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Glossary

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.

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A B C D E F G H I J K L M
 
N O P Q R S T U V W X Y Z


Term Definition
A "TIER"

is a specific list of drugs. Your plan may have several tiers,and your copayment 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)

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 of health care facilities and organizations.

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, copayments, 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 to sign in the following cases: Your doctor gives you a service that he or she believes that Medicare does not consider medically necessary; and your doctor gives you a service that he or she believes that Medicare will not pay for. If you do not get an ABN to sign before you get the service from your doctor, and Medicare does not pay for it, then you do not have to pay for it. If the doctor 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 for it. ABN only applies if you are in the Original Medicare Plan. It does not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan. (See Medicare Managed Care Plan; Original Medicare 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.

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 gets before and during 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 take if you disagree with any decision about your health care services. For example, you would file an appeal if Medicare doesn't pay or doesn't pay enough for a service you got, you don't get, or an item or service you think you should get. This complaint is made to your Medicare health plan or the Original Medicare Plan. There is usually a special process you must use to make your complaint. (See Appeal Process.)

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 tual 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.

ASSIGNMENT

In the Original Medicare Plan, this means a doctor agrees to accept Medicare's fee as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor acepts assignment. You still pay your share of the cost of the doctor's visit. (See Actual Charge; Approved Amount; Coinsurance.)

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.)

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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 insurance through the Medicare or Medicaid program.

BENEFIT PERIOD

The way that Medicare measures your use of hospital and skilled nursing facility 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 hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. (See Deductible; Skilled Nursing Facility.)

BENEFITS

The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.

BENEFITS DESCRIPTION (MEDICARE SERVICES)

The scope, terms and/or condition(s) of Medicare coverage including any limitation(s) associated with Medicare fee-for-service.

BENEFITS DESCRIPTION (PLAN)

The scope, terms and/or condition(s) of coverage including any limitation(s) associated with the plan provision of the service.

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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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.

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.

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.

CERTIFIED (CERTIFICATION)

State government agencies inspect health care providers, including home health agencies, hospitals, nursing homes, and dialysis facilities home health agencies, as well as other health care providers.  These providers are certified if they pass inspection.  Medicare or Medicaid only covers care provided by certified  providers.  Being certified is not the same as being accredited. Medicare or Medicaid only covers care in a certified facility or program.

CERTIFIED NURSING ASSISTANT (CNA)

CNAs are trained and certified to help nurses by providing non-medical assistance to patients, such as help with eating, cleaning and dressing.

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.

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

The percent of the Medicare-approved amount that you have to pay after you pay the deductible for Part A and/or Part B. In the Original Medicare Plan, the coinsurance payment is a percentage of the approved amount for the service (like 20%).

COINSURANCE

A fixed percentage of the total amount paid for a health care service that can be charged to a beneficiary on a per service basis.

COINSURANCE (ASSIGNMENT)

The percentage of the Medicare-approved amount that you have to pay after you pay the deductible for Part A and/or Part B. In the Original Medicare Plan, the coinsurance payment is a percentage of the cost of the service (like 20% for Part B services). (See Assignment; Deductible (Medicare); Original Medicare Plan; Medicare Part A; Medicare Part B.)

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 in certain circumstances if the insurance company or other payer does not pay the bill within 120 days.

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)*

COBRA is a law that makes an employer let you remain covered under the employer's group health plan for a period of time after: the death of your spouse, losing your job, or having your work hours reduced, or getting a divorce. You may have to pay both your share and the employer's share of the premium.

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 disenroll.

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.

COPAYMENT

In some Medicare health plans, the amount you pay for each medical service, like a doctor's visit. A copayment is usually a set amount you pay for a service. For example, this could be $5 or $10 for a doctor's visit. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.

COPAYMENT

A fixed dollar amount charged on a per service basis.

COST SHARING

The cost for medical care that you pay yourself like a copayment, coinsurance, or deductible. (See Coinsurance; Copayment; Deductible.)

COVERAGE BASIC

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).

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 (HOME HEALTH)

Nonskilled care, such as help with activities like grocery shopping, cleaning, and cooking. Medicare home health does not pay for custodial care. (See PERSONAL CARE for covered items.)

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
DATA ENTRY USER

A Data Entry User is any user that the Super User designates within PBP to assist the Super User with data entry.

DEDUCTIBLE

Initial specified dollar amount required to be paid by enrollee for a service category.

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.)

DEDUCTIBLES (MEDIGAP POLICY)

The amount you must pay for health care, before Medicare or some Medigap policies begin to pay. Some Medicare deductibles can change every year. (See Medigap Policy.)

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.

DICTIONARY

A system database that drives the data entry variables and screens.

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.

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 (DME)

Medical equipment that is ordered by a doctor for use in the home. These items must be reuseable, such as walkers, wheelchairs, or hospital beds. DME is paid for under 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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
ELDER LAW*

The group of laws about rights and issues of the health, finances, and well-being of the elderly.

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+Choice 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 Retrirement 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)*

Kidney failure that is severe enough to need lifetime dialysis or a kidney transplant.

ENHANCED BENEFITS

Defined as Additional, Mandatory and Optional Supplemental benefits.

ENROLL

To join a health plan.

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*

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. (See Actual Charge; Approved Amount; Medigap Policy.)

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.

EXPLANATION OF MEDICARE BENEFITS (EOMB)

A notice that is sent to you after the doctor files a claim for Part B services under the Original Medicare Plan. This notice explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. This is being replaced by the Medicare Summary Notice (MSN), which sums up all the services (Part A and B) that were given over a certain period of time, generally monthly. (See Medicare Summary Notice; Medicare Benefits Notice.)

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
GAPS

The costs or services that are not covered under the Original Medicare Plan.

GATEKEEPER

In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

GENERAL ENROLLMENT PERIOD (GEP)

The GEP is January 1 through March 31 of each year. 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.)

GERONTOLOGY*

The study of, and learning about, older people and the process of aging.

GRIEVANCE

A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem with the cleanliness of the health care facility, problems calling the plan, staff behavior, or operating hours. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered.

GROUP HEALTH PLAN

A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.

GROUP OR NETWORK HMO

A health plan that contracts with group practices of doctors to give services in one or more places.

GUARANTEED ISSUE RIGHTS (ALSO CALLED "MEDIGAP PROTECTIONS")

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can't deny you insurance coverage or place conditions on a policy, must cover you for all pre-existing conditions, and can't charge you more for a policy because of past or present health problems.

GUARANTEED RENEWABLE

A right you have that requires your insurance company to allow you to automatically renew or continue your Medigap policy, unless you commit fraud or do not pay your premiums.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
HEALTH CARE FINANCING ADMINISTRATION (HCFA)

Former name of the government agency now called the Centers for Medicare & Medicaid Services.

HEALTH CARE PROVIDER

A person who is trained and licensed to give health care. Also, a place licensed to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies 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.
HOME HEALTH AGENCY

An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and care by home health aides.

HOME HEALTH CARE

Skilled nursing care and certain other health care you get in your home for the treatment of an illness or injury. (See Activities of Daily Living.)

HOMEBOUND

Normally unable to leave home. Leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as a trip to the barber or to attend religious services. A need for adult day care does not keep you from getting home health care for other medical conditions.

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).

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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
INFORMATION, COUNSELING, AND ASSISTANCE PROGRAM

(See State Health Insurance Assistance Program.)

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 (IEP)

The IEP is the first chance you have to enroll in Part B or Part A (if you don't get it automatically without paying a premium). Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months. The Initial Enrollment Period is different from the Initial Coverage Election Period. (See Enrollment/Part A; Election Periods; Initial Coverage Election Period.)

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 contracts with Medicare to pay Medicare Part A bills. (See Fiscal Intermediary.)

INTERNIST

A doctor who finds and treats health problems in adults.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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 based on negligence or inappropriate action or inaction, which results in bodily injury 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 (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

The highest amount of money you can be charged for a covered service by doctors and other health care providers who don't accept assignment. The limit is 15% over Medicare's approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment. (See Approved Amount; Assignment.)

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 facilties. Most long-term care is custodial care. Medicare does not pay for this type of care.

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

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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 every 12 months for women over 40 who are enrolled in Medicare.

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 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.

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)

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).)

MEDICAL UNDERWRITING

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.

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 are not 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 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 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

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.

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. (See Hospital Insurance (Part A).)

MEDICARE PART B (MEDICAL INSURANCE)

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).)

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 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 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.

MEDICARE SAVINGS PROGRAM

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

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 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

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

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."

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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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.

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 bodily injury 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.)

NOTICE OF MEDICARE BENEFITS

A notice you get to show what action was taken on a claim. (See Explanation of Medicare Benefits; Medicare Benefits Notice; Medicare Summary Notice.)

NOTICE OF MEDICARE PREMIUM PAYMENT DUE - HCFA 500

The billing notice sent to Medicare beneficiaries who must pay their Medicare premium directly. Notices are sent either monthly or quarterly.

NURSE PRACTITIONER (NP)

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 things a doctor does.

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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
OCCUPATIONAL THERAPY

Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness either on an inpatient or outpatient basis.

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 (MEDIGAP POLICY)

A one-time only six-month period when you can buy any Medigap policy you want that is sold in your state. It starts when you sign up for Medicare Part B and you are age 65 or older. You cannot be denied coverage or charged more due to present or past health problems during this time period.

OPEN ENROLLMENT PERIODS

A certain period of time when you can join a Medicare health plan. The plan must be open and accepting new members. If a health plan chooses to be open, it must allow all eligible beneficiaries to join. (See Election Periods.)

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 provider who accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). The Original Medicare Plan has two parts: Part A (hospital insurance) and Part B (medical insurance). (See Deductible (Medicare); Approved Amount; Coinsurance; Medicare Part A; Medicare Part B.)

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 will pay 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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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 (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 (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 (MENTAL HEALTH)

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 person whose job is to speak on a patient's behalf and help patients get any information or services they need.

PAYMENT RATE

The total payment that a hospital or community mental health center gets when they give outpatient services to Medicare patients.

PEER REVIEW ORGANIZATION (PRO)

Former name for Quality Improvement Organizations (QIOs).

PELVIC EXAM

An exam to check if internal female organs are normal by feeling their shape and size.

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.

PERSONAL CARE

Nonskilled, 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, 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.

PRE-EXISTING CONDITION (MEDIGAP POLICY)

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.

PREMIUM

The periodic payment to Medicare, an insurance company, or a health care plan for health care coverage.

PREMIUM

The monthly cost charged to the enrollee.

PREVENTIVE CARE

Care to keep you healthy or to prevent illness, such as colorectal cancer screening, yearly mammograms, and flu shots.

PREVENTIVE SERVICES

Health care to keep you healthy or to prevent illness. For example, Pap tests, pelvic exams, yearly mammograms, and flu shots.

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 who has decided not to offer services through the Medicare program. This doctor cannot bill Medicare for any services or supplies given to you and 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.

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.)

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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 ORGANIZATIONS (QIOS)

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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
REFERRAL

An 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 get care from anyone except your primary care doctor. If you do not get a referral first, the plan may not pay for your care. (See Emergency Care; Primary Care Doctor; Urgently Needed 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.

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.

RESTRAINT

Any physical or chemical way to stop a patient from being free to move. These restraints are used to prevent patient injury and are not used for treating medical symptoms.

RISK ADJUSTMENT

The way that payments to health plans are changed to take into account a person's health status.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
SB CROSSWALK

The SB Crosswalk document is available from the PBP HELP menu and provides a detailed explanation of how each SB sentence is derived from the PBP variables.

SCREENS

A screen is an area beneath the tab where variables are presented. A tab represents a screen. The variables on the screen are displayed by selecting a tab. A tab may contain one or more sub tabs.

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 health 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 disemroll 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 must be given or supervised by Registered Nurses. All of your needs are taken care of with this type of service. Examples of skilled nursing care are: getting intravenous injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound. Any service that could be safely done by an average non-medical person (or one's self) without the supervision of a Registered Nurse is not considered skilled care.

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.

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 (SEP)

A set time when you can sign up for Medicare Part B if you did not take Part B during the Initial Enrollment Period, because you or your spouse currently work and have group health plan coverage through the employer or union. You can sign up at any time you are covered under the group plan. If the employment or group health coverage ends, you have 8 months to sign up.The 8-month SEP starts the month after the employment ends or the group health coverage ends, whichever comes first. The Special Enrollment Period is different from the Special Election Period. (See Enrollment; Election Periods; Special Election Period.)

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.

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.

STATE HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP)

A state program that gets money from the federal government to give free health insurance counseling and assistance 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 provide information about programs to help pay medical bills for people with low incomes. Also provides help with prescription drug coverage.

STEP-UP BENEFITS

Benefit Offerings are considered step-up benefits if a plan benefit package includes one of the following benefit structures in a particular service category: 1) more than one optional supplemental benefit; 2) both a mandatory and optional benefit; or 3) both an additional and optional benefit. For example, a plan may offer three prescription drug optional supplemental benefits, which offer varying levels of drug coverage; in this case, two of the optional benefit offerings would be considered step-up benefits. Alternatively, a plan may offer prescription drug benefits as either an additional or mandatory benefit and then an optional benefit; in this case, the optional benefit would be considered a step-up benefit.

SUB SCREENS

A sub screen is an area beneath the sub tab where variables are presented. A sub tab represents a sub screen. The variables on the sub screen are displayed by selecting a sub tab.

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.

SUPER USER

A Super User is the user who defined the plans in HPMS and downloaded from the HPMS Web site.

SUPPLIER

Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
TAB/SUB TAB

A tab/sub tab indicates the screen labels (e.g., Tab Section A-1 is the tab that is used for retrieving the Section A Part 1 screen).

TELEMEDICINE

The use of medical information exchanged from one site to another using electronic communications for the health and education of patients or providers and to improve patient care.

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

TRICARE is the health care program for active duty members of the military, military retirees, and their eligible dependents. TRICARE was called CHAMPUS in the past. (See Civilian Health and Medical Program (CHAMPUS).)

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
UPDATE

A process by which contract and plan information is updated on HPMS over MDCN and downloaded to the client.

UPLOAD

Upload is a process by which the PBP data and ACR spreadsheets are submitted over MDCN to HPMS.

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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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.

VARIABLE

A variable is a data entry field that accepts data according to the specifications and rules specified by the dictionary.

VARIABLE TYPE

Variable types and attributes determine the type of data the system will accept during data entry (e.g., the variable Indicate Coinsurance Percentage Amount accepts only data that are in numeric format).

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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Term Definition
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.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

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.
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Date Last Updated: September 23, 2004

 

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