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Glossary of Terms

Activities of Daily Living (ADLs): Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.  The inability to perform 2 or 3 of these activities is generally used to determine the level and kind of home health or nursing home care needed.

Acute Care: Immediate, short-term medical treatment for a serious illness or injury, usually in a hospital or skilled nursing facility.  May be contrasted with chronic care.

Adult Day Health: Care outside the home provided for adults who require assistance with the activities of daily living or other largely non-medical supervision.  Services may include minimal medical-related services such as supervising the taking of medicine.  Often includes social and recreational programs and, sometimes, occupational and physical therapy.  Primarily intended for care during the hours when family members or other informal caregivers are at work, rather than care on a 24-hour basis.

ADvantage Program: Provides Medicaid services to help people stay at home instead of going to a nursing facility. The program assists elders who are frail and adults who have physical disabilities.

Assisted Living Services: Services provided with housing for those that cannot live independently. Assisted Living may provide assistance with personal care, medications and ambulation.  The center may also provide nursing supervision and information or unscheduled nursing care.  The assisted living center cannot provide 24-hour skilled nursing care as is provided in a nursing facility. 

Caregiver:  A person who helps care for someone who is ill, disabled, or aged.  Some caregivers are relatives or friends who volunteer their help. Some people provide care giving services for a cost.

Case Management: A professional service which arranges and coordinates health and/or social services through assessment, service plan development and modification, monitoring, and quality assurance.

Case Manager: A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients. Case Managers make sure that Members get needed services and track use of facilities and resources.

Centers for Medicare & Medicaid Services (CMS): The federal agency that runs the Medicare program.  In addition, CMS works with the states to run the Medicaid program.  CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

Chronic Care: Continuous, long-term care for persons suffering from chronic conditions. May be contrasted with acute care.

Consumer Directed Agent (CDA): Responsible for monitoring service delivery and the performance of the Member’s designated “authorized representative” or “legal representative” to function in the best interest of the Member.

Consumer Directed Personal Assistance Services and Supports (CD-PASS): Offers ADvantage members the opportunity to direct decisions regarding personal care services. CD-PASS enables members with personal assistance needs to recruit, hire, train, supervise, and when necessary, fire their personal service assistant.

Custodial Care: Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

Disability: For Social Security purposes, the inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to last for a continuous period of not less than 12 months.  Special rules apply for workers aged 55 or older whose disability is based on blindness.  The law generally requires that a person be disabled continuously for 5 months before he or she can qualify for a disabled worker cash benefit. An additional 24 months is necessary to qualify for Medicare.

Eldercare: Public, private, formal and informal programs and support systems, government laws and finding ways to meet the needs of the elderly, including: housing, home care, pensions, social security, long-term care, health insurance and eldercare.

Eligibility: Refers to the process whereby an individual is determined to be eligible for health care coverage through the Medicaid program.  Eligibility is determined by the State.  Eligibility data are collected and managed by the State or by its Fiscal Agent.  In some managed care waiver programs, eligibility records are updated by an Enrollment Broker, who assists the individual in choosing a managed care plan.

Emergency Care: Care given for any urgent condition perceived as requiring immediate medical or surgical evaluation or treatment.

Fee for Service: A plan or PCCM is paid for providing services to enrollees solely through fee-for-service payments, plus, in most cases, a case management fee.

Gatekeeper: In a managed care plan, this is another name for the primary care doctor.  This doctor gives you basic medical services and coordinates proper medical care and referrals.

Health Maintenance Organization (HMO): A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.

Home and Community-Based Service Waiver Programs (HCBS): The HCBS programs offer different choices to some people with Medicaid.  If you qualify, you will get care in your home and community so you can stay independent and close to your family and friends.  HCBS programs help the elderly and disabled, mentally retarded, developmentally disabled, and certain other disabled adults.  These programs give quality and low-cost services.

Home Health Agency: An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.

Home Health Care: Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services. 

Homemaker Services: A variety of non-skilled at-home services, including shopping, meal preparation, laundry services, housekeeping, and similar activities provided either by employees of private home health agencies or state agencies.  Some long-term care policies pay a benefit for such services.

Hospice Care: A special way of caring for people who are terminally ill, and for their family.  This care includes physical care and counseling.  Hospice care is covered under Medicare Part A (Hospital Insurance). 

Intermediate Care: In the context of long-term care and Medicare, refers to a level of nursing services performed intermittently, rather than around the clock, by professional medical personnel, usually a registered or licensed practical nurse or other medical practitioners such as licensed therapists.

Instrumental Activities of Daily Living (IADL): Daily living skills, such as shopping, cooking, cleaning, managing money, using a telephone, doing laundry, taking medication, or accessing transportation, that are necessary for maintaining the home environment.

Levels of Care can include these three levels of long-term care:

Skilled Care: 24 hour a day prescribed care provided by licensed medical professionals who are under the direct supervision of a physician.

Intermediate Care: Prescribed care that can be provided on an intermittent, rather than continuous, basis; for example, physical therapy.

Custodial Care: Care that assists people with daily living requirements, such as dressing, eating, and personal hygiene.

Long-Term Care (LTC): A wide range of medical and non-medical services ranging from custodial help with activities of daily living to occasional nursing care to skilled nursing services provided to people who are physically or mentally unable to provide independent care for themselves.  It is usually used to describe care for the elderly although younger disabled persons also utilize long-term care services.  Care may be needed while recovering from an accident or illness, during an extended period of disability, or simply as a result of the normal aging process.  Home health care, adult day health, respite care, and nursing home stays fall into the category of long-term care.

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. 

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).

Part A Hospital Insurance: Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance: Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Part D Prescription Drug Coverage: Most people will pay a monthly premium for this coverage. As of January 1, 2006, new Medicare prescription drug coverage is available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

Medicare Supplement Insurance: Private insurance policies that "supplement" the benefits provided by Medicare.  A Medicare supplement policy is sometimes called a "Medigap" policy supplement because it fills in the "gaps" left by Medicare benefits.  Generally speaking, Medicare supplements will pay only if Medicare approves some portion of the services provided.  The general rule of thumb is: Medicare supplements supplement Medicare.  Therefore, if Medicare totally denies the claim, the supplement policy will also deny the claim. Medicare supplements do not provide long-term care benefits.

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).

Nursing Facility:  Is care provided in a skilled nursing facility where all three levels of care (skilled, intermediate, and custodial) are provided.  In order to be licensed, nursing homes must meet appropriate standards for the state in which they operate.  They may or may not be Medicare approved.

Performance Measures: A gauge used to assess the performance of a process or function of any organization.  Quantitative or qualitative measures of the care and services delivered to enrollees (process) or the end result of that care and services (outcomes).  Performance measures can be used to assess other aspects of an individual or organization's performance such as access and availability of care, utilization of care, health plan stability, beneficiary characteristics, and other structural and operational aspect of health care services.  Performance measures included here may include measures calculated by the State (from encounter data or another data source), or measures submitted by the MCO/PHP.

Personal Care: Non-skilled personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops.  The Medicare home health benefit does pay for personal care services.

Primary Care Physician: Generally refers to HMOs or other types of member organizations; the doctor selected by the enrollee is called the Primary Care Physician since that doctor is in charge of managing that member’s health care needs.

Rehabilitative (Restorative) Care:  Skilled care provided by a trained medical person (physical therapist, R.N., speech therapist).  Its purpose is to restore health following an accident, injury, or illness. Medicare pays for a limited amount of this type of care.

Skilled Care: A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.

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