The Alliance For Health Reform: Suggest an Edit

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DEDUCTIBLE - A fixed amount, usually expressed in dollars in the form of an annual fee, that the beneficiary of a health insurance plan must pay directly to the health care provider before a health insurance plan begins to pay for any costs associated with the insured medical service.

DEFENSIVE MEDICINE - The practice of health care providers ordering tests that may not be necessary to over-protect themselves from potential malpractice lawsuits. Said to be a major cause of high health care costs.

DEFICIT REDUCTION ACT OF 2005 (DRA) - The DRA made significant changes to the Medicaid program - for example, allowing states to increase premiums and cost-sharing for families and to base benefits on private plans. The law also tightened long-term care asset transfers and capped home equity at $500,000. A DRA provision effective July 1, 2006, requires Medicaid beneficiaries to show proof of citizenship upon applying for or renewing their benefits. For more information, see www.kff.org/medicaid/7465.cfm.

DEFINED BENEFIT - A health insurance model used by an employer or government program where specified health services covered under the plan are standardized and guaranteed. The cost of providing the standard benefits may fluctuate. One example of a defined benefit plan is Medicare. Contrast with Defined Contribution.

DEFINED CONTRIBUTION - A health benefit model used by employers or government programs where health services covered may fluctuate based on choice of plan, but the employer or government contributes a set amount (percentage or dollar amount) towards the purchase of the selected health plan. A defined contribution plan limits the financial liability of employers or the government, because the contribution is defined, or fixed. Contrast with Defined Benefit.

DIAGNOSIS-RELATED GROUP (DRG) - A way of determining payments to hospitals, used under Medicare's prospective payment system (PPS) and by some other public and private payers. The DRG system classifies patients into groups based on the principal diagnosis, treatments and other relevant criteria. Hospitals are paid the same for each case classified in the same DRG, regardless of the actual cost of treatment.

DIRECT CONTRACTING - A method for providing health services to covered employees and their families, by group providers who contract directly with an employer, thereby cutting out "the middleman" or insurance carrier.

DIRECT GRADUATE MEDICAL EDUCATION PAYMENT - Medicare payment to approved teaching hospitals to help cover the direct costs of training residents to become board-eligible in their field. Hospitals receive full payments to help cover resident salaries, fringe benefits and compensation for attending physicians, for residents in their initial residency period (the minimum number of years required to qualify for board certification in that specialty for 5 years) and half payments for residents who have completed their initial training and are sub-specializing. Direct GME payments vary significantly among hospitals and depend on the number of residents at the hospital, the hospital specific per resident amount and the size of the hospital's inpatient Medicare population. For more information, see www.cogme.gov. Also see glossary terms, Graduate Medical Education Payment and Indirect Medical Education Adjustment.

DIRECT-TO-CONSUMER (DTC) ADVERTISING - The use of mass media (television, newspapers, magazines, etc.) and other forms of reaching the general public. DTC advertising is often used by the pharmaceutical industry to promote their products. These advertisements must meet certain standards under federal regulations.

DISPROPORTIONATE SHARE HOSPITAL (DSH) ADJUSTMENT - An increased payment under Medicare's prospective payment system or under Medicaid for hospitals that serve a relatively large number of low-income uninsured patients.

DOUGHNUT HOLE - Coverage gap in Medicare Part D prescription drug coverage. Medicare pays 75 percent of the beneficiary's yearly drug expenses up to $2,405, after which there is a gap in coverage - the doughnut hole. The coverage resumes when total prescription drug expenses reach $5,916.25 (in 2009), after which Medicare pays for 95 percent of the beneficiary's prescription drug costs through the end of the year See Chapter 7, Medicare, for details.

DRUG REIMPORTATION - See Reimportation

DUAL ELIGIBLE - A Medicare beneficiary who also receives either a full range of Medicaid benefits offered in his or her state, or help with Medicare out-of-pocket expenses. For more information, see www.cms.hhs.gov/DualEligible. Also see Qualified Medicare Beneficiary and Specified Low-Income Medicare Beneficiary in glossary.

DURABLE MEDICAL EQUIPMENT (DME) - Medical devices such as wheelchairs, oxygen tanks and apnea monitors.