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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
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.

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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