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MMA 2003

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.

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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