CA Medicare Glossary Help

This web page explains CA Medicare glossary help.

Broker: An individual or firm which acts as an intermediary between insurance companies and people who are looking for insurance. Brokers are usually paid by commission. For insurance brokers a license is required.

Carrier: As it relates to insurance, the insurance company or managed care company.

Covered Benefit: Service which are provided for under the terms of a policy.

Customary charge: The amount of money a provider most frequently charges for a given service. It is one of the factors used to determine how much Medicare will pay the provider for a service. These charges are determined based on charge information collected from the different providers in a given geographical location.

Deductible: The amount of money that the insured needs to spend on covered services before a plan begins paying for services.

Department of Health and Human Services: The federal agency that is in charge of Medicaid, Medicare and other federal health care programs.

Duplication of benefits: This is when someone is covered by two policies which have the same types of benefits.

Effective Date: The date an insurance policy's coverage starts.

End-Stage Renal Disease: Permanent kidney failure which requires a person to receive dialysis or a kidney transplant.

Exclusions: Conditions not covered under a plan.

Exclusivity Clause: This is a clause in a contract between a provider and a carrier that prohibits the provider from working for other managed care organizations.

Fee Schedule: Shows the maximum a plan will pay for specified medical procedures.

Formal care: Care provided in the home by a home health aide, nurse, social worker or therapist. This can include services such as administering medication, wound care, dressing, mobility, and bathing. Non-medical services and services provided by non-professionals are generally not covered by Medicare.

Gatekeeper: A primary care physician, some other individual or individuals who determine what services a patient can have access to. In most, but not all, cases the gatekeeper has to provide a referral for a person to be able to see a specialist. A referral is not usually required for emergency care. HMOs use the gatekeeper mechanism.

Group Model HMO: In a typical group model HMO, the HMO contracts with physician groups to provide services to the members of the HMO. Under this system the physicians are not actually employees of the HMO. The physician groups are usually paid using the capitation system. The actually groups are typically owned by the doctors in the group. The doctors in the groups usually have control over how the services of the HMOs members are provided, and have in control over referrals within the group.

Health Maintenance Organization: A popular form of managed care. They offer a prepaid system of health coverage where the providers are usually paid under the capitation system. There are medical and dental HMOs. HMOs tend to be a very restrictive form of managed care. This is mainly due to the fact that one of their primary functions is to control the costs of health care by controlling the usage of health care resources. The main control tool in accomplishing this is the use of gatekeepers. Members are typically restricted to having to use the HMOs providers. Kaiser is one of the larger and most well known HMOs.

Home care: This is care provided at a person's residence an can include such services as nursing care, occupational therapy, physical, respiratory therapy, speech therapy, assistance with activities of daily living, meal preparation, laundry, and cleaning.

Home health aide: This is an individual who provides health services to people in their homes.

Home Health Care: This term covers a range of services, from skilled care and physical therapy to personal care delivered at home.

Hospice: This is a facility which treats people who are terminally ill. The idea behind hospice is that a person who is terminally ill deserves to live out his or her life with respect and dignity, free of pain, in an environment that promotes the highest possible quality of life. Before the hospice was developed the vast majority of terminally ill people died in the hospital. One of the issues the hospice addresses is that terminal illness profoundly impacts not only the patient, but family and loved ones as well.

Inpatient Care: Care given to a person who has been admitted to a hospital.

Lapse: The termination of an insurance contract because the premium has not been paid.

Limiting Charge: This is the maximum amount a doctor can charge a Medicare beneficiary for a covered service if the physician does not accept assignment. Patients are not required to pay more than the limiting charge.

Long term care: This is extended care which may be provided in a nursing home, adult day care, an assisted living facility or a person's home. This kind of care isn't covered my Medicare, but is instead covered by long term care insurance. Long term care assists people with the activities of daily or who need supervision because of severe cognitive impairment. It can become very expensive and this is why many people purchase long term care insurance.

Medicare approved charge: The amount that Medicare thinks is appropriate for a service covered under Part B of Medicare.

Medicare Part A: This part of Medicare covers several types of health care expenses not covered under Part B. Part A pays for a lot of the expenses incurred while at a hospital. It helps to pay for cost of the general nursing, the room and various hospital supplies. It can also pay for inpatient mental health expenses It also pays for skilled nursing facilities after a three-day inpatient hospital stay. This also pays for hospice expenses. Certain home health care costs are covered by Medicare Part A. Most people do not have to pay for Medicare Part A.

Medicare Part B: This side of Medicare pays for several different types of health care expenses not covered under Part A. Part B covers doctor's services. One exception it that it doesn't pay for the costs of routine physical examinations. This part of Medicare also pays for outpatient medical and surgical costs. This include outpatient mental health care and physical therapy. It can also equipments such as walkers and wheel chairs. Most people pay a monthly premium for Medicare Part B.

Medicare: Medicare is a federal program that provides health insurance for people who qualify. This includes people who are 65 or older, certain people who are not yet 65 but have disabilities, and people who have end-stage renal disease. Medicare is divided into two different parts. Part A is hospital insurance. Part B is medical insurance. Congress enacted the Medicare program in 1965 to help the elderly and disabled with their health care costs.

Primary care physician: A physician or group of physicians responsible for providing primary care services and coordinating all aspects of health for plan members. This can include referring the member to specialists, and making sure the member receives proper rehabilitative services when needed. HMOs use the primary care physician mechanism.

Nursing home: A nursing home is a facility that provides a room and 24 hour assistance with help with activities of daily living. Nursing homes take care of necessities like meals and also provide forms of recreation for the people living there. Generally, nursing home Residents have physical or mental problems that don't allow them to live on their own. Much of the care provided in nursing homes is considered to be long term care.

Outpatient Care: Medical or surgical care that does not require a person to have to stay in the hospital overnight.

Premium: The amount of money paid to an insurance company in return for coverage under a policy.

Preventive Care: Medical care services directed at the prevention or early detection of disease.

Referral: The process of one physician sending a patient to some other physician for further treatment or evaluation. With HMOs it often a requirement that a member receive a referral from the gatekeeper in order to be able to use a provider other than the primary care physician for treatment under the plan.

Spend down: This term is used to describe the process of spending one's assets in order to become eligible for Medicaid by bringing the countable resources below the limit of resources allowed.

Stroke: When a blood vessel to the brain gets clogged by a blood clot or bursts. Part of the brain doesn't get the flow of blood it needs, this deprives it of oxygen causing severe damage to that part of the brain. The damage done by a stroke can be devastating and is often fatal. Strokes often lead to dementia and to the inability to perform the activities of daily living.

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