Interactive Glossary - Section P-R
A-C D-F G-I J-L M-O P-R S-U V-W X-Z
P
Palliative Care: The care of patients with a terminal illness, not with the intent of trying to cure them but to relieve their symptoms. Palliative care consists of relief of pain and nausea, as well as psychological, social and spiritual support services.
Part A: Also known as "Hospital Insurance." The part of Medicare that covers most medically necessary hospital care, skilled nursing facility (SNF) care, home health care, and hospicecare.
Part B: Also known as "Medical Insurance." The part of Medicare that covers most medically necessary doctors' services, preventive care, durable medical equipment (DME), hospitaloutpatient care, laboratory tests, x-rays, mental health, and some home health care and ambulance services.
Part C: Also known as “Medicare Advantage” or “Medicare private health plans.” Formerly known as “Medicare+Choice.” The part of Medicare concerning private health plans. Part C is not a separate benefit. It lets you get your Medicare benefits from a private health plan contracted by the government to provide this coverage. All Medicare private health plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs and coverage restrictions. Some plans (MA-PDs—Medicare Advantage Prescription Drug Plans) offer Part D drug coverage as part of their benefits packages. You must have Medicare Part A and Part B to join a Part C plan. Medicare private health plans include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFFS (Private Fee-for-Service) plans, SNPs (Special Needs Plans) andMSAs (Medical Savings Accounts), and may have a POS (Point-of-Service) option. See alsoPrivate Plan Card.
Part D: Also known as the "Medicare prescription drug benefit." The part of Medicare that provides prescription drug coverage. The benefit is optional to most and provided only by private companies. You can get Part D coverage either through a stand-alone prescription drug plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD)—a Medicareprivate health plan (Part C) that offers Medicare prescription drug coverage. You must choose Part D coverage that works with your Medicare health benefits. People who enroll in Part D pay a monthly premium in addition to their Part B premium. See also Private Plan Card.
Participating Provider: A health care provider who agrees to always take assignment.Participating providers may not charge you more than Medicare's approved amount, even if they charge non-Medicare patients more for the service. You will still pay a coinsurance orcopayment of the cost for a visit or service—usually 80 percent of the Medicare-approved amount, if you have Original Medicare. See also, Non-Participating Provider.
Pastoral Care: Counseling or comfort provided by religious leaders (ministers, rabbis, etc.) to members of their group (church, congregation, etc). This can range from home visitation, to formal counseling by pastors who are licensed to provide pastoral counseling.
Patient Assistant Program: A program typically run by a pharmaceutical company that offers low-cost or free drugs manufactured by that company to people with low incomes.
Personal Care: Assistance with activities of daily living. Providers of personal care (home health aides) are not required to undergo medical training. Medicare only covers personal care if you are homebound and receiving skilled care.
PDP (Prescription Drug Plan): A "stand-alone" Medicare prescription drug plan (Part D) offered through a private insurance company that only offers prescription drug benefits. PDPs work with Original Medicare, MSA (Medical Savings Account) plans, Cost Plans, and PFFS (Private Fee-For-Service) plans without drug coverage.
PFFS (Private Fee-for-Service): A type of managed care plan that allows you to use any doctor or hospital anywhere in the country as long as that provider accepts the plan's terms and conditions. People with Medicare can choose to get their Medicare benefits through a PFFS plan. You may pay more for Medicare benefits, many providers will not take PFFS plans, and you cannot buy a Medigap plan to fill gaps in coverage. See also, Part C.
Pharmacotherapy: The use of drugs to treat a disease or condition.
Physical Therapy: Exercise and physical activities used to condition muscles and improve levels of activity. Physical therapy is helpful for those with physical debilitating illness.
Plan of Care: A doctor’s written plan describing the type and frequency of services and care a particular patient needs.
POS (Point-of-Service Option) Option: The right of managed care plan members to partial coverage for certain services they get outside the managed care plan's network of providers. People with Medicare can choose to get their Medicare benefits through a private managed care plan; some of these plans offer the POS option. See also, Part C.
PPO (Preferred Provider Organization): A type of managed care plan. To get full coverage, you must use providers in the plan’s network, but you should also have partial coverage of care you get from out-of-network providers. People with Medicare can choose to get their Medicare benefits through a PPO. See also, Part C.
Pre-Approval: See Prior Authorization.
Pre-Authorization: See Prior Authorization.
Pre-Existing Condition: A condition or illness with which you were diagnosed or for which you received treatment before your new health care coverage began. Some health plans may impose a waiting period on coverage of any pre-existing conditions you have.
Preferred Provider/Care: A health care provider that is part of a private health plan’s networkor a service that is covered by that private health plan for which the plan will pay its highest reimbursement rates. See also, Non-Preferred Provider/Care.
Premium: The amount that an individual must pay to a Medicare or other health insuranceplan for coverage. Generally paid on a monthly basis.
Premium Penalty: An amount that you must pay to Medicare in addition to the regular monthlypremium for late enrollment in Part B or Part D. The Part B premium is an additional 10 percent of the premium for each year you delay enrollment that you did not have coverage from a current employer. Part D will have a premium penalty of at least 1 percent for every month you delay enrollment that you were without creditable coverage.
Prescription: An order for a health care service or drug written by a qualified health care professional.
Prescription Drug: A drug that can be obtained only by means of a prescription from aprovider. Prescription drugs cannot be bought over-the-counter.
Prescription Drug Insurance: Health coverage that helps you pay for prescription drugs. With a prescription drug insurance plan, you generally pay a copayment or coinsurance for each prescription drug you get that is covered by your plan (on its formulary). If you have Medicare, you can get prescription dug insurance through Part D, the Medicare prescription drug benefit.
Preventive Care: Care to keep you healthy or prevent illness, such as routine checkups, flu shots, and tests like prostate cancer screenings and yearly mammograms.
Primary Care Physician (PCP): The doctor that manages your health care and gives you areferral to consult a specialist if you need it. A managed care plan requires you to have a PCP. If you do not consult your PCP before seeing a specialist, your managed care plan will generally not cover your care.
Primary Insurance: Health insurance that pays first on a claim for medical and hospital care. In most cases, Medicare is your primary insurer. See also, Secondary Insurance.
Prior Authorization: Also called “pre-authorization” or “pre-approval.” A restriction placed on coverage by private health plans and Medicare private drug plans. If a service or medication is covered with “prior authorization,” your doctor must get special permission from the plan to prescribe the service or medication to you before it will be covered. If you fail to get prior authorization before you get a service, your plan generally will not cover it.
Private Duty Nursing: Direct, comprehensive care on an hourly or live-in basis.
Private Health Plan: Also known as a “Managed Care Plan.” Any arrangement for health care in which a private company acts an intermediary between the person seeking care and the physician. In Medicare, you have the choice to get your benefits through the federal government (Original Medicare) or a private health plan that receives a set amount of money from the government to provide Medicare-covered benefits. See also, Part C.
Private Plan Card: The membership card your Medicare private health plan (Part C) orMedicare private drug plan (Part D) sends to you to get health services or prescription drugscovered. You will use this instead of an Original Medicare “red, white and blue card.” It will generally include your name, the name of your insurance policy and the name of the company that sponsors it, as well as your member ID number. It may also list specific copayment orcoinsurance amounts for your primary care physician (PCP) and specialist visits, and show what benefits your insurance plan includes (health, dental, prescription drug coverage, etc.).See also, Medicare Card.
Program of All-Inclusive Care for the Elderly (PACE): Serves individuals who are age 55 or older who are certified by their state to need nursing home care to be able to live safely in the community at the time of enrollment and who live in a PACE service area. The philosophy of PACE states that it is better for the well being of seniors with chronic illness care needs and their families to be served in the community (rather than in a living facility) whenever possible.
Provider: In the realm of health care, an individual or facility (such as a doctor, hospital ordurable medical equipment (DME) supplier), that provides health care services and/or items.
PSO (Provider-Sponsored Organization) A type of managed care plan that is operated by a group of doctors and hospitals that form a network of providers within which you must stay to receive coverage for your care. People with Medicare can choose to get their Medicare benefits through a PSO. This type of plan is not available in most parts of the country. See also, Part C.
Q
QDWI (Qualified Disabled Working Individual): A less common Medicare Savings Program (MSP) administered by each state’s Medicaid program. It pays the Medicare Part A premiumfor people who are under 65, have a disabling impairment, continue to work, and are not otherwise eligible for Medicaid.
QI (Qualifying Individual): Federal program administered by each state's Medicaid program that pays the Medicare Part B premium for people with Medicare who have low income.
QIO Review: The initial step in making an appeal to a denial of coverage (either barring admittance to or discharge from a hospital, home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) or hospice). See also, Quality Improvement Organization (QIO).
QMB (Qualified Medicare Beneficiary): Federal program administered by state Medicaidprograms that helps people with Medicare who have low income pay their coinsurance,deductibles, and premiums.
Qualified Independent Contractor (QIC): An independent entity with which Medicarecontracts to handle the reconsideration level of an Original Medicare (Part A or Part B)appeal.
Quality Improvement Organization (QIO): Formerly known as “Peer Review Organization.” A group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. QIOs must review your complaints about the quality of care you get and appeals for care in inpatient hospitals, hospitaloutpatient care departments, hospital emergency rooms, skilled nursing facilities (SNFs),home health agencies (HHAs), Private Fee-for-Service (PFFs) plans, and ambulatory surgical centers. QIOs also contract with Medicare to conduct appeals. For example, QIOs review expedited appeals when a Medicare private health plan (Part C) denies coverage or terminates services from a hospital, home health agency, SNF, or comprehensive outpatient rehabilitation facility (CORF), or Original Medicare denies coverage of home health care, SNF care, hospice care or CORF care.
Quantity Limit: A restriction used by private health plans and Medicare private drug plans that limits coverage of a particular drug to a specific amount (such as 30 pills a month each year).
R
Railroad Medicare Carrier: A private company that provides Medicare coverage for railroad retirement beneficiaries.
Railroad Retirement Board: An independent agency in the executive branch of the federal government that administers comprehensive retirement-survivor and unemployment-sickness benefit programs for the nation's railroad workers and their families, under the Railroad Retirement Act and Railroad Unemployment Insurance Act.
Reconsideration:
Referral: Authorization that Medicare private health plans (Part C) usually require for services not provided by your primary care physician (PCP). For instance, HMOs generally require you to get a referral from your primary care doctor in order to see a specialist or get an eye exam.
Regional Home Health Intermediary: A private company that contracts with Medicare to payhome health care bills and monitor quality. There are four Regional Home Health Intermediaries in the U.S., each serving states in one of four U.S. regions. See also,Medicare Administrative Contractor (MAC).
Rehabilitative Care: The care of patients with the intent of curing, improving or preventing a worsening of their condition. For example, physical therapy after hip replacement surgery to resume walking, or occupational therapy to prevent carpal tunnel syndrome.
Request for Reconsideration of Part B Premium Amount: The first level of appeal to theSocial Security Administration if you think that Social Security has overestimated your income and is charging you a higher Part B premium than the standard amount. The next level of appeal is to the Administrative Law Judge (ALJ).
Reserve Days: See Lifetime Reserve Days.
Respite Care: A hospice service that provides relief for caregivers of hospice patients by arranging a brief period (up to five days) of inpatient care for the patient.
Retiree Insurance: Health insurance provided by employers to former employees who have retired. Retiree insurance always pays secondary to Medicare. See also, Supplemental Insurance.
Retroactive Disenrollment: A way to discontinue enrollment in a Medicare private health plan(Part C) or Medicare private drug plan (Part D) that you mistakenly joined or joined due tomarketing fraud, effective back to the date you joined. You will be disenrolled from your Medicare private health or drug plan as if you had never joined it.
Palliative Care: The care of patients with a terminal illness, not with the intent of trying to cure them but to relieve their symptoms. Palliative care consists of relief of pain and nausea, as well as psychological, social and spiritual support services.
Part A: Also known as "Hospital Insurance." The part of Medicare that covers most medically necessary hospital care, skilled nursing facility (SNF) care, home health care, and hospicecare.
Part B: Also known as "Medical Insurance." The part of Medicare that covers most medically necessary doctors' services, preventive care, durable medical equipment (DME), hospitaloutpatient care, laboratory tests, x-rays, mental health, and some home health care and ambulance services.
Part C: Also known as “Medicare Advantage” or “Medicare private health plans.” Formerly known as “Medicare+Choice.” The part of Medicare concerning private health plans. Part C is not a separate benefit. It lets you get your Medicare benefits from a private health plan contracted by the government to provide this coverage. All Medicare private health plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs and coverage restrictions. Some plans (MA-PDs—Medicare Advantage Prescription Drug Plans) offer Part D drug coverage as part of their benefits packages. You must have Medicare Part A and Part B to join a Part C plan. Medicare private health plans include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFFS (Private Fee-for-Service) plans, SNPs (Special Needs Plans) andMSAs (Medical Savings Accounts), and may have a POS (Point-of-Service) option. See alsoPrivate Plan Card.
Part D: Also known as the "Medicare prescription drug benefit." The part of Medicare that provides prescription drug coverage. The benefit is optional to most and provided only by private companies. You can get Part D coverage either through a stand-alone prescription drug plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD)—a Medicareprivate health plan (Part C) that offers Medicare prescription drug coverage. You must choose Part D coverage that works with your Medicare health benefits. People who enroll in Part D pay a monthly premium in addition to their Part B premium. See also Private Plan Card.
Participating Provider: A health care provider who agrees to always take assignment.Participating providers may not charge you more than Medicare's approved amount, even if they charge non-Medicare patients more for the service. You will still pay a coinsurance orcopayment of the cost for a visit or service—usually 80 percent of the Medicare-approved amount, if you have Original Medicare. See also, Non-Participating Provider.
Pastoral Care: Counseling or comfort provided by religious leaders (ministers, rabbis, etc.) to members of their group (church, congregation, etc). This can range from home visitation, to formal counseling by pastors who are licensed to provide pastoral counseling.
Patient Assistant Program: A program typically run by a pharmaceutical company that offers low-cost or free drugs manufactured by that company to people with low incomes.
Personal Care: Assistance with activities of daily living. Providers of personal care (home health aides) are not required to undergo medical training. Medicare only covers personal care if you are homebound and receiving skilled care.
PDP (Prescription Drug Plan): A "stand-alone" Medicare prescription drug plan (Part D) offered through a private insurance company that only offers prescription drug benefits. PDPs work with Original Medicare, MSA (Medical Savings Account) plans, Cost Plans, and PFFS (Private Fee-For-Service) plans without drug coverage.
PFFS (Private Fee-for-Service): A type of managed care plan that allows you to use any doctor or hospital anywhere in the country as long as that provider accepts the plan's terms and conditions. People with Medicare can choose to get their Medicare benefits through a PFFS plan. You may pay more for Medicare benefits, many providers will not take PFFS plans, and you cannot buy a Medigap plan to fill gaps in coverage. See also, Part C.
Pharmacotherapy: The use of drugs to treat a disease or condition.
Physical Therapy: Exercise and physical activities used to condition muscles and improve levels of activity. Physical therapy is helpful for those with physical debilitating illness.
Plan of Care: A doctor’s written plan describing the type and frequency of services and care a particular patient needs.
POS (Point-of-Service Option) Option: The right of managed care plan members to partial coverage for certain services they get outside the managed care plan's network of providers. People with Medicare can choose to get their Medicare benefits through a private managed care plan; some of these plans offer the POS option. See also, Part C.
PPO (Preferred Provider Organization): A type of managed care plan. To get full coverage, you must use providers in the plan’s network, but you should also have partial coverage of care you get from out-of-network providers. People with Medicare can choose to get their Medicare benefits through a PPO. See also, Part C.
Pre-Approval: See Prior Authorization.
Pre-Authorization: See Prior Authorization.
Pre-Existing Condition: A condition or illness with which you were diagnosed or for which you received treatment before your new health care coverage began. Some health plans may impose a waiting period on coverage of any pre-existing conditions you have.
Preferred Provider/Care: A health care provider that is part of a private health plan’s networkor a service that is covered by that private health plan for which the plan will pay its highest reimbursement rates. See also, Non-Preferred Provider/Care.
Premium: The amount that an individual must pay to a Medicare or other health insuranceplan for coverage. Generally paid on a monthly basis.
Premium Penalty: An amount that you must pay to Medicare in addition to the regular monthlypremium for late enrollment in Part B or Part D. The Part B premium is an additional 10 percent of the premium for each year you delay enrollment that you did not have coverage from a current employer. Part D will have a premium penalty of at least 1 percent for every month you delay enrollment that you were without creditable coverage.
Prescription: An order for a health care service or drug written by a qualified health care professional.
Prescription Drug: A drug that can be obtained only by means of a prescription from aprovider. Prescription drugs cannot be bought over-the-counter.
Prescription Drug Insurance: Health coverage that helps you pay for prescription drugs. With a prescription drug insurance plan, you generally pay a copayment or coinsurance for each prescription drug you get that is covered by your plan (on its formulary). If you have Medicare, you can get prescription dug insurance through Part D, the Medicare prescription drug benefit.
Preventive Care: Care to keep you healthy or prevent illness, such as routine checkups, flu shots, and tests like prostate cancer screenings and yearly mammograms.
Primary Care Physician (PCP): The doctor that manages your health care and gives you areferral to consult a specialist if you need it. A managed care plan requires you to have a PCP. If you do not consult your PCP before seeing a specialist, your managed care plan will generally not cover your care.
Primary Insurance: Health insurance that pays first on a claim for medical and hospital care. In most cases, Medicare is your primary insurer. See also, Secondary Insurance.
Prior Authorization: Also called “pre-authorization” or “pre-approval.” A restriction placed on coverage by private health plans and Medicare private drug plans. If a service or medication is covered with “prior authorization,” your doctor must get special permission from the plan to prescribe the service or medication to you before it will be covered. If you fail to get prior authorization before you get a service, your plan generally will not cover it.
Private Duty Nursing: Direct, comprehensive care on an hourly or live-in basis.
Private Health Plan: Also known as a “Managed Care Plan.” Any arrangement for health care in which a private company acts an intermediary between the person seeking care and the physician. In Medicare, you have the choice to get your benefits through the federal government (Original Medicare) or a private health plan that receives a set amount of money from the government to provide Medicare-covered benefits. See also, Part C.
Private Plan Card: The membership card your Medicare private health plan (Part C) orMedicare private drug plan (Part D) sends to you to get health services or prescription drugscovered. You will use this instead of an Original Medicare “red, white and blue card.” It will generally include your name, the name of your insurance policy and the name of the company that sponsors it, as well as your member ID number. It may also list specific copayment orcoinsurance amounts for your primary care physician (PCP) and specialist visits, and show what benefits your insurance plan includes (health, dental, prescription drug coverage, etc.).See also, Medicare Card.
Program of All-Inclusive Care for the Elderly (PACE): Serves individuals who are age 55 or older who are certified by their state to need nursing home care to be able to live safely in the community at the time of enrollment and who live in a PACE service area. The philosophy of PACE states that it is better for the well being of seniors with chronic illness care needs and their families to be served in the community (rather than in a living facility) whenever possible.
Provider: In the realm of health care, an individual or facility (such as a doctor, hospital ordurable medical equipment (DME) supplier), that provides health care services and/or items.
PSO (Provider-Sponsored Organization) A type of managed care plan that is operated by a group of doctors and hospitals that form a network of providers within which you must stay to receive coverage for your care. People with Medicare can choose to get their Medicare benefits through a PSO. This type of plan is not available in most parts of the country. See also, Part C.
Q
QDWI (Qualified Disabled Working Individual): A less common Medicare Savings Program (MSP) administered by each state’s Medicaid program. It pays the Medicare Part A premiumfor people who are under 65, have a disabling impairment, continue to work, and are not otherwise eligible for Medicaid.
QI (Qualifying Individual): Federal program administered by each state's Medicaid program that pays the Medicare Part B premium for people with Medicare who have low income.
QIO Review: The initial step in making an appeal to a denial of coverage (either barring admittance to or discharge from a hospital, home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) or hospice). See also, Quality Improvement Organization (QIO).
QMB (Qualified Medicare Beneficiary): Federal program administered by state Medicaidprograms that helps people with Medicare who have low income pay their coinsurance,deductibles, and premiums.
Qualified Independent Contractor (QIC): An independent entity with which Medicarecontracts to handle the reconsideration level of an Original Medicare (Part A or Part B)appeal.
Quality Improvement Organization (QIO): Formerly known as “Peer Review Organization.” A group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. QIOs must review your complaints about the quality of care you get and appeals for care in inpatient hospitals, hospitaloutpatient care departments, hospital emergency rooms, skilled nursing facilities (SNFs),home health agencies (HHAs), Private Fee-for-Service (PFFs) plans, and ambulatory surgical centers. QIOs also contract with Medicare to conduct appeals. For example, QIOs review expedited appeals when a Medicare private health plan (Part C) denies coverage or terminates services from a hospital, home health agency, SNF, or comprehensive outpatient rehabilitation facility (CORF), or Original Medicare denies coverage of home health care, SNF care, hospice care or CORF care.
Quantity Limit: A restriction used by private health plans and Medicare private drug plans that limits coverage of a particular drug to a specific amount (such as 30 pills a month each year).
R
Railroad Medicare Carrier: A private company that provides Medicare coverage for railroad retirement beneficiaries.
Railroad Retirement Board: An independent agency in the executive branch of the federal government that administers comprehensive retirement-survivor and unemployment-sickness benefit programs for the nation's railroad workers and their families, under the Railroad Retirement Act and Railroad Unemployment Insurance Act.
Reconsideration:
- In the Original Medicare (Part A and Part B) appeals process, the second level of appeal, where your appeal is reviewed by a Qualified Independent Contractor (QIC).
- In a Medicare private health plan (Part C) appeals, there are two “reconsideration” phases.
- Reconsideration by the Medicare private health plan. The first step in the appeal of a denial of coverage or denial of payment, in which the plan reviews its initial denial.
- Reconsideration by the Independent Review Entity (IRE). If the plan upholds its initial decision in the redetermination, the appeal is automatically forwarded to the IRE for reconsideration.
- In a Medicare private drug plan (Part D), a review of the plan’s redetermination of its decision to deny coverage or payment. Reconsiderations are conducted by the Independent Review Entity.
- The first step in the Original Medicare process of appeals once you have received aMedicare Summary Notice (MSN) giving you notice of a denial of coverage.
- The first step in the Part D appeals process after the plan denies your coverage orexception request.
Referral: Authorization that Medicare private health plans (Part C) usually require for services not provided by your primary care physician (PCP). For instance, HMOs generally require you to get a referral from your primary care doctor in order to see a specialist or get an eye exam.
Regional Home Health Intermediary: A private company that contracts with Medicare to payhome health care bills and monitor quality. There are four Regional Home Health Intermediaries in the U.S., each serving states in one of four U.S. regions. See also,Medicare Administrative Contractor (MAC).
Rehabilitative Care: The care of patients with the intent of curing, improving or preventing a worsening of their condition. For example, physical therapy after hip replacement surgery to resume walking, or occupational therapy to prevent carpal tunnel syndrome.
Request for Reconsideration of Part B Premium Amount: The first level of appeal to theSocial Security Administration if you think that Social Security has overestimated your income and is charging you a higher Part B premium than the standard amount. The next level of appeal is to the Administrative Law Judge (ALJ).
Reserve Days: See Lifetime Reserve Days.
Respite Care: A hospice service that provides relief for caregivers of hospice patients by arranging a brief period (up to five days) of inpatient care for the patient.
Retiree Insurance: Health insurance provided by employers to former employees who have retired. Retiree insurance always pays secondary to Medicare. See also, Supplemental Insurance.
Retroactive Disenrollment: A way to discontinue enrollment in a Medicare private health plan(Part C) or Medicare private drug plan (Part D) that you mistakenly joined or joined due tomarketing fraud, effective back to the date you joined. You will be disenrolled from your Medicare private health or drug plan as if you had never joined it.
