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Home > Senior Volunteers > Useful Resources > Minnesota Consumer Awareness Education and Resource Guide for 1998 > Chapter VIII: Glossary |
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Useful Resources
AAA - Area Agency on Aging (State designation) AARP - American Association of Retired Persons ALS - Advanced Life Support (Ambulance) AoA - Administration on Aging (Federal) ASC - Ambulatory Surgical Center Bene - Beneficiary BLS - Basic Life Support (Ambulance) CMHC - Community Mental Health Center CMN - Certificate of Medical Necessity CMP - Competitive Medical Plan CORF - Comprehensive Outpatient Rehabilitation Facility CP - Clinical Psychologist CPI - Consumer Price Index CPT - "Physicians' Current Procedural Terminology" (Published yearly by the American Medical Association) CSW - Clinical Social Worker DHS - Department of Health Services (State) DHHS - Department of Health and Human Services (Federal) DOI - Department of Insurance (State) DME - Durable Medical Equipment DMERC - Durable Medical Equipment Regional Carrier DRG - Diagnostic Related Groups EGHP - Employer Group Health Plan EMC - Electronic Media Claims EOB - Explanation of Benefits EOMB - Explanation of Medical Benefits ESRD - End Stage Renal Disease FI - Fiscal Intermediary FPL - Federal Poverty Level FY - Fiscal Year GAO - General Accounting Office (Federal) CMS - Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) (Federal) HHA - Home Health Agency HIC# - Health Insurance Claim Number HMO - Health Maintenance Organization HPSA - Health Professional Shortage Area ICF - Intermediate Care Facility IPL - Independent Physiological Lab I & R - Information and Referral LTC - Long Term Care MEDPARD - Medical Participating Physicians and Suppliers Directory MFIS - Medicare Fraud Information Specialist MSN - Medicare Summary Notice MSP - Medicare as Secondary Payer NAIC - National Association of Insurance Commissioners OAA - Older Americans Act (Federal) OIG - Office of Inspector General ORT - Operation Restore Trust OT - Occupational Therapy Part A - Hospital Insurance (Medicare) Part B - Medical Insurance (Medicare) PHP - Partial Hospitalization Program PPO - Preferred Provider Organization PPS - Prospective Payment System PRO - Peer Review Organization PSA - Planning Service Area (part of AAA) PT - Physical Therapy QMB - Qualified Medicare Beneficiary (State) RHHI - Regional Home Health Intermediary RRB - Railroad Retirement Board SLMB - Specified/Service Limited Medicare Beneficiary SNF - Skilled Nursing Facility SSA - Social Security Administration (Federal) SSI - Social Security Income (Federal) SSN - Social Security Number SSP - Supplemental Security Payment (State) ST - Speech Therapy UR - Utilization Review VA - Veteran's Administration (Federal) Glossary of Terms Activities of Daily Living (ADLs) - Activities which include help in walking, getting in and out of bed, bathing, dressing, eating, toileting, and taking medicine. Also see "Custodial Care". Actual Charge - The amount a physician or other health care provider bills a patient for a particular medical service or procedure. The actual charge may differ from the Medicare approved amount or amount approved by other insurance programs. Acute Hospital - A hospital which provides care for persons who have a crisis, intense or severe illness or condition which requires urgent restorative care. Administration on Aging - An agency of the U.S. Department of Health and Human Services. AoA is a focal point and advocate agency for older persons and their concerns at the federal level. AoA works closely with its nationwide network of State and Area Agencies on Aging (AAA) to plan, coordinate, and develop community level systems of services that meet the unique needs of individual older persons and their care givers. Allowed Amount - See Approved Charge. Appeal - Medicare beneficiaries have the right to request a review of a denied claim, and if not satisfied with the review, to appeal to a higher review. See Medicare Appeal. Approved Charge - The maximum fee that a third party (insurer) will use in reimbursing a provider for a given service. The Medicare "approved" charge is usually less than the customary, prevailing, or actual charge. Area Agencies on Aging (AAA) - Local government agencies which grant or contract with public and private organizations to provide services for older persons within their area. Assignment - The physician or supplier who accepts assignment under Medicare Part B agrees to be paid whatever amount Medicare determines to be allowable. If so, Medicare will pay 80 percent of the approved charge and the beneficiary pays 20 percent. The doctor cannot bill for any additional amount on the service for which assignment was accepted. Beneficiary - Any persons who receives benefits. Benefit Maximum - The limit a health insurance policy will pay for a certain loss or covered service. The benefit can be expressed either as 1) a length of time (for example, 60 days), or 2) a dollar amount (for example, $350 for a specific procedure or illness), or 3) a percentage of the Medicare approved amount. The benefits may be paid to the policyholder or to a third party. This may refer to a specific illness, time frame, or the life of the policy. Benefit Period - This is the period of time for which payments for benefits covered by an insurance policy are available. The availability of certain benefits may be limited over a specified time period. Benefit Period Under Medicare - A Medicare benefit period begins upon entry to a qualified hospital and ends when the patient has been out of a hospital and not receiving Medicare benefits in a facility primarily providing skilled nursing or rehabilitation services for 60 consecutive days, including the day of discharge. Biologicals - Substances, such as whole blood, hemophilia clotting factors, tetanus antitoxins vaccines, tumor chemotherapy agent, etc. Buy-In - Program in which the state's Medicaid program pays the Medicare premiums, deductibles and co-payments for certain low income eligible people. Carrier - A commercial health insurance company under contract with the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) (CMS) to handle claims processing for Medicare Part B, including the payment of claims for items and services provided in a given area. Certificate of Medical Necessity (CMN) - A document completed and signed by a physician to certify a patient's need for certain types of durable medical equipment (e.g. wheelchairs, walkers, etc.). Charges - Prices assigned to units of medical service, such as a visit to a physician or a day in the hospital. Charges for services may not be related to the actual costs of providing the services. Further, the methods by which charges are related to costs vary substantially from service to service and from institution to institution. Chronic - A lasting, lingering or prolonged illness. Claims - A bill requesting that medical services be paid by Medicare or by some other insurance company. COBRA (Consolidated Omnibus Budget Reconciliation Act) - Legislation that allows specific employees and their dependents to continue employer's group health plan coverage for a specified period of time. COBRA Legislation - Legislation that requires that workers who end employment for specified reasons have the option of purchasing group health insurance for 18 months. Coordination of Benefits - Provisions and procedures used by insurers to avoid duplicate payments for losses insured under more than one policy. One of the insurers is usually the primary payer assuring that no more than 100% of the costs are covered. This does not usually apply to indemnity (cash payment) policies. Also see "Medicare as Second Payer". Co-payment - A specified dollar amount or percentage of covered expenses which the beneficiary is required to pay towards medical bills. Medicare Part A Hospital Insurance requires that a co-payment, or co-insurance, is paid by the beneficiary for certain covered services, and the 21st through the 100th day of skilled nursing facility care. Medicare Part B pays 80% of "approved" charges and the beneficiary must pay the 20% coinsurance and the balance of the charges. Costs - Expenses incurred in the provision of services or goods. Charges billed to an individual or third party may not necessarily be the same, as based on the costs. Hospitals often charge more for a given service than it actually costs in order to recoup losses incurred form providing other services where costs exceed feasible charges. Covered Services - Medicare law permits payment only for services that are "reasonable and necessary for the diagnosis or treatment of an illness or injury". Therefore, Medicare can pay for services only as long as they are medically necessary. CPT - "Physicians' Current Procedural Terminology", yearly publication of the American Medical Association. A listing of the descriptive terms and the numeric identifying codes and modifiers for describing and reporting medical services and procedures performed by physicians. These codes are required on claims submitted for Medicare payment. Custodial Care - Care is considered custodial when it is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, eating, toileting, and taking medicine. (These may also be referred to as Activities of Daily Living or ADLs.) Deductible - An initial amount of medical expanse for which the beneficiary is responsible before Medicare or an insurance policy will pay. Demand Bill - When a provider determines that the care to be provided is not covered, the beneficiary must be notified in writing. If a beneficiary is unwilling to accept the providers decision of noncoverage, the beneficiary may request a bill to be submitted to intermediary on their behalf. All "demand bills" are reviewed 100% by Medicare for a coverage decision. Diagnostic Related Groups (DRGs) - DRGs are used to determine the amount that Medicare reimburses hospitals for in-patient services. It is part of the Prospective Payment System. Categories of illnesses are divided into more than 470 groups, one of which is assigned to a Medicare patient being discharged from a hospital. The hospital is reimbursed a fixed amount based on the DRG code for the patient. Duplication of Coverage - Coverage of the same health services by more than one health insurance policy. Expenses for the covered services are only paid for by one policy, meaning the policyholder has two (or more) policies but has only received benefits from one of them. Durable Medical Equipment (DME) - Durable medical equipment, as defined by Medicare, is equipment which can 1) withstand repeated use, 2) is primarily and customarily used to serve a medical purpose, 3) generally not useful to a person in the absence of an illness or injury, and 4) is appropriate for use in the home. Equipment used in the treatment of health conditions and impairments, such as oxygen, wheelchairs, hospital beds, walkers. Durable Medical Equipment Regional Carrier (DMERC) - A commercial health insurance company under contract with the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) (CMS) to handle claims processing for durable medical equipment. There are a total of four DMERCs, each serving a specific geographic area. Durable Power of Attorney for Health Care - This legal document authorizes the person given the power to make decisions regarding the person's medical treatment only when the person giving the power becomes incompetent. Duration of Benefits - Time period or maximum amount of dollars for which an insurance policy will pay benefits. End Stage Renal Disease (ESRD) - Medical condition in which a person’s kidneys no longer function, requiring the individual to receive dialysis or a kidney transplant to sustain his or her life. Enrollment - Procedure in which eligible persons can secure participation in the Medicare program and receive Medicare coverage. It is handled by the Social Security Administration through local Social Security offices. Enrollment Period - Period during which individuals may enroll for an insurance policy, Medicare, or managed care plan. Explanation of Medicare Benefits (EOMB) Form - The statement that Medicare sends the beneficiary to show what action was taken by the carrier in processing the Medicare claim. If payment is being issued to the Medicare beneficiary, a check will be attached. Most Medigap policies pay claims based on the EOMB. Fee for Service - Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. This is the usual method of billing by the majority of physicians. Fee Schedule - A listing of accepted charges or established allowances for specified medical, dental, or other procedures or services. It usually represents either a physician's or third party's standard or maximum charges for the listed procedures. Fiscal Intermediary (FI) - Private health insurance company under contract with the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) (CMS) to handle claims processing for Medicare Part A. General Enrollment Period - Period of time from January 1st to March 31st each year when those eligible can enroll in Part B of Medicare. Grace Period - A specified period after a premium payment is due on an insurance policy or Medicare, in which the policyholder may make such payment, and during which the provisions of the policy continue. Health and Human Services, Department of - An executive department of the federal government which has the ultimate authority for the Medicare and Medicaid programs. Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) (CMS) - A branch of the U.S. Department of Health and Human Services. This federal agency is responsible for administering the Medicare and Medicaid programs. CMS - 1490S - Called the Patient's Request for Medical Payment, this claim form was used by beneficiaries to submit Part B Medicare claims for medical services received prior to September 1, 1990. CMS - 1500 - Claim form required by Medicare for physician, practitioner and supplier claims. Beginning September 1, 1990, all providers are required to submit claims on behalf of Medicare beneficiaries. Health Insurance Claim (HIC) Number - The unique alpha numeric Medicare entitlement number assigned to a Medicare beneficiary and which appears on the Medicare card. (Also referred to as "Medicare number".) Health Maintenance Organization (HMO) - An organization that, for a prepaid fee, provides a comprehensive range of health maintenance and treatment services (including hospitalization, preventive care, diagnosis, and nursing). HMOs are sponsored by large employers, labor unions, medical schools, hospitals, medical clinics, and even insurance companies. Development of HMOs was spurred by the federal government in the 1970’s as a means to correct the structural, inflationary problems with conventional health care payment systems. Home Health Agency (HHA) - A home health agency is a public or private agency that specializes in giving skilled nursing services, home health aides, and other therapeutic services, such as physical therapy, in the home. Home Health Care - Health care services provided in the home on a part time basis for the treatment of an illness or injury. Medicare pays for home care only if the type of care needed is skilled and required on an intermittent basis and is intended to help people recover or improve from an illness, not to provide unskilled services over a long period of time. Hospice - A hospice is a public agency or private organization that primarily provides pain relief, symptom management, and supportive services to terminally ill people and their families in the home. Illegal Sales Practices - Sales techniques used by insurance agents selling health insurance to supplement Medicare (Medigap) in which they mislead older adults into buying unnecessary coverage or paying premiums for no coverage. Indemnity - A specific amount paid for a specified occurrence. Initial Enrollment Period - An individual's first opportunity to enroll in Medicare; the seven months surrounding a person's 65th birth month or 24th month of entitlement to disability benefits. Inpatient - A patient who has been admitted at least overnight to a hospital or other health facility (which is, therefore, responsible for his room and board) for the purpose of receiving a diagnosis, treatment, or other health services. Institutionalization - Admission of an individual to an institution, such as a nursing home, where he or she will reside for an extended period of time or indefinitely. Insured - The individual or organization protected in case of loss or covered service under the terms of an insurance policy. Intermediary - See Fiscal Intermediary. Intermediate Care Facility (ICF) - An ICF provides health related care and services to individuals who do not require the degree of care or treatment given in a hospital or skilled nursing facility, but who (because of their mental or physical condition) require care and services which is greater than custodial care and can only be provided in an institutional setting. Length of Stay - The time a patient stays in a hospital or other health facility. Lifetime Reserve - Medicare Part A provides a 60 day, one time only benefit period beyond the 90th day of hospital coverage. This is not renewable and a co-payment is required. Long Term Care (LTC) - The broad spectrum of medical and support services provided to persons who have lost some or all capacity to function on their own due to chronic illness or condition and who are expected to need such services over a prolonged period of time. Long term care can consist of care in the home, by family members assisted with voluntary or employed help (such as provided by home health care agencies), adult day health care, or care in institutions. Managed Care - Medical care delivery system, such as HMO or PPO, where someone "manages" health care services a beneficiary receives; each plan has its own group of hospitals, doctors and other health care providers called a "network"; usually promote preventive health care; may have to pay a fixed monthly premium and a co-payment each time a service is used. Long Term Care Insurance - A policy designed to help alleviate some of the costs associated with long term care needed. Often, benefits are paid in the form of a fixed dollar amount (per day or per visit) for covered LTC expenses and may exclude or limit certain conditions from coverage. Mammogram - The X-ray of the breast to diagnose or screen for breast cancer. Managed Care - Medical care delivery system, such as HMO or PPO, where someone "manages" health care services a beneficiary receives; each plan has its own group of hospitals, doctors, and other health care providers called a "network;" usually promote preventative health care; may have to pay a fixed monthly premium and a copayment each time a service is used. Medicaid - Title XIX of the Social Security Act, federally assisted state administered program to finance health care services for low-income persons of all ages. It is supported by Federal and State taxes. Medically Necessary - Medical necessity must be established (via diagnostic and/or other information presented on the claim under consideration) before the carrier or insurer will make payment. Medicare - Title XVIII of the Social Security Act, federal health insurance program for people 65 and older and some under 65 who are disabled. Medicare has two parts. Part A is Hospital Insurance and primarily provides coverage for inpatient care. Part B is Medical Insurance and provides limited coverage for outpatient care, physician services, diagnostic tests, supplies and ambulance services for the diagnosis and treatment of illness or injury. Medicare Appeal (Reconsideration) - Procedure by which a beneficiary who disagrees with the amount of Medicare Part B reimbursement can challenge the Medicare carrier or intermediary within six months of the date of the EOMB. If dissatisfied with the decision for an amount over $100 beneficiary may request a hearing within 6 months from review letter. If the amount in question is over $500, beneficiary may request a hearing by an Administrative Law Judge within 60 days from the date of the hearing letter. Medicare Part A appeals have different time limits and amounts in controversy limits. Medicare Benefit Notice - Form a Medicare beneficiary receives from the intermediary or carrier explaining the amount of Medicare reimbursement for a claim. Medicare Part A - The same as Medicare Hospital Insurance. Medicare Part B - The same as Medicare Medical Insurance. Medicare Summary Notice (MSN) - A newly designed format replacing the Explanation of Medicare Benefits form. The MSN shows what action was taken by the carrier or fiscal intermediary in processing the Medicare claim. Medicare as Secondary Payer (MSP) - Situations, defined by law, in which payment may be made only after another source of medical benefits has either paid or denied payment of medical items and/or services. Medicare Supplemental Policy (also known as Medigap) - Type of insurance policy with coverage specifically designed to pay the major benefit gaps in Medicare (deductibles and co-payment). Medigap Policy - Insurance designed to supplement Medicare by "filling some of the gaps left by Medicare coverage." MEDPARD - Medicare Participating Physicians and Suppliers Directory. Directory issued by a carrier listing all Medicare participating physicians (physicians who accept assignment) located in that carrier’s area. Minnesota Family Investment Program - Statewide (MFIP-S) - Beginning 1-1-98 program replaces AFDC in Minnesota. National Association of Insurance Commissioners (NAIC) - The organization that prepares model provisions and guidelines for insurance companies and state legislatures. Notice of Continued Stay Denial - A Medicare beneficiary may become liable for costs of hospital care after he/she is given a written Notice of Continued Stay Denial. This notice of noncoverage states that in the hospital’s opinion and with the attending physician’s or PRO’s concurrence, the beneficiary no longer requires inpatient hospital care. Liability begins on the third day after the receipt of this notice from the hospital. Medicare beneficiaries can appeal written denials of coverage through an expedited appeal to the PRO or through the usual Medicare Part A Appeals procedure. Nonparticipating Physician - A doctor who does not pledge to accept assignment on all claims by signing the Medicare participation agreement. Nonparticipating Facility - Health care facility which does not participate in the Medicare program and generally does not accept Medicare payment for services received in the facility. Nursing Home - also convalescent hospital. A place where persons reside who need some level of medical assistance and/or assistance with activities of daily living. A term used to cover a wide range of institutions including Skilled Nursing Facilities, Intermediate Care Facilities and Custodial Care Facilities. Not all nursing homes are Medicare approved/certified facilities. Nursing Home Policy - Type of limited health insurance policy which generally pays indemnity benefits for medically necessary stays in nursing facilities (sometimes referred to as Long term Care policies). Occupational Therapy - Activities designed to improve the useful functioning of physically and/or mentally disabled persons. Office of Inspector General (OIG)/DHHS - The agency within the U.S. Department of Health and Human Services responsible for the investigation of suspected fraud and abuse and performing audits and inspections of HHS programs. The OIG has authority to levy certain sanctions and civil money penalties. Older Americans Act - Federal legislation enacted in 1965 to provide money for programs and direction for a multitude of services designed to enrich the lives of senior citizens, for example, adequate housing, income, employment, nutrition and health care. Ombudsman - A "citizen’s representative" who protects a person’s rights through advocacy, providing information and encouraging institutions or agencies to respect citizens’ rights. Open Enrollment - A period when new subscribers may elect to enroll in a health insurance plan or managed care plan. Operation Restore Trust (ORT) - The special HHS initiative establishing a two-year demonstration project (May 95 - May 97) against fraud, waste and abuse in the Medicare and Medicaid programs. The project targeted areas of high spending growth (home health agencies, nursing homes and durable medical equipment) in the top five states in terms of beneficiary population and expenditures (California, Florida, Illinois, New York and Texas). Out-of-Pocket Expenses - Costs borne directly by the patient without benefit of insurance; direct costs. Outpatient - A patient who receives care at a hospital or other health facility without being admitted to the facility. Outpatient care also refers to care given in organized programs, such as outpatient clinics. (Continued) Part A - See "Medicare". Part B - See "Medicare". Partial Hospitalization Program (PHP) - A program designed to keep patients with severe mental conditions from becoming hospitalized by providing intensive psychotherapy in a day outpatient setting. Participating Facility - Health care facility which participates in the Medicare program and accepts Medicare payment for services received in the facility. Participating Physician/Supplier Agreement - An agreement, by an individual physician or supplier, to always accept assignment on claims for Medicare-covered items and services. This agreement is valid for the calendar year and may be renewed annually. Always use a current MEDPARD when looking for a participating physician/supplier. Peer Review Organizations (PRO’s) - Organizations that have a contract with the federal government to oversee quality of care for Medicare beneficiaries in hospitals, skilled nursing facilities, home health agencies, ambulatory surgical centers, and managed care plans. If the quality of care you received from one of these facilities was unsatisfactory or you think you are being discharged from the hospital too early, you may file a written complaint with your state’s PRO. Personal Care - Assistance provided to people who need help with bathing, cooking, dressing, eating, grooming or personal hygiene. These services are paid for by Medicaid when medically necessary. Personal Convenience Items -Medicare does not pay for personal convenience items such as a telephone, toothpaste, slippers, television in your room, for private duty nurses, or for any extra charges for a private room unless it is medically necessary. Physical Therapy - Services provided by specially trained and licensed physical therapists in order to relieve pain, restore maximum function, and prevent disability, injury or loss of a body part. Physician Payment Reform - Physician Payment Reform, which began January 1, 1991, requires that all physicians and practitioners who accept Medicare, whether participating or not, use the Medicare approved amount to determine their actual charges, which can be set at no more than 115 percent above the Medicare approved amount. This legislation also established a national Physician Fee Schedule. Power of Attorney - A legal document which gives a person (usually a spouse, other relative or friend) the power to act on behalf of another. The person giving the power must be competent, and does not lose the legal right to act on his own behalf. Preferred Provider Organization (PPO) - Membership organizations that offer members a network of physicians and suppliers who accept assignment. They may also offer additional benefits such as discounts on prescription drugs, transportation discounts and access to health education programs. Premium - Dollar amount paid periodically (monthly, quarterly, or yearly) by an insured person or Medicare beneficiary in exchange for a designated amount of insurance or Medicare coverage. Prior Authorization - Approval may be required before a medical service is provided. For procedures which require prior authorization, an insurer can deny coverage for services already provided or for proposed services which are deemed to not be medically necessary. It is generally the responsibility of the provider to obtain the authorization. Primary Payer - Provider of medical coverage first responsible for making payment on a Medicare claim. Prospective Payment System (PPS) - A standardized payment system implemented in 1983 by Medicare to help manage health care reimbursement whereby the incentive for hospitals to deliver unnecessary care is eliminated. Under PPS, hospitals are paid fixed amounts based on the principal diagnosis for each Medicare hospital stay. In some cases, the Medicare payment will be more than the actual cost of providing services for that stay; in other cases, the payment will be less than the hospital’s actual cost. Provider - Someone who provides medical services or supplies, such as a physician, hospital, x-ray company, home health agency, or pharmacy. Qualified Medicare Beneficiaries (QMB) - A federally required program where states must pay the Medicare deductibles, co-payments as well as Part B premiums for Medicare beneficiaries who qualify based on income and resources. Railroad Retirement - Persons who worked for a railroad company are entitled to their benefits at retirement (includes Medicare). Reasonable and Necessary Care - The amount and type of health services generally accepted by the health community as being required for the treatment of a specific disease or illness. Reconsideration (or Review) - The first step in the Medicare Part A appeal process in which the beneficiary sends a written request to the intermediary showing his or her disagreement with the Part A payment allowed for a claim and asking that the payment decision be reviewed. Regional Home Health Intermediary (RHHI) - Private health insurance company under contract with the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) (CMS) to handle claims processing for home health and hospice claims. There are currently eight RHHIs serving specific geographic areas. Respite - The in-home care of a chronically ill beneficiary intended to give the care-giver a rest. Can also be provided in a hospice or nursing home (as with hospice respite care). Review (or Reconsideration) - The first step in the Medicare Part B appeal process in which the beneficiary sends a written request to the carrier showing his or her disagreement with the Part B payment allowed for a claim and asking that the payment decision be reviewed. Santions - Action taken when people fail to comply with MFIP-S work requirements. Secondary Payer - A payer of medical benefits whose payments cannot be made until another, primary party has processed the claim and issued a claim determination. Skilled Nursing Care - Care which can only be provided by or under the supervision or licensed nursing personnel. Skilled rehabilitation care must be provided or supervised by licensed therapy personnel. All care is under the general direction of a physician and necessary on a daily basis. Therapy that is needed only occasionally, such as twice a week, or where the skilled services that are needed do not require inpatient care, do not qualify as skilled level of care. Skilled Nursing Facility (SNF) - A Medicare approved skilled nursing facility which is staffed and equipped to furnish skilled nursing care, skilled rehabilitation services and other important related health services for which Medicare pays benefits. Social Security - A national insurance program that provides income to workers when they retire or are disabled and to dependent survivors when a worker dies. Retirement payments are based on worker’s earnings during employment. Social Security Administration (SSA) - The federal agency responsible for determining Medicare eligibility and for the Medicare enrollment process. Specified Low-Income Medicare Beneficiary (SLMB) - A federally required program where state must pay the Medicare Part B premium based on income, resources, and assets. Speech Therapy - The study, examination, and treatment of defects and diseases of the voice, speech, spoken and written language. Spousal Impoverishment - The community property and assets of a married nursing home patient may be divided according to CMS standards to protect the property and assets of the spouse. Supplemental Health Insurance - See Medicare Supplemental Policy. Supplemental Security Income (SSI) - A federal program that pays monthly checks to people in need who are 65 years or older and to people in need at any age who are blind and disabled. The purpose of the program is to provide sufficient resources so that any one who is 65 or blind or disabled can have a basic monthly income. Eligibility is based on income and assets. Suppliers - Persons or organizations, other than physicians or health care facilities, that furnish medical equipment or services, such as ambulance firms, laboratories, and equipment rental outlets. Third Party Liability - A party other than the beneficiary who is responsible for payment of part or all of a specific Medicare claim. Medicare supplemental insurance (Medigap) coverage is one example. Title XVIII - That portion of the Social Security Act which clearly defines the provisions of Medicare. Title XIX - That portion of the Social Security Act which establishes that Social Security funds will be used to fund, on a federal/state cost sharing basis, a general medical assistance program, known as Medicaid. Unassigned Claim - A claim submitted to a carrier, fiscal intermediary or health insurer by the person or on behalf of the person, who received a service, with payment made to that person rather than to the provider. Underwriting - The process by which an insurer establishes and assumes risks according to insurability. Utilization Review Committee (URC) - Committee in a health care facility which evaluates the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. This includes a current and retroactive review of the appropriateness of admissions, services ordered and provided, length of stay, and discharge practices. Visit - An encounter between a patient and a health care professional which requires either the patient to travel from his home to the professional’s usual place of practice (an office visit), or for the doctor or other health care provider to see the patient in the hospital, skilled nursing facility, or in the patient’s home. Doctors’ services can be covered in any of these settings under Medicare.
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