Glossary

Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.

Without the written consent of the individual, the Privacy Act prohibits release of protected information maintained in a system of records unless of 1 of the 12 disclosure provisions applies.

When the Decision Memorandum is issued, the NCA is considered closed. However, the policy change is not effective until the NCD is issued.

When care takers do not give a person they care for the goods or services needed to avoid harm or illness.

When another person does something on purpose that causes you mental or physical harm or pain.

When a requestor formally requests permission to rerelease CMS data that has been formatted into statistical or aggregated information by the recipient. CMS is responsible for reviewing the files/reports to ensure that they contain no data elements or combination of data elements that could allow for the deduction of the identity of the Medicare beneficiary or a physician and that the level of cell size aggregation meets the stated requirement.

When a provider bills you for the balance remaining on the bill that your plan doesn't cover. This amount is the difference between the actual billed amount and the allowed amount. This happens most often when you see an out-of-network provider (non-preferred provider). These balance bill costs are in addition to what you pay out-of-pocket for out-of-network services according to your health plan coverage. An in-network provider (preferred provider) may not balance bill you for covered services.

When a health plan has no money or other means to stay open and give health care to patients.

What you pay out-of-pocket for services and care for participating providers and services through your health plan. An in-network copayment is a fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health plan. In-network copayments usually are less than out-of-network copayments. An in-network coinsurance is your share (for example, 20%) of the allowed amount for covered health care services. Your share is usually lower for in-network covered services.

What you pay out-of-pocket according to your health plan coverage when you get care from a provider or service that doesn't contract with your health plan for lower in-network service rates. An out-of-network copayment is a fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health plan. Out-of-network copayments usually are more than in-network copayments. An out-of-network coinsurance is your share (for example, 40%) of the allowed amount for covered health care services to providers who don't contract with your health plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.