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Definitions & Glossary of Terms

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

A
A "TIER": A specific list of drugs. Your plan may have several tiers, and your co-payment amount depends on which tier your drug is listed. Plans can choose their own tiers, so members should refer to their benefit booklet or contact the plan for more information.

ABUSE (PERSONAL): When another person does something on purpose that causes you mental or physical harm or pain.

ACCESS:The patient’s ability to get medical care, determined by factors such as the availability of medical services, their acceptability to the patient, the location of healthcare facilities, transportation, hours of operation, and the cost of care.

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.

ACCREDITED (ACCREDITATION): Means having a seal of approval. Being accredited means that a facility or health care organization 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 and organizations. Organizations that accredit Medicare Managed Care Plans include the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and the American Accreditation HealthCare Commission/URAC.

ACT/LAW/STATUTE:  Term for legislation that passed through Congress and was signed by the President or passed over his veto.

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.

ACTUAL CHARGE:  The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves. (See Approved Amount; Assignment.)

ACUTE CARE:  Medical services provided after an accident or for a disease, usually for a short time.

ADDITIONAL BENEFITS:  Health care services not covered by Medicare and reductions in premiums or cost sharing for Medicare-covered services. Additional benefits are specified by the MA Organization and are offered to Medicare beneficiaries at no additional premium. Those benefits must be at least equal in value to the adjusted excess amount calculated in the ACR. An excess amount is created when the average payment rate exceeds the adjusted community rate (as reduced by the actuarial value of coinsurance, co-payments, and deductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the adjusted excess, which will be used to pay for services not covered by Medicare and/or will be used to reduce charges otherwise allowed for Medicare-covered services. Additional benefits can be subject to cost sharing by plan enrollees. Additional benefits can also be different for each MA plan offered to Medicare beneficiaries.

ADEQUATE:  As used in the DMR regulations, this term means that services and supports are in compliance with the regulations of the Department.

ADJUSTED AVERAGE PER CAPITA COST (AAPCC):  An estimate of how much Medicare will spend in a year for an average beneficiary. (See Risk Adjustment.)

ADJUSTED COMMUNITY RATING (ACR):  How premium rates are decided based on members' use of benefits and not their individual use of benefits.

ADMINISTRATIVE LAW JUDGE (ALJ):  A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors.

ADMITTING PHYSICIAN:  The doctor responsible for admitting a patient to a hospital or other inpatient health facility.

ADULT:  An individual who is 18 years of age and over.

ADVANCE BENEFICIARY NOTICE (ABN):  A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it. If the doctor or supplier does give you an

ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor or supplier for it. ABN's only apply if you are in the Original Medicare Plan. They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan.

ADVANCE COVERAGE DECISION:  A decision that your Private Fee-for-Service Plan makes on whether or not it will pay for a certain service.

ADVANCE DIRECTIVE (HEALTH CARE):  Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.

ADVANCE DIRECTIVES:  A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.

ADVERSE SELECTION: Occurs when those joining a health plan have higher medical costs than the general population; if too many enrollees have higher than average medical costs, the health plan experiences adverse selection.

ADVOCATE:  A person who gives you support or protects your rights.

AFFILIATED PROVIDER:  A health care provider or facility that is paid by a health plan to give service to plan members.

AFTERCARE: Services that are administered following hospitalization or rehabilitation that are individualized for each patient’s needs.

ALLIANCE: A group of providers who join together to increase their savings by sharing resources and developing group purchasing arrangements.

ALLOWABLE COSTS: Charges for services that are reimbursable under a given health plan.

ALTERNATIVE DELIVERY SYSTEMS (ADS): A general term referring to any organized method of providing health care other than private practice, fee-for-service reimbursement.

AMBULATORY CARE: Outpatient medical services (not provided in a hospital). If the patient makes the trip to the doctor’s office or surgical center without an overnight stay, it is considered ambulatory care, but if he or she is treated at home, it is not.

AMBULATORY SETTING: A type of health care setting at which health services are provided on an outpatient basis. Ambulatory settings usually include clinics and surgery centers.

AMBULATORY SURGICAL CENTER: A place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, you may stay for only a few hours or for one night.

ANCILLARY CARE: Additional health care services performed, such as lab work and X-rays.

ANCILLARY SERVICES:  Professional services by a hospital or other inpatient health program. These may include x-ray, drug, laboratory, or other services.

ANESTHESIA:  Drugs that a person is given before surgery so he or she will not feel pain. A doctor or a specially trained nurse should always give anesthesia.

ANNUAL ELECTION PERIOD:  The Annual 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. (See Election Periods.)

APPEAL:  An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if Medicare doesn’t pay for an item or service you think you should be able to get. There is a specific process that your Medicare Advantage Plan or the Original Medicare Plan must use when you ask for an appeal.

APPEAL 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 an item or 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, or 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.)

APPROPRIATE:  As used in the DMR regulations, this term means that   a service or support or facility that is sufficient to provide the quality and quantity of staff, assistance, intervention, and environment to meet the individual's needs or objectives indicated in his or her ISP (see ISP).

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." (See Actual Charge; Assignment.)

AREA AGENCY ON AGING (AAA):  State and local programs that help older people plan and care for their life-long needs. These needs include adult day care, skilled nursing care/therapy, transportation, personal care, respite care, and meals.

AREA DIRECTOR (AD):  The person who manages and oversees the administration of a DMR Area Office as well as the services and supports this office offers to eligible individuals and families.

AREA OFFICE (AO):  One of 23 statewide locally based DMR offices responsible for the organization, coordination, and provision of services or supports to individuals and families who live within the office's service area.

ASSESSMENT:  The gathering of information to rate or evaluate your health and needs, such as in a nursing home.

ASSIGNED CLAIM:  A claim submitted for a service or supply by a provider who accepts Medicare assignment.

ASSIGNMENT:  In the Original Medicare Plan, this means a doctor agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor’s visit.

ASSISTED LIVING:  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 get.

AUTHORIZATION:  MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)

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B
BALANCE BILLING:  A situation in which Private Fee-for-Service Plan providers (doctors or hospitals) can charge and bill you 15% more than the plan's payment amount for services.

BASIC BENEFITS:  Basic Benefits includes both Medicare-covered benefits (except hospice services) and additional benefits.

BASIC BENEFITS (MEDIGAP POLICY):  Benefits provided in Medigap Plan A. They are also included in all other standardized Medigap policies. (See Medigap Policy.)

BEHAVIOR HEALTH CARE:  Provided for the treatment of mental and/or substance abuse disorders.

BENEFICIARY:  The name for a person who has health care insurance through the Medicare or Medicaid program.

BENEFIT PERIOD:  The way that Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven’t received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins if you are in the Original Medicare Plan. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

BENEFITS:  The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.

BENEFITS DESCRIPTION (PLAN):  The scope, terms and/or condition(s) of coverage including any limitation(s) associated with the plan provision of the service.

BIOLOGICALS:  Usually a drug or vaccine made from a live product and used medically to diagnose, prevent, or treat a medical condition. For example, a flu or pneumonia shot.

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.

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C
CAPITATION:  A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.

CAPITATION:  A way of pre-paying a health plan, provider, or hospital for health services based on a fixed monthly or yearly amount per person, no matter how few or how many services a consumer uses.

CAPPED RENTAL ITEM:  Durable medical equipment (like nebulizers or manual wheelchairs) that costs more than $150, and the supplier rents it to people with Medicare more than 25 percent of the time.

CARE PLAN:  A written plan for your care. It tells what services you will get to reach and keep your best physical, mental, and social well-being.

CAREGIVER:  A person who helps care for someone who is ill, disabled, or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a cost.

CARRIER:  A private company that has a contract with Medicare to pay your Medicare Part B bills. (See Medicare Part B.)

CARVE OUT:  A program delivery and financing arrangement by which certain health care services, often for certain populations, are administered and funded separate from general health care services.

CASE MANAGEMENT:  An active relationship between the DMR and individuals and families that provides support, guidance, problem-solving and assistance in accessing a range of supports such as community activities, educational opportunities, and other community resources (e.g. day care, health benefits, and medical supports.  See Community Resources).

CASE MANAGEMENT:  A process by which the services provided to a specific enrollee are coordinated and managed to achieve the best outcome, in the most cost-effective manner.

CASE MANAGER:  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.

CASE MIX:  The number and frequency of hospital admissions or managed care services utilized, reflecting the assorted needs and uses of a hospital’s or managed care organization’s resources.

CATASTROPHIC ILLNESS:  A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause you financial hardship.

CATASTROPHIC LIMIT:  The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges. Setting a maximum amount you will have to pay protects you.

CATEGORICAL ELIGIBILITY:  This refers to persons who qualify for coverage due to their membership in a given class or population, as opposed to their income.

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS):  The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

CENTRAL OFFICE:  The main headquarters of the Department of Mental Retardation located at 500 Harrison Avenue in Boston.

CERTIFICATE OF MEDICAL NECESSITY:  A form required by Medicare that allows you to use certain durable medical equipment prescribed by your doctor or one of the doctor’s office staff.

CERTIFIED (CERTIFICATION):  This means a hospital has passed a survey done by a State government agency. Being certified is not the same as being accredited. Medicare only covers care in hospitals that are certified or accredited.

CERTIFIED NURSING ASSISTANT (CNA):  CNA's are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom.

CERTIFIED REGISTERED NURSE ANESTHETIST:  A nurse who is trained and licensed to give anesthesia. Anesthesia is given before and during surgery so that a person does not feel pain. (See Anesthesia.)

CHILD:  Individual who is younger than 18 years of age.

CIVILIAN HEALTH AND MEDICAL PROGRAM (CHAMPUS):  Run by the Department of Defense, in the past CHAMPUS gave medical care to active duty members of the military, military retirees, and their eligible dependents. (This program is now called "TRICARE")

CLAIM:  A claim is a request for payment for services and benefits you received. 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 the Carrier. (See Carrier; Fiscal Intermediaries; Medicare Part A; Medicare Part B.)

CLAIMS REVIEW:  The method by which an enrollee’s health care service claims are reviewed before reimbursement is made.

CLINICAL BREAST EXAM:  An exam by your doctor/health care provider to check for breast cancer by feeling and looking at your breasts. This exam is not the same as a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.

CLINICAL PRACTICE GUIDELINES:  Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.

CLINICAL TRIALS:  Clinical trials are one of the final stages of a long and careful research process to help patients live longer, healthier lives. They help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care, like how well a new cancer drug works. The trials help doctors and researchers see if the new care works and if it is safe. They may also be used to compare different treatments for the same condition to see which treatment is better, or to test new uses for treatments already in use.

COGNITIVE IMPAIRMENT:  A breakdown in a person's mental state that may affect a person's moods, fears, anxieties, and ability to think clearly.

COINSURANCE (MEDICARE PRIVATE FEE-FOR-SERVICE PLAN):  The percentage of the Private Fee-for-Service Plan charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).

COINSURANCE (OUTPATIENT PROSPECTIVE PAYMENT SYSTEM):  The percentage of the Medicare payment rate or a hospital's billed charge that you have to pay after you pay the deductible for Medicare Part B services.

COINSURANCE:  The percentage of the costs of medical services paid by the patient. This is a characteristic of indemnity insurance plans and PPO plans (see definition). The coinsurance is usually 20 percent of the cost of medical services, after the deductible is paid.

COMMUNITY:  A city, town, district, neighborhood, or other commonly recognized geographical, social, or political area.

COMMUNITY MENTAL HEALTH CENTER:  A place where Medicare patients can go to receive partial hospitalization services.

COMMUNITY RESOURCES:  Workplaces, businesses, places of worship, social groups, consultants, health care facilities or professionals, places for recreation or entertainment, and other facilities, professionals, or supports generally available to the population-at-large within a community.

COMPETENT:  Means a person is capable of making informed decisions in specific areas regarding the conduct of one's personal and/or financial affairs.

COMPLAINT:  (See Grievance.)

COMPREHENSIVE CARE:  A system of care that covers primary (including prevention), secondary, and tertiary care and addresses physical health, mental health, nutrition, and oral health. The system

integrates health and health related services with education, social services, and family support systems.

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF):  A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation.

CONCURRENT REVIEW:  An assessment of the medical necessity or appropriateness of services that occurs while they are being completed.

CONDITIONAL PAYMENT:  A payment made by Medicare for services for which another payer is responsible.

CONFIDENTIALITY:  Your right to talk with your health care provider without anyone else finding out what you have said.

CONSENT:  Voluntary approval given by a person who has adequate information, knowledge and understanding to comprehend the consequences of the decision.

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA):  A law that lets some people keep their employer group health plan coverage for a period of time after: the death of your spouse, losing your job, having your working hours reduced, leaving your job voluntarily, or getting a divorce. You may have to pay both your share and the employer’s share of the premium. Generally, you also have to pay an administrative fee.

CONSUMER ASSESSMENT OF HEALTH PLANS STUDY (CAHPS):  An annual nationwide survey that is used to report information on Medicare beneficiaries' experiences with managed care plans. The results are shared with Medicare beneficiaries and the public.

CONSUMER REGISTRY SYSTEM (CRS):  The internal DMR information database system that tracks past and current service information on individuals who are known to the DMR service system. Type of information entered can include: name, social security number, date of birth, address, area of tie, date of eligibility, diagnosis, and other pertinent information.

CONTINUATION OF ENROLLMENT:  Allows MCO’s to offer enrollees the option of continued enrollment in the M+C plan when enrollees leave the plan’s service area to reside elsewhere. CMS has interpreted this to be on a permanent basis. M+C Organizations that choose the continuation of enrollment option must explain it in marketing materials and make it available to all enrollees in the service area. Enrollees may choose to exercise this option when they move or they may choose to unenroll.

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 full-time 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 CCRC’s is usually expensive. Generally, CCRC’s require a large payment before you move in and charge monthly fees.

CONTINUITY OF CARE:  Comprehensive care that is provided during all transitions, such as hospital to home, home to hospital, etc. Planning ensures linkages with education, health, and community resources.

CONTINUOUS QUALITY (CQI):  A management principle that emphasizes the improvement of the process of service delivery through the use of creative approaches, monitoring, feedback, and organizational learning.

CONTINUUM OF CARE:  An array of services that meets the needs of the covered population in an appropriate and cost-effective manner.

COORDINATED CARE:  The system that has services that are coordinated to assure timeliness, appropriateness, continuity, and completeness of care.

COORDINATION OF BENEFITS:  Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called crossover.

COORDINATION PERIOD:  A period of time when your employer group health plan will pay first on your health care bills and Medicare will pay second. If your employer group health plan doesn't pay 100% of your health care bills during the coordination period, Medicare may pay the remaining costs.

CO-PAYMENT:  What a consumer pays for each health visit or services rendered; usually under $10.00.

COST EFFECTIVENESS:  The degree to which a service meets its intended goal at an acceptable cost.

COST SHARING:  Financing arrangements such as deductibles, co-payments, and coinsurance that shift some of the cost of services to the covered person.

CORI:  Criminal Offender Records Information that DMR and other state agencies review to determine appropriateness of present or prospective direct care staff and volunteers to work with DMR consumers.

COVERAGE BASIS:  The M+C Plan charge schedule used to base the maximum dollar coverage or coinsurance level for a service category (e.g., a $500 annual coverage limit for a prescription drug benefit may be based on a Published Retailed Price schedule, or 20% coinsurance for DME benefit may be based on a Medicare FFS fee schedule).

COVERED BENEFIT:  A health service or item that is included in your health plan, and that is paid for either partially or fully.

COVERED CHARGES:  Services or benefits for which a health plan makes either partial or full payment.

CREDENTIALING:  Examination of a physician or other health care provider’s credentials to determine whether they should be entitled to clinical privileges at a hospital or managed care organization.

CREDITABLE COVERAGE:  Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. (See Pre-existing Conditions.)

CRITICAL ACCESS HOSPITAL:  A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.

CUSTODIAL CARE:  Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

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D
DECISION TREE:  The decision tree, the basic rational means for decision review, is a way of showing the concrete and reasonable steps of a clinical decision problem. Its form highlights three structural components: the options available, the probable events that follow, and the outcomes for the patient.

DEDUCTIBLE (MEDICARE):  The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. (See Benefit Period; Medicare Part A; Medicare Part B.)

DEDUCTIBLE:  Annual amount that a consumer agrees to pay for health services before an insurance plan pays.

DEEMED:  Providers are deemed when they know, before providing services, that you are in a Private Fee-for-Service Plan, and they agree to give you care. Providers that are deemed agree to follow your plan’s terms and conditions of payment for the services you get.

DEFICIENCY (NURSING HOME):  A finding that a nursing home failed to meet one or more federal or state requirements.

DEHYDRATION:  A serious condition where your body's loss of fluid is more than your body's intake of fluid.

DELIVERY SYSTEM:  An organized array of service providers coordinated to deliver a set package of services.

DEMAND REDUCTION:  A strategy for reducing health care costs by reducing the demand for services.

DEMAND RISK:  The risk that enrollees may demand different levels of service than what was projected.

DENIAL OF CARE:  The determination that a request for service is inappropriate or not medically necessary.

DESIGNATED PROVIDER:  An organization or individual with which a health plan contracts to provide services.

DIABETIC DURABLE MEDICAL EQUIPMENT:  Purchased or rented ambulatory items, such a glucose meters and insulin infusion pumps, prescribed by a health care provider for use in managing a patient's diabetes, as covered by Medicare.

DIAGNOSIS:  The name for the health problem that you have.

DIAGNOSTIC RELATED GROUPS:  A classification system for service payments based on a person’s primary and secondary diagnoses, demographics, and complicating factors.

DIALYSIS:  Dialysis is a treatment that cleans your blood when your kidneys don’t work. It gets rid of harmful wastes and extra salt and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they are not a cure for permanent kidney failure (See hemodialysis and peritoneal dialysis.).

DIETHYLSTILBESTROL (DES):  A drug given to pregnant women from the early 1940s until 1971 to help with common problems during pregnancy. The drug has been linked to cancer of the cervix or vagina in women whose mother took the drug while pregnant.

DISCHARGE PLANNING:  A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves 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.

DISCOUNT DRUG LIST:  A list of certain drugs and their proper dosages. The discount drug list includes the drugs the company will discount.

DISENROLL:  Ending your health care coverage with a health plan.

DISENROLLMENT:  The termination or ending of enrollment for an individual or group by a health plan.

DMR:  Department of Mental Retardation.

DPPC:  Disabled Persons Protection Commission

DRUG MAINTENANCE LIST:  Also called an "additional drug benefit list," it is a catalog of a limited number of prescription medications, as designated by a managed health care organization, commonly prescribed by health care providers for long-term patient use. This list is usually modified on a regular basis.

DRUG TIERS:  Drug tiers are definable by the plan. The option “tier” was introduced in the PBP to allow plans the ability to group different drug types together (i.e., Generic, Brand, Preferred Brand). In this regard, tiers could be used to describe drug groups that are based on classes of drugs. If the “tier” option is utilized, plans should provide further clarification on the drug type(s) covered under the tier in the PBP notes section(s). This option was designed to afford users additional flexibility in defining the prescription drug benefit.

DUAL ELIGIBLES:  Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.

DUMPING:  Generic term referring to obtaining care for an enrollee at the expense of another party.

DURABLE MEDICAL EQUIPMENT:  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 B and Part A for home health services.

DURABLE MEDICAL EQUIPMENT (DME):  Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant or clinical nurse specialist) for use in the home. A hospital or nursing home that mostly provides skilled care can’t qualify as a home in this situation. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC):  A private company that contracts with Medicare to pay bills for durable medical equipment.

DURABLE MEDICAL EQUIPMENT:  Necessary medical equipment that is not disposable, (e.g., wheelchairs, walkers, ventilators, etc.).

DURABLE POWER OF ATTORNEY:  A legal document that enables you to designate another person, called the attorney-in-fact, to act on your behalf, in the event you become disabled or incapacitated.

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E
EARLY INTERVENTION:  Providing services to prevent further deterioration, delay, or increased need.

ELDERCARE:  Public, private, formal, and informal programs and support systems, government laws, and finding ways to meet the needs of the elderly, including: housing, home care, pensions, Social Security, long-term care, health insurance, and elder law.

ELECTION:  Your decision to join or leave the Original Medicare Plan or a Medicare+Choice plan.

ELECTION PERIODS:  Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare+Choice plan. There are four types of election periods in which you may join and leave Medicare health plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.  Annual Election Period: The Annual Election Period is the month of November each year. Medicare health plans enroll eligible beneficiaries into available health plans during the month of November each year. Starting in 2002, this is the only time in which all Medicare+Choice health plans will be open and accepting new members.  Initial Coverage Election Period: The three months immediately before you are entitled to Medicare Part A and enrolled in Part B. If you choose to join a Medicare health plan during your Initial Coverage Election Period, the plan must accept you. The only time a plan can deny your enrollment during this period is when it has reached its member limit. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP).  Special Election Period: You are given a Special Election Period to change Medicare+Choice plans or to return to Original Medicare in certain situations, which include: You make a permanent move outside the service area, the Medicare+Choice organization breaks its contract with you or does not renew its contract with CMS; or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).  Open Enrollment Period: If the Medicare health plan is open and accepting new members, you may join or enroll in it. If a health plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.

ELIGIBILITY/MEDICARE PART A:  You are eligible for premium-free (no cost) Medicare Part A (Hospital Insurance) if; You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retirement Board, or, You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or ·   You or your spouse had Medicare-covered government employment, or, You are under 65 and have End-Stage Renal Disease (ESRD). If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if; You are age 65 or older, and You are enrolled in Part B, and You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the 5 years immediately before the month in which you apply.

ELIGIBILITY/MEDICARE PART B:  You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the 5 years immediately before the month during which you enroll in Part B.

EMERGENCY CARE:  given for a medical emergency when you believe that your health is in serious danger when every second counts.

EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERSA):  A law that mandates reporting and disclosure requirements for group life and health plans.

EMPLOYER GROUP HEALTH PLAN (GHP):  A GHP is a health plan that gives health coverage to employees, former employees, and their families, and is from an employer or employee organization.

EMPLOYMENT:  A job.  DMR works in partnership with private agencies and other resources to provide employment to individuals with mental retardation.  Working with the individual, families, and the potential employer efforts are made to secure meaningful work that is a  good match for the individual and the new employer.

ENCOUNTER:  When a covered person receives services from a health care provider.

END-STAGE RENAL DISEASE (ESRD):  Permanent kidney failure requiring dialysis or a kidney transplant.

END-STAGE RENAL DISEASE NETWORK:  A group of private organizations that make sure you are getting the best possible care. ESRD networks also keep your facility aware of important issues about kidney dialysis and transplants.

ENHANCED BENEFITS:  Defined as Additional, Mandatory and Optional Supplemental benefits.

ENROLL:  To join a health plan.

ENROLLMENT FEE:  The amount you must pay every year to get a Medicare-approved drug discount card.

ENROLLMENT PERIOD:  A certain period of time when you can 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.

ENROLLMENT/PART A:  There are four periods during which you can enroll in premium Part A: Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), and Transfer Enrollment Period (TEP).  Initial Enrollment Period: The IEP is the first chance you have to enroll in premium Part A. Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months. ·      General Enrollment Period: January 1 through March 31 of each year. Your premium Part A coverage is effective July 1 after the GEP in which you enroll.  Special Enrollment Period: The SEP is for people who did not take premium Part A during their IEP because you or your spouse currently work and have group health plan coverage through your current employer or union. You can sign up for premium Part A at any time you are covered under the Group Health Plan based on current employment. If the employment or group health coverage ends, you have 8 months to sign up. The 8 months start the month after the employment ends or the group health coverage ends, whichever comes first.  Transfer Enrollment Period: The TEP is for people ages 65 or older that have Part B only and are enrolled in a Medicare managed care plan. You can sign up for premium Part A during any month in which you are enrolled in a Medicare managed care plan. If you leave the plan or if the plan coverage ends, you have 8 months to sign up. The 8 months start the month after the month you leave the plan or the plan coverage ends. If you enroll in Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, your coverage starts on July 1. (See Enrollment.)

EPISODE OF CARE:  The health care services given during a certain period of time, usually during a hospital stay.

ESSENTIAL PROVIDERS:  Types of providers or provider organizations (e.g., physicians, psychologists, pediatricians) whose services are required to be included in benefit plans by state or federal statute.

EVIDENCE:  Signs that something is true or not true. Doctors can use published studies as evidence that a treatment works or does not work.  Excerpted from material written by the Lukers for the Michigan Protection and Advocacy Services

EXCESS CHARGES:  If you are in the Original Medicare Plan, this is the difference between a doctor’s or other health care provider’s actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.

EXCLUSIONS (MEDICARE):  Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home.

EXCLUSIVE PROVIDER ORGANIZATION (EPO):  A health plan in which only treatment provided by participating providers is reimbursable.

EXPECTED CLAIMS:  The expected claim amount for services over a specific time period.

EXPEDITED APPEAL:  A Medicare+Choice organization's second look at whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

EXPEDITED ORGANIZATION DETERMINATION:  A fast decision from the Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

EXTENDED CARE FACILITY:  A nursing home-type setting that offers skilled, intermediate, or custodial care.

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FACILITY:  (Formerly known as a State School).  Also referred to as a   developmental center, intermediate care facility for the mentally retarded, or ICF/MR in Massachusetts.  A facility is a large complex that provides to the residents a program of active treatment as well as medical, psychological, nursing and habilitative services, and a program of active treatment.   DMR currently operates six facilities across the state.

FACILITY CHARGE:  Some plans may vary cost shares for services based on place of treatment, in effect, charging a cost for the facility in which the service is received.

FAMILY:   Parent, foster parents, spouses, siblings, and others who perform the roles and functions of family members in the life of an individual, including persons in a relationship of mutual support with an individual that is exclusive and expected to endure over time.

FAMILY ADVISORY COUNCIL:  A group consisting primarily of family members that   advises the Family Support Provider Agency (FSPA) on a variety of topics including, planning, implementation, and evaluations of services and supports.

FAMILY DIRECTED PROJECTS:  Family support initiatives where families are fully involved in guiding the manner in which supports are offered for each particular family support project.  DMR and Family Support Provider Agencies maintain the governance of the project.

FAMILY GOVERNED PROJECTS:  Family support initiatives where families exercise control over major operational aspects of the project including the hiring   and firing of staff, managing the budget, and developing policies and procedures.   Family governance through these initiatives allows family groups to determine their membership from an identified group of eligible individuals and to prioritize and allocate family support funds for individuals.

FAMILTY IDENTIFIED PROJECTS:  A program where family independently recruits and hires   staff for support (respite, skills training, etc.).

FAMILY SUPPORT:  A DMR supplemental support service model for families who care for their family member with a disability at home.  Family Support is designed to provide a wide array of options to families of individuals with disabilities that enable them to stay together and to be welcomed, and contributing members of their home communities.

FAMILY SUPPORT AGENCY/FAMILY SUPPORT PROVIDER AGENCY (FSPA):  The provider agency with day-to-day- responsibility for the operation of   family services and   supports pursuant to its contract with DMR.

FAMILY SUPPORT ALLOCATIONS:  The amount of dollars available to a family based on completion of needs assessment, availability of resources and their identified prioritization for funding as determined by the Area Director.  The allocation is inclusive of other service costs, such as case management, as well as flexible allocation.  This allocation is managed either by the Family Support Provider Agency or by the family. .

FAMILY SUPPORT PLAN (FSP):  This plan includes a listing of supports, goods, and services that have been identified as appropriate to meet the needs of the family during   each fiscal year (See Fiscal Year) as well as the associated cost to DMR.  The FSP is signed by the designated provider agency staff, family member, and when appropriate, the individual.

FEDERAL FINANCIAL PARTICIPATION (FFP):  Payment by the federal government to a state as its share of Medicaid costs.

FEDERALLY QUALIFIED HEALTH CENTER (FQHC):  Health centers that have been approved by the government for a program to give low cost health care. Medicare pays for some health services in FQHC's that are not usually covered, like preventive care. FQHC's include community health centers, tribal health clinics, migrant health services, and health centers for the homeless.

FEE SCHEDULE:  A listing that defines a pre-established payment amount for services to be delivered.

FEE-FOR-SERVICE REIMBURSEMENT:  A payment system that pays providers for each unit of service delivered.

FISCAL INTERMEDIARY:  A private company that has a contract with Medicare to pay Part A and some Part B bills. (Also called "Intermediary.")

FISCAL YEAR:  For Medicare, a year-long period that runs from October 1st through September 30th of the next year. The government and some insurance companies follow a budget that is planned for a fiscal year.

FLEXIBLE BENEFIT PLAN:  A program that annually provides enrollees with plan options from which they can choose their benefits for the next year to meet their specific needs.

FLEXIBLE FAMILY SUPPORT:  A component of the Family Support model that provides funds to families that can be used in a flexible manner to purchase goods and services to support their family member with a disability in the family home and community.

FORMULARY DRUGS:  Listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to covered enrollees.

FORMULARY:  List of approved prescription medications which health plan pays for; medicines not listed in the formulary will not be covered.

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 produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare. This is not the same as fraud.

FREE LOOK (MEDIGAP POLICY):  A 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. If you cancel, you will get your money back.

FREEDOM OF CHOICE WAIVER:  Section 1915(b) Waiver.

FREEDOM OF INFORMATION ACT (FOIA):  A law that requires the U.S. Government to give out certain information to the public when it receives a written request. FOIA applies only to records of the Executive Branch of the Federal Government, not to those of the Congress or Federal courts, and does not apply to state governments, local governments, or private groups.

FUNDING AUTHORITY:  The agency authorized to pay and over see contracts with all service providers within a defined geographic area.

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GAPS:  The costs or services that are not covered under the Original Medicare Plan.

GATEKEEPER:  In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

GATEKEEPING:  The use of primary care clinicians, case managers, or some other mechanism as the initial contact for care in order to ensure that only appropriate and cost-effective care is utilized.

GENERAL ENROLLMENT PERIOD (GEP):  The General Enrollment Period is January 1 through March 31 of each year. If you enroll in Premium Part A or Part B during the General Enrollment Period, your coverage starts on July 1.

GENERIC DRUG:  A prescription drug that has the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

GENERIC SERVICES:  Services, supports, treatment or life options that are available to the general public and may or may not require special accommodations.

GOVERNING BOARD: The governing body of a provider.

GRIEVANCE:  A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered (see Appeal).

GRIEVANCE PROCEDURE:  Defined process in a health plan for consumers or providers to use when there is a disagreement about a plan’s services, billings, or general procedures.

GROUP HEALTH PLAN:  A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.

GROUP OR NETWORK HMO:  A health plan that contracts with group practices of doctors to give services in one or more places.

GUARANTEED ISSUE RIGHTS (ALSO CALLED "MEDIGAP PROTECTIONS"):  Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can't deny you insurance coverage or place conditions on a policy, must cover you for all pre-existing conditions, and can't charge you more for a policy because of past or present health problems.

GUARANTEED RENEWABLE:  A right you have that requires your insurance company to automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud or don’t pay your premiums.

GUARDIAN:  A person or entity that has legal guardianship is a natural or adoptive parent, individual or agency that has legal guardianship of persons under the age 18 years.  With respect to persons 18 years of age or older, it is the individual, organization or agency, if any, that has been appointed legal guardian of the person by a court of competent jurisdiction.

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HABILITATION: The process by which an individual acquires and maintains the life skills necessary to cope more effectively with personal and environmental demands or to improve physical, mental, and social competencies.

HCFA WAIVERS:  Agreements with the federal government that allow states specific flexibility in the administration of their state’s Medicaid plan.

HEALTH CARE FINANCING ADMINISTRATION (HCFA):  The federal agency that administers Medicare and oversees the states’ administration of Medicaid.

HEALTH CARE PROVIDER:  A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

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 find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare & Medicaid Services (CMS) collects HEDIS data for Medicare plans. (See Centers for Medicare & Medicaid Services.)

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA):  A law passed in 1996, which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage; usually gives you credit for health coverage you have had in the past; may give you special help with group health coverage when you lose coverage or have a new dependent; and generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance.

HEALTH MAINTENANCE ORGANIZATION (HMO): A health care organization that meets the following characteristics: (1) offers an organized system for providing health care within a specific geographic area; (2) it provides a set of basic and supplemental health maintenance and treatment services; and (3) it provides care to an enrolled group of people. There are four basic models of HMO’s: group model, individual practice association model, network model, and staff model.

HEDIS:  System for determining the quality of a health plan’s services and outcomes, based on certain health providers and hospitals, usually those within.

HEMODIALYSIS (HD):  This treatment is usually done in a dialysis facility but can be done at home with the proper training and supplies. HD uses a special filter (called a dialyzer or artificial kidney) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body (See dialysis and peritoneal dialysis.).

HOME AND COMMUNITY-BASED SERVICE WAIVER PROGRAMS (HCBS):  The HCBS programs offer different choices to some people with Medicaid. If you qualify, you will get care in your home and community so you can stay independent and close to your family and friends. HCBS programs help the elderly and disabled, mentally retarded, developmentally disabled, and certain other disabled adults. These programs give quality and low-cost services.

HOME HEALTH AGENCY:  An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.

HOME HEALTH CARE:  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 (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

HOMEBOUND:  Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn't keep you from getting home health care.

HOSPICE:  Hospice is 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).

HOSPICE CARE:  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 INDEMNITY INSURANCE:  This kind of insurance pays a certain cash amount for each day you are in the hospital up to a certain number of days. Indemnity insurance doesn’t fill gaps in your Medicare coverage.

HOSPITAL INSURANCE (PART A):  The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

HOSPITALIST:  A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over your care from your primary doctor when you are in the hospital, keep your primary doctor informed about your progress, and will return you to the care of your primary doctor when you leave the hospital.

HOUSING: A DMR program that provides a home or lodging to an individual with mental retardation.

HUMAN RISK MANAGEMENT:  The reduction of treatment demand by identifying and managing health risks of covered persons prior to the development of treatment needs.

HYDRATION:  This is the level of fluid in the body. The loss of fluid, or dehydration, occurs when you lose more water or fluids than you take in. Your body cannot keep adequate blood pressure, get enough oxygen and nutrients to the cells, or get rid of wastes if it has too little fluid.

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IMMUNOSUPPRESSIVE DRUGS:  Transplant drugs used to reduce the risk of rejecting the new kidney after transplant. Transplant patients will need to take these drugs for the rest of their lives.

INCURRED BUT NOT REPORTED (IBNR):  Service cost incurred but not yet reported to the entity at-risk.

INCURRED CLAIMS:  The total actual liability for covered services incurred over a specified period by the entity at-risk for services; this includes both claims paid and those owed (IBNR) for services occurred within the specified time period.

INDEMNITY:  An insurance program in which the payer reimburses providers (either directly or through the covered person) for covered services received.

INDIRECT COSTS:  Indirect costs are usually termed overhead costs, as they are the costs that are shared by many services concurrently, for example, maintenance, administration, equipment, electricity, and water.

INDIVIDUAL:  A person receiving services or supports provided, purchased, or arranged by DMR.

INDIVIDUAL SUPPORT PLAN (ISP):  A written plan of services or supports for an individual over the age of 22 which is developed, implemented, reviewed, and modified according to the requirements of the DMR’s regulations on individual support plans.

INFORMATION, COUNSELING, AND ASSISTANCE PROGRAM:  (See State Health Insurance Assistance Program.)

INFUSION PUMPS:  Pumps for giving fluid or medication into your vein at a specific rate or over a set amount of time.

INITIAL COVERAGE ELECTION PERIOD:  The 3 months immediately before you are entitled to Medicare Part A and enrolled in Part B. You may choose a Medicare health plan during your Initial Coverage Election Period. The plan must accept you unless it has reached its limit in the number of members. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP). (See Election Periods; Enrollment/Part A; Initial Enrollment Period (IEP).)

INITIAL ENROLLMENT PERIOD:  The Initial Enrollment Period is the first chance you have to enroll in Medicare Part B. Your Initial Enrollment Period starts three months before you first meet all the eligibility requirements for Medicare and lasts for seven months.

INITIAL ENROLLMENT QUESTIONNAIRE (IEQ):  A questionnaire sent to you when you become eligible for Medicare to find out if you have other insurance that should pay your medical bills before Medicare.

INPATIENT CARE:  Health care that you get when you are admitted to a hospital.

INSOLVENCY:  When a health plan has no money or other means to stay open and give health care to patients.

INTEGRATED BEHAVIOR HEALTH NETWORK:  A carved out health plan that combines various managed behavioral health care services in a single, coordinated delivery system.

INTEGRATED DELIVERY SYSTEM:  A generic term that refers to any of a variety of types of joint efforts between clinicians and service providers.

INTERMEDIARY:  A private company that has a contract with Medicare to pay Part A and some Part B bills.

INTERNIST:  A doctor who finds and treats health problems in adults.

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JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO):  A private, non-profit organization that sets standard, evaluates, and accredits hospitals, health care organizations, and networks.

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LARGE GROUP HEALTH PLAN:  A group health plan that covers employees of either an employer or employee organization that has 100 or more employees.

LEAD AGENCY:  An organization that serves as a single clinical and fiscal authority that provides and/or subcontracts for services toward a desired outcome.

LEAST RESTRICTIVE:  Those settings, modes of service, and styles of living and working that are most similar to and most integrated with what is typical and age-appropriate in the community, and which interfere the least with the individual's independence.

LIABILITY INSURANCE:  Liability insurance is insurance that protects against claims for negligence or inappropriate action or inaction, which results in injury to someone or damage to property.

LIABILITY RISK:  The risk of change in the likelihood of a lawsuit.

LICENSE:  As used in the DMR regulations, l authorization granted by DMR to a person or entity to offer and provide to the public mental retardation services or supports.

LICENSED (LICENSURE):  This means a long-term care facility has met certain standards set by a State or local government agency.

LIFETIME RESERVE DAYS:  In the Original Medicare Plan, 60 days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. These 60 reserve days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($438 in 2004).

LIFETIME RESERVE DAYS (MEDICARE):  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 during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($406 in 2002).

LIMITING CHARGE:  In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.

LIVING WILLS:  A legal document also known as a medical directive or advance directive. It states your wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent.

LOCAL MENTAL HEALTH:  Local organizational entity (usually with some statutory authority) that centrally maintains administrative, clinical, and fiscal authority for an organized system of behavioral health care.

LONG-TERM CARE:  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 doesn’t pay for this type of care if this is the only kind of care you need.

LONG-TERM CARE INSURANCE:  A private insurance policy to help pay for some long-term medical and non-medical care, like help with activities of daily living. Because Medicare generally does not pay for long-term care, this type of insurance policy may help provide coverage for long-term care that you may need in the future. Some long-term care insurance policies offer tax benefits; these are called "Tax-Qualified Policies."

LONG-TERM CARE OMBUDSMAN:  An advocate (supporter) for nursing home and assisted living facility residents who works to resolve problems between residents and nursing homes or assisted living facilities.

LONG-TERM CARE:  Services ordinarily provided in a skilled nursing, intermediate-care, personal care, supervisory-care, or eldercare facility.

LONG-TERM OUTCOME:  The result of care over time, as opposed to more immediate effects.

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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 a year for women over 40.

MANAGED ACCESS:  A strategy for controlling health care costs by manipulating the structure of the benefits package.

MANAGED BENEFITS:  A strategy for controlling health care costs by manipulating the structure of the benefits package.

MANAGED CARE ORGANIZATION (MCO):  Various strategies that seek to optimize the value of provided services by controlling their cost and utilization, promoting their quality and measuring performance to ensure cost-effectiveness. An organization that provides a managed health care plan.

MANAGED CARE PLAN:  In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extra benefits, like extra days in the hospital. In most cases, a type of Medicare Advantage Plan that is available in some areas of the country. Your costs may be lower than in the Original Medicare Plan.

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.)

MANAGED HEALTH CARE PLAN:  A single-service product that integrates the financing, administration, and delivery of health care services for an enrolled population.

MANAGED SERVICE ORGANIZATION (MSO):  An organization that provides management and administrative support services to individual clinicians and group practices.

MANDATED BENEFITS:  Health plan benefits that are required by state or federal law.

MANDATORY ENROLLMENT:  Requirements that certain groups of people must enroll in a program (e.g., Medicaid managed care).

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 Medicare Advantage plan. Medicare Advantage Plans must ensure that any particular group of Medicare beneficiaries does not use mandatory supplemental benefits to discourage enrollment.

MAXIMUM ALLOWABLE FEE SCHEDULE:  A payment system that reimburses services up to a specified amount.

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.

MEDICAID:  A federal program administered individually by participating states that share in the program’s costs to provide medical benefits to specific groups of low income and/or categorically eligible persons.

MEDICAL INSURANCE (PART B):  Medicare medical insurance that helps pay for doctors services, outpatient hospital care, durable medical equipment, and some medical services that aren’t covered by Part

MEDICAL NECESSITY:  A specific health care service that is medically appropriate and/or necessary to meet the person’s health needs, consistent with the person’s diagnosis, and consistent with established standards of care.

MEDICAL UNDERWRITING:  The process that an insurance company uses to decide, based on your medical history, 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 aren’t 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 ADVANTAGE PLAN:  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 (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.

MEDICARE BENEFITS:  Health insurance available under Medicare Part A and Part B through the traditional fee-for service 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 COORDINATION OF BENEFITS CONTRACTOR:  A Medicare contractor who collects and manages information on other types of insurance or coverage that pays before Medicare. Some examples of other types of insurance or coverage are: Group Health Coverage, Retiree Coverage, Workers’ Compensation, No-fault or Liability insurance, Veterans’ benefits, TRICARE, Federal Black Lung Program, and COBRA.

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:  A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care 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 managed care 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.

MEDICARE PART B (MEDICAL INSURANCE):  Medicare medical insurance that helps pay for doctors’ services, outpatient hospital care, durable medical equipment, and some medical services that aren’t covered by Part A.

MEDICARE PART B PREMIUM REDUCTION AMOUNT:  Since CY 2003, MCO's 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 PREFERRED PROVIDER ORGANIZATION (PPO) PLAN:  A type of Medicare Advantage Plan 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.

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 type of Medicare Advantage plan in which 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 pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn’t cover.

MEDICARE SAVINGS PROGRAM:  Medicaid programs that help pay some or all Medicare premiums and deductibles.

MEDICARE SAVINGS PROGRAMS:  There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay Medicare deductibles and coinsurance. You can apply for these programs if: You have Medicare Part A (Hospital Insurance). (If you are eligible for Medicare Part A but don’t think you can afford it, there is a program that may pay the Medicare Part A premium for you.), you are an individual with resources of $4,000 or less, or are a couple with resources of $6,000 or less. Resources include money in a savings or checking account, stocks, or bonds and You are an individual with a monthly income of less than $1,031, or a couple with a monthly income of less than $1,384. Income limits will change slightly in 2004. If you live in Hawaii or Alaska, income limits are slightly higher. Note: If your income is less than the amounts listed above, you may qualify for Medicaid.

MEDICARE SECONDARY PAYER:  Any situation where another payer or insurer pays your medical bills before Medicare.

MEDICARE SELECT:  A type of medical 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 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 you must pay.

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:  An entitlement program run by the Health Care Financing Administration of the federal government by which people aged 65 years or older receive health care insurance. Medicare Part A covers hospitalization and is a compulsory benefit. Medicare Part B covers outpatient services and is a voluntary service.

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:  In the Original Medicare Plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare and you 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.)

MEMBER ASSISTANCE PROGRAM (MAP):  A type of risk management that tries to lower health care costs by lowering treatment demand through preventive interventions.

MINOR:  A person under the age of 18.

MORBIDITY:  The incidence and severity of situations requiring treatment (e.g., illness, accidents) within a specific group of persons.

MULTI-EMPLOYER GROUP HEALTH PLAN:  A group health plan that is sponsored jointly by two or more employers or by employers and employee organizations.

MULTI-EMPLOYER PLAN:  A group health plan that is sponsored jointly by two or more employers or by employers and unions.

MULTIPLE FUNDING STREAMS:  A method where funding flows to a service provider in independent streams from different funding sources.

MULTIPLE OPTION PLAN:  A health care plan that allows enrollees to choose from several models of care.

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NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA):  A non-profit organization that accredits and measures the quality of care in Medicare health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system. (See Health Employer Data and Information Set (HEDIS).)

NATIONAL MEDIAN CHARGE:  The national median charge is the exact middle amount of the amounts charged for the same service. This means that half of the hospitals and community mental health centers charged more than this amount and the other h