Glossary of Terms

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.

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 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.

ANCILLARY SERVICES

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

DEFICIENCY (NURSING HOME)

A finding that a nursing home failed to meet one or more federal or state requirements.

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.

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.

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 Retrirement 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.

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 age 65 or older who 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.)

FEE SCHEDULE

A complete listing of fees used by health plans to pay doctors or other providers.

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.

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.

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).

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.

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).)

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.

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.

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.

MEDICAID

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

MEDICAL INSURANCE (PART B)

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

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 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, MCOs are able to use their adjusted excess to reduce the Medicare Part B premium for beneficiaries. When offering this benefit, a plan cannot reduce its payment by more than 125 percent of the Medicare Part B premium. In order to calculate the Part B premium reduction amount, the PBP system must multiply the number entered in the “indicate your MCO plan payment reduction amount, per member” field by 80 percent. The resulting number is the Part B premium reduction amount for each member in that particular plan (rounded to the nearest multiple of 10 cents).

NURSING FACILITY

A facility which primarily provides skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals.

NURSING HOME

A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.

OCCUPATIONAL THERAPY

Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness.

OMBUDSMAN

An advocate (supporter) who works to solve problems between residents and nursing homes, as well as assisted living facilities. Also called “Long-term Care Ombudsman.”

OUTPATIENT HOSPITAL SERVICES (MEDICARE)*

Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:

• blood transfusions;
• certain drugs;
• hospital billed laboratory tests;
• mental health care;
• medical supplies such as splints and casts;
• emergency room or outpatient clinic, including same day surgery; and
• emergency room or outpatient clinic, including same day surgery; and
• x-rays and other radiation services.

PATIENT ADVOCATE

A hospital employee whose job is to speak on a patient’s behalf and help patients get any information or services they need.

PERSONAL CARE

Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. The Medicare home health benefit does pay for personal care services.

PHYSICAL THERAPY

Treatment of injury and disease by mechanical means, such as heat, light, exercise, and massage.

POWER OF ATTORNEY

A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.

QUALITY ASSURANCE

The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and then checking to see if what you did worked.

REHABILITATION

Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.

SECONDARY PAYER

An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.

SKILLED NURSING FACILITY CARE

This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.

SUBSIDIZED SENIOR HOUSING

A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.