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33 Cards in this Set
- Front
- Back
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Part A
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Hospital Insurance, is financed through a portion of the payroll tax (FICA).
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Part B
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Medical Insurance, is financed from monthly premiums paid by insureds and from the general revenues of the federal government.
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Part C
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allows people to receive all of their health care services through available provider organizations
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Part D
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for prescription drug coverage.
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Actual Charge
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The amount a physician or supplier actually bills for a particular service or supply.
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Ambulatory Surgical Services
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Care that is provided at an ambulatory center. These are surgical services performed at a center that do not require a hospital stay unlike in-patient hospital surgery.
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Approved Amount
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The amount Medicare determines to be reasonable for a service that is covered under Part B of Medicare.
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Assignment
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The physician or a medical supplier agrees to accept the Medicare approved amount as full payment for the covered services.
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Carriers
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Organizations that process claims that are submitted by doctors and suppliers under Medicare.
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Coinsurance
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The portion of Medicare’s approved amount that the beneficiary is responsible for paying.
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Comprehensive Outpatient Rehabilitation Facility Services
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Outpatient services received from a Medicare participating comprehensive outpatient rehabilitation facility.
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Deductible
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The amount of expense a beneficiary must first incur before Medicare begins payment for covered services.
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Durable Medical Equipment
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Medical equipment such as oxygen equipment, wheel chairs, and other medically necessary equipment that a doctor prescribes for use in the home.
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Excess Charge
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The difference between the Medicare approved amount for a service or supply and the actual charge.
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Intermediaries
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Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of health services.
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Limiting Charge
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The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment.
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Non-Participating
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octors or suppliers who may choose whether or not to accept assignment on each individual claim.
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Outpatient Physical and Occupational Therapy and Speech Pathology Services
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Medically necessary outpatient physical and occupational therapy or speech pathology services prescribed by a doctor or therapist.
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Pap Smear Screening
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Provides for a pap smear to screen for cervical cancer once every three years.
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Partial Hospitalization for Mental Health Treatment
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A program of outpatient mental health care.
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Participating Doctor or Suppliers
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Doctors and suppliers who sign agreements to become Medicare participating. For example, they have agreed in advance to accept assignment on all Medicare claims.
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Peer Review Organizations
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Groups of practicing doctors and other health care professionals who are paid by the government to review the care given to Medicare patients.
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Medicare Part A Qualifications
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Automatic if socially secured or Over 65 or can be younger than 65 if:
ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease) End Stage Renal Disease - permanent kidney failure that requires dialysis or a transplant - "ESRD" |
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Medicare Part A services:
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Inpatient Hospital Care
Skilled Nursing Facility Care - Home Health Care Hospice Care |
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Doctor Services – Part B
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covers doctor services no matter where received in the United States. Covered doctor services include surgical services, diagnostic tests and X-rays that are part of the treatment, medical supplies furnished in a doctor’s office, and services of the office nurse.
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Outpatient Hospital Services – Part B
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covers outpatient hospital services received for diagnosis and treatment, such as care in an emergency room, outpatient clinic, or a hospital.
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Home Health Visits - part B
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Medicare will pay for home health services as long as these services are recommended by the insured's doctor and the insured is eligible. However, these services are provided on a part-time basis with limits on the number of hours per day and days per week. The services that are not fully covered by Medicare will get coverage from Medicaid.
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Drugs and Biologicals – part B
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Only medicines that are administered at the hospital or at a doctor’s office are covered by Medicare. Drugs which can be self administered (taken at home) are not covered, even if prescribed by a doctor.
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Outpatient Treatment of Mental Illness – part B
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Medicare covers outpatient treatment by a doctor for mental illness, but with a 50% copayment, instead of the usual 20%.
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Medicare Advantage
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Medicare provided by an approved Health Maintenance Organization or Preferred Provider Organization. Many HMOs or PPOs do not charge premiums beyond what is paid by Medicare.
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Medicare Private Fee-for-Service Plan
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Medicare Advantage Plan offered by a private insurance company. Medicare pays a set amount of money every month to the private insurance company to provide health care coverage. The insurance company decides how much enrollees pay for the services they get.
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Medicare Advantage Plan (Part C), Special Needs Plans
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provide more focused and specialized health care for specific groups of people. This includes people who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.
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Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
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This act implemented a plan to add a Part D - Prescription Drug Benefit to the standard Medicare Coverages.
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