CHAA Glossary

Provides care under contract to medicare, a member is still in the medicare program, must have Medicare part A and B and continue to pay the Part B premium, may be able to get extra benefits (prescription drugs, additional days in the hospital)

A medicare supplemental insurance. It is a private insurance designed to help pay medicare cost sharing amounts such as coinsurance, deductibles, and uncovered services.

The traditional healthcare payment system, under whichphysicians and other providers receive a payment for each unit of service provided.

A listing of accepted fees or established allowances for specifiedmedical procedures. As used in medical care plans, it usuallyrepresents the maximum amounts the program will pay for thespecified procedures. Usually associated with ancillary servicessuch as lab or radiology.

A type of medicare supplemental health insurance - it is the same as Medigap, with the only difference being that each insurer has specific hospitals and doctors the participants must use.

An easy to read, monthly statement that clearly lists claims information. This replaced the Explanation of your medicare part B benefits (EOMB) and the Medicare benefits notice, and benefit denial letters

Given to all medicare beneficiaries who are inpatients in participating hospitals. It explains the patients rights as hospital patients and advises beneficiaries about what to do if they feel they are being discharged early and provides the phone number for the Peer Review Organization.

If medically necessary, Part A helps pay for up to 100 days in each benefit period. Medicare pays all approved charges for the first 20 days; patients pay a coinsurance amount for days 21-100.

Medicare pays the full approved cost of services. This includes intermittent skilled nursing services prescribed by a physician for treatment of homebound patients. The only amount patients pay for is a 20% coinsurance for medicare equipment.

A health insurance plan or another entity that processes andpays healthcare bills. May be called a third party payor, payor,carrier, or insurer. These terms are interchangeable. Carriermay also refer to an organization contracted with the Centers forMedicare and Medicaid Services (CMS) to process and payMedicare Part B claims.

A decision to separately purchase a service, which is typically apart of an indemnity of a Health Maintenance Organization(HMO) plan. For example, an HMO may “carve out” thebehavioral health benefits and select a specialized vendor tosupply these services on a stand-alone basis. Carve outs mayalso include medical devices that the plan pays for in addition tothe contracted per diem or case rate.

This is determined by dividing the sum of all Diagnosis Related Group (DRG) relative weights for every DRGused by Medicare patients by the total number of Medicareinpatient cases for the hospital. This is used to adjust thehospital base rate, which is a factor in computing the totalhospital payment under a Prospective Payment System (PPS).

A method of cost sharing in which the subscriber is responsiblefor a specified percentage of the cost of healthcare under feefor-service plans. Plans where the insured is responsible for20% while the insurance will cover 80% are fairly typical.Frequently there is a maximum amount the insured is requiredto pay, called a stop loss amount. This isrelate to Part A Medicare benefits. For each day ofhospitalization over 60 days and up to the 90th day, acoinsurance payment of one-quarter of the inpatient deductibleis due.

A national file of Medicare claims.

A person, guardian, official, or institution designated totake over and protect the interests of an incompetent person.This includes being responsible for paying the individual'shealthcare bills.