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Glossary |
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Administrative Law Judge
Medicare administrative law judges is a hearing officer who make decisions regarding Medicare appeals that have passed the first levels of consideration.
Advance Directive
A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.
Annual Election Period (AEP)
The Annual Election Period for Medicare beneficiaries is from November 15 – December 31 each year. Generally, this is the only time Medicare Advantage health plans accept new members. However, there are exceptions. Enrollment changes take effect January 1 of the next year.
Annual Notice of Change (ANOC)
Since health benefits may change each year, Health Plans send their members an ANOC each fall prior to the Annual Election Period. The ANOC describes changes in the Health Plan’s benefits and services that will become effective in January.
Any Willing Doctor
A doctor, hospital, or other health care provider that agrees to accept the Health Plan's terms and conditions related to payment and that meets other requirements for coverage.
Appeal
A special kind of complaint you make if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if you request a health care service, supply, or prescription that you think you should be able to get, or if you request payment for health care you already got, and Medicare or your plan denies the request. You can also appeal if you are already getting coverage and Medicare or the plan stops paying. (Also see “Grievance”.)
Approved Amount
The fee that Medicare sets as its rate for a medical service. Medicare will generally cover 80 percent of this amount, and you (or your supplemental insurance) are responsible for the remainder. All providers who take assignment must accept this approved amount as full payment, even if they normally charge more for the service.
Assignment
An agreement by a doctor to accept Medicare's approved amount as payment in full. Any doctor who is a "participating provider" in the Medicare program always takes assignment.
Authorization
Authorization refers to the requirement by many Health Plans to obtain authorization before certain types of health care services are covered. Typically, if PCP must authorize a referral to a different doctor or a type of procedure before the visit or procedure, the Health Plan will not pay for the service. (Generally, an authorization is different from a referral in that, an authorization is a verbal or written approval from the Health Plan while a referral is a written document from one doctor to another doctor. Also see “Referral”) |
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Benefit Period
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| The way that the Original Medicare Plan measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods, although inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
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| Catastrophic Coverage |
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Once your total drug costs reach the set “Catastrophic Coverage” maximum, you pay a small coinsurance (like 5%) or a small co-payment for covered drug costs until the end of the calendar year.
Centers for Medicare and Medicaid Services (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS is part of the United States Department of Health and Human Services (DHHS).
Certificate of Authority (COA)
The state-issued operating license for a Health Plan. In Florida, the Office of Insurance Regulation issues COAs.
Certificate of Medical Necessity (CMN)
Documentation from a doctor which Medicare requires before it will cover certain durable medical equipment (DME). The CMN states the patient’s diagnosis, prognosis, reason for the equipment, and estimated duration of need.
Claim
The term used to describe a bill for services and benefits from a health care provider to a Health Plan.
Coinsurance
An amount you may be required to pay for services after you pay any plan deductibles. In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare-approved amount. You have to pay this amount after you pay the Part A and/or Part B deductible. In a Medicare Prescription Drug Plan, the coinsurance will vary by plan and will depend on how much you have spent.
Copayment
An amount you pay in some Medicare health and prescription drug plans, for each medical service, like a doctor’s visit, or prescription. A copayment is usually a set amount. For example, you could pay $10 or $20 for a doctor’s visit or prescription. Copayments are lower for people with Medicaid and people who qualify for extra help. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.
Cost Plan
A type of health plan. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan (your Cost Plan pays for emergency services, or urgently needed services).
Coverage Determination (Part D)
The first decision made by a Medicare drug plan (not the pharmacy) about the drug benefits you may be entitled to get, including decisions about the following:
- Whether to provide or pay for a drug
- An exception request you may have made
- The amount you have been asked to pay for a drug
- Whether you have satisfied a coverage rule for a requested drug
If the drug plan doesn't give you a prompt decision, and you can show that the delay would affect your health, the plan's failure to act is considered to be a coverage determination. If you disagree with the coverage determination, the next step is an appeal.
Creditable Prescription Drug Coverage
Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.
Critical Access Hospital
A small facility that gives limited outpatient and inpatient services to people in rural areas.
Custodial Care
Nonskilled 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. |
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| Deductible |
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The amount you must pay for health care or prescriptions, before the Original Medicare Plan, your prescription drug plan, or other insurance begins to pay. For example, in the Original Medicare Plan, you pay a new deductible for each benefit period for Part A and each year for Part B. These amounts can change every year. People who qualify for extra help either pay no deductible, or a small deductible for prescription drug coverage.
Demonstration
A type of Medicare project designed to explore future improvements in coverage, costs, and quality of care within the Medicare Program.
Discharge Planning
A process used to decide what a patient needs for a smooth move from one level of care to another (for example, returning home after an inpatient hospital visit). This is done by a social worker or other health care professional. Discharge planning may also include the services of home health agencies to help with the patient's home care.
Disease Management
The process of managing a particular disease. Disease Management encompasses all settings of care and places a heavy emphasis on prevention and maintenance.
Disenroll or Disenrollment
Ending your health care coverage with a health plan.
Drug List
See “Formulary”
Dual Eligibles
Beneficiaries who are entitled to coverage under both Medicare and Medicaid.
Durable Medical Equipment (DME)
Certain medical equipment that is ordered by your doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. DME is paid for under both Part A and Part B for home health services.
Durable Power of Attorney
A legal document that enables you to designate another person, called the attorney-in-fact, to act on your behalf, in the event you become disabled or incapacitated. |
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| Emergency Care |
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Care given for a medical emergency when you believe that your health is in serious danger when every second counts.
Enroll or Enrollment
Joining a health plan
Evidence of Benefits (EOB)
A statement sent to a Beneficiary explaining how and why a claim was paid or not paid.
Evidence of Coverage (EOC)
A document that describes the health care benefits covered by the Health Plan. It provides the Beneficiary with some form of documentation of what that insurance covers and how it works. (Also known as a Certificate of Benefits)
Exception
A type of coverage determination. A formulary exception is a decision to cover a drug that’s not on the formulary or a decision to waive a coverage rule. A tiering exception is a decision to charge you a lower amount for a drug that is on the non-preferred drug tier. Your doctor must send a supporting statement explaining the medical reason for the exception.
Expedited Appeal
A fast appeal of a denial of health care services when a person's "life, health, or ability to regain maximum function" is in jeopardy.
Extra Help
A program to help people with limited income and resources pay prescription drug costs. Also called the “low-income subsidy.” |
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| Grievance |
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| A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered. (Also see “Appeal”) |
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| Formulary |
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| A list of drugs covered by a plan. |
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| Health Maintenance Organization (HMO) |
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A type of Medicare Advantage Plan (Part C) available in some areas of the country. Plans must cover all Part A and Part B health care. Many HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in the Original Medicare Plan.
Health Insurance Portability & Accountability Act of 1996 (HIPAA)
A federal law that guaranteed patients new rights and protections against the misuse or disclosure of their Personal Health Information (PHI).
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, speechlanguage therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Hospice
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).
Hospitalist
A doctor who concentrates solely on hospitalized patients. |
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| Inpatient Care |
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Health care that you get when you are admitted to a hospital or skilled nursing facility.
Inpatient Rehabilitation Facility
A hospital, or part of a hospital that provides an intensive rehabilitation program.
Institution
A facility that meets Medicare’s definition of a long-term care facility, such as a nursing facility or skilled nursing facility, not including assisted or adult living facilities, or residential homes.
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| Lifetime Reserve Days |
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In the Original Medicare Plan, these are additional days that Medicare will pay for when you are in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Living Will
A legal document also known as a medical directive or advance directive. It states your wishes regarding lifesupport or other medical treatment in certain circumstances, usually when death is imminent.
Long-Term Care
A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care you need.
Low-Income Subsidy
See “Extra Help” |
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| Maximum Out-Of-Pocket Costs |
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The most amount of money that a beneficiary will need to pay for covered services during a contract year before the Health Plan starts paying costs.
Medicaid
A joint Federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
Medically Necessary
Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.
Medicare Advantage Plan (Part C)
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Also called “Part C,” Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans (PFFS Plans), Special Needs Plans (SNPs), and Medicare Medical Savings Account Plans (MSAs). If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and aren’t paid for under the Original Medicare Plan. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare-approved Amount
In the Original Medicare Plan, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.
Medical Savings Account (MSA) Plan
MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare in the account. You can use it to pay your medical expenses until your deductible is met.
Medicare Part A
Medicare hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B
Medicare medical insurance that helps pay for doctors’ services, outpatient hospital care, durable
medical equipment, and some medical services that aren’t covered by Part A.
Medicare.gov
The official U.S. Government website for people with Medicare is www.medicare.gov. You may also get information and help with your Medicare questions 24 hours a day, seven days a week by calling 1-800-MEDICARE (1-800-633-4227) or TTY: 1-877-486-2048.
Medicare Savings Program
Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums and deductibles.
Medicare Summary Notice (MSN)
A notice you get after the doctor or provider files a claim for Part A and Part B services in the Original Medicare Plan. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.
Medigap Policy
Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. |
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| National Committee for Quality Assurance (NCQA) |
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A non-profit organization that accredits and measures the quality of care in Medicare health plans.
Network
A group of doctors, hospitals, pharmacies, and other health care providers hired by a health plan to take care of its members. (Also called “Provider Network”.)
Non-Formulary Drug
A drug not on a Health Plan’s approved formulary (drug list) and as such, may not be paid for by the Health Plan.
Non-Participating Provider (Non-Par Provider)
A doctor or supplier who is not in the Health Plan’s network. As such, services from this provider may not be paid for by the Health Plan. |
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| Original Medicare Plan |
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The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). It’s a fee-for-service health plan. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
Out-of-Pocket Costs
Health care costs that you must pay because Medicare or other insurance does not cover them.
Outpatient Hospital Care
Medical or surgical care furnished by a hospital to you if you have not been admitted as an inpatient but are registered on hospital records as an outpatient. If a doctor orders that you must be placed under observation, it may be considered outpatient care, even if you stay under observation overnight. |
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| Participating Provider (Par Provider) |
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A doctor or supplier who is in the Health Plan’s provider network.
Penalty
An amount added to your monthly premium for Medicare Part A and/or Part B, or for a Medicare drug plan (Part D), if you don’t join when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.
Point-of-Service
A Health Maintenance Organization (HMO) option that lets you use doctors and hospitals outside the plan for an additional cost.
Power of Attorney
A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.
Pre-Existing Condition
A health problem you had before the date that a new insurance policy starts.
Premium
The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.
Preferred Provider Organization (PPO) Plan
A type of Medicare Advantage Plan (Part C) available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Many Medicare Advantage Plans are PPOs.
Prescription Drug Plan (PDP)
A stand-alone drug plan that adds prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that must follow the same rules as Medicare Prescription Drug Plans.
Preventive Services
Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).
Primary Care Provider (PCP)
Your primary care provider is the doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.
Prior Authorization
See “Authorization”
Private Fee-For-Service (PFFS) Plan
A type of Medicare Advantage Plan (Part C) in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn’t cover.
Programs of All-Inclusive Care for the Elderly (PACE)
A program that combines medical, social, and long-term care services to help frail people stay independent and living in their community as long as possible, while getting the high-quality care they need. PACE is available only in states that have chosen to offer it under Medicaid.
Provider Network
See “Network” |
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| Quality Improvement Organization (QIO) |
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| A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to people with Medicare. |
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| Referral |
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A written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for your care. (Also see “Authorization”)
Rehabilitation
Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists.
Religious Nonmedical Health Care Institution
A facility that provides nonmedical health care items and services to people for whom the acceptance of medical services would be inconsistent with their religious beliefs. To qualify, you would need hospital or skilled nursing facility care if it weren’t for your religious beliefs and you need to file a written election at the facility.
Reserves
The amount of money that a Health Plan is required by state law to put aside to cover health care costs.
Respite Care
Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off. |
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| Service Area |
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The area where a plan accepts members. For plans that require you to use their doctors and hospitals, it’s also the area where services are provided. The plan may disenroll you if you move out of the plan’s service area.
Skilled Nursing Facility (SNF) Care
This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (such as help with activities of daily living, like bathing and dressing) cannot qualify you for Medicare coverage in a skilled nursing facility if that’s the only care you need. However, if you qualify for coverage based on your need for skilled nursing care or rehabilitation, Medicare will cover all of your care needs in the facility, including help with activities of daily living.
Special Enrollment Period (SEP)
A time when a person who didn’t sign up for Medicare coverage under Part A, Part B, or Part D when first eligible can sign up without waiting for a general enrollment period. In most cases, the person can also sign up without paying a penalty (higher premium).
Special Needs Plan (SNP)
A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.
State Health Insurance Assistance Program (SHIP)
A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.
State Pharmacy Assistance Program (SPAP)
A state program that provides help paying for drug coverage based on financial need, age, or medical condition.
Subrogation
The contractual right of a Health Plan to recover payment made to a Beneficiary or Provider for health care costs after that Beneficiary has received payment for those health care costs in a legal action.
Supplemental Security Income (SSI)
A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits aren’t the same as Social Security benefits. |
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| Telemedicine |
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Medical or other health services given to a patient using a communications system (like a computer, telephone, or television) by a practitioner in a location different than the patient’s.
Tiers (Part D)
To have lower costs, many Health Plans place drugs into different "tiers," which have different copayments or coinsurance amounts. Each plan can form their tiers in different ways. For example, a Health Plan may create the following Tiers:
- Tier 1 - Generic drugs. Tier 1 drugs will cost you the least amount.
- Tier 2 - Preferred brand-name drugs. Tier 2 drugs will cost you more than Tier 1 drugs.
- Tier 3 - Non-preferred brand-name drugs. Tier 3 drugs will cost you more than Tier 1 and Tier 2 drugs.
Transparency
This terms refers to making data available to the public. Pricing Transparency specifically refers to making public the prices for services from various providers.
TTY
A teletypewriter (TTY) is a communication device used by people who are deaf, hard-of-hearing, or have a severe speech impairment. People who don't have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages. |
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| Urgently Needed Care |
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Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening.
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