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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
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.

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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