Glossary of Terms

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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.
Accreditation A seal of approval. Being accredited means that a facility has met certain quality standards. These standards are set by private nationally recognized groups that check on the quality of care at health care facilities.
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.
Advance Beneficiary Notice (ABN) A notice that a doctor or supplier should give a Medicare beneficiary to sign in the following cases:

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 are not responsible for paying for that service. If the doctor does give you an ABN, which you agree to sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor for the service. ABN only applies if you are in the Original Medicare Plan. It does not apply if you are in a Medicare managed care plan. (See definition of the Original Medicare Plan.)

Advance Directives Your written statement, also called a Living Will, that tells others how you would like to receive health care, including routine treatments and life-saving methods, if you are unable to do so. You can also choose someone to act on your behalf (your Health Care Proxy) to make medical decisions if you are unable to do so. In New York State, a properly executed Health Care Proxy is considered acceptable documentation of a person's wishes.
Affiliated Provider A health care provider or facility that is paid by a health plan to give services to health plan members.
Ancillary Services Professional services by a hospital or other inpatient health program. These may include x-ray, drug, laboratory or other services.
Ambulatory Care All types of health services that do not require an overnight hospital stay.
Ambulatory Surgical Center A free-standing facility or separate part of a hospital that does outpatient surgery.
Appeals 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 a 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, 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 medical service covered under Medicare Part B (Medical Insurance). It may be less than the actual amount charged. Approved Amount is sometimes also called "Approved Charge." (See Actual Charge, Assignment.)
Area Agencies on Aging (AAA) Local government agencies, which contract with public and private organizations to provide services for seniors within their area.
Assessment The rating of your health status and care needs done by staff in a hospital, nursing home, home care agencies, or other health care settings.
Assignment In the Original Medicare Plan, a process through which a doctor or supplier agrees to accept the amount of money Medicare approves for their fees as payment in full. You must pay any coinsurance amount. (See Actual Charge; Approved Amount.)
Assisted living A type of living arrangement where 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. They typically pay additional fees for the services they get.
Beneficiary The name for a person who has health care insurance through the Medicare or Medicaid Program.
Benefits The money or services offered to a beneficiary by an insurance policy. In Medicare or a health plan, benefits take the form of health care.
Board and care home A type of group living arrangement designed to meet the needs of people who cannot live on their own. These homes offer help with some personal care services.
Case Management A process used by a doctor, nurse, or other health care professional to manage your care and health-related matters. Case management makes sure that needed services are given, and keeps track of the use of facilities and resources.
The Centers for Medicare & Medicaid Services (CMS) The federal agency within the Department of Health and Human Services that runs the Medicare, Medicaid, Clinical Laboratories (under CLIA program), and Children's Health Insurance programs, and works to make sure that the beneficiaries in these programs are able to get high quality health care.
Claim A claim is a request for payment for a provided service. "Claim" and "Bill" are used for all Part A and Part B services billed through Fiscal Intermediaries. "Claim" is used for Part B physician/supplier services billed through the Carrier.
Coinsurance The percent of the Medicare-approved amount that you have to pay after you pay the deductible for Part A and/ or Part B. In the Original Medicare Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).
Community-Based Services Those services that are designed to help older people remain independent and in their own homes. These services can include senior centers, transportation, delivered meals or meal sites, visiting nurses or home healthcare depending on specific conditions and individual needs.
Confidentiality Your right to talk with your health care provider without anyone else finding out what was discussed.
Continuing Care Retirement Community (CCRC) A housing community that provides different levels of care based on what each resident needs over time. This is sometimes called "life care" and can range from independent living in an apartment to assisted living to fulltime care in a nursing home. Residents move from one setting to another based on their needs but continue to live as part of the community. Care in CCRCs is usually expensive. Generally, CCRCs require a large payment before you move in and charge monthly fees.
Copayment In some Medicare health plans, this is the amount that you pay for each medical service you get, like a doctor visit. In the Medicare program, a copayment is usually a set amount you pay for a service, like $5.00 or $10. 00 for a doctor visit.
Cost Sharing The cost for medical care that you pay yourself, like a copayment, coinsurance, or deductible.
Coverage The extent of financial protection provided by an insurance company.
Custodial Care Personal care, such as bathing, cooking, and shopping, that is not covered by the Medicare program.
Deductible The amount you must pay for health care, before Medicare begins to pay. There is a 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 (DHHS) Administers the Medicare program through its divisions, Social Security Administration and The Centers for Medicare & Medicaid Services.
Diagnosis The identification of a disease from its signs and symptoms.
Diagnosis Related Groups (DRGS) A way for Medicare to pay hospitals based on diagnosis, age, sex, and complications.
Discharge Planning The process that social workers or other health professionals use to decide what a patient needs to make a smooth transition from one level of care to another, such as from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient's home care.
Disenroll Leaving or ending your health care coverage with a health plan.
Do Not Resuscitate (DNR) Order An order by an attending physician, with patient consent (or possibly by surrogate consent) that directs hospital personnel not to revive the patient if cardio-pulmonary arrest occurs. In some locations people may exercise a DNR order that protects them from resuscitation at home or in alternate settings.
Durable Medical Equipment Regional Carrier (DMERC) They can tell you what durable medical equipment is covered by Medicare and what the Medicare approved amount is.
Durable Medical Equipment (DME) 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 Medicare Part B.
Elderly Pharmaceutical Insurance Coverage (EPIC) Coverage that can help Medicare beneficiaries pay for their prescription medicine, depending on income. Available in New York State only.
Emergency Care Care to treat severe pain, an injury, sudden illness, or suddenly worsening illness that you believe may cause serious danger to your health if you do not get immediate medical care. Medicare health plans must provide access to emergency care services 24 hours a day, 7 days a week. Your plan must pay for your emergency care and cannot require prior approval for emergency care you receive from any provider. You can receive emergency care anywhere in the United States. Under the Original Medicare Plan, you can always go to any hospital of your choice, not only in an emergency.
Enrollment Period of time during which people can enroll in an insurance policy, original Medicare or Health Maintenance Organization (HMO).
ESRD Patient A person with irreversible and permanent kidney failure who requires a regular course of dialysis or kidney transplantation to maintain life.
Fast Track Appeal An appeal right for Medicare Advantage (formerly Medicare + Choice) enrollees whereby they can request a "fast" appeal when they have been advised in writing that services they received in a skilled nursing facility, home health agency or comprehensive outpatient rehabilitation facility that were arranged by their health plan may be terminated.
Fiscal Intermediary (FI) A private insurance company that contracts with the Centers for Medicare & Medicaid Services (CMS) to process beneficiary bills (claims) for Medicare Part A Services.
Formulary A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the plan's formulary.
Fraud and Abuse
Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided.
Abuse: Sending in claims or bills for services that should not be paid by Medicare or Medicaid. This is not the same as fraud.
Free Look (Medigap) Period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled.
Gaps (also called Medicare Gaps) The costs or services that are not paid for under the Original Medicare Plan.
Gatekeeper Primary care physicians, otherwise known as gatekeepers, are responsible for coordinating and managing the patient's medical care. This physician is also responsible for referring the patient to a specialist or other health care facility.
Generic Drugs A generic drug is a copy that is the same as a brand name drug in dosage, safety, strength, how it is taken, quality performance and intended use.
Grievance Complaints about the way your Medicare health plan is providing your care (other than complaints concerning your request for a service or payment), such as cleanliness of the health care facility, problems calling the plan by phone, staff behavior, or operating hours.
Group or Network HMO A health plan that contracts with group practices of doctors to provide health care services in one or more places.
Guaranteed Renewable Policy A medical policy that your insurance company must allow you to continue unless you do not pay your premiums.
Health care provider A person who is trained and licensed to give health care. Also, a place licensed to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies are examples of health care providers.
Health Care Proxy or Durable Power of Attorney for Health Care A legal document naming an agent who will make health care decisions about life sustaining medical procedures, if the individual signing becomes incapable of making or communicating decisions. New York State recognizes a properly executed Health Care Proxy.
Health Employer Data and Information Set (HEDIS®) A set of standard performance measures that can give you information about the quality of a health plan. You can get information on the effectiveness of care, access, cost, and other measures you can use to compare the quality of managed care plans. The National Committee for Quality Assurance (NCQA) collects HEDIS data. (See National Committee for Quality Assurance.)
Health Insurance Information Counseling and Assistance Program (HIICAP) HIICAP offers free current unbiased information on Medicare, Medigap policies, Medicare HMOs, Medicaid eligibility, and long term care insurance. HIICAP counselors help beneficiaries with their questions and paperwork. In New York call 1-800-333-4114.
Health Maintenance Organization (HMO) A group of doctors, hospitals, and other health care providers who have agreed to provide care to Medicare beneficiaries in exchange for a fixed amount of money from Medicare every month. In an HMO, you usually must get all your care from the providers that are part of the plan.
Health Maintenance Organization (HMO) with a Point of Service Option (POS) A type of managed care plan that allows you to use doctors and hospitals outside the plan for an additional cost.
Heart Attack A heart attack (also called an acute myocardial infarction or AMI) occurs when the arteries leading to the heart become blocked, and the blood supply is stopped. When the heart muscle can't get the oxygen and nutrients it needs, the part of the heart tissue that is affected dies. Heart attacks can last for several hours. (Seek help right away if you think an attack is beginning.)
Heart Failure Heart failure is a weakening of the heart's pumping power that increases the pressure in the heart. Not enough oxygen and nutrients are pumped through the body to meet its needs. The heart tries to pump more blood by stretching its chambers, but the muscle walls become weaker over time.
Hospital Issued Notice of Noncoverage (HINN) Document issued by a hospital stating that Medicare will no longer pay for the hospital stay, due to the patient no longer needing acute or skilled services.
Home Health Agency An organization that provides home care services, including skilled nursing care, physical therapy, occupational therapy, speech therapy, and care by home health aides.
Home Health Care Health care that is given at home, such as physical therapy or skilled nursing care. It is different from at-home recovery care, which is help with bathing, eating, and other daily living activities. (See Activities of Daily Living.)
Hospice A special way of caring for people with a terminal illness that provides medical, emotional, and social help in a comfortable and familiar place, usually the patient's own home. Hospice care is covered by Medicare whether you are in the Original Medicare Plan or another Medicare health plan.
Hospital Insurance (Part A) The part of Medicare that covers hospice care, home health care, skilled nursing facilities, and inpatient hospital stays.
Lifetime Reserve Days Sixty days that Medicare will pay for when you are in a hospital for more than 90 days. These 60 reserve days can be used only once in a lifetime. For the lifetime reserve days (91-150) Medicare pays for all covered costs except for coinsurance. In 2008, the co-payment will be $512 per day for days 91-150.
Living Will A written, signed and witnessed document or provision in a document, expressing in advance the signer's wishes regarding the use of extreme life supporting measures, if the signer is terminally ill and unable to express his/her wishes. Many states have enacted statutes that enable a person to execute a living will.
Long-Term Care A variety of services that help people with health or personal needs and activities of daily living over a long period of time. Long term care can be provided at home, in the community, or various types of facilities. Most long term care is "custodial" care. Medicare does not pay for custodial care.
Long-Term Care Ombudsman An independent advocate or supporter for nursing home and assisted living residents who works to solve problems between residents and nursing homes or assisted living facilities. In New York State, the number is 1-800-342-9871.
Managed Care Plan A group of doctors, hospitals, and other health care providers who have agreed to give health care to Medicare beneficiaries in exchange for a fixed amount of money from Medicare every month. Managed care plans include Health Maintenance Organizations (HMO), HMOs with a Point of Service Option (POS), Provider Sponsored Organizations (PSO), and Preferred Provider Organizations (PPO).
Mediation An approach to resolving or settling complaints or differences between two parties. It can be used effectively in health care situations.
Medicaid A joint federal and state program that helps with medical costs for 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, outpatient hospital care, and other medical services that Part A doesn't cover, such as physical and occupational therapy.
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 (ESRD) (those with permanent kidney failure who need dialysis or a transplant).
Medicare Benefits Notice A notice you get after your doctor files a claim for Part A services under the Original Medicare Plan. This notice explains what the provider billed for, the 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-Certified This means a health facility has met certain quality standards. Medicare only covers care in hospitals that are certified or accredited.
Medicare Advantage (formerly Medicare+Choice) A Medicare program that allows for more choices among Medicare health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.
Medicare Coverage Medicare coverage is made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B).
Medicare Part A (Hospital Insurance) Medicare hospital insurance that pays for hospice care, home health care, care in a skilled nursing facility, and inpatient hospital stays. (See Hospital Insurance.)
Medicare Part B (Medical Insurance) Medicare 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.)
Medicare Summary Notice (MSN) A notice you receive after the doctor files a claim for Part A and Part B services under the Original Medicare Plan. This notice explains what the provider billed for, the approved amount, how much Medicare paid, and what you must pay.
Medicare Saving Programs (Help from Medicaid paying Medicare premiums) States have programs for people with limited income and resources that pay Medicare premiums and, in some cases, may also pay Medicare Part A and Part B deductibles and coinsurance. Additional information about qualifying for these programs can be obtained by calling 1-800-633-4227.
Medigap Medicare supplemental insurance policies that are sold by private insurance companies to Medicare beneficiaries to fill the "gaps" in Original Medicare Plan coverage. There are ten standardized policies, labeled Plan A through Plan J. Your State decides which of the 10 policies can be sold in your State. Medigap policies only work with the Original Medicare Plan. (See Gaps; Supplemental Insurance.)
Notice of Discharge and Medicare Appeal Rights (NODMAR) A written discharge notice that states if a beneficiary chooses to stay in the hospital, he/she will be responsible for services provided beginning on the third day after the notice has been received; the notice also explains the Medicare appeal process.
Notice of Medicare Benefits Statements that Medicare sends you to show what action was taken on a claim (See Explanation of Medicare Benefits; Medicare Benefits Notice; Medicare Summary Notice.)
Nursing home A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.
Occupational Therapy Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness.
Original Medicare Plan The traditional pay-per-visit health plan that lets you go to any doctor, hospital, or other health care provider who accepts Medicare. You pay the deductible. Medicare pays its share of the Medicare-approved mount, and you pay your share (coinsurance). The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
Out-Of-Pocket Costs Health care costs that you must pay because they are not covered by insurance.
Outpatient care Medical or surgical care that does not include an overnight hospital stay.
Pain Management A systematic study of clinical and basic sciences and their application for the reduction of pain and suffering. It involves knowledge and participation of patients and caregivers as well as professional staff.
Palliative Care Care provided to a terminally ill patient, often through a hospice program. It is intended to ease suffering and promote physical and emotional comfort but not to cure illness or prolong life.
Participating Facility, Provider, or Supplier A health care facility, doctor, or therapist, or equipment supplier that participates in Medicare and accepts payment for services received by Medicare beneficiaries.
Physical Therapy Treatment of injury and disease by mechanical means, such as heat, light, exercise, and massage.
Premium Your monthly payment for health care coverage to Medicare, an insurance company, or a health care plan.
Preferred Provider Organization (PPO) Managed care entities that contract with networks or panels of providers for servicing the PPO's enrolled population(s) and are paid on a negotiated fee scale basis.
Preventive Care Care to keep you healthy or to prevent illness, such as routine checkups and some tests like colorectal cancer screening, 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.
Private Contract A contract between you and a doctor or other provider who has decided not to offer services through the Medicare program. This doctor cannot bill Medicare for any service or supplies given to you and all his/her 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.
Private Fee-For-Service Plan A private insurance plan that accepts Medicare beneficiaries. You may go to any doctor or hospital you want. The insurance plan, rather than the Medicare program, decides how much you pay for the services you receive. You may pay more for Medicare covered benefits. You may have extra benefits the Original Medicare Plan doesn't cover.
Primary Payer The insurance company that pays first on a claim for someone on Medicare. This would be Medicare or some other insurance, i.e., an employee group health plan.
Procedure Something done to fix a health problem or learn more about it. For example, surgery, tests and putting in an IV line are procedures.
Quality Assurance The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and evaluating actions taken.
Quality Improvement Organization (QIO) Groups of practicing doctors and other health care experts paid by the federal government to monitor and improve the care given to Medicare patients. They must review your complaints about the quality of care provided by inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare managed care plans, and ambulatory surgical centers.
Qualified Medicare Beneficiaries (QMB) Persons who have Medicare Part A, low monthly incomes and limited resources, but who are not otherwise eligible for Medicaid. If you qualify for QMB, Medicaid pays for Part A-premium and deductibles and co-insurance amounts for services provided by Medicare providers. Check with your state, county or local Medicare Assistance office to see if you qualify for this program or other programs-In New York the number is 1-800-541-2831.
Quality Measures Are one way of measuring the degree to which a provider competently and safely delivers clinical services that are appropriate for the patient. Measures provide a way to compare one provider to another based on standards of care.
Respite Care One of the hospice care benefits that includes short-term relief for caregivers in the patient's home or in an inpatient facility covered by the patient's insurance.
Skilled Nursing Care A level of care that must be given or supervised by licensed nurses and is under the general direction of a doctor. Examples of Skilled Nursing Care include: getting intravenous injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound. Any service that could be safely performed by an average nonmedical person or one's self, without the direct supervision of a licensed nurse, is not covered.
Skilled Nursing Facility (SNF) A facility that provides skilled nursing or rehabilitation services to help with recovery after a hospital stay.
Social Security Administration (SSA) Determines eligibility for Medicare, handles enrollment and conducts Part A and Part B Hearings.
Speech-Language Therapy Treatment to regain and strengthen speech skills.
Supplemental Insurance There are many types of private health insurance/coverage that you can buy to supplement, or fill the gaps, in your Medicare coverage. This supplemental insurance will pay for some or all of your health care costs that are not covered by Medicare. These types of private health insurance/coverage include:

People often refer to all of these types of private health insurance/coverage as supplemental insurance. However, "Medicare Supplemental" or "Medigap" insurance is a specific type of private insurance that is subject to federal and state laws. (See Gaps; Medigap.)

Supplier A health care facility, doctor, or therapist, or equipment supplier that participates in Medicare and accepts payment for services received by Medicare beneficiaries.
Treatment Options The choices you have when there is more than one way to treat a health problem.
Urgently Needed Care An unexpected illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than the Original Medicare Plan. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.
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