Search Frequenty Asked Questions

A public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider sponsored organization receiving waivers) that is certified by CMS as meeting the M+C contract requirements. See 42 C.F.R. § 422.2.

Health benefits coverage offered under a policy or contract offered by a Medicare+Choice Organization under which a specific set of health benefits are offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the service area of the M+C plan. See 42 C.F.R. § 422.2. An M+C plan may be a coordinated care plan (with or without point of service options), a combination of an M+C medical savings account (MSA) plan and a contribution into an M+C MSA established in accordance with 42 CFR part 422.262, or an M+C private fee-for-service plan. See 42 C.F.R. § 422.4(a).

A health problem caused by the lack (or too much) of needed nutrients.

A special x-ray of the breasts. Medicare covers the cost of a mammogram once every 12 months for women over 40 who are enrolled in Medicare.

Includes Health Maintenance Organizations (HMO), Competitive Medical Plans (CMP), and other plans that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract they have with Medicare. See also "Medicare+Choice".

Managed Care Organizations are entities that serve Medicare or Medicaid beneficiaries on a risk basis through a network of employed or affiliated providers.
Stands for Managed Care Organization. The term generally includes HMOs, PPOs, and Point of Service plans. In the Medicaid world, other organizations may set up managed care programs to respond to Medicaid managed care. These organizations include Federally Qualified Health Centers, integrated delivery systems, and public health clinics.
Is a health maintenance organization, an eligible organization with a contract under §1876 or a Medicare-Choice organization, a provider-sponsored organization, or any other private or public organization, which meets the requirements of §1902 (w) to provide comprehensive services.

See Suspension of Payments Includes Health Maintenance Organizations (HMO), Competitive Medical Plans (CMP), and other plans that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract they have with Medicare. See also "Medicare+Choice."

A managed care plan that lets you use doctors and hospitals outside the plan for an additional cost. (See Medicare Managed Care Plan.)

Integrates the financing and delivery of appropriate health care services to covered individuals by means of: arrangements with selected providers to furnish a comprehensive set of health care services to members, explicit criteria for the selection of health care provides, and significant financial incentives for members to use providers and procedures associated with the plan. Managed care plans typically are labeled as HMOs (staff, group, IPA, and mixed models), PPOs, or Point of Service plans. Managed care services are reimbursed via a variety of methods including capitation, fee for service, and a combination of the two.

Outlays for entitlement programs (Medicare and Medicaid) that are not subject to the Federal appropriations process.

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 M+C plan offered by an M+C Organization. M+C Organizations must ensure that any particular group of Medicare beneficiaries does not use mandatory supplemental benefits to discourage enrollment.

Review, pre- or postpayment, that requires the intervention of PSC personnel.

Manual transmittals announce policy revisions. National coverage determinations are announced in transmittals for the Medicare National Coverage Determinations Manual. Changes to Local Medical Review Policy are announced in transmittals for the Medicare Program Integrity Manual.

See "Hospital market basket."

A location where providers administer pneumococcal pneumonia and influenza virus vaccination and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy, or mall but may include a physician's office setting (4408.8, Part 3 of MCM).

A serious flaw in management controls requiring high-priority corrective action.

Under HIPAA, this is all of the required data elements for a particular standard based on a specific implementation specification. An entity creating a transaction is free to include whatever data any receiver might want or need. The recipient is free to ignore any portion of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is needed for coordination of benefits.

The beneficiary's maximum dollar liability amount for a specified period.

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.

Annual dollar amount above which earnings in employment covered under the HI program are not taxable. Beginning in 1994, the maximum tax base is eliminated under HI.

See "Maximum tax base."

These are standards that States set for plan structure, operations, and the internal quality improvement/assurance system that each MCO/PHP must have in order to participate in the Medicaid program.

The systematic process of data collection, repeated over time or at a single point in time.

To settle differences between two parties.

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.

A CMS approved system that supports the operation of the Medicaid program. The MMIS includes the following types of sub-systems or files: recipient eligibility, Medicaid provider, claims processing, pricing, SURS, MARS, and potentially encounter processing.

A Medicaid MCO provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

A Medicaid-only MCO is an MCO that provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

Codes that characterize a medical condition or treatment. These code sets are usually maintained by professional societies and public health organizations. Compare to administrative code sets.

The part of Medicare that covers doctors' services and outpatient hospital care. It also covers other medical services that Part A does not cover, like physical and occupational therapy. (See Medicare Part B (Medical Insurance).)

An organization that promotes the development and acceptance of electronic health care record systems.

Contractor reviews of Medicare claims to ensure that the service was necessary and appropriate.

The process that an insurance company uses to decide 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.

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 are not mainly for the convenience of you or your doctor.

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).

Health insurance available under Medicare Part A and Part B through the traditional fee-forservice payment system.

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.)

A private company that contracts with Medicare to pay Part B bills.

A Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)

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).)

The MCAC advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law. They perform this task via a careful review and discussion of specific clinical and scientific issues in an open and public forum. The MCAC is advisory in nature, with the final decision on all issues resting with CMS. Accordingly, the advice rendered by the MCAC is most useful when it results from a process of full scientific inquiry and thoughtful discussion, in an open forum, with careful framing of recommendations and clear identification of the basis of those recommendations.

The MCAC is used to supplement CMS's internal expertise and to ensure an unbiased and contemporary consideration of "state of the art" technology and science. Accordingly, MCAC members are valued for their background, education, and expertise in a wide variety of scientific, clinical, and other related fields. In composing the MCAC, CMS was diligent in pursuing ethnic, gender, geographic, and other diverse views, and to carefully screen each member to determine potential conflicts of interest.

The MCAC advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law. They perform this task via a careful review and discussion of specific clinical and scientific issues in an open and public forum. The MCAC is advisory in nature, with the final decision on all issues resting with CMS. Accordingly, the advice rendered by the MCAC is most useful when it results from a process of full scientific inquiry and thoughtful discussion, in an open forum, with careful framing of recommendations and clear identification of the basis of those recommendations.

The MCAC is used to supplement CMS's internal expertise and to ensure an unbiased and contemporary consideration of "state of the art" technology and science. Accordingly, MCAC members are valued for their background, education, and expertise in a wide variety of scientific, clinical, and other related fields. In composing the MCAC, CMS was diligent in pursuing ethnic, gender, geographic, and other diverse views, and to carefully screen each member to determine potential conflicts of interest.

A Medicare contractor responsible for administering Durable Medical Equipment (DME) benefits for a region.

An index often used in the calculation of the increases in the prevailing charge levels that help to determine allowed charges for physician services. In 1992 and later, this index is considered in connection with the update factor for the physician fee schedule.

The Medicare Handbook provides information on such things as how to file a claim and what type of care is covered under the Medicare program. This handbook is given to all beneficiaries when first enrolled in the program.

These are health care choices (like HMOs) in some areas of the country. In most 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 plans cover extras, like prescription drugs. Your costs may be lower than in the Original Medicare Plan.

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.

(Formerly the Coverage Issues Manual) The National Coverage Determinations Manual contains implementing instructions for National Coverage Determinations. The manual includes information whether specific medical items, services, treatment procedures, or technologies are paid for under the Medicare program on a national level.

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).)

A Medicare contractor that administers the Medicare Part A (institutional) benefits for a given region.

Medical insurance that helps pay for doctors' services, outpatient hospital care, and other medical services that are not covered by Part A. (See Medical Insurance (Part B).)

A Medicare contractor that administers the Medicare Part B (Professional) benefits for a given region.

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).

A commission established by Congress in the Balanced Budget Act of 1997 to replace the Prospective Payment Assessment Commission and the Physician Payment Review Commission. MedPAC is directed to provide the Congress with advice and recommendations on policies affecting the Medicare program.

The contractor that handles all Medicare direct billing payments for direct billed beneficiaries. MPCC is located in Pittsburgh, Pennsylvania.

A private insurance plan that accepts people with Medicare. 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 will pay for the services you get. You may pay more for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan does not cover.

A national administrative code set for providing either claim-level or service-level Medicare-related messages that cannot be expressed with a Claim Adjustment Reason Code. This code set is used in the X12 835 Claim Payment & Remittance Advice transaction.

Medicaid programs that help pay some or all Medicare premiums and deductibles.

A statutory requirement that private insurers providing general health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers.

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.

A notice you get after the doctor 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. You might also get a notice called an Explanation of Medicare Benefits (EOMB) for Part B services or a notice of utilization. (See Explanation of Medicare Benefits; Medicare Benefits Notice.)

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.)

Treasury accounts established by the Social Security Act for the receipt of revenues, maintenance of reserves, and disbursement of payments for the HI and SMI programs.

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.

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.

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 actual amount charged by a doctor or supplier. The approved amount is sometimes called the "Approved Charge."

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.)

A document providing a general description of the responsibilities that are to be assumed by two or more parties in their pursuit of some goal(s). More specific information may be provided in an associated SOW.

An instrument used when agencies enter into a joint project in which
they each contribute their own resources in which the scope of work
is very broad and not specific to any one project; or in which there is no
exchange of goods or services between the participating agencies.

Credits recognizing that military personnel receive other cash payments and wages in kind (such as food and shelter) in addition to their basic pay. Noncontributory wage credits of $160 are provided for each month of active military service from September 16, 1940 through December 31, 1956. For years after 1956, the basic pay of military personnel is covered under the Social Security program on a contributory basis. In addition to contributory credits for basic pay, noncontributory wage credits of $300 are granted for each calendar quarter in which a person receives pay for military service from January 1957 through December 1977. Deemed wage credits of $100 are granted for each $300 of military wages in years after 1977. (The maximum credits allowed in any calendar year are $1,200.) See also "Quinquennial military service determinations and adjustments."

A medical facility operated by one or more of the Uniformed Services.
A Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Services (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

The principle that, to the extent practical, individually identifiable health information should only be disclosed to the extent needed to support the purpose of the disclosure.

Methods of treatment for kidney failure/ESRD. Modality types include transplant, hemodialysis, and peritoneal dialysis.

Under this system of calculating summary measures, the actuarial balance is defined as the difference between the arithmetic means of the annual cost rates and the annual income rates, with an adjustment included to account for the offsets to cost that are due to (1) the starting trust fund balance and (2) interest earned on the trust fund.

Under HIPAA, this is a change adopted by the Secretary, through regulation, to a standard or an implementation specification.

A planned, systematic, and ongoing process to gather and organize data, and aggregate results in order to evaluate performance.

Activities related to the monitoring of standards that have been set for plan structure, operations, and quality improvement/assurance to determine that standards have been established, implemented, adhered to, etc.

A diseased state, often used in the context of a "morbidity rate" (i.e. The rate of disease or proportion of diseased people in a population). In common clinical usage, any disease state, including diagnosis and complications is referred to as morbidity.

The rate of illness in a population. The number of people ill during a time period divided by the number of people in the total population.

The death rate often made explicit for a particular characteristic (e.g. gender, sex, or specific cause of death). Mortality rate contains three essential elements: the number of people in a population exposed to the risk of death (denominator), a time factor, and the number of deaths occurring in the exposed population during a certain time period (the numerator).

A group health plan that is sponsored jointly by two or more employers or by employers and employee organizations.

A health plan sponsored by two or more employers. These are generally plans that are offered through membership in an association or a trade group.