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Glossary

Glossary

This glossary explains terms found on the cms.hhs.gov web site, but it is not a legal document.

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M

Term Definition
M+C ORGANIZATION (MEDICARE+CHOICE)

A public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider sponsored organization receiving waivers) that is certified by CMS as meeting the M+C contract requirements. See 42 C.F.R. 422.2.

M+C PLAN

Health benefits coverage offered under a policy or contract offered by a Medicare+Choice Organization under which a specific set of health benefits are offered at a uniform premium and uniform level of cost-sharing to all Medicare beneficiaries residing in the service area of the M+C plan. See 42 C.F.R. 422.2. An M+C plan may be a coordinated care plan (with or without point of service options), a combination of an M+C medical savings account (MSA) plan and a contribution into an M+C MSA established in accordance with 42 CFR part 422.262, or an M+C private fee-for-service plan. See 42 C.F.R. 422.4(a).

MALNUTRITION

A health problem caused by the lack (or too much) of needed nutrients.

MAMMOGRAM

A special x-ray of the breasts. Medicare covers the cost of a mammogram once a year for women over 40.

MANAGED CARE

Includes Health Maintenance Organizations (HMO), Competitive Medical Plans (CMP), and other plans that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract they have with Medicare. See also "Medicare+Choice".

MANAGED CARE ORGANIZATION

Managed Care Organizations are entities that serve Medicare or Medicaid beneficiaries on a risk basis through a network of employed or affiliated providers. Stands for Managed Care Organization. The term generally includes HMOs, PPOs, and Point of Service plans. In the Medicaid world, other organizations may set up managed care programs to respond to Medicaid managed care. These organizations include Federally Qualified Health Centers, integrated delivery systems, and public health clinics. Is a health maintenance organization, an eligible organization with a contract under 1876 or a Medicare-Choice organization, a provider-sponsored organization, or any other private or public organization, which meets the requirements of 1902 (w) to provide comprehensive services.

MANAGED CARE PAYMENT SUSPENSION

See Suspension of Payments Includes Health Maintenance Organizations (HMO), Competitive Medical Plans (CMP), and other plans that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract they have with Medicare. See also "Medicare+Choice."

MANAGED CARE PLAN

In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan?s list except in an emergency. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extra benefits, like extra days in the hospital. In most cases, a type of Medicare Advantage Plan that is available in some areas of the country. Your costs may be lower than in the Original Medicare Plan.

MANAGED CARE PLAN WITH A POINT OF SERVICE OPTION (POS)

A managed care plan that lets you use doctors and hospitals outside the plan for an additional cost. (See Medicare Managed Care Plan.)

MANAGED CARE SYSTEM

Integrates the financing and delivery of appropriate health care services to covered individuals by means of: arrangements with selected providers to furnish a comprehensive set of health care services to members, explicit criteria for the selection of health care provides, and significant financial incentives for members to use providers and procedures associated with the plan. Managed care plans typically are labeled as HMOs (staff, group, IPA, and mixed models), PPOs, or Point of Service plans. Managed care services are reimbursed via a variety of methods including capitation, fee for service, and a combination of the two.

MANDATORY SPENDING

Outlays for entitlement programs (Medicare and Medicaid) that are not subject to the Federal appropriations process.

MANDATORY SUPPLEMENTAL BENEFITS

Services not covered by Medicare that enrollees must purchase as a condition of enrollment in a plan. Usually, those services are paid for by premiums and/or cost sharing. Mandatory supplemental benefits can be different for each Medicare Advantage plan. Medicare Advantage Plans must ensure that any particular group of Medicare beneficiaries does not use mandatory supplemental benefits to discourage enrollment.

MANUAL CLAIM REVIEW

Review, pre- or postpayment, that requires the intervention of PSC personnel.

MANUAL TRANSMITTALS

Manual transmittals announce policy revisions. National coverage determinations are announced in transmittals for the Medicare National Coverage Determinations Manual. Changes to Local Medical Review Policy are announced in transmittals for the Medicare Program Integrity Manual.

MARKET BASKET

See "Hospital market basket."

MASS IMMUNIZATION CENTER

A location where providers administer pneumococcal pneumonia and influenza virus vaccination and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy, or mall but may include a physician's office setting (4408.8, Part 3 of MCM).

MATERIAL WEAKNESS

A serious flaw in management controls requiring high-priority corrective action.

MAXIMUM DEFINED DATA SET

Under HIPAA, this is all of the required data elements for a particular standard based on a specific implementation specification. An entity creating a transaction is free to include whatever data any receiver might want or need. The recipient is free to ignore any portion of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is needed for coordination of benefits.

MAXIMUM ENROLLEE OUT-OF-POCKET COSTS

The beneficiary's maximum dollar liability amount for a specified period.

MAXIMUM PLAN BENEFIT COVERAGE

The maximum dollar amount per period that a plan will insure. This is only applicable for service categories where there are enhanced benefits being offered by the plan, because Medicare coverage does not allow a Maximum Plan Benefit Coverage expenditure limit.

MAXIMUM TAX BASE

Annual dollar amount above which earnings in employment covered under the HI program are not taxable. Beginning in 1994, the maximum tax base is eliminated under HI.

MAXIMUM TAXABLE AMOUNT OF ANNUAL EARNINGS

See "Maximum tax base."

MCO/PHP STANDARDS

These are standards that States set for plan structure, operations, and the internal quality improvement/assurance system that each MCO/PHP must have in order to participate in the Medicaid program.

MEASUREMENT

The systematic process of data collection, repeated over time or at a single point in time.

MEDIATE

To settle differences between two parties.

MEDICAID

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

MEDICAID MANAGEMENT INFORMATION SYSTEM

A CMS approved system that supports the operation of the Medicaid program. The MMIS includes the following types of sub-systems or files: recipient eligibility, Medicaid provider, claims processing, pricing, SURS, MARS, and potentially encounter processing.

MEDICAID MCO

A Medicaid MCO provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

MEDICAID-ONLY MCO

A Medicaid-only MCO is an MCO that provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

MEDICAL CODE SETS

Codes that characterize a medical condition or treatment. These code sets are usually maintained by professional societies and public health organizations. Compare to administrative code sets.

MEDICAL INSURANCE (PART B)

Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.

MEDICAL RECORDS INSTITUTE

An organization that promotes the development and acceptance of electronic health care record systems.

MEDICAL REVIEW/UTILIZATION REVIEW

Contractor reviews of Medicare claims to ensure that the service was necessary and appropriate.

MEDICAL UNDERWRITING

The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your State law allows it), and how much to charge you for that insurance.

MEDICALLY NECESSARY

Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren?t mainly for the convenience of you or your doctor.

MEDICARE

The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).

MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) permitted the Centers for Medicare & Medicaid Services (CMS) to consolidate the Fiscal Intermediary (Part A) and Contractor (Part B) systems into a new system administered by Medicare Administrative Contractors (MACs), covering both Part A and Part B claims in one or more geographic jurisdictions.

MEDICARE ADVANTAGE PLAN

A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans.

MEDICARE BENEFITS

Health insurance available under Medicare Part A and Part B through the traditional fee-forservice payment system.

MEDICARE BENEFITS NOTICE

A notice you get after your doctor files a claim for Part A services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN). (See Explanation of Medicare Benefits; Medicare Summary Notice.)

MEDICARE CARRIER

A private company that contracts with Medicare to pay Part B bills.

MEDICARE CONTRACTOR

A Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)

MEDICARE COORDINATION OF BENEFITS CONTRACTOR

A Medicare contractor who collects and manages information on other types of insurance or coverage that pay before Medicare. Some examples of other types of insurance or coverage are: Group Health Coverage, Retiree Coverage, Workers? Compensation, No-fault or Liability insurance, Veterans? benefits, TRICARE, Federal Black Lung Program, and COBRA.

MEDICARE COVERAGE

Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).)

MEDICARE COVERAGE DOCUMENTS (MCDS)

Documents that are published by CMS that help to relay information that is related to coverage on a national level.

MEDICARE DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER

A Medicare contractor that was responsible for administering Durable Medical Equipment (DME) benefits for a region. The term DME MAC has replaced the term DMERC.

MEDICARE ECONOMIC INDEX

An index often used in the calculation of the increases in the prevailing charge levels that help to determine allowed charges for physician services. In 1992 and later, this index is considered in connection with the update factor for the physician fee schedule.

Medicare Evidence Development & Coverage Advisory Committee (MEDCAC)(formerly know as MCAC)

The MEDCAC (formerly know as MCAC) advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law. They perform this task via a careful review and discussion of specific clinical and scientific issues in an open and public forum. The MEDCAC (formerly know as MCAC) is advisory in nature, with the final decision on all issues resting with CMS. Accordingly, the advice rendered by the MEDCAC (formerly know as MCAC) is most useful when it results from a process of full scientific inquiry and thoughtful discussion, in an open forum, with careful framing of recommendations and clear identification of the basis of those recommendations.

The MEDCAC (formerly know as MCAC) is used to supplement CMS's internal expertise and to ensure an unbiased and contemporary consideration of "state of the art" technology and science. Accordingly, MEDCAC (formerly know as MCAC) members are valued for their background, education, and expertise in a wide variety of scientific, clinical, and other related fields. In composing the MEDCAC (formerly know as MCAC), CMS was diligent in pursuing ethnic, gender, geographic, and other diverse views, and to carefully screen each member to determine potential conflicts of interest.

MEDICARE HANDBOOK

The Medicare Handbook provides information on such things as how to file a claim and what type of care is covered under the Medicare program. This handbook is given to all beneficiaries when first enrolled in the program.

MEDICARE MANAGED CARE PLAN

A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan?s list. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extras, like prescription drugs. Your costs may be lower than in the Original Medicare Plan.

MEDICARE MEDICAL SAVINGS ACCOUNT PLAN (MSA)

A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Insurance Policy with a high deductible. The other part is a special savings account where Medicare deposits money to help you pay your medical bills.

MEDICARE NATIONAL COVERAGE DETERMINATIONS MANUAL

(Formerly the Coverage Issues Manual) The National Coverage Determinations Manual contains implementing instructions for National Coverage Determinations. The manual includes information whether specific medical items, services, treatment procedures, or technologies are paid for under the Medicare program on a national level.

MEDICARE PART A (HOSPITAL INSURANCE)

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

MEDICARE PART A FISCAL INTERMEDIARY

A Medicare contractor that administers the Medicare Part A (institutional) benefits for a given region.

MEDICARE PART B (MEDICAL INSURANCE)

Medicare medical insurance that helps pay for doctors? services, outpatient hospital care, durable medical equipment, and some medical services that aren?t covered by Part A.

MEDICARE PART B CARRIER

A Medicare contractor that administers the Medicare Part B (Professional) benefits for a given region.

MEDICARE PART B PREMIUM REDUCTION AMOUNT

Since CY 2003, MCOs are able to use their adjusted excess to reduce the Medicare Part B premium for beneficiaries. When offering this benefit, a plan cannot reduce its payment by more than 125 percent of the Medicare Part B premium. In order to calculate the Part B premium reduction amount, the PBP system must multiply the number entered in the "indicate your MCO plan payment reduction amount, per member" field by 80 percent. The resulting number is the Part B premium reduction amount for each member in that particular plan (rounded to the nearest multiple of 10 cents).

MEDICARE PAYMENT ADVISORY COMMISSION

A commission established by Congress in the Balanced Budget Act of 1997 to replace the Prospective Payment Assessment Commission and the Physician Payment Review Commission. MedPAC is directed to provide the Congress with advice and recommendations on policies affecting the Medicare program.

MEDICARE PREFERRED PROVIDER ORGANIZATION (PPO) PLAN

A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

MEDICARE PREMIUM COLLECTION CENTER (MPCC)

The contractor that handles all Medicare direct billing payments for direct billed beneficiaries. MPCC is located in Pittsburgh, Pennsylvania.

MEDICARE PRIVATE FEE-FOR-SERVICE PLAN

A type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan?s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn?t cover.

MEDICARE REMITTANCE ADVICE REMARK CODES

A national administrative code set for providing either claim-level or service-level Medicare-related messages that cannot be expressed with a Claim Adjustment Reason Code. This code set is used in the X12 835 Claim Payment & Remittance Advice transaction.

MEDICARE SAVINGS PROGRAM

Medicaid programs that help pay some or all Medicare premiums and deductibles.

MEDICARE SAVINGS PROGRAMS

There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay Medicare deductibles and coinsurance. You can apply for these programs if: You have Medicare Part A (Hospital Insurance). (If you are eligible for Medicare Part A but don?t think you can afford it, there is a program that may pay the Medicare Part A premium for you.), you are an individual with resources of $4,000 or less, or are a couple with resources of $6,000 or less. Resources include money in a savings or checking account, stocks, or bonds and You are an individual with a monthly income of less than $1,031, or a couple with a monthly income of less than $1,384. Income limits will change slightly in 2004. If you live in Hawaii or Alaska, income limits are slightly higher. Note: If your income is less than the amounts listed above, you may qualify for Medicaid.

MEDICARE SECONDARY PAYER

A statutory requirement that private insurers providing general health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers.

MEDICARE SECONDARY PAYER

Any situation where another payer or insurer pays your medical bills before Medicare.

MEDICARE SELECT

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

MEDICARE SUMMARY NOTICE (MSN)

A notice you get after the doctor or provider files a claim for Part A and Part B services in the Original Medicare Plan. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

MEDICARE SUPPLEMENT INSURANCE

Medicare supplement insurance is a Medigap policy. It is sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Minnesota, Massachusetts, and Wisconsin, there are 10 standardized policies labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. (See Gaps and Medigap Policy.)

MEDICARE TRUST FUNDS

Treasury accounts established by the Social Security Act for the receipt of revenues, maintenance of reserves, and disbursement of payments for the HI and SMI programs.

MEDICARE+CHOICE

A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.

MEDICARE+CHOICE PLAN

A health plan, such as a Medicare managed care plan or Private Fee-for-Service plan offered by a private company and approved by Medicare. An alternative to the Original Medicare Plan.

MEDICARE-APPROVED AMOUNT

In the Original Medicare Plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare and you for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the ?Approved Charge.?

MEDIGAP POLICY

A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Massachusetts, Minnesota and Wisconsin, there are 10 standardized plans labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. (See Gaps.)

MEMORANDUM OF UNDERSTANDING

A document providing a general description of the responsibilities that are to be assumed by two or more parties in their pursuit of some goal(s). More specific information may be provided in an associated SOW.

MEMORANDUM OF UNDERSTANDING

An instrument used when agencies enter into a joint project in which they each contribute their own resources in which the scope of work is very broad and not specific to any one project; or in which there is no exchange of goods or services between the participating agencies.

MILITARY SERVICE WAGE CREDITS

Credits recognizing that military personnel receive other cash payments and wages in kind (such as food and shelter) in addition to their basic pay. Noncontributory wage credits of $160 are provided for each month of active military service from September 16, 1940 through December 31, 1956. For years after 1956, the basic pay of military personnel is covered under the Social Security program on a contributory basis. In addition to contributory credits for basic pay, noncontributory wage credits of $300 are granted for each calendar quarter in which a person receives pay for military service from January 1957 through December 1977. Deemed wage credits of $100 are granted for each $300 of military wages in years after 1977. (The maximum credits allowed in any calendar year are $1,200.) See also "Quinquennial military service determinations and adjustments."

MILITARY TREATMENT FACILITY

A medical facility operated by one or more of the Uniformed Services. A Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Services (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

MINIMUM SCOPE OF DISCLOSURE

The principle that, to the extent practical, individually identifiable health information should only be disclosed to the extent needed to support the purpose of the disclosure.

MODALITY

Methods of treatment for kidney failure/ESRD. Modality types include transplant, hemodialysis, and peritoneal dialysis.

MODIFIED AVERAGE-COST METHOD

Under this system of calculating summary measures, the actuarial balance is defined as the difference between the arithmetic means of the annual cost rates and the annual income rates, with an adjustment included to account for the offsets to cost that are due to (1) the starting trust fund balance and (2) interest earned on the trust fund.

MODIFY OR MODIFICATION

Under HIPAA, this is a change adopted by the Secretary, through regulation, to a standard or an implementation specification.

MONITORING

A planned, systematic, and ongoing process to gather and organize data, and aggregate results in order to evaluate performance.

MONITORING OF MCO/PHP STANDARDS

Activities related to the monitoring of standards that have been set for plan structure, operations, and quality improvement/assurance to determine that standards have been established, implemented, adhered to, etc.

MORBIDITY

A diseased state, often used in the context of a "morbidity rate" (i.e. The rate of disease or proportion of diseased people in a population). In common clinical usage, any disease state, including diagnosis and complications is referred to as morbidity.

MORBIDITY RATE

The rate of illness in a population. The number of people ill during a time period divided by the number of people in the total population.

MORTALITY RATE

The death rate often made explicit for a particular characteristic (e.g. gender, sex, or specific cause of death). Mortality rate contains three essential elements: the number of people in a population exposed to the risk of death (denominator), a time factor, and the number of deaths occurring in the exposed population during a certain time period (the numerator).

MULTI-EMPLOYER GROUP HEALTH PLAN

A group health plan that is sponsored jointly by two or more employers or by employers and employee organizations.

MULTI-EMPLOYER PLAN

A group health plan that is sponsored jointly by two or more employers or by employers and unions.

MULTIPLE EMPLOYER PLAN

A health plan sponsored by two or more employers. These are generally plans that are offered through membership in an association or a trade group.


*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.


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