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TERM

DEFINITION

	A "TIERs		is a specific list of drugs. Your plan may have several tiers, and your copayment 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.

	ACCESS		Your ability to get needed medical care and services.

	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.

	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.)

	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 alculated 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, copayments, and eductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the djusted excess, which will be used to pay for services not covered by Medicare and/or will be used to educe 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.

	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.

	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.

	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.

	AMBULATORY CARE		All types of health services that do not require an overnight hospital stay.

	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 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. Anesthesia should always be given by a doctor or a specially trained nurse.

	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.)

	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 a tual 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.

	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 s		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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TERM

DEFINITION

	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.)

	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.

	BOARD-CERTIFIED		This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.

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TERM

DEFINITION

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.

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.)

CASE MANAGEMENT		A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.

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.

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.

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.

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)		CNAs 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.)

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.)

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.

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

COMPLAINT		(See Grievance.)

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.

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.

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.

CONTINUATION OF ENROLLMENT		Allows MCOs 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 disenroll.

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 CCRCs is usually expensive. Generally, CCRCs require a large payment before you move in and charge monthly fees.

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 cross-over.

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.

COST SHARING	The cost for medical care that you pay yourself like a copayment, coinsurance, or deductible. (See Coinsurance; Copayment; Deductible.)

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.

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	Nonskilled, 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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TERM

DEFINITION

	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.)

	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.

	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.

	DIAGNOSIS-RELATED GROUPS		A way to pay hospitals for health care based on diagnosis, age, gender, and complications.

	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.

	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.

	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 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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TERM

DEFINITION

	ELDERCARE s		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 Se