENROLLMENT PERIOD A one-time-only six month period when you can buy any Medigap policy you want that is sold in your State. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can?t be denied coverage or charged more due to past or present health problems.
OPTIONAL SUPPLEMENTAL BENEFITS Services not covered by Medicare that enrollees can choose to buy or reject. Enrollees that choose such benefits pay for them directly, usually in the form of premiums and/or cost sharing. Those services can be grouped or offered individually and can be different for each M+C plan offered.
ORGANIZATIONAL DETERMINATION A health plan's decision on whether to pay all or part of a bill, or to give medical services, after you file an appeal. If the decision is not in your favor, the plan must give you a written notice. This notice must give a reason for the denial and a description of steps in the appeals process. (See Appeals Process.)
ORIGINAL MEDICARE PLAN A pay-per-visit health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
OUT OF AREA Services provided to enrollees by providers that have no contractual or other relationship with M+C Organizations.
OUT OF NETWORK BENEFIT Generally, an out-of-network benefit provides a beneficiary with the option to access plan services outside of the plan?s contracted network of providers. In some cases, a beneficiary?s out-of-pocket costs may be higher for an out-of-network benefit.
OUT-OF-POCKET COSTS Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.
OUTPATIENT CARE Medical or surgical care that does not include an overnight hospital stay.
OUTPATIENT HOSPITAL SERVICES (MEDICARE)* Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:
  • blood transfusions;
  • certain drugs;
  • hospital billed laboratory tests;
  • mental health care;
  • medical supplies such as splints and casts;
  • emergency room or outpatient clinic, including same day surgery; and
  • emergency room or outpatient clinic, including same day surgery; and
  • x-rays and other radiation services.
OUTPATIENT PROSPECTIVE PAYMENT SYSTEM The way that Medicare pays for most outpatient services at hospitals or community mental health centers under Medicare Part B.
OUTPATIENT SERVICES A service you get in one day (24 hours) at a hospital outpatient department or community mental health center.
PAP TEST A test to check for cancer of the cervix, the opening to a woman's womb. It is done by removing cells from the cervix. The cells are then prepared so they can be seen under a microscope.
PART A (HOSPITAL INSURANCE) Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
PART A (MEDICARE) Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care. (See Hospital Insurance (Part A).)
PART B (MEDICAL INSURANCE) Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A.
PART B (MEDICARE) Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A. (See Medical Insurance (Part B).)
PARTIAL HOSPITALIZATION A structured program of active treatment for psychiatric care that is more intense than the care you get in your doctor's or therapist's office.
PARTICIPATING PHYSICIAN OR SUPPLIER A doctor or supplier who agrees to accept assignment on all Medicare claims. These doctors or suppliers may bill you only for Medicare deductible and/or coinsurance amounts. (See Assignment.)
PATIENT ADVOCATE A hospital employee whose job is to speak on a patient's behalf and help patients get any information or services they need.
PATIENT LIFTS Equipment to move a patient from a bed or wheelchair using your strength or a motor.
PAYMENT RATE The total payment that a hospital or community mental health center gets when they give outpatient services to Medicare patients.
PELVIC EXAM An exam to check if internal female organs are normal by feeling their shape and size.
PERFORMANCE MEASURE Is information that shows how well a health plan provides a certain treatment, test, or other health care service to its members. For example, Medicare uses performance measures from NCQA's Health Plan Employer Data and Information Set (HEDIS®) to get information on how well health plans perform in quality, how easy it is to get care, and members? satisfaction with the health plan and its doctors.
PERIODS OF CARE (HOSPICE) A set period of time that you can get hospice care after your doctor says that you are eligible and still need hospice care.
PERITONEAL DIALYSIS (PD) PD uses a cleaning solution, called dialysate, that flows through a special tube into your abdomen. After a few hours, the dialysate gets drained from your abdomen, taking the wastes from your blood with it. Then you fill your abdomen with fresh dialysate and the cleaning process begins again. This treatment can be done at home, at your workplace, or at another convenient location (See dialysis and hemodialysis.).
PERSONAL CARE Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. The Medicare home health benefit does pay for personal care services.
PHYSICAL THERAPY Treatment of injury and disease by mechanical means, such as heat, light, exercise, and massage.
PHYSICIAN ASSISTANT (PA) A person who has 2 or more years of advanced training and has passed a special exam. A physician assistant works with a doctor and can do some of the things a doctor does.
PHYSICIAN SERVICES Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included.
PLAN OF CARE Your doctor's written plan saying what kind of services and care you need for your health problem.
POINT OF SERVICE (POS) An additional, mandatory supplemental, or optional supplemental benefit that allows the enrollee the option of receiving specified services outside of the plan's provider network.
POINT-OF-SERVICE (POS) A Medicare Managed Care Plan option that lets you use doctors and hospitals outside the plan for an additional cost.
POWER OF ATTORNEY A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.
PRE-EXISTING CONDITION A health problem you had before the date that a new insurance policy starts.
PREFERRED PROVIDER ORGANIZATION (PPO) A managed care in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
PREFERRED PROVIDER ORGANIZATION (PPO) PLAN A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
PREMIUM SURCHARGE The standard Medicare Part B premium will go up ten percent for each full 12-month period (beginning with the first month after the end of your Initial Enrollment Period) that you could have had Medicare Part B but didn't take it. The additional premium amount is called a ?premium surcharge.? There will be a surcharge for Part D also.
PREVENTIVE SERVICES Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms).
PRIMARY CARE A basic level of care usually given by doctors who work with general and family medicine, internal medicine (internists), pregnant women (obstetricians), and children (pediatricians). A nurse practitioner (NP), a State licensed registered nurse with special training, can also provide this basic level of health care.
PRIMARY CARE DOCTOR A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare managed care plans, you must see your primary care doctor before you see any other health care provider.
PRIMARY PAYER An insurance policy, plan, or program that pays first on a claim for medical care. This could be Medicare or other health insurance.
PRIVATE CONTRACT A contract between you and a doctor, podiatrist, dentist, or optometrist who has decided not to offer services through the Medicare program. This doctor can't bill Medicare for any service or supplies given to you and all his/her other Medicare patients for at least 2 years. There are no limits on what you can be charged for services under a private contract. You must pay the full amount of the bill.
PRIVATE FEE-FOR-SERVICE PLAN A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn't cover.
PROCEDURE Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.
PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE combines medical, social, and long-term care services for frail people. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must:
  • Be 55 years old, or older,
  • Live in the service area of the PACE program,
  • Be certified as eligible for nursing home care by the appropriate state agency , and
  • Be able to live safely in the community.

The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need.

PROS AND CONS The good and bad parts of treatment for a health problem. For example, a medicine may help your pain (pro), but it may cause an upset stomach (con).
PROVIDER A doctor, hospital, health care professional, or health care facility.
PROVIDER NETWORK The providers with which an M+C Organization contracts or makes arrangements to furnish covered health care services to Medicare enrollees under an M+C coordinated care or network MSA plan.
PROVIDER SPONSORED ORGANIZATION (PSO)

 
A group of doctors, hospitals, and other health care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. This type of managed care plan is run by the doctors and providers themselves, and not by an insurance company. (See Managed Care Plan.)
QUALIFIED MEDICARE BENEFICIARY (QMB) This is a Medicaid program for beneficiaries who need help in paying for Medicare services. The beneficiary must have Medicare Part A and limited income and resources. For those who qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.
QUALIFYING INDIVIDUALS (1) (QI-1S) This is a 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, the Medicaid program pays full Medicare Part B premiums only.
QUALIFYING INDIVIDUALS (2) (QI-2S) This is a 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.
QUALITY Quality is how well the health 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.
QUALITY ASSURANCE The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and then checking to see if what you did worked.
QUALITY IMPROVEMENT ORGANIZATION 


 
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 your complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for Service plans, and ambulatory surgical centers.
REFERRAL A written OK from your primary care doctor for you to see a specialist or get certain services. In many Medicare Managed Care Plans, you need to get a referral before you can get care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for your care.
REFERRAL A plan may restrict certain health care services to an enrollee unless the enrollee receives a referral from a plan-approved caregiver, on paper, referring them to a specific place/person for the service. Generally, a referral is defined as an actual document obtained from a provider in order for the beneficiary to receive additional services.
REGIONAL HOME HEALTH INTERMEDIARY (RHHI) A private company that contracts with Medicare to pay home health bills and check on the quality of home health care.
REHABILITATION Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.
REPORT CARD Is a way to check up on the quality of care delivered by health plans. Report cards provide information on how well a health plan treats its members, keeps them healthy, and gives access to needed care. Report cards can be published by States, private health organizations, consumer groups, or health plans.
RESERVE DAYS (See Lifetime Reserve Days.)
RESPITE CARE Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off.
RESTRAINTS Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.
RISK ADJUSTMENT  
 
The way that payments to health plans are changed to take into account a person's health status.
SECOND OPINION This is when another doctor gives his or her view about what you have and how it should be treated.
SECONDARY PAYER An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.
SERVICE AREA The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may dis-enroll you if you move out of the plan's service area.
SERVICE AREA (PRIVATE FEE-FOR-SERVICE) The area where a Medicare Private Fee-for-Service plan accepts members.
SERVICE CATEGORY DEFINITION A general description of the types of services provided under the service and/or the characteristics that define the service category.
SIDE EFFECT A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy. Most treatments have side effects.
SKILLED CARE A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.
SKILLED NURSING CARE A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
SKILLED NURSING FACILITY (SNF) A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.
SKILLED NURSING FACILITY CARE This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.
SOCIAL HEALTH MAINTENANCE ORGANIZATION (SHMO) A special type of health plan that provides the full range of Medicare benefits offered by standard Medicare HMOs, plus other services that include the following: prescription drug and chronic care benefits, respite care, and short-term nursing home care; homemaker, personal care services, and medical transportation; eyeglasses, hearing aids, and dental benefits.
SPECIAL ELECTION PERIOD A set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: you move outside the service area, your Medicare + Choice organization violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election Periods; Enrollment; Special Enrollment Period (SEP).)
SPECIAL ENROLLMENT PERIOD A set time when you can sign up for Medicare Part B if you didn't take Medicare Part B during the Initial Enrollment Period, because your or your spouse were working and had group health plan coverage through the employer or union. You can sign up at anytime you are covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment ends or the group health coverage ends, whichever comes first.
SPECIALIST A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.
SPECIALTY PLAN A type of Medicare Advantage Plan that provides more focused health care for some people. These plans give you all your Medicare health care as well as more focused care to manage a disease or condition such as congestive heart failure, diabetes, or End-Stage Renal Disease.
SPECIFIED DISEASE INSURANCE This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn't fill gaps in your Medicare coverage.
SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB) A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.
SPEECH-LANGUAGE THERAPY Treatment to regain and strengthen speech skills.
STATE CHILDREN’S HEALTH INSURANCE PROGRAM Free or low-cost health insurance is available now in your state for uninsured children under age 19. State Children's Health Insurance Programs help reach uninsured children whose families earn too much to qualify for Medicaid, but not enough to get private coverage. Information on your state's program is available through Insure Kids Now at 1-877-KIDS NOW (1-877-543-7669). You can also look at www.insurekidsnow.gov on the web for more information.
STATE HEALTH INSURANCE ASSISTANCE PROGRAM A State program that gets money from the Federal Government to give free local health insurance counseling to people with Medicare.
STATE INSURANCE DEPARTMENT A state agency that regulates insurance and can provide information about Medigap policies and any insurance-related problem.
STATE MEDICAL ASSISTANCE OFFICE A State agency that is in charge of the State's Medicaid program and can give information about programs to help pay medical bills for people with low incomes. Also provides help with prescription drug coverage.
STATE SURVEY AGENCY Agency that inspects dialysis facilities and makes sure that Medicare standards are met.
SUBSIDIZED SENIOR HOUSING A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.
SUPPLIER Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.
TELEMEDICINE Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.
TREATMENT Something done to help with a health problem. For example, medicine and surgery are treatments.
TREATMENT OPTIONS The choices you have when there is more than one way to treat your health problem.
TRICARE A health care program for active duty and retired uniformed services members and their families.
TRICARE FOR LIFE (TFL) Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.
TTY



 
A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who don't have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.
UNASSIGNED CLAIM A claim submitted for a service or supply by a provider who does not accept assignment.
URGENTLY NEEDED CARE


 
Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than the Original Medicare Plan. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.
VALIDATION
 
The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data is collected.
WAITING PERIOD The time between when you sign up with a Medigap insurance company or Medicare health plan and when the coverage starts.
WORKERS COMPENSATION
 
Insurance that employers are required to have to cover employees who get sick or injured on the job.
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