Interactive Glossary - Section M-O
A-C D-F G-I J-L M-O P-R S-U V-W X-Z
M
Maintenance Care: Care given to people with chronic illnesses to keep them from getting worse. For example, exercise and physical therapy can minimize abnormal or painful positioning of the joints and may prevent or delay curvature of the spine in a person with Muscular Dystrophy.
Managed Care Plan: Any arrangement for health care in which an organization, such as an insurance company, acts as an intermediary between the person seeking care and the medical care provider. In Medicare, you have the choice to get your benefits through the federal government (Original Medicare) or a private managed care plan that receives a set amount of money from the government to provide Medicare-covered benefits. See also, Part C.
MA-PD (Medicare Advantage Drug Plan): A Medicare private health plan (Part C) that offers Medicare prescription drug coverage (Part D).
Marketing Fraud: When Medicare private plans deceive you—through marketing materials or through a person mis-representing the plan—about what the plan offers and how much it costs. See also, Medicare Fraud.
Maximus: Formerly known as the Center for Health Dispute Resolution (CHDR) forMedicare private health plan (Part C) appeals. The Qualified Independent Contractor (QIC)level of appeals for Medicare private health plans (Part C) and for Medicare private drug plans (Part D).
Medicaid: A state-run program that covers medical expenses for people with low or limited incomes.
Medicaid Buy-In: A state-run Medicaid program that allows people with disabilities under the age of 65 to work and still get the comprehensive benefits of Medicaid. The program allows people who are not eligible for traditional Medicaid—because their income or assets are too high—to “buy in” to the program for a small percentage of their income. Not all states have Medicaid Buy-In.
Medicaid Spend-Down: A state-run Medicaid program for people whose income is higher than would normally qualify them for Medicaid, but who have high medical expenses that reduce their incomes to the Medicaid eligibility level. Not all states have Medicaid spend-down.
Medical Insurance: See Part B.
Medical Social Services: A service generally intended to help the patient and family cope with the logistics of daily life with an advanced illness. Medical social services include assessing social and emotional factors related to the patient’s illness and care; evaluating the patient’s home situation, financial resources, and availability of community resources; and helping the patient access community resources to assist in recovery. The social worker may also provide counseling to the patient and family to address emotions and issues related to the illness.
Medical Supplies: Under Medicare, items covered by Medicare if they are used by home health agency staff to fulfill the plan of care, such as wound dressings.
Medically Necessary: Procedures, services, or equipment that meet good medical standards and are necessary for the diagnosis and treatment of a medical condition.
Medicare: A federal government health insurance program that gives you health care coverage if you are 65 or older, or are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months due to a severe disability, begin receiving SSDI due toALS/Lou Gehrig’s Disease or have End-Stage Renal Disease (ESRD), no matter your income. You can receive health coverage directly through the federal government (seeOriginal Medicare) or administered through a private company (see Part C).
Medicare Administrative Contractor (MAC): Beginning in 2008, Medicare began replacingfiscal intermediaries, carriers and Regional Home Health Intermediaries with Medicare Administrative Contractors (MACs). These MACs will process claims for both Medicare Part A and Part B in assigned regions. To find who you should call with billing issues, and whether your state has already been assigned to a MAC region, call 800-MEDICARE.
Medicare Advantage: See Part C.
Medicare Appeals Counsel (MAC): The second highest level of Medicare appeals in the Medicare appeals process.
Medicare-Approved Amount: See Approved Amount.
Medicare Card: Also know as the “red, white and blue card.” Everyone who enrolls inMedicare receives a Medicare card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare claim number, which is the same as your Social Security number and identifies you in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say "Railroad Retirement Board" at the top. If you choose to get your Medicare benefits from a Medicare private health plan (Part C), you will use your plan’s card instead of the Medicare card. See also, Private Plan Card.
Medicare-Certified: Offering services at a level of quality approved by Medicare. Medicare will not pay for services received from a health care provider that is not Medicare-certified.
Medicare+Choice: See Part C.
Medicare Fraud: When doctors or other health care providers deceive Medicare into paying when it should not or into paying more than it should. See also, Marketing Fraud.
Medicare Private Health Plan: See Part C.
Medicare Prescription Drug Benefit: See Part D.
Medicare Private Drug Plan: A drug plan run by a private a company through which people with Medicare can get Medicare prescription drug coverage (Part D). A stand-alone Medicare private drug plan, which generally works with Original Medicare, is called a PDP (Prescription Drug Plan). A Medicare private health plan (Part C) that offers prescription drug coverage is called an MA-PD (Medicare Advantage Prescription Drug Plan).
Medicare Savings Programs (MSP): Also known as “Medicare Buy-In” programs. They help pay your Medicare premiums and sometimes also coinsurance and deductibles. There are three main Medicare Savings Programs, with different eligibility limits: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) program. The Qualified Disabled Working Individual (QDWI) program is a less common MSP for people who are under 65, have a disabling impairment, and continue to work.
Medicare SELECT: A type of Medigap policy that will generally give you full coverage as long as you go to doctors and hospitals in its network.
Medicare Summary Notice (MSN): A notice you get in the mail from Original Medicare that lists services you received over the previous three months from doctors, hospitals or other health care providers. It tells you what the provider billed Medicare, Medicare's approved amount for the service, the amount Medicare paid, and what you have to pay. The MSN is not a bill. See also, Explanation of Medicare Benefits (EOMB).
Medigap: A supplemental insurance policy that is sold by private insurance companies to fill "gaps" in Medicare. This insurance policy is usually available in the form of twelve different plans labeled A through L and works only with Original Medicare.
MSA (Medical Savings Account): A type of managed care plan included in the choices offered through Medicare Part C that combines a savings account and a very high-deductible health plan. Medicare deposits a certain amount of money you can use towards thedeductible. The amount deposited each year is generally much lower than the deductible. MSAs cannot offer Medicare prescription drug coverage (Part D).
N
National Coverage Determination (NCD): A decision about particular treatments thatMedicare will or will not cover for particular conditions. Medicare contractors are required to follow NCDs.
Network: A group of doctors, hospitals and pharmacies that contract with a managed care plan to provide health care services to plan members. Generally, managed care plan members may only receive covered services from providers in the plan's network. Networks may be made up of both preferred and non-preferred providers.
Non-Participating Provider: In Original Medicare, a health care provider that does not routinely take assignment. When you see such a provider, you may pay up to 15 percent ofMedicare’s approved amount for the service or item on top of the Medicare coinsurance. In addition, the provider can request full payment up front and you must submit the bill to Medicare for reimbursement. See also, Participating Provider.
Non-Preferred Provider/Care: A health care provider or service covered by a private health plan or Medicare private drug plan (Part D) for which the plan will pay lower reimbursement rates. You will pay more for non-preferred services or services given at a non-preferred provider than for preferred providers and services.
Notice of Medicare Non-Coverage (NOMNC): If you are enrolled in a Medicare private health plan (Part C), a notice that tells you when care you are receiving from a home health agency (HHA), skilled nursing facility (SNF) or comprehensive outpatient rehabilitation facility (CORF) is ending and how you can contact a Quality Improvement Organization (QIO) toappeal.
Notice of Medicare Provider Non-Coverage (NOMPNC): If you have Original Medicare, tells you when care you are receiving from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) or hospice agency is ending and how you can contact a Quality Improvement Organization (QIO) to appeal.
Nursing Home: Also called a “convalescent home” or “long-term care facility” or “skilled nursing facility.” A residential facility for persons with chronic illness or disability, particularly older people who have mobility and eating problems. Nursing homes may provide skilled care. If you meet certain health criteria, Medicare covers a limited stay in a Medicare-certifiedskilled nursing facility. While a skilled nursing facility is a nursing home, not all nursing homes are Medicare-certified skilled nursing facilities.
O
Occupational Therapy: Therapy using meaningful activities of daily living to assist people who have difficulty acquring or performing meaningful work due to impairment or limitation of physical or mental function.
Off-Label: The prescribed use of a particular drug for a reason other than the use approved by the U.S. Food and Drug Administration.
Open Enrollment Period (OEP): A period of time from January 1 through March 31 of every year when you can join a Medicare health plan (either Original Medicare or a Medicareprivate health plan—Part C), or switch health plans. If accepting new members, the plan must allow all eligible individuals to join at that time. You cannot add or drop Medicare prescription drug coverage (Part D) at this time.
Opt-Out: Doctors can “opt-out” of Medicare by notifying the Medicare carrier that they will not accept Medicare payments and telling their patients–in writing before treating them–that Medicare will not pay for their services and that the patients must pay for the care themselves. Doctors who have “opted-out” can charge as much as they want, and their patients have to pay the entire bill themselves. The only time a doctor who has opted out can receive payment from Medicare is when the doctor provides a patient emergency or urgent care services and the patient does not have a contract with that doctor. If the doctor did not provide a written contract before the patient received the services, the patient is not liable for payment.
Original Medicare: Also known as "Traditional Medicare." The federal health insuranceprogram, created in 1965, under which the government pays providers directly for each service a person receives (on a fee-for-service basis). Almost all doctors and hospitals in the United States accept Original Medicare. The majority of people with Medicare are enrolled in Original Medicare, as opposed to a Medicare private health plan (Part C).
Out-of-Network: Not part of a managed care plan's network of health care providers. If you get services from an out-of-network doctor, hospital or pharmacy, it usually means that you likely will have to pay the full cost out of your own pocket for the services you received.
Out-of-Pocket Costs: Health care costs that you must pay because Medicare or other health insurance does not cover them.
Out-of-Pocket Limit: See Catastrophic Limit.
Outpatient: A patient who is not in the hospital overnight but who visits a hospital, clinic, doctor’s office or other health care facility for diagnosis or treatment.
Outpatient Care: Medical care that does not require you to stay in the hospital overnight.
Outpatient Prospective Payment System (OPPS): The system through which Medicaredecides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. The rate of reimbursement varies with the location of the hospital or clinic.
Over-the-Counter Drug: A drug that you can buy, without a prescription, at your local pharmacy or drug store. These drugs are not covered by the Medicare prescription drugbenefit (Part D).
Maintenance Care: Care given to people with chronic illnesses to keep them from getting worse. For example, exercise and physical therapy can minimize abnormal or painful positioning of the joints and may prevent or delay curvature of the spine in a person with Muscular Dystrophy.
Managed Care Plan: Any arrangement for health care in which an organization, such as an insurance company, acts as an intermediary between the person seeking care and the medical care provider. In Medicare, you have the choice to get your benefits through the federal government (Original Medicare) or a private managed care plan that receives a set amount of money from the government to provide Medicare-covered benefits. See also, Part C.
MA-PD (Medicare Advantage Drug Plan): A Medicare private health plan (Part C) that offers Medicare prescription drug coverage (Part D).
Marketing Fraud: When Medicare private plans deceive you—through marketing materials or through a person mis-representing the plan—about what the plan offers and how much it costs. See also, Medicare Fraud.
Maximus: Formerly known as the Center for Health Dispute Resolution (CHDR) forMedicare private health plan (Part C) appeals. The Qualified Independent Contractor (QIC)level of appeals for Medicare private health plans (Part C) and for Medicare private drug plans (Part D).
Medicaid: A state-run program that covers medical expenses for people with low or limited incomes.
Medicaid Buy-In: A state-run Medicaid program that allows people with disabilities under the age of 65 to work and still get the comprehensive benefits of Medicaid. The program allows people who are not eligible for traditional Medicaid—because their income or assets are too high—to “buy in” to the program for a small percentage of their income. Not all states have Medicaid Buy-In.
Medicaid Spend-Down: A state-run Medicaid program for people whose income is higher than would normally qualify them for Medicaid, but who have high medical expenses that reduce their incomes to the Medicaid eligibility level. Not all states have Medicaid spend-down.
Medical Insurance: See Part B.
Medical Social Services: A service generally intended to help the patient and family cope with the logistics of daily life with an advanced illness. Medical social services include assessing social and emotional factors related to the patient’s illness and care; evaluating the patient’s home situation, financial resources, and availability of community resources; and helping the patient access community resources to assist in recovery. The social worker may also provide counseling to the patient and family to address emotions and issues related to the illness.
Medical Supplies: Under Medicare, items covered by Medicare if they are used by home health agency staff to fulfill the plan of care, such as wound dressings.
Medically Necessary: Procedures, services, or equipment that meet good medical standards and are necessary for the diagnosis and treatment of a medical condition.
Medicare: A federal government health insurance program that gives you health care coverage if you are 65 or older, or are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months due to a severe disability, begin receiving SSDI due toALS/Lou Gehrig’s Disease or have End-Stage Renal Disease (ESRD), no matter your income. You can receive health coverage directly through the federal government (seeOriginal Medicare) or administered through a private company (see Part C).
Medicare Administrative Contractor (MAC): Beginning in 2008, Medicare began replacingfiscal intermediaries, carriers and Regional Home Health Intermediaries with Medicare Administrative Contractors (MACs). These MACs will process claims for both Medicare Part A and Part B in assigned regions. To find who you should call with billing issues, and whether your state has already been assigned to a MAC region, call 800-MEDICARE.
Medicare Advantage: See Part C.
Medicare Appeals Counsel (MAC): The second highest level of Medicare appeals in the Medicare appeals process.
Medicare-Approved Amount: See Approved Amount.
Medicare Card: Also know as the “red, white and blue card.” Everyone who enrolls inMedicare receives a Medicare card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare claim number, which is the same as your Social Security number and identifies you in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say "Railroad Retirement Board" at the top. If you choose to get your Medicare benefits from a Medicare private health plan (Part C), you will use your plan’s card instead of the Medicare card. See also, Private Plan Card.
Medicare-Certified: Offering services at a level of quality approved by Medicare. Medicare will not pay for services received from a health care provider that is not Medicare-certified.
Medicare+Choice: See Part C.
Medicare Fraud: When doctors or other health care providers deceive Medicare into paying when it should not or into paying more than it should. See also, Marketing Fraud.
Medicare Private Health Plan: See Part C.
Medicare Prescription Drug Benefit: See Part D.
Medicare Private Drug Plan: A drug plan run by a private a company through which people with Medicare can get Medicare prescription drug coverage (Part D). A stand-alone Medicare private drug plan, which generally works with Original Medicare, is called a PDP (Prescription Drug Plan). A Medicare private health plan (Part C) that offers prescription drug coverage is called an MA-PD (Medicare Advantage Prescription Drug Plan).
Medicare Savings Programs (MSP): Also known as “Medicare Buy-In” programs. They help pay your Medicare premiums and sometimes also coinsurance and deductibles. There are three main Medicare Savings Programs, with different eligibility limits: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) program. The Qualified Disabled Working Individual (QDWI) program is a less common MSP for people who are under 65, have a disabling impairment, and continue to work.
Medicare SELECT: A type of Medigap policy that will generally give you full coverage as long as you go to doctors and hospitals in its network.
Medicare Summary Notice (MSN): A notice you get in the mail from Original Medicare that lists services you received over the previous three months from doctors, hospitals or other health care providers. It tells you what the provider billed Medicare, Medicare's approved amount for the service, the amount Medicare paid, and what you have to pay. The MSN is not a bill. See also, Explanation of Medicare Benefits (EOMB).
Medigap: A supplemental insurance policy that is sold by private insurance companies to fill "gaps" in Medicare. This insurance policy is usually available in the form of twelve different plans labeled A through L and works only with Original Medicare.
MSA (Medical Savings Account): A type of managed care plan included in the choices offered through Medicare Part C that combines a savings account and a very high-deductible health plan. Medicare deposits a certain amount of money you can use towards thedeductible. The amount deposited each year is generally much lower than the deductible. MSAs cannot offer Medicare prescription drug coverage (Part D).
N
National Coverage Determination (NCD): A decision about particular treatments thatMedicare will or will not cover for particular conditions. Medicare contractors are required to follow NCDs.
Network: A group of doctors, hospitals and pharmacies that contract with a managed care plan to provide health care services to plan members. Generally, managed care plan members may only receive covered services from providers in the plan's network. Networks may be made up of both preferred and non-preferred providers.
Non-Participating Provider: In Original Medicare, a health care provider that does not routinely take assignment. When you see such a provider, you may pay up to 15 percent ofMedicare’s approved amount for the service or item on top of the Medicare coinsurance. In addition, the provider can request full payment up front and you must submit the bill to Medicare for reimbursement. See also, Participating Provider.
Non-Preferred Provider/Care: A health care provider or service covered by a private health plan or Medicare private drug plan (Part D) for which the plan will pay lower reimbursement rates. You will pay more for non-preferred services or services given at a non-preferred provider than for preferred providers and services.
Notice of Medicare Non-Coverage (NOMNC): If you are enrolled in a Medicare private health plan (Part C), a notice that tells you when care you are receiving from a home health agency (HHA), skilled nursing facility (SNF) or comprehensive outpatient rehabilitation facility (CORF) is ending and how you can contact a Quality Improvement Organization (QIO) toappeal.
Notice of Medicare Provider Non-Coverage (NOMPNC): If you have Original Medicare, tells you when care you are receiving from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) or hospice agency is ending and how you can contact a Quality Improvement Organization (QIO) to appeal.
Nursing Home: Also called a “convalescent home” or “long-term care facility” or “skilled nursing facility.” A residential facility for persons with chronic illness or disability, particularly older people who have mobility and eating problems. Nursing homes may provide skilled care. If you meet certain health criteria, Medicare covers a limited stay in a Medicare-certifiedskilled nursing facility. While a skilled nursing facility is a nursing home, not all nursing homes are Medicare-certified skilled nursing facilities.
O
Occupational Therapy: Therapy using meaningful activities of daily living to assist people who have difficulty acquring or performing meaningful work due to impairment or limitation of physical or mental function.
Off-Label: The prescribed use of a particular drug for a reason other than the use approved by the U.S. Food and Drug Administration.
Open Enrollment Period (OEP): A period of time from January 1 through March 31 of every year when you can join a Medicare health plan (either Original Medicare or a Medicareprivate health plan—Part C), or switch health plans. If accepting new members, the plan must allow all eligible individuals to join at that time. You cannot add or drop Medicare prescription drug coverage (Part D) at this time.
Opt-Out: Doctors can “opt-out” of Medicare by notifying the Medicare carrier that they will not accept Medicare payments and telling their patients–in writing before treating them–that Medicare will not pay for their services and that the patients must pay for the care themselves. Doctors who have “opted-out” can charge as much as they want, and their patients have to pay the entire bill themselves. The only time a doctor who has opted out can receive payment from Medicare is when the doctor provides a patient emergency or urgent care services and the patient does not have a contract with that doctor. If the doctor did not provide a written contract before the patient received the services, the patient is not liable for payment.
Original Medicare: Also known as "Traditional Medicare." The federal health insuranceprogram, created in 1965, under which the government pays providers directly for each service a person receives (on a fee-for-service basis). Almost all doctors and hospitals in the United States accept Original Medicare. The majority of people with Medicare are enrolled in Original Medicare, as opposed to a Medicare private health plan (Part C).
Out-of-Network: Not part of a managed care plan's network of health care providers. If you get services from an out-of-network doctor, hospital or pharmacy, it usually means that you likely will have to pay the full cost out of your own pocket for the services you received.
Out-of-Pocket Costs: Health care costs that you must pay because Medicare or other health insurance does not cover them.
Out-of-Pocket Limit: See Catastrophic Limit.
Outpatient: A patient who is not in the hospital overnight but who visits a hospital, clinic, doctor’s office or other health care facility for diagnosis or treatment.
Outpatient Care: Medical care that does not require you to stay in the hospital overnight.
Outpatient Prospective Payment System (OPPS): The system through which Medicaredecides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. The rate of reimbursement varies with the location of the hospital or clinic.
Over-the-Counter Drug: A drug that you can buy, without a prescription, at your local pharmacy or drug store. These drugs are not covered by the Medicare prescription drugbenefit (Part D).
