
GLOSSARY OF MEDICARE-RELATED TERMS

     actual charge -- the amount a physician or supplier actually
bills a patient for a particular medical service or supply. 
(This may differ from the customary, prevailing, and/or
reasonable charges under Medicare.)
     assignment -- a process through which a doctor or supplier
agrees to accept the Medicare program's payment as payment in
full except for specific coinsurance and deductible amounts
required of the patient.
     carrier -- a private insurance organization that contracts
with the Federal government to handle claims from doctors and
suppliers of services covered by Medicare medical insurance. 
     claim -- a request to a carrier or intermediary by a
beneficiary or a provider acting on behalf of a beneficiary for
payment of benefits under Medicare.
     coinsurance -- a cost-sharing requirement that a beneficiary
will assume a portion or percentage of the costs of covered
services.
     competitive medical plan (CMP) -- an organization that
provides a full range of health care coverage in exchange for a
monthly, fixed fee.  CMPs with Medicare contracts offer Medicare
beneficiaries all services covered by fee-for-service Medicare. 
Medicare pays these plans on a monthly basis for each Medicare
beneficiary.  Medicare beneficiaries get all Medicare-covered
hospital and medical insurance benefits through the plan.  The
CMP may also collect a premium from each Medicare member enrolled
in the plan.
     custodial care -- treatment or services, regardless of who
recommends them or where they are provided, that could be given
safely and reasonably by a person not medically skilled, and are
designed mainly to help the patient with daily living.  Examples
include help with walking, bathing, dressing, and using the
toilet.
     customary charge -- the amount a doctor or supplier most
frequently charges for each separate service and supply
furnished.
     deductible -- the amount of expense a beneficiary must first
meet before Medicare begins payment for covered services.
     health maintenance organization (HMO) -- an organization
that provides a full range of health care coverage in exchange
for a monthly fixed fee.  HMOs with Medicare contracts offer
Medicare beneficiaries all services covered by fee-for-service
Medicare.  Medicare pays the organizations on a monthly basis for
each Medicare beneficiary.  Medicare beneficiaries get all
Medicare-covered hospital and medical insurance benefits through
the organizations.  The HMO may also collect a premium from each
Medicare member enrolled in the plan.
     home health agency -- a public or private organization that
specializes in giving skilled nursing services and other
therapeutic services such as physical therapy in a beneficiary's
home.
     hospice -- a program operated by a public agency or private
organization primarily  providing pain relief, symptom
management, and supportive services for terminally ill people and
their families.
     hospital insurance -- the part of Medicare that helps pay
for inpatient hospital care, some inpatient care in a skilled
nursing facility, home health care, and hospice care.
     intermediary -- a private insurance organization under
contract to the Federal government to handle Medicare payment for
services by hospitals, skilled nursing facilities, hospices,
outpatient rehabilitation providers and home health agencies.
     medical insurance -- the part of Medicare that helps pay for
medically necessary doctors' services, outpatient hospital
services, and a number of other medical services and supplies not
covered by the hospital insurance part of Medicare, as well as
some home health services.
     medigap policy -- private health insurance designed to
supplement Medicare.
     outpatient facility -- a facility designed to provide health
and medical services to individuals who are not inpatients.
     participating physician or supplier -- a physician or
supplier who agrees to accept assignment on all Medicare claims.
     peer review organizations (PROs) -- groups of practicing
doctors and other health care professionals under contract to the
Federal government to review the care provided to Medicare
patients.
     prepayment health care plans -- health care providers such
as Health Maintenance Organizations (HMOs) and Competitive
Medical Plans (CMPs).  Medicare pays these plans on a monthly
basis for each Medicare beneficiary.  Medicare beneficiaries get
all Medicare-covered hospital and medical insurance benefits
through the plan.
     prevailing charge -- based upon the customary charges for
covered medical insurance services or items, the prevailing
charge is the maximum charge Medicare can approve for any item or
service.
     prospective payment system -- a process started in l983
under which hospitals are paid fixed amounts based on the
principal diagnosis for each Medicare hospital stay.
     quality review organizations (QROs) -- groups of practicing
doctors and other health care professionals under contract to the
Federal government to review the care provided to Medicare
patients enrolled in HMOs and CMPs.
     reasonable charges -- amounts approved by the Medicare
carrier which will be either the customary charge, the prevailing
charge, or the actual charge, whichever is the lowest.
     routine physical examinations -- physical checkups or X-ray,
laboratory, or other tests made in the absence of definite
symptoms of disease or injury.
     rural health clinic -- a specially qualifed outpatient
facility located in an area designated as rural, where there is a
shortage of health care service or medical professionals.
     skilled nursing facility -- a specially qualified facility
with the staff and equipment to provide skilled nursing care or
rehabilitation services and other related health services.
     supplemental health insurance -- also called "Medigap"
insurance -- private health insurance designed to fill some of
the gaps in Medicare.
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