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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
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.

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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