GLOSSARY OF HEALTH INSURANCE TERMS

M

Mail Order Drug Program — a method of dispensing medication directly to the patient through the mail by means of mail order drug distribution company. Offers greatly reduced costs for prescriptions, especially for long-term therapy.

Major Medical Expense Insurance — policies designed to help offset the heavy medical expenses resulting from catastrophic or prolonged illness or injury. They generally provide benefits payments for 75 to 80 percent of most types of medical expenses above a deductible paid by the insured.

Malpractice Insurance — insurance against the risk of suffering financial damage due to professional misconduct or lack of ordinary skill.

Managed Care — health care programs that impose some controls on the utilization of health care services and providers who offer such care, and/or the fees charged for such services. Managed care can by provided through HMOs, PPOs, and managed indemnity plans. The primary goal is to deliver cost-effective health care without sacrificing quality or access.

Managed Care Organization (MCO) — any entity that uses certain concepts or techniques to manage the accessibility, cost and quality of health care.

Managed Indemnity Plans — health insurance plans that are administered like traditional indemnity plans but which include managed care "overlays" such as precertification and other utilization review techniques.

Mandated Benefits — benefits that health plans are required by law to provide.

Medicaid (Title XIX) — a joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid serves the poor, blind, aged, disabled or members of families with dependent children (AFDC). Each state has its own standards for qualification. A Federally aided, state-operated and administered program that provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for the poor. It does not cover all of the poor, however, but only persons who meet specified eligibility criteria.

Medical Review, Medical Review Criteria — screening of healthcare utilization and the criteria used for this screening. Medical reviews are usually conducted by insurance companies, third-party payers, review organizations and case managers.

Medical Student — a student enrolled in medical school (medical school is a four-year program) You may hear the term 2nd-year or 3rd-year medical student.

Medicare — administered by the Social Security Administration, Medicare is the U.S. federal government plan for paying certain hospital and medical expenses for those who qualify, primarily those over age 65. Part A, Hospital insurance, provided for inpatient hospital and posthospital care. Part B pays for medically necessary doctors' services and outpatient services.

Medicare Advantage Plan — a plan offered by a private company that contracts with Medicare to provide an enrollee with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, Private Fee-for-Service Plans, and Special Needs Plans. When an individual is enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare.

Medicare Approved Amount — in the original Medicare Plan, this is the amount a doctor or supplier can be paid, including what Medicare pays and any deductible, coinsurance, or copayment that the citizen pays. Same as Medicare Approved Charge.

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 Coverage — made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). The term of coverage does not include Medicare Drug Plans (Part D).

Medicare Part A — the Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, confinement in nursing facilities or other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.

Medicare Part B — the Medicare component that provides benefits to cover the costs of physicians' professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home, or an insured's home.

Medicare Part D — A prescription drug benefit clause in the U.S. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that gives Medicare recipients three choices: stay in traditional Medicare without signing up for the prescription drug benefit, stay in traditional Medicare and enroll in an independently provided drug plan, or enroll in a comprehensive private health plan.

Medicare+Choice — The Medicare component that addresses how covered services are delivered to enrollees and increases the numbers and types of healthcare organizations allowed to participate in Medicare.

Medicare Supplement Policy — a voluntary, contributory private insurance plan available to Medicare eligibles to cover the costs of deductibles, coinsurance, physicians' services and other medical and health services not covered by Medicare. Also, called Medigap policies.

Medigap — individual medical expense insurance policies sold by state-licensed private insurance companies. Private health insurance plans that supplement Medicare benefits by covering some costs not paid for by Medicare. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 standardized plans labeled Plan A through Plan L. Medigap policies only work with the Original Medicare Plan.

Mental Health Parity and Mental Health Parity Act — mental health parity refers to providing the same insurance coverage for mental health treatment as that offered for medical and surgical treatments. The Mental Health Parity Act was passed in 1996 and established parity in lifetime benefit limits and annual limits. A law which prohibits group health plans from applying more restrictive annual and lifetime limits on coverage for mental illness than for physical illness.

Mental Health Provider — psychiatrist, social worker, hospital or other facility licensed to provide mental health services.

Miscellaneous Expenses — hospital charges, other than room and board, such as those for X-rays, drugs, laboratory fees, and other ancillary services.

Morbidity — the extent of illness, injury, or disability in a defined population. It is usually expressed in general or specific rates of incidence or prevalence.