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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
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.

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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