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Medicare, Medigap, Mental Health and Other Health Insurance Terms

Health Insurance Glossary Page 5

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Medicare Limiting Charge. The maximum percentage above the allowable amount that a nonparticipating provider can generally charge a Medicare beneficiary.

Medicare Nonparticipating Provider. A provider that does not accept the Medicare allowable amount as the fee.

Medicare Participating Provider. A provider that accepts the Medicare allowable amount as the fee.

Medigap Policy. A policy designed to help Medicare beneficiaries pay for Medicare deductible and co-insurance amounts, and for other specific services.

Mental and Emotional Illness Provision. A provision in a health insurance plan that includes coverage for the treatment of depression, anxiety, schizophrenia, bipolar disorder, and similar illnesses or conditions.

Mental Health Parity Act. A federal law passed in October of 1996 that prohibits insurers and self-funded plans that offer coverage for the treatment of mental illnesses from establishing lower yearly or lifetime maximums for reimbursement for the treatment of mental illnesses than for the treatment of physical illnesses. A number of states have also passed laws that deal with the issue of mental health parity.

Newborns' and Mothers' Health Protection Act. A federal law passed in the fall of 1996 that requires all insurance policies and self-funded plans that offer coverage for childbirth to provide benefits for a full 48 hours of hospital care in relation to childbirth and 96 hours of hospital care in relation to a Caesarean delivery.

Not Medically Necessary. A term used by insurers to mean either that additional documentation is required before the insurer can determine whether a treatment is medically necessary, or that a decision has been made that a treatment is not covered under the terms of the policy.

Nursing Home. A residential facility designed to provide personal care for senior citizens with severe chronic conditions or disabilities.

Operative Report. A detailed description of an operation, usually written by the physician who performed the surgery.

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