Term
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Definition
| Short-term medical care that Medicare provides at home while you recover from an injury or illness. It includes part-time or occasional skilled nursing care, some equipment, supplies, and other services. |
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Term
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Definition
On going help with personal and health care, which might be provided by a nursing home or assisted living facility.
Medicare does not cover this kind of care. |
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Term
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Definition
| A federal and state program separate from Medicare that helps pay medical costs for people with low incomes and limited assets. |
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Term
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Definition
| An alternative to Medicare Parts A and B, in which a private company provides your health care coverage. |
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Term
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Definition
| Medicare insurance that pays for stays in the hospital and skilled nursing facilities, along with hospice care, and some home health care. |
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Term
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Definition
| Medicare insurance that pays for doctor's visits, laboratory tests, medical equipment, and some other medical services. |
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Term
| Health Maintenance Organization (HMO) |
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Definition
| A type of Medicare Advantage plan that requires you to choose a primary care physician from a network of approved healthcare providers. If you need to see a specialist, you must have a referral from your primary care physician. |
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Term
| Medical Savings Account (MSA) plan |
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Definition
| An insurance plan for people with Medicare that combines a high deductible health plan and a bank account. |
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Term
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Definition
| Also known as "traditional Medicare." A government-sponsored Medicare plan administered by the Centers for Medicare & Medicaid Services (CMS). |
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Term
| Preferred Provider Organization (PPO) |
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Definition
| A type of Medicare Advantage plan that allows you to see in-network or out-of-network doctors and other healthcare providers - but you save money by using providers who are in the plan's network. |
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Term
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Definition
| An individual who has Medicare |
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Term
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Definition
Health care service or item that:
- meets medical standards
- is required for the diagnosis and treatment of a medical condition
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Term
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Definition
The amount an individual pays to have health insurance, usually paid on a monthly basis.
(aka the most BULLSHIT CHARGE imo) |
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Term
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Definition
| The amount an individual owes the provider before health insurance begins to cover the cost of health care services. Usually resets each calendar year. |
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Term
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Definition
The amount (%) an individual owes for each service or item after meeting the deductible.
(Percentage of approved amount for services) |
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Term
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Definition
The amount ($1.00) an individual owes for each service or item after meeting the deductible.
Fixed amount per health care services. |
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Term
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Definition
| Individual or facility that provides health care services and/or items. Some examples include hospitals, doctors, pharmacies, and medical suppliers. |
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Term
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Definition
| Patient that has been formally admitted into the hospital by an attending physician. |
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Term
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Definition
| Patient that has not been formally admitted into the hospital. |
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Term
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Definition
| Care intended to detect and prevent illness or keep individual healthy. Examples include flu shots and routine cancer screenings. |
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Term
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Definition
| Care intended to address symptoms or conditions that an individual already has. |
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Term
| Skilled nursing facility (SNF) |
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Definition
| Facility that provides short-term and post-hospital extended care at a lower level of care than an inpatient in a hospital. |
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Term
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Definition
| Agency that provides care in the home, often through a licensed nurse. Services can include therapy, skilled nursing, and/or personal care. |
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Term
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Definition
| Provides medical and non-medical care to those who have a chronic illness or disability. |
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Term
| Durable medical equipment (DME) |
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Definition
| Equipment that serves a medical purpose, can withstand repeated use, and is appropriate for use in the home. |
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Term
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Definition
| Provider accepts Medicare’s approved amount for health care services as payment in full. |
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Term
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Definition
| A provider who accepts Medicare and takes assignment in all cases. |
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Term
| Non-participating provider |
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Definition
A provider who accepts Medicare but does not agree to take assignment in all cases. These providers can charge beneficiaries up to 15% more than Medicare’s approved amount for the cost of health care services.
(Note: Durable medical equipment (DME) suppliers are not subject to the limiting charge.) |
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Term
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Definition
| A provider who does not accept Medicare at all and has signed an agreement to withdraw from the Medicare program. These providers can charge Medicare beneficiaries whatever they want for services and cannot receive any payment from Medicare. |
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Term
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Definition
| A provider who contracts with a Medicare Advantage Plan to provide health care services to plan members at a negotiated rate. |
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Term
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Definition
| A provider who does not contract with the Medicare Advantage Plan. |
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Term
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Definition
| Individual who has been formally admitted to the hospital by an attending physician. |
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Term
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Definition
| Individual who has not been formally admitted to the hospital. |
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Term
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Definition
| Therapy that helps an individual complete activities of daily living and is intended for those who have difficulty acquiring or performing work due to impairment or limitation of physical or mental function. |
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Term
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Definition
| Treatment for speech impairments, such as lisping or stuttering or speech difficulties that result from illness. |
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Term
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Definition
| Therapy to help individuals with activities of daily living. Occupational therapy assists those who have difficulty acquiring or performing work due to impairment or limitation of physical or mental function. |
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Term
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Definition
| Medical care that addresses a specific symptom or condition in accordance with a physician’s orders. It is provided by or under the direct supervision of a qualified health care professional, such as a registered nurse or licensed physical therapist. |
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Term
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Definition
| Non-medical care, such as help with bathing, dressing, and using the bathroom, which can be provided by a home health aide. |
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Term
| Advance Beneficiary Notice (ABN) |
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Definition
| Notice a provider gives to the beneficiary if they have reason to believe that Medicare will not pay for a service because it is not reasonable and necessary based on Medicare coverage rules. The ABN allows a beneficiary to decide whether to get the care in question and to pay for the service out of pocket if Medicare does not pay for the service received. |
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Term
| Medicare Summary Notice (MSN) |
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Definition
| Original Medicare notice, sent at three-month intervals, that summarizes health care services received, says how much Medicare approved and paid for the services, and notes how much the beneficiary owes the health care provider for the services. An MSN is not a bill. |
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Term
| Explanation of Benefits (EOB) |
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Definition
Medicare Advantage notice that summarizes health care services received, says how much the plan paid for the services, and notes how much the beneficiary owes the health care provider for the services.
An EOB is not a bill. |
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Term
| Medicare Administrative Contractors (MAC) |
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Definition
| Point of contact between Medicare and providers enrolled in Medicare programs. MACs process Original Medicare claims, educate providers about billing requirements, and review cases as part of the appeals process. |
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Term
| Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC -QIO) |
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Definition
| Protects quality and safety of care provided to beneficiaries. QIOs handle quality of care complaints related to hospital, skilled nursing facility, home health, and hospice care. They are also Medicare contractors that review cases as part of the appeals process. |
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Term
| Qualified Independent Contractor |
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Definition
| Reviews appeals at the second stage in the appeals process with an independent team of doctors and health professionals. |
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