The New Improved Medicare

Chapter 7

Terms

Terms come from several sources. Medicare sets down specific definitions for specific services or items; the federal and state governments have specific terms for specific services or items, insurers have their own defined terms, and the general public has assumed definitions for items and services they receive or request to receive. The differences in perceptions of what a term relates to can cause confusion, in some cases even loss of financial security. It is necessary for the field agent to confirm the definition of important terms that he or she uses with his or her clients. Failure to do so can cause misunderstandings that eventually cause financial harm to the insured.

The final authority on any term that is specific to the policy is found in the policy itself. While these terms are mostly mandated by legislation, it does not mean that the general public understands the meanings of important terms. It is the agents responsibility to point out important terminology and it is the insureds responsibility to read the policy they purchase. Of course, we know that many agents do not read the policies they sell and many consumers do not read the policies they buy.

The following represents terms that are common to the insurance industry. Some are provided by Medicares Medicare & You handbook (signified by M&Y), Rupps Insurance & Risk Management Glossary (signified by Rupp), and the Centers for Medicare & Medicaid Services (signified by CMS).

Accreditation (Rupp): The process by which an organization recognizes a program of study or an institution as meeting predetermined standards. Two organizations that accredit managed care plans are the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

Activities of Daily Living (ADL) (CMS): Activities an individual usually does during a normal day, such as getting in and out of bed, dressing, bathing, eating, and using the bathroom. These activities directly relate to the use of long-term care services and payment under long-term care insurance policies.

Actuary (Rupp): In insurance, a person trained in statistics, accounting and mathematics who determines policy rates, reserves, and dividends by deciding what assumptions should be made with respect to each of the risk factors involved and who endeavors to secure as valid statistics as possible on which to base assumptions.

Administrative Law Judge (ALJ) (CMS): A hearings officer who presides over appeal conflicts between providers of services or beneficiaries, and Medicare contractors.

Adverse Selection (Rupp): The problem of attracting members who are sicker than the general population, specifically members who are sicker than was anticipated when developing the budget for medical costs.

Affiliated Provider (Rupp): A health care provider or facility that is part of the HMOs network usually having formal arrangements to provide services to the HMO member.

Allowable Charge (Rupp): The maximum charge for which a third party will reimburse a provider for a given service. An allowable charge is not necessarily the same as either a reasonable, customary, maximum, actual, or prevailing charge.

Ancillary Services (CMS): Professional services by a hospital or other inpatient health care provider. Services may include x-rays, drugs, laboratories, and other services.

Appeal (M&Y): A special kind of complaint filed when the patient disagrees with certain kinds of decisions made by Medicare or their health care plan. Patients can file an appeal when a health care service, supply or prescription has been requested but denied by Medicare or the service plan. An appeal may also be filed if the service has already been received, but Medicare or the health plan has denied payment. Additionally an appeal may be filed when services are already being received and the plan stops paying for them. There is a specific process for filing appeals with Medicare Advantage Plans, other Medicare Health Plans, Medicare drug plans, or Original Medicare plans, which enrollees must follow.

Approved Amount (CMS): The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by the beneficiary and Medicare combined for a service or supply. It may be less than the actual amount normally charged by the doctor or supplier. The approved amount may also be referred to as the approved charge.

Assigned Claim (CMS): A claim submitted for a service or supply by a provider who accepts Medicare assignment (the amount approved for payment by Medicare).

Assignment (CMS): In the Original Medicare Plan, this means a doctor agrees to accept the Medicare-approved amount as full payment. If the beneficiary is in the Original Medicare Plan it can save him or her money if the doctor accepts assignment. The patient or the patients medical plan would still pay his or her portion, which is 20% of Medicares approved amount (Medicare pays 80%).

Assisted Living (CMS): 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 receive.

Auto-assignment (Rupp): A term used with Medicaid mandatory managed care enrollment plans. Medicaid recipients who do not specify their choice for a contracted plan within a specified time frame are assigned to a plan by the state.

Balance Billing (CMS): The amount Medicare approves on Part B Charges is considered to represent 100% of the bill. Any amount charged above the amount approved by Medicare is called balance billing. Private Fee-for-Service Plan providers can charge and bill the patient up to 15% more than the amount approved by Medicare. The limiting fee prevents providers from charging more than 15%. A non-Medicare provider is not required to follow the 15% rule.

Basic Benefits (CMS): Benefits provided in Medigap Plan A. They are also included in all other standardized Medigap policies.

Benefit Package (Rupp): Aggregate services specifically defined by an insurance policy or HMO that can be provided to patients.

Benefit Period (M&Y): The way that the Original Medicare Plan measures a patients use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day the patient goes to a hospital or skilled nursing facility. The benefit period ends when the patient has not received any hospital care (or skilled care in a SNF) for 60 days in a row. If the patient goes into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. The patient must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods one can have.

Biologicals (CMS): Usually a drug or vaccine made from a live product and used medically to diagnose, prevent, or treat a medical condition, such as a flu or pneumonia shot.

Capitation (Rupp): A method of payment for health care services in which the provider accepts a fixed amount of payment per subscriber per period of time, in return for providing specified services.

Care Plan (CMS): A written plan of care. It tells the individual what services will be available for physical, mental and social well being.

Carrier (CMS): A private company that has a contract with Medicare to pay Medicares Part B bills.

Case Manager (CMS): 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.

Certificate of Medical Necessity (CMS): A form required by Medicare that allows a patient to use certain durable medical equipment prescribed by their doctor or one of the doctors office staff.

Claim (CMS): A request for payment for services or benefits that have been received by an individual. 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 a Carrier.

Closed Access (Rupp): A managed health care arrangement in which covered persons are required to select providers only from the plans list of participating providers.

Cognitive Impairment (CMS): A breakdown in a persons mental state that may affect a persons moods, fears, anxieties, and ability to think clearly. This is an accepted reason for nursing home admission and nursing policy payment in most cases.

Cohort (CMS): A population group that shares a common property, characteristic, or event, such as a year of birth or year of marriage. The most common is the birth cohort, a group of individuals born within a defined time period, usually a calendar year or a five-year interval.

Coinsurance (M&Y): The amount an enrollee may be required to pay for services received following any plan deductibles. In the Original Medicare Plan, this is a percentage (20% for Part B services) of the Medicare-approved amount. The enrollee must pay this amount after reaching the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much the enrollee has spent.

Community Rating (Rupp): A method of calculating health plan premiums using the average cost of actual or anticipated health services for all subscribers within a specific geographic area. The premium does not vary for different groups or subgroups of subscribers on the basis of their specific claims experience.

Competitive Medical Plan (Rupp): A type of managed care organization (MCO) created by the 1982 Tax Equity and Fiscal Responsibility Act to facilitate the enrollment of Medicare beneficiaries into managed care plans. Competitive medical plans are organized and financed much like HMOs but are not bound by all the regulatory requirements facing HMOs.

Conditional Payment (CMS): A payment made by Medicare for services for which another payer is responsible. This often happens when a Medicare beneficiary has been in an automobile accident, for example. The auto policy is actually responsible for medical costs, so Medicare intends to be reimbursed.

Coordination of Benefits (CMS): A program that determines which plan or insurance policy will pay first if two health plans or insurance policies cover the same claims or benefits. If one of the plans is a Medicare health plan, Federal law may decide who pays first.

Copayment (M&Y): In some Medicare health and prescription drug plans, the amount the insured pays for each medical service, such as a doctors visit or prescription. A copayment is usually a set amount that is owed by the patient. For example, this could be $10 or $20 for a doctors visit or prescription. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.

Covered Charges (CMS): Services or benefits for which a specified health plan makes either partial or full payment.

Creditable Coverage (CMS): Any previous health insurance coverage that can be used to shorten the preexisting condition waiting period.

Creditable Prescription Drug Coverage (M&Y): Prescription drug coverage (from an employer or union, for example), that pays out on average as much as or more than Medicares standard prescription drug coverage.

Custodial Care (CMS): Nonskilled, personal care such as help with the activities of daily living (bathing, dressing, eating, transferring, or using the bathroom for example). It may include care that most people do for themselves, like using eye drops. In most cases, Medicare does not pay for custodial care.

Custodial Care Facility (CMS): A facility that provides room, board, and other personal assistance services, generally on a long-term basis and which does not include a medical component. Such a facility would not be licensed to provide either intermediate or skilled nursing care.

Customary Charge (Rupp): One of the factors determining a physicians payment for a service under Medicare. It is partially calculated by the median physician charge for that service over a prior 12-month period.

Deductible (M&Y): The amount an enrollee must pay for health care or prescriptions, before Original Medicare, ones prescription drug plan or other insurance begins to pay. For example, in the Original Medicare Plan the beneficiary pays a new deductible for each benefit period for Part A and each year for Part B. These amounts can change every year.

Department of Health and Human Services (CMS): DHHS administers many of the social programs at the Federal level dealing with the health and welfare of the citizens of the United States. It is the parent of the Centers for Medicare and Medicaid Services (CMS).

Diagnosis-Related Group (DRG) (Rupp): System involving classification of medical cases and payment to hospitals on the basis of diagnosis. Used under Medicares prospective payment system to reimburse inpatient hospitals, regardless of the cost to the hospital to provide services.

Discount Drug List (CMS): A list of certain drugs and their proper dosages. The discount drug list includes the drugs the company will discount.

Drug Tier: See Tier

Dual Eligible or Dual Eligibility (CMS): Individuals who are entitled to Medicare Part A and/or Part B and who are also eligible for Medicaid.

Durable Medical Equipment (DME) (CMS): Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part A and Part B for home health services.

Election (CMS): An individuals decision to join or leave the Original Medicare Plan or a Medicare+Choice plan. Also see Plan Election Periods.

Enrollment Fee (CMS): The amount a Medicare beneficiary must pay every year to get a Medicare-approved drug discount card.

Enrollment Period (CMS): A certain period of time when an individual may join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.

Excess Charges (CMS): In the Original Medicare Plan, an excess charge is the difference between a doctors or other health care providers actual charge and the Medicare-approved payment amount.

Federal Qualification (Rupp): A status designated by HCFA after conducting an extensive evaluation of an HMOs organization and operations. An organization must be federally qualified or be designated as a competitive medical plan (CMP) to be eligible to participate in Medicare and cost and risk contracts.

Fee-for Service (FFS) (Rupp): Refers to payment made to providers for individual services rendered, as opposed to payment with salaries or under capitation.

Formulary (M&Y): A list of certain kinds of prescription drugs that a Medicare drug plan will cover subject to limits and conditions.

Fraud (CMS): As it applies to Medicare and Medicaid, the intentional billing of services that were never given or billing for a service that has a higher reimbursement rate than the service that was actually performed. Abuse is defined as billing for items or services that were delivered, but should not be paid for by Medicare. Billing for unapproved services may be either intentional or accidental on the part of providers. Abuse is not the same as fraud.

Freedom of Choice (Rupp): A principle of Medicaid, which allows a recipient the freedom to choose among participating Medicaid providers.

Free Look (CMS): Medigap policies contain a period of time, usually 30 days, when the insured can read the Medigap policy and return it for any reason. During this period of time the policy may be canceled with full refund of any premiums paid, unless a claim has been made, in which case the amount of the paid claim may be deducted from the premium refunded.

Gatekeeping (Rupp): The process by which a primary care physician directly provides primary care and coordinates all diagnostic testing and specialty referrals required for a patients medical care. Referrals and some procedures must often be preauthorized by the gatekeeper, unless there is an emergency.

General Enrollment Period (GEP) (CMS): The General Enrollment Period is January 1 through March 31 of each year. If an individual enrolls in and begins paying premium for Part A or Part B during the General Enrollment Period, (not when first eligible for coverage at age 65) coverage begins on July 1.

Guaranteed Issue Rights (CMS): Also called Medigap Protections, they are rights the individual has in certain situations when insurance companies are required by law to sell or offer a Medigap policy. In these situations, an insurance company cannot deny insurance coverage or place conditions on a policy. It must cover the individual for all preexisting conditions and cannot charge more for the policy due to past or present health problems.

Guaranteed Renewable (CMS): The insurance company must automatically renew such policies or continue the Medigap policy, unless the insured makes untrue statements to the insurer, commits fraud, or does not pay premiums in a timely manner, as required by the policy contract.

Health Care Financing Administration (HCFA) (Rupp): The federal agency responsible for administering Medicare and for overseeing the states management of Medicaid. This agency is within the Department of Health and Human Services.

Health Maintenance Organization Plan (M&Y): A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, the enrollee can only go to doctors, specialists, or hospitals that are on the plans list, except in an emergency. Plan costs may be lower than many Original Medicare Plans.

Home Health Agency (CMS): An organization that provides home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.

Home Health Care (CMS): From a Medicare standpoint, limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment, medical supplies and other services.

Hospice (CMS): A special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (hospital insurance).

Hospital Coinsurance (CMS): Amounts for which the Medicare patient is responsible (unless an insurance policy has been purchased). From the 61^st through 90^th day of hospitalization in a benefit period, a daily amount accrues for which the patient is responsible; it is equal to one-fourth of the Medicare inpatient hospital deductible; for Medicare lifetime reserve days, a daily amount for which the patient is responsible; it is equal to one-half of the inpatient Medicare hospital deductible.

Initial Enrollment Period (CMS): The Initial Enrollment Period is the first chance and individual has to enroll in Medicare Part B. Your Initial Enrollment Period starts three months before the beneficiary first meets all the eligibility requirements for Medicare and lasts for seven months.

Initial Enrollment Questionnaire (IEQ) (CMS): A questionnaire sent to an individual when he or she becomes eligible for Medicare to find out if the individual has other insurance that should pay the medical bills prior to Medicare paying.

In-Plan Services (Rupp): Services that are covered under the state Medicaid plan and included in the patients managed care contract and/or are furnished by a participating provider.

Institution (M&Y): A facility that meets Medicares definition of a long-term care facility, such as a nursing home or skilled nursing facility; doesnt include assisted living or adult living facilities, or residential homes.

Intermediary (CMS): A private company that has a contract with Medicare to pay Part A and some Part B bills.

Intermediate Care Facility (CMS): A facility that primarily provides health-related care and services above the level of custodial care; while not providing the type of care qualifying as skilled medical care, it is a higher level of care than custodial. If the facility is not also licensed as a skilled care facility it would not be able to provide services for Medicare in most cases, since Medicare pays only for skilled care.

Lifetime Reserve Days (CMS): Sixty days that Medicare will pay for when a beneficiary is in a hospital for more than 90 days. These 60 reserve days can be used only once during the patients lifetime (thus the name). For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance amount, which will vary from year to year. Consult Medicares Medicare & You handbook for current coinsurance amounts.

Limiting Charge (CMS): In the Original Medicare Plan, the highest amount of money a patient can be charged for a covered service by doctors and other health care suppliers who dont accept assignment. The limiting charge is 15% over Medicares approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.

Lock-In (Rupp): A contractual provision by which members are required to use certain health care providers in order to receive coverage (except in cases of urgent or emergent need).

Long-Term Care: (M&Y): A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare does not pay for this type of care if it is the only kind that is needed (only skilled nursing care is covered by Medicare).

Managed Care Organization (MCO) (Rupp): An organization that provides practice management, administrative, and support service to individual physicians or group practices. It may also be known as a Medical Service Organization or a Shared Services Organization (SSO).

Medicaid (M&Y): 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 the person qualifies for both Medicare and Medicaid.

Medically Necessary (M&Y): Services or supplies that are needed for the diagnosis or treatment of an individuals medical condition, are provided for the diagnosis, and treatment of medical conditions, meets the standards of good medical practice in the local area, and is not mainly for the convenience of the patient or the patients family.

Medicare Advantage Plans (M&Y): A plan offered by private companies that contract with Medicare to provide all Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. A Medicare Advantage Plan can be an HMO, PPO, or a Private Fee-for-Service Plan.

Medicare-Approved Amount (M&Y): In the Original Medicare Plan, this is the amount a doctor or supplier can be paid, including what Medicare pays and any deductible, coinsurance, or copayment that must be met by the patient.

Medicare Cost Plan (M&Y): A Medicare Cost Plan is a type of HMO. In a Medicare Cost Plan, if the enrollee receives services outside of the plans network without a referral. The patients Medicare-covered services will be paid for under the Original Medicare Plan, except the plan pays for emergency services, or urgently needed services outside the normal service area.

Medicare Health Plan (M&Y): A Medicare Advantage Plan (such as an HMO, PPO, or Private Fee-for-Service Plan) or other plan such as a Medicare Cost Plan. Everyone who has Medicare Part A and Part B is eligible for a plan in their area, except those who have End-Stage Renal Disease (unless certain exceptions apply).

Medicare Medical Savings Account Plan (MSA) (CMS): 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 pay for medical expenses.

Medicare Prescription Drug Plan (M&Y): A stand-alone drug plan, offered by insurance or other private companies to add prescription drug coverage to the Original Medicare Plan, Medicare Private Fee-for-Service Plans that do not have prescription drug coverage, and Medicare Cost Plans.

Medicare SELECT (CMS): A type of Medigap policy that may require the participant to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Medicare Summary Notice (MSN) (CMS): A notice the participant receives after the doctor or provider 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 amount remains for the patient or the patients insurance policy to pay.

Medigap Policy (M&Y): Medicare supplement insurance sold by private insurance companies to fill in the gaps in the Original Medicare Plan coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 standardized plans labeled Plans A through L. Medigap policies only work with the Original Medicare Plan.

NCQA (Rupp): National Committee for Quality Assurance.

Network (Rupp): A list of physicians, hospitals, and other medical providers who provide health care services to the beneficiaries of a specific managed care organization.

Non-covered Service (CMS): Medicare will not pay for some services if it does not meet the requirements of a Medicare benefit category, is statutorily excluded from coverage on grounds other than 1862(a)(1), or is not reasonable and necessary under 1862(a)(1).

Nursing Facility (CMS): A facility which primarily provides skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons on a regular basis. Care in a nursing facility is more complex than that given in a custodial care or intermediate care facility. Many facilities combine all levels of care.

Open Enrollment Period (CMS): A one-time-only six month period when an individual can purchase any Medigap policy desired that is available in the state of residence. It starts in the first month in which the individual is 65 years old and covered by Medicare Part B. During this time, the applicant many not be denied coverage or charged more due to past or present health problems. Even smoker rates would not apply to a smoker during this time period.

Original Medicare Plan (M&Y): A fee-for-service health plan that allows the beneficiary to go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. The beneficiary must pay the deductible. Medicare pays its share of the Medicare-approved amount, and then the beneficiary pays his or her share (coinsurance). In some cases the beneficiary may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Out-of-Network Provider (Rupp): A health care provider with whom a managed care organization does not have a contract to provide health care services. Because the beneficiary must pay all or part of the costs of care from an out-of-network provider, these providers are not generally accessible to Medicaid beneficiaries but may be available to Medicare beneficiaries.

Peer Review Organization (PRO) (Rupp): An organization established by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 to review quality of care and appropriateness of admissions, readmissions, and discharges for Medicare and Medicaid. These organizations are held responsible for maintaining and lowering admission rates, reducing lengths of stay, while insuring against inadequate treatment.

Penalty (M&Y): An amount added to a recipients monthly premium for Medicare Part B, or for a Medicare drug plan, if he or she did not join when first eligible. The beneficiary pays the higher amount as long as he or she has Medicare. There are some exceptions.

Personal Care (CMS): Nonskilled, personal care, such as help with the activities of daily living. It may also include care that most people do for themselves, like using eye drops. The Medicare home health benefit does not pay for personal care services.

Physician Payment Review Commission (Rupp): Established by Congress in 1986, its job is to advise on reforms being considered regarding Medicare payment of physician services. It submits a report to Congress annually.

Plan Election Period (CMS): The Plan 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. This may also be referred to as the Annual Election Period.

Point-of-Service (POS) (M&Y): An HMO option that allows their membership to use doctors and hospitals outside their plan for an additional cost.

Preferred Provider Organization Plan (PPO) (M&Y): A type of Medicare Advantage Plan in which the member pays less if he or she uses doctors, hospitals, and providers that belong to the network. The member can use doctors, hospitals, and providers outside the network for an additional cost.

Preferred Providers (Rupp): Physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan.

Premium (M&Y): The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.

Primary Care Physician (Rupp): A generalist such as a family practitioner, pediatrician, internist, or obstetrician. In a managed care organization, a primary care physician is accountable for the total health services of enrollees including referrals, procedures and hospitalization.

Private Fee-for-Service Plan (M&Y): A type of Medicare Advantage Plan in which the enrollee may go to any Medicare-approved doctor or hospital that accepts the plans payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what the insured pays for their portion of the services. The insured may pay more or less for Medicare-covered benefits. There may be extra benefits that the Original Medicare Plan does not cover.

Prospective Payment System (CMS): A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service. The DRGs for inpatient hospital services would be an example of this.

Provider Sponsored Organization (PSO) (CMS): A group of doctors, hospitals, and other health care providers that have agreed to give health care to Medicare beneficiaries for a set amount of money from Medicare each month. This type of managed care plan is run by the doctors and providers themselves, not by an insurance company. It is often grouped under managed care plans.

Qualified Medicare Beneficiary (QMB) (CMS): A Medicaid program for beneficiaries who need help paying for their Medicare services. The beneficiary must have Medicare Part A and limited income and resources. For those who qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.

Quality Improvement Organization (CMS): Groups of practicing doctors and other health care experts who are paid by the federal government to check on and improve the care given to Medicare patients. They must review complaints concerning quality of care in hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for-Service Plans, and ambulatory surgical centers.

Recipient (CMS): The previous term for an individual covered by the Medicaid program that is now referred to as a beneficiary.

Referral (M&Y): A written okay from a primary care doctor for the insured to see a specialist or get certain services. In many HMOs, the insured needs to get a referral before he or she can get the care form anyone other than their primary care doctor. Without a referral the plan may not pay for the service, even if they otherwise would have.

Resource-Based Relative Value Scale (RBRVS) (Rupp): Established as part of the Omnibus Reconciliation Act of 1989, Medicare payment rules for physician services were altered by established an RBRVS fee schedule. This payment methodology has three components: a relative value for each procedure, a geographic adjustment factor, and a dollar conversion factor.

Respite Care (CMS): Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off.

Service Area (CMS): The area where a health plan accepts members. For plans that require the individual to use their doctors and hospitals, it is also the area where services are provided. The plan may dis-enroll a member if he or she moves out of their service area.

Skilled Nursing Facility Care (M&Y): This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, could not be provided on an outpatient basis. Skilled care would include such things as intravenous injections and physical therapy. The need for custodial care, which would include assistance with activities of daily living like bathing or dressing, cannot qualify an individual for Medicare coverage in a skilled nursing facility. However, if the individual qualifies for coverage based on their need for skilled nursing or rehabilitation, Medicare will then cover all their care needs in the facility, including such things as dressing or bathing.

Special Enrollment Period (CMS): A set time when an individual can sign up for Medicare Part B if he or she didnt take Medicare Part B during the Initial Enrollment Period because they or their spouse were working and had group health plan coverage through the employer or union. An individual can sign up at any time he or she is covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment ends or the group health coverage ends, whichever comes first.

Special Needs Plan (M&Y): A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, or those who reside in a nursing home.

Spell of Illness (CMS): A period of consecutive days, beginning with the first day on which a beneficiary is furnished inpatient hospital or extended care services and ending with the close of the first period of 60 consecutive days thereafter in which the beneficiary is in neither a hospital nor a skilled nursing facility.

Spend Down (Rupp): A term used in Medicaid for persons whose income and assets are above the threshold for the states designated medically needy criteria, but are below this threshold when medical expense are factored in.

State Health Insurance Assistance Program (M&Y): A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

Telemedicine (M&Y): Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.

Teletypewriter (TTY) (M&Y): A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who do not have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.

Tier (CMS): A tier is a specific list of drugs. Each plan may have several tiers with copayment amounts depending on which tier the drug is listed in. Plans can choose their own tiers so members should refer to their benefit booklet or contact the plan for more information.

Tricare (CMS): A health care program for active duty and retired uniformed services members and their families.

Tricare for Life (TFL) (CMS): Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.

Unassigned Claim (CMS): A claim submitted for a service or supply by a medical provider that does not accept Medicare assignment.

Urgently Needed Care (CMS): Care given for a sudden illness or injury that needs medical care right away, but is not life threatening. The primary care doctor generally provides urgently needed care if the patient is in a Medicare health plan other than the Original Medicare Plan. If the patient is out of his her plans service area for a short time and cannot wait until he or she returns home, the health plan must pay for urgently needed care.

Value Added Items and Services (VAIS) (RUPP): Items and services offered to plan members by their plan that does not meet the definition of benefits under the Medicare program and involves only administrative or minimal costs.

Waiting Period (CMS): The time between purchase of a Medigap insurance policy or a Medicare health plan and the point when coverage for all medical conditions begins, even those that existed at the time of purchase.

There may be additional terms relating to Medicare. We could become very technical if we wanted to be. For use with the general public, however, these are the most likely terms to see in general use.

End of Chapter Seven

End of Course