California Medicare Glossary Help

This internet web page covers California Medicare glossary help.

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 insurance brokers a license is required.

Carrier: An insurance company or managed care company.

Covered Benefit: These are medically necessary services which are provided for under the terms of a plan.

Customary charge: The amount 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 information collected from the different providers in a given geographical area.

Deductible: The amount of money that the insured needs to spend on covered costs before the plan will begin to pay for services.

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

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

Effective Date: The date a policy goes into effect.

End-Stage Renal Disease: This is permanent kidney failure which requires a person to have dialysis or a kidney transplant.

Exclusions: Conditions not covered under a plan.

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

Fee Schedule: Lists 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 typically not covered by the Medicare system.

Gatekeeper: A primary care physician, some other individual or individuals who determine what services a patient can have access to. 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 most group model HMOs, the HMO contracts with physician groups to provide all services to the members of the HMO. The physicians are not actually 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 tend to 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 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 typically restricted to using the HMOs providers. Kaiser is one of the larger and most well known HMOs.

Home care: This is care provided at an individual's home 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 wide range of services, from skilled care and physical therapy to personal care delivered at home.

Hospice: A facility that 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: This is care administered 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 doctor does not accept assignment. Patients are not required to pay more than the limiting charge for the service.

Long term care: 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 is not 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: This is the amount that Medicare thinks is appropriate for a service covered by Part B of Medicare.

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

Medicare Part B: This side of Medicare covers several kinds of medical care costs not covered under Part A. Part B covers physician services. One exception it that it doesn't pay for the costs of routine physical examinations. This part of Medicare also covers outpatient medical and surgical costs. This include outpatient mental health care and physical therapy. It also pays for items like wheel chairs and walkers. Most people pay a monthly premium for Medicare Part B.

Medicare: Medicare is a 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 divided into two 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 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.

Nursing home: This is a facility that provides a room and 24 hour assistance with help with activities of daily living. They take care of things like meals 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 generally considered to be long term care.

Outpatient Care: Health 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.

Primary care physician: A doctor or group of doctors 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.

Referral: The process of one doctor sending a patient to some other doctor for further treatment or evaluation. HMOs often require that a member receive a referral from the gatekeeper in order to be able to see someone 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 assets allowed.

Stroke: Occurs when a blood vessel to the brain bursts or is clogged by a blood clot. 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 can lead to dementia and to the inability to perform the activities of daily living.

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