Assignment
In Medicare, an agreement by which a physician accepts a specific charge or fee for his or her services.

Benefit Period
Under Medicare Part A, a benefit period starts when you enter a hospital. It ends when you have been out of a hospital or skilled nursing facility for 60 days in a row. There is no limit to the number of benefit periods you can have.

Brochure
The booklet showing the complete details of a health plan's benefits, limitations, exclusions, and definitions. The brochure is a plan's contractual statement of benefits.

Catastrophic Protection
A feature of fee-for-service plans to limit the amount you would have to pay in a calendar year if you or your family incurred large and unusual medical bills. The catastrophic protection limit is the maximum amount of covered expenses, usually in addition to the deductible, you would have to pay out of your own pocket during the year for yourself or your family. Please note that there is separate catastrophic protection for medical/surgical expenses and inpatient mental health care.

Charges
Amounts allowed by health carriers for specific services and procedures, determined on the basis of a physician's or supplier's customary charges for the service and on the prevailing charges in the locality for similar services. A charge cannot be higher than that applicable for the carrier's own policy holders for similar services under comparable circumstances.

Coinsurance
Medical or health insurance in which the patient pays part of the bill and the insurance carrier pays part of the bill. In Medicare, the Federal Government pays 80 percent, while the patient pays 20 percent.

Co-payment
A fixed dollar amount you must pay for a service or benefit provided by a plan. For example, some plans charge a co-payment of $50 to $100 per hospital admission or $5 to $10 for a doctor's visit.

Covered Charge
The amount of your medical expenses that are covered or reimbursable. An expense that is not a covered charge cannot be used to satisfy the plan's deductible. Often a plan includes as covered charges only an amount specified in a scheduled allowance or based on a customary and reasonable profile. Read the plan brochures to find out how covered charges are determined. Covered charges do not include expenses for non medical items related to an illness or injury, or for specific items excluded by the plan.

Covered Days of Care
The number of days of care that claims have been approved for payment. Because of interim claims for part of a hospital stay, the number of covered days of care per claim may not represent the number of covered days of care per discharge.

Custodial Care
Primarily personal care, such as housekeeping, cooking, and other duties, performed by home health aides in nursing homes. Medicare will not pay for this type of care.

Customary and Reasonable Charges
One of two general methods plans used to determine covered charges. The other method is the Scheduled Allowance defined below. Under the Customary and Reasonable Charge method, a plan allows coverage for an amount that is usually charged for the same procedure by most providers in the geographic area where the service was rendered.

Deductible
The amount of covered charges you must incur in a calendar year before the plan pays benefits. Generally, calendar year deductibles apply to medical care charges and not hospital charges. However, some plans have a separate deductible if you are a hospital bed patient.

Disabled Enrollee
A person under age 65 who is enrolled in the Medicare program solely on the basis of end-stage renal disease or Social Security disability benefits for at least 24 months or Civil Service disability benefits for 29 months. In the case of a civil service disability annuitant, all Social Security requirements for disability must be met.

Enrollment Area
The geographic or local area within which a Comprehensive Medical Plan/Health Maintenance Organization (CMP/HMO) enrolls members. To be eligible to enroll in a CMP/HMO, you must live within this area. The plan brochure identifies the enrollment area.

Exclusions
Charges, services, or supplies that are not covered. A plan does not provide or pay for excluded items, nor do the charges apply toward deductibles or catastrophic limits.

Home Health Agency
An approved organization, either private or nonprofit, that employs skilled personnel to deliver medical care in a patient's home.

Home Health Services
These are services furnished a patient in his/her home by an agency engaged primarily in providing skilled-nursing and other therapeutic services. The service is under a plan established and supervised by a physician.

Covered services may include:

• part-time or intermittent nursing care;
• physical, occupational, and speech therapy;
• part-time or intermittent services of a home health aide;
• medical supplies (other than drugs and biological);
• the use of medical appliances; and
• in certain cases, services of an intern or resident-in-training of a teaching hospital.

The services must be furnished by or under arrangement with an approved home health agency.

Hospice
A public or private organization, or part of either, that is primarily engaged in providing specific services to the terminally ill on an as-needed 24-hour basis. Medicare covers four categories of hospice care – general inpatient care, inpatient respite care, routine home care, and continuous home care.

Hospital Reserve Days
A lifetime reserve of 60 days that you can use to remain in a hospital under Medicare Part A coverage. However, you cannot replace hospital reserve days, once they are used they are gone.

Inpatient Service
The care provided while you are a bed patient in a hospital that has coverage.

Large Case Management
Provides medical resources to patients, who have long term illnesses, in the most cost-effective manner, while maintaining a high level of quality.

Medically Necessary Care
Covered services and supplies that the plan determines to be consistent with standards of good medical practice, and necessary to treat your condition or diagnosis — not primarily for you or your doctor's convenience. In the case of inpatient care, it must be care that could not have been provided safely on an outpatient basis.

Medicaid
A combined state-Federal program that pays for many medical expenses for the poor.

Medicare
A program enacted in 1965 to provide hospital insurance and supplementary medical insurance.

Outpatient Service
The care provided to you in the outpatient department of a hospital, in a clinic, other medical facility, or in a doctor's office.

Pre-Admission Certification
The fee-for-service plans (Blue Cross, Alliance, GEHA, etc.) require you to pre-certify (approve in advance) non-emergency hospital admissions. Pre-admission certification means that you, your doctor, or the hospital must contact your FEHB plan before your admittance to the hospital, or within 2 business days of an emergency admission. If you do not follow the correct procedures, there is a $500 penalty. The $500 deduction is from the costs normally paid by the plan on your claim.

Preferred Provider
Some physicians, hospitals, and discount drug store chains providing medical services and supplies who offer the plan a discount or below market price. These providers are clearly preferred by the plan. They may or may not be preferred by you.

Prospective Payment System
A prospective payment system for Medicare payment of inpatient hospital services. Under this system, Medicare payment is made at a predetermined, specific rate for each discharge. The payment rate relates to the cost of treatment of that illness. All discharges are classified according to a list of diagnosis — related groups (DRG'S). There are 468 specific DRG'S under which you may be discharged. Determination for Medicare payment for inpatient hospital services is fully under a national DRG payment methodology.

Scheduled Allowance
One of two benefit maximums plans use as the amount of your medical or dental care expenses they will cover for a particular service. (The other is the Reasonable and Customary Charge, defined above.) A Scheduled Allowance is the fixed dollar amount that has been assigned to a covered medical or dental service. You must pay any amount the provider charges above it. (Because a plan's Scheduled Allowance for a particular service applies nationwide, and the amount a provider charges for that service may vary geographically, the Scheduled Allowance is likely to defray more of the provider's charge in some areas than in others.

Service Area
The geographic or local area where Comprehensive Medical Plan/Health Maintenance Organization providers and facilities are available to you. This is the plan's enrollment area.

Skilled Nursing Facility
According to the Social Security Administration, this is a specially qualified facility which has the staff and equipment to provide skilled care or rehabilitation services as well as related health services. It can be a separate institution, or a distinct part of an existing hospital or other health care facility.