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| MA / MA-PD |
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Medicare Advantage Plans (MAs) and Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs) are private plans that provide doctor and Hospital services in place of Medicare and Medicare pays these private companies to manage the healthcare instead of paying for the Beneficiary Claims directly. Examples of MAs or MA-PDs that administer your Medicare Part A and Medicare Part B, as well as possibly providing Prescription Drug Coverage are: Health Maintenance Organization (HMO), Private, Fee for Service Organizations (PFFS), or Preferred Provider Organization (PPO). Typically, the MA-PDs also provide additional value-added service to its Members such as additional covered days in the hospital. If you purchase a MA-PD plan, you do not need to purchase a PDP plan (see above) nor do you need a Medicare Supplement.
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| Mail-Order Pharmacy Programs |
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Programs that offer drugs ordered and delivered through the mail to plan Members at a reduced cost.
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| Mail-Service Pharmacies |
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Mail-service pharmacies are used by many plans as a cost-saving and convenient alternative to retail pharmacies. Members typically order their drugs by phone, fax, email or Internet. Most Outpatient Rx - Prescription Order are filled and received by Members in two to four days.
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| Maintenance of Effort |
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A requirement of theMedicare catastrophic Coverage act that affects employers with plans that duplicate 50% or more of the new catastrophic Benefits. Under MOE, they have to "maintain their effort" by providing Eligible Employees/retirees/dependents with additional Benefits or a "refund" equal in value to the duplicated Benefits.
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| Major Hospitalization Policy |
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The same as Major Medical Insurance, except that it applies to expenses incurred only when the Insured is hospitalized. See also Major Medical Insurance.
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| Major Medical |
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Health Insurance (HI) Coverage for expenses associated with Hospital confinements, surgeries and/or medical conditions requiring a broad range of medical services and supplies
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| Major Medical Insurance |
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A type of Health Insurance (HI) that provides Benefits up to a high limit for most types of medical expenses incurred, subject to a large Deductible. Such contracts may contain limits on specific types of charges, like room and board, and a percentage Participation clause sometimes called a Coinsurance Clause. These policies usually pay Covered Expenses whether an individual is in or out of the Hospital.
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| Malocclusion |
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Teeth that do not fit together properly which creates a bite problem.
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| Managed Behavioral Health Organization (MBHO) |
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An organization that provides Behavioral Health services using Managed Care techniques.
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| Managed Care |
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An organized way to manage costs, use, and Quality of the health care system. The major types of Managed Care Plans are Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO).
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| Managed Care Organization (MCO) |
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Any entity that utilizes certain concepts or techniques to manage the Accessibility, cost, and Quality of healthcare. Also known as a Managed Care Plan.
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| Managed Care Plan |
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See Managed Care Organization (MCO).
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| Managed Dental Care |
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Any dental plan offered by an organization that provides a Benefit plan that differs from a traditional Fee-for-Service plan.
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| Managed Health Care Plan |
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A plan which involves financing, managing, and delivery of health care services. Typically, it involves a group of Providers who share the financial risk of the plan or who have an incentive to deliver cost effective, but Quality, service.
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| Managed Indemnity Plans |
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Health Insurance (HI) plans that are administered like traditional indemnity plans but which include Managed Care "overlays" such as Pre-Certification and other Utilization Review (UR) techniques.
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| Management Services Organization (MSO) |
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An organization, owned by a Hospital or a group of investors, that provides management and administrative support services to individual physicians or Small Group practices in order to relieve physicians of non-medical business functions so that they can concentrate on the clinical aspects of their practice.
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| Mandated Benefits |
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Benefits required by state or federal law.
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| Mandated Providers |
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Types of Providers of medical care whose services must be included by state or federal law.
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| Mandibular Protrusion or Recession |
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A large chin which causes an underbite or a small chin which causes an overbite.
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| Manual Rates |
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Rates based on average Claims data for a large number of groups. These rates are then adjusted for specific groups based on that group's characteristics, such as the type of industry, changes in Benefits from the standard, etc.
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| Manual Rating |
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A Rating method under which a Health Plan uses the plan's average Experience with all groups - and sometimes the Experience of other Health Plans - rather than a particular group's Experience to calculate the group's Premium. An MCO often lists Manual Rates in an Underwriting or Rating manual.
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| Market Assistance Plan (MAP) |
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A plan promulgated by the Department of Insurance to assist buyers to obtain certain types of insurance when they are limited in availability.
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| Market Segmentation |
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The process of dividing the total market for a product or service into smaller, more manageable subsets or groups of customers.
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| Market Segments |
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Subsets or manageable groups of customers in a total market.
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| Marketing Director |
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Individual responsible for marketing a Managed Care Plan, whose duties include oversight of marketing representatives, advertising, client relations, and Enrollment forecasting.
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| Marriage Counseling |
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Marriage Counseling is generally falls under the category of Behavioral Health.
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| Master Policy |
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The group insurance Policy that explains Coverage to all Members of the group.
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| Material Duties |
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means the duties which produce the majority of Your income within the occupation described on Your application for this insurance.
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| Maxillary or Mandibular Hypoplasia |
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Undergrowth of the upper or lower jaw.
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| Maxillary or Mandibulary Hyperplasia |
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Excess growth of the upper or lower jaw.
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| Maximum Allowable Amount |
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The maximum amount of a billed charge the Insurance Carrier will consider when determining Covered Charges, as determined by the Insurance Carrier. Benefit payments of Covered Charges are not based on the amount billed but, rather, they are based on what the Insurance Carrier determines to be the Maximum Allowable Amount. Amounts billed in excess of the Maximum Allowable Amount by or on behalf of a Health Care Practitioner, facility or supplier are not payable by the Insurance Carrier. See the Provider Charges and Maximum Allowable Amount Provisions section of your Policy for the method(s) used to determine the Maximum Allowable Amount.
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| Maximum Allowable Costs (MAC) List |
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A list of prescriptions where the reimbursement will be based on the cost of the generic product.
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| Maximum Disability Policy |
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A form of Noncancellable ("Non-Can") Disability Income Insurance that limits an insurer's liability for any one Claimm but not the aggregate amount of all claims. In other words, for any one claim there is a maximum amount payable, but there could be any number of separate claims for different disabilities.
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| Maximum Dollar Limit |
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The maximum amount of money that an insurance company (or self-insured company) will pay for Claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.
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| Maximum Lifetime Benefit |
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The maximum amount, as shown in the Benefit Summary, that the Insurance Carrier will pay for Covered Charges Incurred by each Covered Person under the plan. This maximum will apply even if Coverage und the plan is interrupted. When the Maximum Lifetime Benefit has been received, no other Benefits are payable for that Covered Person.
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| Maximum Out-of-Pocket Costs |
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The most a Member will pay considering Copayments, Coinsurance, Deductibles, etc.
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| MBHO |
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See Managed Behavioral Health Organization (MBHO).
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| McCarran-Ferguson Act |
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A federal act that placed the primary responsibility for regulating Health Insurance (HI) companies and HMOs that service private sector (commercial) plan Members at the state level.
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| MCO |
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See Managed Care Organization (MCO).
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| Medicaid |
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A medical Benefits program administered by states and subsidized by the federal government. Under this plan, various medical expenses will be paid to those who qualify. It is technically referred to as Title XIX Benefits.
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| Medical Advisory Committee |
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Committee whose purpose is to review general medical management issues brought to it by the Medical Director.
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| Medical Care Insurance |
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See Medical Expense Insurance.
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| Medical Center |
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See Ambulatory Care Facility (ACF).
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| Medical Clinic |
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See Ambulatory Care Facility (ACF).
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| Medical Director |
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Manager in a healthcare organization responsible for Provider relations, Provider recruiting, Quality and Utilization Management (UM), and medical Policy.
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| Medical Examination |
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The Examination of an applicant for insurance or a Claimant by a physician who acts in the capacity of the insurer's agent.
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| Medical Examiner |
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The physician who examines an applicant or Claimant on behalf of the insurer and as an agent of the insurer.
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| Medical Expense Insurance |
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A form of Health Insurance (HI) that provides Benefits for medical, surgical, and Hospital expenses. This term is used to include Coverage under the names Hospital-Surgical Coverage, Hospital-Surgical Expense Insurance and Medical Care Insurance.
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| Medical Facility - Acute (Hospital) |
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A facility that provides acute care or Subacute Medical Care for Sickness or an Injury on an Inpatient basis. This type of facility may also be referred to as a subacute medical facility or a long term acute care facility and must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered and Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Medicare to provide acute care or Subacute Medical Care.
b. Be staffed by an on duty physician 24 hours per day.
c. Provide nursing services supervised by an on duty Registered Nurse (RN) 24 hours per day.
d. Maintain daily medical records that document all services provided for each patient.
e. Provide immediate access to appropriate in-house laboratory and imaging services.
f. Not primarily provide care for Behavioral Health, Substance Abuse although these services may be provided in a distinct section of the same physical facility.
g. Provide care in an intensive care unit (ICU), a neonatal intensive care unit (NCU), a coronary intensive care unit (CCU) and step-down units.
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| Medical Facility - Acute Rehabilitation |
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"A facility that provides acute care for Rehabilitation Services for a Sickness or an Injury on an Inpatient basis. A distinct section of an Acute Medical Facility (Hospital) solely devoted to providing acute care for Rehabilitation Services would also qualify as an Acute Medical Rehabilitation Facility. These type of facility must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered and Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF) to provide acute care for Rehabilitation Services.
b. Be staffed by an on duty physician 24 hours per day.
c. Provide nursing services supervised by an on duty Registered Nurse (RN) 24 hours per day.
d. Provide an initial, clearly documented care plan upon admission and ongoing care plans for patients on a regular basis that include reasonable, appropriate and attainable short and intermediate term goals.
e. Provide a total of at least 3 hours per day of any combination of active physical Therapy, Occupational Therapy and Speech Therapy by an appropriately licensed Health Care Practitioner to each patient at least 6 days per week. A covered Person must be able and willing to participate actively in these services for at least the above referenced time frames. Cognitive therapy, counseling services, passive range of motion therapy, respiratory therapy and similar services may be provided but are not included in the 3 hour minimum per day requirement of active Physical Therapy, Occupational Therapy and Speech Therapy.
f. Not primarily provide care for Behavioral Health or Substance Abuse although these services may be provided in a distinct section of the same physical facility."
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| Medical Facility - Free-Standing Facility |
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"A facility that provides interventional services, on an Outpatient basis, which require hand-on care by a physician and includes the administration of general or regional anesthesia or conscious sedation to patients. This type of facility may also be referred to as an ambulatory surgical center, an interventional diagnostic testing facility, a facility that exclusively performs endoscopic procedures or a dialysis unit. A designated area within a Health Care Practitioner's office or clinic that is used exclusively to provide interventional services and administer anesthesia or conscious sedation and a licensed birth center are also considered to be a Free-Standing Facility. Room and board and overnight services are not covered. These facilities must meet all of the following requirements:
a. Be licensed by the state in accordance with the laws for the specific services being provided in that facility.
b. Not primarily provide care for Behavioral Health or Substance Abuse or be an Urgent Care Facility."
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| Medical Facility - Skilled Nursing Facility |
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A facility that provides continuous skilled nursing services on an Inpatient basis for person recovering from a Sickness or an Injury. The facility must meet all of the following requirements:
a. Be licensed by the state to provide skilled nursing services.
b. Be staffed by an on call physician 24 hours per day.
c. Provide skilled nursing services supervised by an on duty Registered Nurse (RN) 24 hours per day.
d. Maintain daily clinical records.
e. Not primarily be a place for rest, for the aged or for Custodial Care or provide care for Behavioral Health or Substance Abuse although these services may be provided in a distinct section of the same physical facility. The facility may also provide extended care or Custodial Care which would not be covered under the plan.
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| Medical Facility - Subacute Rehabilitation Facility |
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A facility that provides Subacute Medical Care for Rehabilitation Services for a Sickness or an Injury on an Inpatient basis. This type of facility must meet all of the following requirements:
a. Be licensed by the state in which the services are rendered to provide Subacute Medical Care for Rehabilitation Services.
b. Be staffed by an on call physician 24 hours per day.
c. Provide nursing services supervised by an on duty Registered Nurse (RN) 24 hours per day.
d. Not primarily provide care for Behavioral Health or Substance Abuse although these services may be provided in a distinct section of the same physical facility. The facility may also provide extended care or Custodial Care which would not be covered under the plan.
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| Medical Facility - Urgent Care Facility |
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A facility that is attached to an Acute Medical Facility (Hospital) but separate from the Emergency Room or a separate facility that provides Urgent Care on an Outpatient basis. A Health Care Practitioner's office is not considered to be an Urgent Care Facility even if services are provided after normal business hours. Room and board and overnight services are not covered. This type of facility must meet all of the following requirements:
a. Be licensed by the state in in accordance wit the laws for the specific services being provided in that facility.
b. Be staffed by an on duty physician during operating hours.
c. Provide services to stabilize patients who need Emergency Treatment and arrange immediate transportation to an Emergency Room.
d. Provide immediate access to appropriate in-house laboratory and imaging services.
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| Medical Foundation |
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A not-for-profit entity, usually created by a Hospital or health system, that purchases and manages physician practices.
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| Medical Group Practice |
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See Consolidated Medical Group.
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| Medical Information Bureau (MIB) |
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A data pool service that stores coded information on the health histories of persons who have applied for insurance from subscribing companies in the past. Most Life and Health insurers subscribe to this bureau to get more complete Underwriting information.
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| Medical Loss Ratio |
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Total health Benefits divided by total Premium.
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| Medical Review Manager |
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The Insurance Carrier or an organization or entity, designated by the Insurance Carrier, which may:
1. Review services as required by the Utilization Review (UR) Provisions section; or
2. Perform Discharge Planning
and care management services; or
3. Evaluate the Medical Necessity of treatment, services or supplies; or
4. Administer treatment for Behavioral Health or Substance Abuse through Health Care Practitioners, facilities or suppliers; or
5. Review a Covered Person's Behavioral Health or Substance Abuse condition and evaluate the Medical Necessityy of referral treatment.
The Medical Review Manager's name is shown on the insurance coverage identification (ID) card.
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| Medical Savings Account (MSA) |
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A tax-advantaged personal savings account used in conjunction with a high Deductible health Policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual Deductibles and Copayments.
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| Medical Supplies |
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Disposable medical products or Personal Medical Equipment that are used alone or with Durable Medical Equipment.
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| Medical Supply Provider |
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Agencies, facilities or wholesale or retail outlets that make Medical Supplies available for use.
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| Medical Underwriting |
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The evaluation of health questionnaires submitted by all proposed plan Members to determine the insurability of the group.
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| Medically Necessary or Medical Necessity |
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Treatment, services or supplies that are rendered to diagnose or treat a Sickness or an Injury. Medical Necessity does not include care that is prescribed or provided on the recommendation of a Covered Person's Immediate Family Member. The Insurance Carrier must be able to determine that such care:
1. Is appropriate and consistent with the Diagnosis and does not exceed in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate Diagnosis and treatment of the Sickness or Injury; and
2. Is commonly accepted as proper care or treatment of the condition in accordance with United States medical practice and federal government guidelines; and
3. Can reasonably be expected to result in or contribute substantially to the improvement of a condition resulting from a Sickness or an Injury; and
4. Is provided in the most conservative manner or in the least intensive setting without adversely affecting the condition or the quality of medical care provided.
The fact that a Health Care Practitioner may prescribe, order, recommend or approve a treatment, service or supply does not, of itself, make the treatment, service or supply Medically Necessary for the purpose of determining eligibility for coverage under the plan.
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| Medically Needy Individuals |
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Enrollees inMedicaid programs whose income or assets exceed the maximum threshold for certain federal programs.
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| Medical-Necessity Review |
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See Prior Authorization.
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| Medicare |
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The United States federal government plan for paying certain Hospital and medical expenses for persons qualifying under the plan, usually those over 65. The Hospital Benefits are Medicare Part A, and the medical expense portion is Medicare Part B. Medicare Part A is compulsory social insurance; Medicare Part B is voluntary government-subsidized, government-operated insurance.
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| Medicare Advantage Plans |
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Health Plans offered by private insurance companies that contract withMedicare to provideMedicare Coverage. Depending on where the Beneficiary lives,Medicare Advantage Plans may be available both with and without Part D plans. Medicare Advantage Plans are also calledMedicare Health Plans. TheMedicare Advantage Plans used to be called the Medicare+Choice plans.
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| Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA) |
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See Centers for Medicare and Medicaid Services (CMS) .
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| Medicare Beneficiary |
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Anyone entitled toMedicare Benefits based on the designation by the Social Security Administration.
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| Medicare Part A |
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The part ofMedicare that provides basic Hospital insurance Coverage automatically for most Excepted Periods. See alsoMedicare.
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| Medicare Part B |
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A voluntary program that is part of Medicare and provides Benefits to cover the costs of physicians' services. See also Medicare.
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| Medicare Part C |
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The part of Medicare that expands the list of different types of entities allowed to offer Health Plans to a Medicare Beneficiary. Also known as Medicare+Choice. See also Medicare.
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| Medicare Part D |
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The part of Medicare Optional Benefits that cover prescription drugs. See www.medicare-partd.com
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| Medicare Prescription Drug Plan |
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Insurance plans offering prescription drug Coverage that meets the standards established by Medicare. Other Names for these plans include Part D prescription drug plans, PDPs, or MA-PDs. However, not all private insurance plans offering prescription drug Coverage are Part D plans. You'll want to pay close attention to whether a plan is a Part D plan.
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| Medicare Prescription Drug Program (Part D) |
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The Medicare Prescription Drug Program (Part D) is insurance offered by the federal government and sold through private companies that helps pay for prescription drugs. The Medicare Prescription Drug Program became available to all Medicare beneficiaries on January 1, 2006.
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| Medicare Prescription Drug, Improvement and Modernization Act of 2003 |
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"The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 is a federal law that brought the most dramatic changes to the Medicare program since it began in 1965. These changes include more affordable health care, prescription drug Coverage to all people with Medicare, expanded Health Plan options, improved health care Access for rural Americans, and
Preventive Care services, such as flu shots and mammograms."
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| Medicare Supplement |
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A supplemental insurance Policy to help cover the difference between approved medical charges and Benefits paid byMedicare. These plans are also known as "Medigap" plans.
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| Medicare Supplement Insurance |
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Insurance Coverage sold on an individual or group basis which helps to fill the gaps in the protection provided by theMedicare program. Medicare Supplements cannot duplicate any Benefits provided byMedicare, but may pay part or all ofMedicare's Deductibles and Copayments, and may cover some services and expenses not covered byMedicare.
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| Medicare Supplements |
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Medicare Supplements or Medigap Plans provide additional Coverage to your Original Medicare plans (Medicare A and B). For instance, Medicare Supplements will pay a portion of your Medicare Coinsurance. There are a series of Medicare Supplements that provide a variety of Coverage options at varying Premiums. Stand-alone Prescription Drug Plan (PDP) can be used together with your Medicare Supplements. A Medicare Advantage Plan (MA / MA-PD ) cannot be used with a Medicare Supplement.
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| Medicare+Choice |
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See Medicare Part C.
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