A plan sponsor’s prescription drug plan that is at least equal to or better in terms of benefits when compared to a Medicare Part D Prescription Drug Plan.
A doctor, hospital, or other health care provider that agrees to accept the health service plan’s terms and conditions with regards to payment and that meets other requirements for coverage. The physicians and doctors who enroll as “any willing provider” agree to the plan’s terms with regard to patient care and fees and may provide discounts.
A process by which an accredited certification body assesses and reviews the quality of the health care organization’s policies, procedures, and performance based on established standards. Accreditation bodies themselves are evaluated and overseen by the International Accreditation Forum (IAF).
A notice given by a health care provider, doctor, or supplier gives to a Medicare beneficiary before providing a service or furnishing a product for which Medicare may deny payment. In such a case, if you aren’t given an ABN before you receive the service or product and Medicare denies payment, you may not have to pay for that service or product. If you receive and accept an ABN by signing it, and Medicare denies payment, you may have to pay for the service or product. ABNs only apply if a Medicare beneficiary is enrolled in Original Medicare, Part A and Part B. ABNs aren’t applicable to Medicare beneficiaries enrolled in a Medicare Managed Care Plan or a Private Fee-for-Service Plan.
A preliminary determination of Private Fee-For-Service plan, such as Medicare Advantage (Medicare Part C), about whether or not Medicare will pay for a certain service. This is unrelated to the Advance Beneficiary Notice (ABN), which only applies to people with Original Medicare, Part A and Part B.
Written individual instructions, which may include a living will or a power of attorney, for health care and for medical decisions to be made if the individual is not capable of making them himself/herself.
ALS stands for amyotrophic lateral aclerosis, which is a degenerative disease that affects nerve cells in the spinal cord and brain and results in severe muscular weakness and atrophy. ALS is also called Lou Gehrig’s disease, in reference to the New York Yankees baseball player who died from the disease.
A public or private licensed facility established to perform medical procedures or surgeries that do not require patients to stay overnight in a hospital or health care center.
A health condition characterized by severe chest pain caused by insufficient blood flow to the heart. The pain often spreads to the neck, shoulders, and arms.
A surgical or non-surgical procedure performed to treat blocked or diseased arteries.
An action taken by a Medicare beneficiary in case of disagreement with a coverage or payment decision made by Medicare or a Medicare plan. Appeals can be submitted if Medicare or a Medicare plan denies a Medicare beneficiary’s requests for:
- Health care service, supply, or prescription drug for which the beneficiary believes he or she is eligible
- Payment for health care service, supply, or a prescription drug which the Medicare beneficiary has already received
- Changing the amount that must be paid by the Medicare beneficiary for a prescription drug or health care service A Medicare beneficiary who is already receiving coverage can also appeal if Medicare or the Medicare plan stops paying for health services.
An agreement to pay Medicare benefits directly to Medicare beneficiary’s doctor, supplier, or healthcare provider. Under such an agreement, a Medicare beneficiary will not be billed anything over the Medicare deductible and coinsurance. Medicare payments may be assigned to participating providers only.
The term to identify a person who receives health care benefits through Medicare or Medicaid.
The amount of time during which Medicare pays for hospital and skilled nursing facility (SNF) services. As measured by Original Medicare, Part A and Part B, a benefit period begins the first day you enter the hospital or SNF and ends when you no longer receive hospital care or skilled care in an SNF for 60 days in a row. If you enter a hospital or SNF after one benefit period has ended, a new benefit period begins. You pay a new deductible for each new benefit period. There is no limit to the number of benefit periods. Your coinsurance is determined by the number of days you have been in the facility during each benefit period.
A private company that has a contract with Medicare to pay your physician and process other Medicare Part B claims as well.
Insurance plan designed to protect you from paying very high out-of-pocket costs and targeted mostly for patients who are generally healthy and don’t necessarily need to visit their physician regularly. The plan usually covers hospital stays, x-rays, and surgical expenses, but does not normally cover mental health care or maternity care. Original Medicare, Part A and Part B, does not offer catastrophic coverage and always pays the same amount regardless of how much you have spent. Medicare Part D (prescription drug coverage) does offer catastrophic coverage. After you have spent a certain amount out-of-pocket, you will only pay 5% of the cost of each prescription drug (in addition to your monthly plan premium). Medicare private plans, like regional PPOs (Preferred Provider Organizations), may also have catastrophic coverage or caps on out-of-pocket costs, but these caps may exclude certain high cost services. Also, Medicare Medical Savings Accounts (MSAs) must pay all or most of your Original Medicare costs after you have met your deductible.
The federal agency responsible for administering Medicare, Medicaid, SCHIP (State Children’s Health Insurance), and several other health-related programs.
A written certificate issued by a group health plan or health insurance provider (including an HMO) stating the period of time you were covered by your health plan. Possession of this certificate usually reduces how long a health care plan may exclude you from coverage for a pre-existing health condition.
See Medicare-certified provider.
A program administered by the United States Department of Health and Human Services that provides health coverage for children in families with an income too high to qualify for Medicaid but too low to afford private health care. Children’s Health Insurance Programs now provides free or low-cost health insurance in your state for uninsured children under age 19. Information on your state’s program is available through Insure Kids Now at 1-877-KIDS NOW (1-877-543-7669).
A request for payment that you submit to Medicare or other health insurance when you receive services or benefits that you expect to be covered. Medicare Part A claims are processed by fiscal intermediaries, and Medicare Part B claims are processed by Medicare carriers. Medicare Advantage (Medicare Part C) private health plans and Medicare Part D (prescription drug coverage) claims are processed by each individual plan.
A physical examination of the breast done by a health professional. Clinical breast exams are used along with mammograms to check women for breast cancer and other breast problems. CBE is usually done in the doctor’s office during the Pap test and the pelvic exam.
An individual designated by CMS to conduct the appeals process for a claim dispute. Within 30 calendar days from the receipt of request for the hearing, a CMS hearing officer will schedule a hearing to review the case.
The amount you may be required to pay for health care services after you meet your plan’s deductibles. In Original Medicare, Part A and Part B, this is a percentage (usually 20%) of the Medicare-approved amount. You have to pay this amount after you pay the deductible for Medicare Part A and/or Medicare Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent. The maximum percentage you may be responsible for is generally no more than 50%.
A health care facility that provides outpatient diagnostic, therapeutic, psychological, and restorative services for rehabilitation from an injury, disability, or illness.
The sharing of costs by two or more health plans, according to their respective financial responsibilities, for your health care claims. This is the process when your primary and secondary insurance plans coordinate benefits in order to pay your medical bills.
The portion of the cost of each medical service and prescription you have to pay. A copayment is usually a set amount (for example, $10 or $20), which you pay for a doctor’s visit or for a prescription drug from the pharmacy. In Original Medicare, Part A and Part B, copayments are also used for some hospital outpatient services.
A tube placed in the coronary arteries that supply the heart to keep the arteries open in the treatment of coronary heart disease. The coronary stent is used in a procedure called percutaneous coronary intervention (PCI). Stents reduce chest pain and have been shown to improve survivability in the event of an acute myocardial infarction.
The amount you pay for health care and/or prescription drugs. This amount can include copayments, coinsurance, and/or deductibles.
The first decision made by your Medicare drug plan (not the pharmacy) about whether a drug prescribed for you is covered by the plan and the amount you may be required to pay for the prescription. In general, a coverage determination cannot come from a pharmacy. You need to call or write your plan to ask for a formal decision about the coverage.
A period of time in which you pay higher cost sharing for prescription drugs, until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year. During this coverage gap period in Medicare Part D (prescription drug coverage), your drug costs may increase. As a result of health reform, the coverage gap is gradually being phased out. It will be completely phased out in 2020 when you will pay no more than 25% of the cost of your drugs throughout the entire year.
A person who has (or had) coverage under a group health plan.
Health coverage you have had in the past, such as group health plan, Medicare, Medicaid, or other, and which was not interrupted by a significant break in coverage. The time period of this prior coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan. Usually, creditable coverage may be any health insurance coverage you had within 63 days of securing a new insurance policy that can be used to shorten the waiting period for pre-existing conditions. Proof of your creditable coverage may be shown by a certificate of creditable coverage or by other documents showing you had health coverage, such as a health insurance ID card.
Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy. See also Pre-existing condition.
Prescription drug coverage that is considered to be as good as, or better than, Medicare Part D (prescription drug coverage) in terms of benefits.
A small medical facility that provides limited outpatient and inpatient hospital services to people in rural areas.
Non-skilled, personal care, such as help with activities of daily living like cooking, cleaning, shopping, bathing, dressing, eating, getting in and out of a bed or chair, moving around, and using the bathroom. Custodial care may also include care that most people do themselves, like taking medications or using eye drops. In most cases, Medicare does not pay for custodial care.
The amount you must pay for health care or prescriptions before Medicare Part A and Part B, your prescription drug plan, or your other insurance begins to pay. In Original Medicare, Part A and Part B, you pay a new deductible for each benefit period for Part A, and each year for Part B. Deductible amounts can change every year.
A health care provider or supplier earns “deemed status” when they have been evaluated and accredited by a national accreditation program (approved by the Centers for Medicare & Medicaid Services) and have demonstrated compliance with required rules and regulations.
Special projects, also called “pilot projects” or “research studies,” to evaluate improvements in Medicare’s payment coverage policies and quality of health care services. Demonstrations usually operate only for a limited time, for a specific group of people, and in specific areas.
A department of the United States government established to manage programs protecting the health of all Americans and providing essential human services. The department’s goal is “improving the health, safety, and well-being of America.”
An x-ray used in women’s breast examinations to detect, evaluate, and diagnose unusual breast changes, such as a lump, pain, nipple discharge, and change in breast size or shape.
A hormone with estrogen that used to be prescribed to pregnant women to prevent miscarriages and premature births. Its usage was standard practice in the 1940s until 1971. The drug has been linked to cancer of the cervix or vagina in women whose mothers took the drug while pregnant.
A private company contracted with the Centers for Medicare & Medicaid Services (CMS) to provide greater efficiency in the Medicare program as it applies to Durable Medical Equipment, Prosthetics, and Orthotics and Supplies (DMEPOS). Each DME MAC covers a specific geographic area of the country and processes Medicare claims for DMEPOS items.
A list of drugs covered by a health care plan. This list is also called a formulary.
Special equipment, such as a walker, wheelchair, hospital bed, etc., prescribed by a physician for use inside the home and to provide therapeutic benefits or enable the beneficiary to perform certain tasks that he/she is unable to undertake due to certain medical conditions and/or illnesses. DME is covered by Medicare Part B under home health services.
A private company that contracts with Medicare to process claims and payments for durable medical equipment. DMERC also provides medical policy for coverage of speech-generating devices (SGDs). Each DMERC covers a specific geographic area of the country.
A legal document that allows you to designate another individual to act on your behalf in the event you become disabled or incapacitated. The individual chosen to act on your behalf is usually called an agent.
Your decision to join or leave Original Medicare, Part A and Part B, or a Medicare Advantage (Medicare Part C) plan.
Electronic (computer-based) exchange or transfer of money, from one account to another, within a single or multiple financial institutions.
Health care and/or prescription drug plans offered by employer or employee organizations to their current or former employees and their families.
Permanent kidney failure that will not allow a patient to live without dialysis or a kidney transplant. ESRD is usually caused by diabetes or high blood pressure.
A system of partner company activities adopted to develop and administer different aspects of retiree drug subsidy program (RDS), such as enrollment, payments, appeals, etc.
Medicare Prescription Drug Plan decision in response to your formal written request to have the plan pay for a drug you need that is not on its list of covered drugs (formulary), or to lower the price of a drug you need that is on its formulary but costs too much. A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. When you request an exception, your physician or other prescriber must send certain documents supporting the medical reason for the exception.
The difference between the amount your doctor or other health care provider actually charges and the amount approved by Medicare.
A fast decision taken by Medicare Advantage (Medicare Part C) about whether they will provide a health service. Expedited Organization Determination may be received within 72 hours if life, health, or ability to regain function may be at risk.
If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare Part D (prescription drug coverage). Depending on your income, you may receive full Extra Help or partial Extra Help.
A health center or a clinic that is a non-profit organization funded by the federal government and that provides primary care services to under-served areas and populations even if patients cannot afford to pay. Such services are provided on a sliding scale fee basis and the patient’s ability to pay.
A private organization contracted by Medicare to process Medicare Part A and some Medicare Part B claims and pay bills, such as hospital bills. A fiscal intermediary is also simply referred to as intermediary.
A list of prescription drugs for which Medicare private health plans will help to pay. In general, drugs that are not on the formulary are not covered by private health care plans.
A copy of a brand-name drug that, according to the FDA’s regulations, is identical in dosage, quality, strength, performance, and safety. A generic drug is also taken the same way as a brand-name drug, and it is intended for the same use. Generics are generally as effective as the brand-name drugs, but are cheaper because they don’t require the kind of research, development, and patenting involved with the brands.
A fluid solution prepared for checking the accuracy of test strips and monitors for diabetes.
A complaint or dispute in regards to unsatisfactory operation, behavior, or activities of your Medicare private health plan or its provider. If you have a complaint, you need to file a grievance in writing or orally within 60 days after the event or incident happened. You may file a grievance, for instance, if you are upset with how people working for your private insurance health plan respond to your requests or if you are not provided with adequate conditions when you are staying in a health care facility. However, you cannot file a grievance if you are not satisfied with a treatment decision or a service that is not covered by your insurance plan. In such cases you should use file and appeal instead of a grievance. Usually, if your health plan cannot grant you an expedited appeal, Medicare private health and drug plans must respond to your grievance within 24 hours. Also, within 30 days upon receiving your grievance, your Medicare drug plan must notify you of its decision or extend the deadline of the notification up to 14 calendar days. Private health plans don’t have such deadlines.
Employer- or union-based health plan provided through a private insurance company to current or former employees and their families. Depending on your current employment status and the size of the company you work for, this group health plan may be primary or secondary to Medicare.
A number to be assigned to all group health plans by the Centers for Medicare & Medicaid Services (CMS) department managing transactions, codes, security, and administrative simplification portions of the Health Insurance Portability and Accountability Act (HIPAA).
General Services Administration. The GSA is an agency that’s part of the United States government and that helps support and manage federal agencies.
Consumer protection rights that allow you to buy a Medigap supplemental insurance policy. Because of these rights, an insurance company cannot deny you insurance coverage or place conditions on a policy based on your pre-existing conditions, and it cannot charge you more for a policy because of your current or past health issues. Guaranteed issue rights are also referred to as Medigap Protections.
A right you have that requires your insurance company to automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud, or fail to pay your premiums. Though renewal of the policy is guaranteed, if you have filed claims, have an injury, or other factors that may increase the risk of future claims, the premiums can be raised during the life of the policy. Since 1992, all Medigap policies are guaranteed renewable policies.
An individual or a facility licensed to provide health care services. Doctors, nurses, and hospitals are examples of health care providers.
The “Standard for Privacy of Individually Identifiable Health Information” (also called the “Privacy Rule”) of HIPAA is a federal law designed to protect a subset of sensitive information known as Protective Health Information (PHI).
A managed health care plan that generally offers coverage of the services provided within the HMO plan’s network. Medicare members may get their benefits through an HMO. This includes a Medicare Advantage (Medicare Part C) plan with coverage for Original Medicare, Part A and Part B. HMO beneficiaries must choose a primary care physician (PCP) acting as coordinator and gatekeeper to their health care.
A treatment of a failed kidney that removes certain waste products from the blood, such as creatinine and urea, as well as extra fluids. Hemodialysis is usually an outpatient or inpatient therapy, but it can sometimes be done at home. Hemodialysis uses a special filter called a dialyzer, or artificial kidney, to clean the patient’s blood. In a clinic, dialysis treatments are administered by nurses and technicians. At home, dialysis can be done by the patient himself/herself or jointly with the help of a trained person, who is often a family member.
A type of Medigap policy that has a high deductible and a low premium. The deductible must be paid by the Medigap beneficiary before Medigap approves any policy payments. The amount of the deductible may change yearly.
An organization that provides health care at home.
Home health care services and intermittent or part-time skilled nursing care is provided on a limited basis. The care may include occupational therapy, physical therapy, medical social services, speech-language pathology services, durable medical equipment (such as hospital beds, oxygen, wheelchairs, and walkers), medical supplies, and other services.
A person confined at home due to illness or injury.
Hospice care is care and support provided for people who are terminally ill. It includes inpatient care and outpatient care, counseling, pain management, respite care, prescription drugs, as well as services for the person’s family or caregiver. Hospice care is covered under Medicare Part A (hospital insurance).
A level of health care for patients whose condition requires admission to a hospital. Patients are generally admitted to a hospital when they are extremely ill or have severe physical injury.
A hospital department allocated for outpatient services. Services include emergency care, surgery center, observation unit, or pain clinic.
An independent organization that contracts with Medicare to review your case if you appeal your Medicare plan’s coverage decision or payment. Your case is also reviewed if your plan does not respond with a decision to your appeal in a timely manner.
Your plan’s out-of-pocket maximum, which you reach after you have paid your yearly deductible, copayment, or coinsurance for each covered drug. Then, you will enter your plan’s coverage gap (also called the “donut hole”).
A group of doctors, hospitals, pharmacies, and other health-care providers that have agreed to provide discounted services and supplies to beneficiaries of a certain insurance plan. Some insurance plans will cover services only from in-network doctors, hospitals, pharmacies, and other health-care providers.
Health care services provided in a hospital or skilled nursing facility.
Health care services provided in a hospital, including bed and board, diagnostic or therapeutic services, medical or surgical services, and nursing services.
A payment system that allows hospitals contracted with Medicare to provide acute inpatient care and accept a predetermined rate as payment in full.
A medical facility, which can be part of a hospital, that provides an intensive rehabilitation program to inpatients.
An institution that provides inpatient, comprehensive care in a Medicare- or Medicaid- certified facility. Examples may include skilled nursing facilities, long-term care hospitals, and psychiatric hospitals.
A group health plan supported by an employer or employee organization with 100 or more employees.
Under Original Medicare, Part A and Part B, beneficiaries have an extra 60 days of hospital coverage after being in a hospital for more than 90 days during a benefit period. These 60 reserve days can be used only once during a lifetime. For each lifetime reserve day, Medicare pays covered costs, and the beneficiary is responsible for a daily copayment.
In Original Medicare, Part A and Part B, this is the highest amount of money you can be charged for a covered service by doctors or other health-care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s approved amount. The beneficiary is responsible for the excess or limiting charge. Some Medigap policies offer benefits that pay the excess charge. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.
A written legal document, also called a “medical directive” or “advance directive.” It shows what type of treatments you want or don’t want in case you can’t speak for yourself, like whether you want life support. Usually, this document only comes into effect if you’re unconscious.
Long-term care services include both medical and non-medical care provided to people who cannot perform basic daily living activities, like getting dressed, eating, or bathing. Long-term supports and services can be provided at home, in the community, in assisted living, or in nursing homes. People may need long-term supports and services at any age. Medicare and most health insurance plans do not pay for long-term care.
A hospital that provides treatment for patients who need acute care and usually stay on average more than 25 days. Most individuals in long-term care hospitals are transferred from critical care or intensive care units. Long-term care hospitals provide such services as comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
An advocate who resolves problems for residents of certain health-care facilities, such as skilled nursing homes, board homes, residential care facilities, assisted living facilities, and other adult care organizations. An ombudsman also informs residents and their family members of their rights and protections while residing in a facility and can be a resource for those looking for more information on local home health agencies. In addition, they advocate for change at the local, state, and national levels that will improve quality of care for residents.
A joint federal and state program that helps people with low incomes and limited resources pay health care costs. If you qualify for both Medicare and Medicaid, most of your health care costs will be covered.
A health-care provider approved by Medicaid. Medicaid-certified providers include home health agencies, hospitals, nursing homes, and dialysis facilities. Providers are considered to be approved, or “certified,” if they have passed an inspection by a state government agency.
When you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death.
The process that an insurance company uses to decide, based on your medical history, whether to take your insurance application, whether to add a waiting period for coverage of pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.
Health-care services or supplies that are medically necessary to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
The federal health insurance program for people who are of age 65 or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD). Medicare is administered by the Centers for Medicare & Medicaid Services (CMS).
A company that processes claims for Medicare.
Medicare Advantage (Medicare Part C) plans let you get your Medicare benefits from a Medicare health plan, offered through private insurance companies that are contracted by Medicare to provide this coverage. All Medicare Advantage plans must offer at least the same benefits as Original Medicare, Part A and Part B, but can do so with different rules, costs, and coverage restrictions. Some plans (like Medicare Advantage Prescription Drug Plans, or MA-PD) offer Medicare Part D drug prescription coverage as part of their benefits packages or may include additional benefits, such as routine vision or dental, hearing, and wellness programs. Medicare Advantage plans can include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Private Fee-for-Service (PFFS) plans, and Medical Savings Account (MSA) plans. To enroll, beneficiaries must have Original Medicare, Part A and Part B, live in the service area of the Medicare Advantage plan, and cannot have end-stage renal disease (with some exceptions).
Medicare Advantage (Medicare Part C) plan that offers both Medicare prescription drug (Medicare Part D) coverage and Original Medicare, Part A and Part B, benefits in one plan.
Medicare Advantage (Medicare Part C) plans offer health care through an established provider network that is approved by Medicare, such as Health Maintenance Organizations (HMOs), HMOs with a Point of Service option (HMO-POS), Preferred Provider Organizations (PPOs), and Special Needs Plans (SNPs).
A company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a Medicare beneficiary may have, and to then determine which entity pays first.
A type of Medicare health plan available in some areas. 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 Original Medicare (your Cost Plan pays for emergency services or urgently needed services).
A type of coverage consisting of two parts: hospital insurance (Medicare Part A) and medical insurance (Medicare Part B).
A type of Medicare Advantage (Medicare Part C) plan available in some areas of the country. Most HMO plans require you to choose a primary care physician (PCP) who will refer you for specialist care. Most HMOs require you to use doctors, specialists, and hospitals within the plan’s provider network (with the exception of emergency or urgent care).
A plan offered by a private insurance company that contracts with Medicare to provide you with your Medicare Part A and Medicare Part B benefits. Medicare health plans include all Medicare Advantage plans, Medicare Cost plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
A type of Medicare Advantage (Medicare Part C) plan whose beneficiaries can get coverage for health care that Original Medicare doesn’t pay for and generally only go to doctors, specialists, or hospitals on the plan’s list. Medicare Managed Care Plans are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) that must offer the same benefits as Original Medicare, Part A and Part B, and may cover additional services, such as prescription drugs.
MSA plans combine a high-deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins..
The part of Original Medicare that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
The part of Original Medicare that covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
A plan other than Original Medicare, Part A and Part B, that provides coverage for your Medicare health care and prescription drugs costs. This term includes all Medicare health plans and Medicare Prescription Drug Plans.
A type of Medicare Advantage (Medicare Part C) managed care plan that encourages members to use doctors, hospitals, and other providers that belong to the plan’s network. Though members may see providers outside the network, the copayment is lower when members use the PPO network providers instead of providers outside the network.
Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by private insurance companies approved by Medicare.
A type of Medicare Advantage (Medicare Part C) plan in which you, as a member of Original Medicare, Part A and Part B, can generally go to any doctor or hospital you choose if the doctor or hospital agrees to treat you. The plan determines your share of payment to doctors and hospitals for health care services. A Private Fee-For-Service Plan is different than Original Medicare, so you must follow the plan rules carefully when you need to get health care services. When you are in a Private Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits than in Original Medicare.
A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.
A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.
A special type of Medicare Advantage plan (Part C) that provides more focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.
A notice you get after the doctor, other health-care provider, or supplier files a claim for Part A or Part B services in Original Medicare. It explains what the doctor, other health care provider, or supplier billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.
In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.
A company, person, or agency that has been certified by Medicare to provide you with a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.
A health care provider certified by Medicare. This includes hospitals, home health agencies, nursing homes, or dialysis facilities that have been certified by Medicare if they have passed an inspection conducted by a state government agency. Medicare will not pay for services received from a health care provider that is not Medicare-certified.
Benefits that all Medigap policies must cover, including Part A and Part B coinsurance amounts, blood, and additional hospital benefits not covered by Original Medicare.
A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.
Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.
In general, a group health plan sponsored jointly by two or more employers.
Pharmacies that have agreed to provide services and supplies at a discounted price to members of certain Medicare plans. Some Medicare plans will cover your prescriptions only if you get them filled at network pharmacies.
Drugs that are not on a health care plan’s approved drug list.
A pharmacy that’s part of a Medicare drug plan’s network but isn’t a Preferred Pharmacy. If you get your prescription drugs from a Non-Preferred Pharmacy instead of a Preferred Pharmacy, you may end up paying higher out-of-pocket costs.
Treatment that helps you return to your usual daily activities, such as preparing meals, bathing, housekeeping, etc., after an injury or illness.
Services that Medicare doesn’t cover, but that a Medicare health plan may choose to offer. If you enroll in a plan with these services, you may choose to buy the services. If you choose to buy these benefits, you’ll pay for them directly, usually as a premium, copayment, and/or coinsurance. These services may be offered individually or as a group of services, and they may be different for each Medicare health plan.
Original Medicare is coverage managed by the federal government. It is fee-for-service health insurance that has two parts: Part A (hospital insurance) and Part B (medical insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
A benefit that may be provided by your Medicare Advantage (Medicare Part C) plan. Generally, this benefit allows you to receive health care services from outside of the plan’s network of health care providers. However, you may have to pay higher out-of-pocket costs for out-of-network services.
Health care services or prescription drug costs you will have to pay yourself because they are not covered by Medicare or other insurance plans.
Medical or surgical care you get from a hospital when your doctor hasn’t written an order to admit you to the hospital as an inpatient. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests, or X-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.
A test to check for cancer of the cervix, the opening to a woman’s uterus. It’s done by removing cells from the cervix. The cells are then prepared so they can be seen under a microscope.
A medical device used to lift a patient from a bed or wheelchair.
An exam to check if internal female organs are normal by feeling their shape and size.
An amount added to your monthly premium for Medicare Part B, or for a Medicare Prescription Drug Plan, if you did not enroll in the plan when you first became eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.
A network of pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. Some Medicare plans will cover your prescriptions only if you get them filled at network pharmacies.
Treatment of an injury or a disease by mechanical means, like exercise, massage, heat, and light treatment.
Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services do not include the services given while in the hospital and listed on the hospital bill.
A person responsible for a health care plan management. The plan administrator is specifically designated by the terms of the plan. If the plan does not make such a designation, then the plan sponsor is generally the plan administrator.
Generally, an employer, an employee organization, such as a union, or other entity that creates or maintains an employee benefit plan, including a group health plan. See also Sponsor.
A foot doctor.
In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside of the plan for an additional cost.
A document you sign in order to appoint someone you trust to make decisions about your medical care on your behalf, if you are unable to make such decision yourself. This type of advance directive may be called a health care proxy, appointment of health care agent, or a durable power of attorney for health care. The individual chosen to act on your behalf is called an agent.
A condition or illness with which you were diagnosed, or for which you received treatment before your new health care coverage began. Some health plans may impose a waiting period on coverage for any pre-existing conditions you have.
A type of Medicare Advantage plan 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.
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).
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.
A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that agrees to treat you under the plan and that accepts the plan’s payment terms. The plan decides how much you must pay for services.
A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage
Feeling in your foot or leg that is warning you that your skin is being injured. Loss of feeling in the foot or leg due to nerve damage can be caused by diabetes. This condition is also called “loss of protective sensations” (LOPS) and may result in skin loss, blisters, or ulcers.
Generally, qualified beneficiaries include covered employees, their spouses (or former spouses), and their dependent children who are covered under a group health plan on the day before the qualifying event. In certain cases, retired employees, their spouses, and dependent children may be qualified beneficiaries.
A Medicare Savings state program that helps beneficiaries with low income and limited assets pay their Medicare Part A plan premiums.
A Medicare Savings state program that helps beneficiaries pay their Medicare Part B premiums if they have low income and limited assets.
A Medicare Savings state program that helps beneficiaries pay their Original Medicare, Part A and Part B, premiums, if they have low income and limited assets. QMB may also help with other cost sharing, such as deductibles, coinsurance, and copayments.
Estimation of how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person, and getting the best possible results.
Groups of practicing doctors and other health care experts contracted by the Centers for Medicare & Medicaid Services (CMS). Quality Improvement Organizations are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for-Service Plans, and ambulatory surgical centers. These doctors also review fast-track termination decisions in comprehensive outpatient rehabilitation facilities, skilled nursing facilities, and home health and hospice settings for people in Medicare health plans. For example, QIOs review expedited appeals when a Medicare Advantage (Medicare Part C) health plan denies coverage or terminates services from a hospital, home health agency, skilled nursing facilities, or comprehensive outpatient rehabilitation facility; or when Original Medicare, Part A and Part B, denies coverage of home health care, skilled nursing facilities care, hospice care, or comprehensive outpatient rehabilitation facility care.
A company that acts on behalf of Medicare to identify and recover improper Medicare payments paid to health care providers under fee-for-service Medicare plans.
A written order from your primary care physician (PCP) for you to visit a medical specialist or get certain services. A referral is needed to receive authorization from some Medicare Advantage health plans for services not provided by your PCP. For instance, HMOs generally require you to get a referral from your PCP in order to see a medical specialist or get an eye exam. If you don’t get a referral first, the plan may not pay for the services.
A private company contracted with Medicare to pay Original Medicare, Part A and Part B, home health and hospice bills, and check on the quality of home health care.
Health care services for patients with the intent to cure, improve, or prevent the worsening of a condition resulting from illness or injury. These services are given by nurses and also physical, occupational, and speech therapists. Examples include physical therapy after hip replacement surgery to resume walking, or occupational therapy to prevent carpal tunnel syndrome.
A facility that provides non-medical health care services and supplies to people who need hospital or skilled nursing facility care, but for whom that care would be inconsistent with their religious beliefs.
Short-term, temporary care provided in a nursing home, hospice inpatient facility, or hospital, so that a family member or friend who is the patient’s caregiver can get a rest or take some time off. Respite care usually lasts for a period of up to five days.
An individual who is provided coverage under a group health plan after that individual has retired. The Retiree Drug Subsidy (RDS) Program is offered by the Centers for Medicare & Medicaid Services (CMS).
A process of adjusting health plan payments according to a person’s health conditions.
A Federally Qualified Health Center (FQHC) that provides health care services in rural areas where there is a shortage of health care services.
A medical procedure for women to check for breast cancer before she or a doctor may be able to find it manually.
An opinion from another doctor about your health condition and its treatment.
A payer, such as an insurance policy, health plan, or program that pays second on a claim for medical care. Depending on the situation, this may include Medicare, Medicaid, or other insurance.
The area in which a private health plan or Medicare private drug plan provides medical services to its members. In many private health plans, this is the area where your network of providers is located. The health plan may cancel your enrollment if you move out of the plan’s service area.
A general description of the types of services provided under the service and/or the characteristics that define the service category.
An effect that is secondary to the one intended by the treatment. Though the term is predominantly used to describe adverse effects, it can also apply to beneficial but unintended effects, such as drug usage consequences.
In general, a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual’s coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage.
A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.
Medically necessary care performed by a therapist or skilled nurse. If someone at home can provide help with activities of daily living, it is not considered skilled nursing care. Skilled nursing includes care from Registered Nurses and Licensed Practical Nurses. Skilled therapy includes care from licensed physical, occupational, and speech therapists.
A Medicare-approved facility that provides short-term, post-hospital extended care services. Though SNF care is at a lower level of care compared to a hospital, it has required staff and equipment to provide skilled nursing care, skilled rehabilitation services, and other related health services.
Medical care, including skilled nursing care and rehabilitation services, provided on a continuous daily basis in a skilled nursing facility. In general, skilled nursing facility care is not practical to provide on an outpatient basis. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be administered by a registered nurse or doctor. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.
An organization providing a special type of health plan with a full range of Medicare benefits offered by standard Medicare HMOs. SHMO combines Original Medicare, Part A and Part B, coverage with various extended and chronic care benefits, into an integrated health plan. The benefits cover prescription drug and chronic care, respite care, dental care, short-term nursing home care, homemaker and personal care, medical transportation, and medical supplies, such as eyeglasses and hearing aids.
A set time during which a beneficiary can change health plans or return to Original Medicare, Part A and Part B. For instance, a beneficiary can change health plans or return to Original Medicare if any of the following happen: he or she moves outside the service area; the beneficiary’s Medicare Advantage (Medicare Part C) plan violates its contract; the organization does not renew its contract with the Center for Medicare & Medicaid Services (CMS); or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election and Special Enrollment Period (SEP)).
A set time when you can sign up for Medicare Part B if you didn’t apply for Medicare Part B during the Initial Enrollment Period, because you or your spouse were working and had group health plan coverage through the employer or union. You can sign up at any time you are covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period start the month after the employment ends or the group health coverage ends, whichever comes first.
A Medicare Advantage (Medicare Part C) health plan that mostly serves members who have a special need. An SNP may serve people who have both Medicare and Medicaid (dual eligibility), people who have a specific chronic illness, such as diabetes, as well as people who are in long-term care facilities, nursing home, or require an institutional level of care. Some SNPs may serve more than one type of special need.
A doctor who only treats certain parts of the body, a certain health condition, or certain age groups. For example, some doctors (who are called cardiologists) only treat heart problems.
An insurance that pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn’t fill gaps in your Medicare coverage.
Beneficiary of a Medicaid program that helps pay Medicare Part B premiums for individuals who have Medicare Part A, low-income, and limited assets.
A state program that helps pay Medicare Part B premiums for individuals who have Medicare Part A, low-income, and limited assets.
Therapeutic treatment of speech impairments, such as lisping and stuttering, or speech difficulties that result from illness.
An entity that provides funding support for a health plan. This can be an employer, a union, or some other entity.
See Children’s Health Insurance Program (CHIP).
A national program that offers one-on-one counseling and assistance to people with Medicare and their families. SHIP provides free counseling and assistance via telephone and face-to-face interactive sessions, public education presentations and programs, as well as media activities.
A state agency that regulates insurance rules and regulations and can provide information about private insurance plans, such as Medigap.
A state agency that is managing the state’s Medicaid program and can provide information about programs that help pay medical bills for people with low income and limited assets.
A state program that provides people with assistance in paying for drug coverage, based on financial need, age, or medical condition, and not based on current or former employment status. These programs are run by and funded by the states.
A state-subsidized program that provides assistance in paying for prescription drug costs based on a person’s financial situation, age, or medical condition. SPAPs vary by state.
A state agency that oversees health-care facilities that participate in the Medicare and/or Medicaid programs. The State Survey Agency inspects health-care facilities and investigates complaints to ensure that health and safety standards are met.
A coverage restriction placed on drug coverage by private health plans and Medicare private drug plans. The coverage restriction requires that before your plan covers some (generally more expensive) drugs, you must try other (generally less expensive) drugs that treat your condition to see if they will work for you.
A health condition when one or more of the bones of your spine move out of position and create pressure and/or pain on your spinal nerves.
A program that is available through the Federal Department of Housing and Urban Development and some states to help people pay for housing if they have low incomes and limited assets.
A monetary grant paid by the government to a private person or company to assist an enterprise considered helpful to the public.
A monthly benefit paid by Social Security to people with low income and limited assets who are disabled, blind, or age 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.
Generally, a company, person, or agency that gives you a medical service or item, such as a wheelchair or walker.
A method that provides professional services to a patient remotely, through an interactive telecommunications system.
A system that Medicare private drug plans use to establish prices for prescription drugs. Generic drugs are generally on the first, least expensive tier (Tier 1), followed by brand-name drugs (Tier 2), and then specialty drugs (Tiers 3 and above), with each subsequent tier requiring higher out-of-pocket costs.
A set of medical techniques and drugs to cure your abnormal health condition, such as illness or injury.
Choices you have to treat your health problem.
A health care program serving active duty service members, National Guard and Reserve members, retirees, their families, survivors and certain former spouses worldwide.
A teletypewriter required at both ends of the conversation that enables people who are deaf, hard of hearing, or speech-impaired to use the telephone to communicate. TTY works by allowing people to type messages back and forth to one another instead of talking and listening. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who don’t have a TTY can communicate with a TTY user through a message relay center (MRC) that has TTY operators available to send and interpret TTY messages.
A claim submitted for a service or item by a provider who does not accept assignment.
Care that you get for a sudden, non-life-threatening illness or injury that needs immediate medical care. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than Original Medicare, Part A and Part B. If you are out of your plan’s service area for a short time and cannot wait until you return home to receive care, the health plan must pay for urgently needed care.
A process that allows users to verify the integrity and correctness of data. Validation can be accomplished immediately for a specific data item available, or after a complete set of data is collected.
The time period between the day when you (an employee or dependent) sign up for a Medigap or Medicare Advantage (Medicare Part C) private health plan, and when the coverage begins. Waiting periods for Medicare-related benefits are most often imposed if you have a pre-existing condition and have not had creditable coverage for a certain amount of time. If you are a late enrollee or are on a special enrollment date, any period before the late or special enrollment date is not a waiting period. If a plan has a waiting period and a pre-existing condition exclusion, the pre-existing condition exclusion period begins when the waiting period begins. Days in a waiting period are not counted toward creditable coverage unless there is other creditable coverage during that time. Days in a waiting period are not counted when determining a significant break in coverage.
Insurance that employers must have to cover employees who get sick or injured on the job.
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Last Updated Date: 06/17/2017