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The purpose of this internet web page is to explain California Medigap glossary. Broker: An individual or firm which acts as an intermediary between insurance companies and people who are looking for insurance. Most 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: This is 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 charge information collected from various providers in a geographical location.
Deductible: The amount of money that the insured needs to spend on covered services before a 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 two policies which have the same types of benefits.
Effective Date: The date a policy goes into effect.
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: A clause in a contract between a carrier and a provider which prohibits the provider from working for multiple managed care organizations.
Fee Schedule: This 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 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 most, but not necessarily 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 multiple 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 coverage where 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 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 an individual'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: An individual who provides health services to people in their homes.
Home Health Care: This 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 a person who has been admitted to a hospital.
Lapse: The termination of an insurance contract due the premium not being paid.
Limiting Charge: This is the maximum amount a doctor 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.
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 type 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: An amount that Medicare determines is appropriate for a covered service by Part B of Medicare.
Medicare Part A: This part of Medicare covers several different kinds of medical care costs not covered under Part B. Part A pays for much of the expenses relating to a hospital. It helps to pay for the room, general nursing, and various hospital supplies. It also covers inpatient mental health expenses It also pays for skilled nursing facilities after a three-day inpatient hospital stay. Part A also pays for hospice costs. Certain 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 part of Medicare covers several different kinds of medical care costs not covered under Part A. Part B covers doctor's services. It doesn't pay for the costs of routine physical examinations. This part of Medicare also pays for outpatient medical and surgical expenses. This include outpatient mental health care and physical therapy. It can also 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 certain 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 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 medical 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 providing a room and 24 hour assistance with help with activities of daily living. Nursing homes take care of things like meal preparation and also provide forms of recreation for the people living there. In many cases, 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: 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 that are directed at the prevention or early detection of disease.
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 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. 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 resources below the limit of resources 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, depriving it of oxygen and causing severe damage to that part of the brain. The damage done by a stroke can be devastating and is in many cases fatal. Strokes often lead to dementia and to the inability to perform the activities of daily living. With more than twenty years experience assisting Californians with their Medicare Supplement needs we can help you too. Let us analyze your needs, and assist you with getting coverage. Are you confused by the complexity of Medicare? With the huge amount of information it is easy to have trouble finding the answers you require. Don't waste your time trying to find which plan is best for you. We have the answers you need. |