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The purpose of this internet web page is to discuss CA Medigap glossary. Broker: An individual or firm which acts as an intermediary between insurance companies and those looking for insurance. Brokers are usually paid by commission. For brokers in the insurance industry, a license is required.
Carrier: An insurance company or managed care company.
Covered Benefit: Service which are covered 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 area.
Deductible: This is the amount that the insured needs to spend on covered costs before a plan begins paying for services.
Department of Health and Human Services: The federal agency that is in charge of Medicaid, Medicare and some other federal health care programs.
Duplication of benefits: This is when someone is covered by more than one policies which have the same benefits.
Effective Date: The date an insurance policy's coverage starts.
End-Stage Renal Disease: This is 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 within a contract between a provider and a carrier that prohibits the provider from working for multiple managed care organizations.
Fee Schedule: This lists the maximum amounts 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 often includes services such as administering medication, wound care, dressing, mobility, and bathing. Non-medical services and services provided by non-professionals are typically not covered by the Medicare system.
Gatekeeper: A primary care physician, some other individual or individuals who determine what services a patient can access. In many, but not necessarily all, cases the gatekeeper has to provide a referral for a person to be able to see a specialist. Emergency care does not typically require a person to have a referral. 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. The physicians are not employees of the HMO. The physician groups are usually paid using the capitation system. The 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: This is 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 dental HMOs and medical HMOs. HMOs are a very restrictive form of managed care. This is because 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 usually to the providers within the HMO itself. Kaiser is one of the larger and most well known HMOs.
Home care: This is care provided at a person's home and includes 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: A person 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: A facility which specializes in treating 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: This is care given to an individual 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 physician 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 for the service.
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. Long term care can become very expensive and this is why many people purchase long term care insurance.
Medicare approved charge: An amount that Medicare believes is appropriate for a service covered under Part B of Medicare.
Medicare Part A: This side of Medicare pays for several different types of medical care costs not covered under Part B. Part A pays for a lot of the costs incurred while at a hospital. It pays for the general nursing, the room and various hospital supplies. It also covers inpatient mental health costs. It also pays for skilled nursing facilities after a three-day inpatient hospital stay. This also covers hospice care expenses. Some home health care costs are also paid for under Medicare Part A. Most people do not have to pay for Medicare Part A.
Medicare Part B: This side of Medicare pays for several kinds of medical care expenses not covered under Part A. Part B covers physician services. It does not cover 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 also pays for equipments like walkers and wheel chairs. Most people pay a monthly premium for Medicare Part B.
Medicare: Medicare is a federal government 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 broken up into two parts. Part A is hospital insurance. Part B is medical insurance. Congress enacted the Medicare program in 1965 to assist 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 care for members of the plan. This may 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. They take care of necessities like meal preparation and also provide forms of recreation for the people living there. Typically, nursing home Residents have physical or mental problems that don't allow them to live on their own. Most 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: Health care services that are directed at the prevention or early detection of disease.
Primary care physician: A doctor or group of doctors responsible for providing primary care services and coordinating all aspects of medical 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.
Referral: The process of one health care provider sending a patient to some other health care provider 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 someone other than the primary care physician for treatment under the plan.
Spend down: This describes the process of spending one's assets in order to become eligible for Medicaid by bringing the countable assets below the limit of assets 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 result in dementia and to the inability to perform the activities of daily living. We have been helping Californians with their Medicare Supplement needs for more than twenty years. We want to help you with your Medicare Supplement needs. Let us answer all your Medicare questions. We will find the best policy for you. If you have questions relating to Medicare then call us. We will give you the information you require right now. One email or phone call to us can take all the confusion and solve the problem. |