Medicare Glossary– Look up the definitions of common Medicare terminology
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
A plan sponsor must offer a prescription drug plan that is actuarially (a term relating to the statistical calculation of risk) the same or better than the Medicare Part D prescription drug plan.
AMBULATORY SURGICAL CENTER
A health care facility which offers patients the ability to have selected surgical and procedural services performed outside of a hospital.
ANNUAL ENROLLMENT PERIOD
October 15 - December 7. This period is for people who did not enroll during their Initial Enrollment Period and do not qualify for a Special Enrollment Period or who had dropped coverage previously. Beneficiaries can enroll in, disenroll from, or change their MA, Cost or Part D Plan.
ANY WILLING DOCTOR
A doctor, hospital, or other health care provider that agrees to accept the plan's terms and conditions related to payment and that meets other requirements for coverage.
A special kind of complaint you make if you disagree with certain kinds of decisions made by Original Medicare or by your health plan. You can appeal if you request a health care service, supply or prescription that you think you should be able to get from your health plan, or you request payment for health care you already received, and Medicare or the health plan denies the request. You can also appeal if you are already receiving coverage and Medicare or the plan stops paying. There are specific processes your Medicare Health Plan and Original Medicare must use when you ask for an appeal.
In Original Medicare, this means a doctor or supplier agrees to accept the Medicare-approved amount as full payment. You must still pay your share of the cost.
Health plan approval necessary prior to the receipt of care.
The name for a person who has health care insurance through the Medicare or Medicaid program.
A "benefit period" begins the day you go to a hospital or skilled nursing facility (SNF). The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins.
A health plan.
Once your total Part D out-of-pocket prescription drug costs reach a defined maximum ($4,550 in 2011), you pay a small coinsurance (like 5%) or a small copayment for covered drug costs until the end of the calendar year.
CERTIFICATE OF CREDITABLE COVERAGE
A written certificate issued by a group health plan or health insurance plan that states the period of time you were covered by your health plan.
CHILDREN'S HEALTH INSURANCE PROGRAM
Children's Health Insurance Programs help reach uninsured children whose families earn too much to qualify for Medicaid, but not enough to get private coverage.
Centers for Medicare & Medicaid Services.
CMS HEARING OFFICER
An individual designated by CMS to conduct the appeals process for a claim dispute
The amount you may be required to pay for services after you pay any plan deductibles. It is typically a percentage (like 20%) of the cost of the service provided.
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF)
A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physician's services, physical therapy, social or psychological services, and outpatient rehabilitation.
COORDINATION OF BENEFITS
Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim.
The amount you pay for each medical service, like a doctor's visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor's visit or prescription. Copayments are also used for some hospital outpatient services in Original Medicare.
The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and/or deductibles. It does not include the amount your health plan pays for your health care.
An individual who is (or was) provided coverage under a group health plan. See also Group health plan, Retiree
CREDITABLE COVERAGE (MEDIGAP)
Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy. (See pre-existing conditions.)
CREDITABLE PRESCRIPTION DRUG COVERAGE
Prescription drug coverage (like from an employer or union), that pays out, on average, as much as or more than Medicare's standard prescription drug coverage.
CRITICAL ACCESS HOSPITAL
A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
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. In most cases, Medicare doesn't pay for custodial care.
The amount you must pay for health care or prescriptions, before your prescription drug plan or insurance plan begins to pay.
DISPOSABLE MEDICAL SUPPLIES
Any medical equipment that is used only once, or a limited number of times before being disposed of. Examples, diabetes testing supplies, ostomy supplies.
A list of drugs covered by a plan. This list is also called a formulary.
DUAL ELIGIBLE (MEDICARE-MEDICAID)
A person who has or is eligible for Medicare and Medicaid coverage
DURABLE MEDICAL EQUIPMENT (DME)
Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds.
DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC)
A private company that contracts with Medicare to pay bills for durable medical equipment.
Your decision to join or leave Original Medicare or a Medicare health plan.
ELECTRONIC DATA INTERCHANGE (EDI)
Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.
ELECTRONIC FUNDS TRANSFER (EFT)
A term used to describe the electronic transfer of monies from one financial institution to another
Any care you resonably believe is an emergency; when you believe that your health is in serious danger.
END-STAGE RENAL DISEASE (ESRD)
Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
EXCESS CHARGES (SEE LIMITING CHARGE)
If you are in Original Medicare, this is the difference between a doctor's or other health care provider's actual charge and the Medicare-approved payment amount. See Limiting Charge.
EXPEDITED ORGANIZATION DETERMINATION
A fast decision from the Medicare health plan organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.
EXTRA HELP (LIMITED INCOME SUBSIDY, LIS
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
A private company that has a contract with Medicare to pay Part A and some Part B bills on behalf of Medicare (for example, bills from hospitals). (Also called "Intermediary")
A list of drugs covered by a plan.
A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem with customer serivce 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 (see Appeal)
GROUP HEALTH PLAN
An employee (or retiree) benefit plan established or maintained by an employer or union group that provides medical care to employees (or retirees) through insurance plans.
GUARANTEED ISSUE RIGHTS (ALSO CALLED "MEDIGAP PROTECTIONS")
Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can't deny you a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can't charge you more for a policy because of past or present health problems.
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 don't pay your premiums.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA ) OF 1996
A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.
HEALTH MAINTENANCE ORGANIZATION (HMO) (MEDICARE)
A type of Medicare managed care plan that provides health coverage through a network of contracted providers. Medicare HMOs must provide Medicare Part A and Part B services. Some HMOs cover extra benefits, like extra days in the hospital, or extra preventive care. In Medicare Advantage HMOs, generally you can only go to doctors, specialists or hospitals that are on the plan's list of providers. When you belong to a Medicare Cost plan HMO, if you go to a provider that is not on the plan's provider list, the services are covered under Original Medicare. (See Medicare Cost Plan)
This treatment is usually done in a dialysis facility but can be done at home with the proper training and supplies. HD uses a special filter (called a dialyzer or artifical kidney) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body
HOME HEALTH CARE
Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient's family or caregiver as well.
INITIAL ENROLLMENT PERIOD
(FOR PART B MEDICARE)
The time period in which you can apply for a Medicare health plan. Begins 3 months before you turn 65, the month you turn 65, and 3 months after you turn 65. If you are eligible for Medicare through disability you have 3 months before the month of entitlement, the month of entitlement and 3 months after the month of entitlement. Enrollment is through the SSA.
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 to inpatients.
A facility that provides short term or long term care, such as a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences, such as an assisted living facility, or group home are not considered institutions for this purpose.
LATE ENROLLMENT PENALTY (PART D) (LEP)
A penalty which is assessed to Medicare eligible beneficiaries if they do not enroll in Part D when first eligible or do not have creditable drug coverage. The penalty is calculated based on when you are eligible and how many months you do not have creditable drug coverage. The penalty is added to the base Part D premium once you do enroll in a Part D plan
LIFETIME RESERVE DAYS
In Original Medicare, a total of 60 extra days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, you don't get any more extra days during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
In Original Medicare, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don't accept assignment. The limiting charge is 15% over Medicare's approved amount. The limiting charge only applies to certain services and doesn't apply to supplies or equipment
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.
LONG-TERM CARE HOSPITAL
Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance.
Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of you or your doctor.
MEDICARE ADVANTAGE PLAN
A plan offered by a private company that contracts with Medicare to provide Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans, and other plan types. When enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare. A Medicare Cost plan is not a Medicare Advantage plan.
MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) PLAN
A Medicare Advantage plan that also offers Medicare Prescription Drug coverage.
MEDICARE COORDINATED CARE PLAN
A plan that includes a network of providers that are under contract or arrangement with the organization to deliver the benefit package approved by CMS. CCPs may use mechanisms to control utilization, such as referrals from a gatekeeper for an enrollee to receive services within the plan, and financial arrangements that offer incentives to providers to furnish high quality and cost-effective care.
MEDICARE COST PLANS
A Medicare Cost plan is a type of HMO that contracts as a Medicare health plan. With a Cost plan you get more benefits than Original Medicare. You can use in-network providers for your Medicare covered services, or you can choose to go out-of-network and use your Original Medicare for covered services. You would pay Medicare deductibles and coinsurance for services received out-of-network, unless services are urgent, emergent or have been preauthorized.
Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B).
MEDICARE HEALTH PLAN
A plan offered by a private company that contracts with Medicare to provide you with your Medicare Part A and/or Part B benefits. Medicare health plans include Medicare Advantage plans (including HMO, PPO, or Private Fee-for-Service Plans), Medicare Cost plans, PACE plans, and special needs plans.
Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug plans.
MEDICARE PRESCRIPTION DRUG COVERAGE (MEDICARE PART D)
Optional coverage available to all people with Medicare through insurance companies and other private companies.
MEDICARE PRESCRIPTION DRUG PLAN
A drug plan offered by private insurance companies to provide coverage for outpatient prescription drugs received at a pharmacy.
MEDICARE SAVINGS PROGRAM (QMB, SLMB, QI, QDWI)
Programs which assist Medicare beneficiaries of modest means pay all or some of Medicare's cost sharing amounts (premiums, deductibles and copayments). To qualify an individual must be eligible for Medicare and must meet certain income guidelines which change April 1 of each year.
QMB - Qualified Medicare Beneficiary program
SLMB - Specified Low-Income Medicare Beneficiary program
QI - Qualified Individual program
QDWI - Qualified Disabled and Working Individual
In Original Medicare, 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.
MEDIGAP OPEN ENROLLMENT PERIOD
A one-time-only six month period when you can buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can't be denied coverage or charged more due to past or present health problems. Pre-existing condition exclusions may apply.
Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare coverage. There are a limited number of standardized plans labeled Plan A, B, C, D, F, G, K, L, M and N. Medigap policies only work with Original Medicare. Different than a Cost Plan.
Drugs not on a plan-approved drug list (Formulary).
A Federal fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
A device for support, specifically for the foot.
OUT-OF-POCKET MAXIMUM (ANNUAL)
This is the maximum amount that you pay per plan year. Does not include plan premiums. Typically includes deductible(s) and plan cost-sharing. The plan provides coverage even after you have paid the Annual Out-of-Pocket Maximum.
OUTPATIENT HOSPITAL CARE
Medical or surgical care furnished by a hospital if you have not been admitted as an inpatient but are registered on hospital records as an outpatient
PART B DRUGS VS. PART D DRUGS (WHAT'S THE DIFFERENCE)
Part B drugs are typically injectable and infusible drugs that are not usually self-administered and that are furnished and administered as part of a physician service.
Part D drugs are defined as drugs available only by prescription, and typically obtained at an outpatient pharmacy in the United States. Part D also covers medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs, and gauze).
PART D COVERAGE GAP (DONUT HOLE)
The coverage gap begins after you and your Medicare Part D plan have spent a certain amount of money for covered drugs and ends when you have satisfied the out-of-pocket amount to reach the Catastrophic Coverage minimum amount.
PART D INITIAL COVERAGE PERIOD
The period where you pay the deductible or copayment or coinsurance specified by your Medicare Part D plan until you and your plan have spent the mount that reaches the lower limit of the Part D Coverage Gap.
An amount added to your monthly premium for Medicare Part B, or for a Medicare Prescription Drug Plan, if you don't join when you are first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.
Services provided by an individual licensed under state law to practice medicine or osteopathy.
A health problem you had before the date that a new insurance policy starts.
Typically the monthly cost of a health plan.
An annual physical, flushot, health screenings.
PRIMARY CARE DOCTOR
A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy and should be the central repository for your health care needs and records.
PRIVATE FEE-FOR-SERVICE PLAN (PFFS PLAN)
A type of Medicare Advantage Plan. RMHP does not offer PFFS Plans.
PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)
PACE combines medical, social, and long-term care services for frail people to help people stay independent and living in their community as long as possible, while getting the care they need. Typically requires eligibility for Nursing Home care.
A device that substitutes for missing or defective parts of the body.
Quality is how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means giving the right care at the right time, in the right way, for the right person—and getting the best possible results.
QUALITY IMPROVEMENT ORGANIZATION
Groups of practicing doctors and other health care experts. They are paid by the federal government to check and improve the care given to Medicare patients. They review complaints about the quality of care given by inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, and ambulatory surgical centers. They 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.
A written order from 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. RMHP Cost plans do not require a referral to see plan Specialists.
Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.
An individual who is provided coverage under a group health plan after that individual has retired.
An insurance policy, plan, or program that pays second on a claim for medical care. For example Medicaid, Medicare or other insurance.
The geographic area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy.
SIGNIFICANT BREAK IN COVERAGE (LAPSE IN COVERAGE)
Generally, a significant break in coverage is 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.
SKILLED NURSING CARE
A level of care that includes services that can only be performed safely and correctly by a licensed nurse (e.g., a registered nurse, a licensed practical nurse).
SKILLED NURSING FACILITY (SNF)
A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.
SKILLED NURSING FACILITY CARE
This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, can't be provided on an outpatient basis. Examples of skilled nursing facility care include intravenous injections and physical therapy. 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.
SPECIAL ELECTION PERIOD (SEP)
A set time that a beneficiary can change Medicare health plans or return to Original Medicare, such as: you move outside the service area, your health plan does not renew its contract with CMS, or other exceptional conditions determined by CMS.
SPECIAL ENROLLMENT PERIOD (SEP)
A set time when you can sign up for Medicare Part B if you didn't take Medicare Part B during the Initial Enrollment Period because your or your spouse were working and had group health plan coverage through the employer or union. OR A set time to enroll in Part D coverage if you didn't take Part D because you had creditable prescription drug coverage.
You have 8 months from the time your group coverage or employment ends (whichever is first) to enroll in Part B, and 2 months after the time your current coverage ends to enroll in Part D.
SPECIAL NEEDS PLAN (SNP)
A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.
A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.
SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB)
A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.
Treatment to regain and strengthen speech and language skills.
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. Often staffed with volunteers.
STATE INSURANCE DEPARTMENT
A state agency that regulates insurance and can provide information about Medigap policies.
STATE MEDICAL ASSISTANCE OFFICE
A state agency that is in charge of the state's Medicaid program and can give information about programs that help pay medical bills for people with low incomes.
Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.
Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.
To have lower costs, many plans place drugs into different "tiers," which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its 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
Something done to help with a health problem. For example, medicine and surgery are treatments.
The choices you have when there is more than one way to treat your health problem.
A health care program for active duty and retired uniformed services members and their families.
TrOOP (TRUE OUT OF POCKET COSTS, PART D
The expenses that count toward a person's Medicare drug plan out-of-pocket threshold. Defines when you exit the Coverage Gap (Donut Hole) and enter into the Catastrophic Coverage stage of your Medicare Part D prescription drug plan.
A TTY (TeleTYpewriter) or TDD (Telecommunication Device for the Deaf) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY/TDD consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who don't have a TTYTDD can communicate with a TTY/TDD user through a message relay center (MRC). An MRC has TTY/TDD operators available to send and interpret TTYTDD messages.
A claim submitted for a service or supply by a provider who does not accept Medicare assignment.
URGENTLY NEEDED CARE
Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than Original Medicare. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.
The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data is collected.