A
- Accountable Care Organizations (ACOs) Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care professionals that work together to provide coordinated care. ACOs aim to improve the quality of patient care while also lowering costs to Medicare.
- Activities of Daily Living (ADL) Activities of daily living (ADL) are activities that most people do on a daily basis. For example, eating, bathing, dressing, toileting, and moving from one place to another are considered ADLs.
- Acute Illness An acute illness is a disease or condition that comes on rapidly and severely, but it can usually be cured with proper treatment. Examples include pneumonia or a broken bone.
- Administrative Law Judge (ALJ) An Administrative Law Judge (ALJ) is a hearing officer who presides over appeals to Medicare by Medicare beneficiaries or their providers. In Medicare’s appeals process, the ALJ makes decisions at the Office of Medicare Hearings and Appeals (OMHA) level.
- Advance Beneficiary Notice (ABN) An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice health care providers and suppliers are required to give a person with Original Medicare when they believe that Medicare will not cover their services or items. Providers should give the ABN before providing care, and it must list the reason why they believe Medicare will deny payment. Providers are not required to give an ABN for services or items Medicare never covers.
- Advance Coverage Decision An advance coverage decision is a Private Fee-For-Service (PFFS) plan’s determination about whether or not it will pay for a certain service. Note: this is unrelated to an Advance Beneficiary Notice (ABN), which only applies to people with Original Medicare.
- Advance Directive An advance directive is a legal document that outlines how you want medical and financial decisions made if you can no longer communicate your wishes. A health care advance directive may include a health care proxy, living will, and a health care power of attorney.
- Advanced Illness An advanced illness is a serious disease or condition that has progressed too far to be cured in most circumstances, such as cancer that has spread throughout the body.
- Affordable Care Act (also known as the Health Care Law) Signed by President Obama on March 23, 2010, the Affordable Care Act (ACA) included provisions to expand health coverage to eligible Americans, control health care costs, and improve the health care delivery system. The ACA closed the Medicare Part D donut hole/coverage gap and expanded coverage of preventive services for people with Medicare. The Act also created state-specific Marketplaces, where individuals can go to purchase health insurance. Generally, people who are eligible for Medicare should not buy health insurance in the Marketplace.
- ALS (Amyotrophic Lateral Sclerosis)/Lou Gehrig’s Disease ALS (Amyotrophic Lateral Sclerosis) is a disease that affects the motor nerve cells of the spinal cord and causes loss of muscle control. Patients with this disease can qualify for Medicare coverage regardless of age. Those with ALS who qualify for Social Security Disability Insurance (SSDI) do not have a 24-month waiting period for Medicare—their Medicare benefits begin the first month they receive SSDI based on ALS.
- Ambulette An ambulette is a wheelchair-accessible van that provides non-emergency transportation for people with disabilities.
- Annual Election Period (AEP) See Fall Open Enrollment.
- Annual Notice of Change (ANOC) The Annual Notice of Change (ANOC) is a notice you receive from your Medicare Advantage or Part D plan in late September. The ANOC gives a summary of any changes in the plan’s costs and coverage that will take effect January 1 of the next year. Review this notice to see if your plan will continue to meet your health care needs in the following year. If you do not receive an ANOC, you should contact your plan. The ANOC is typically mailed or emailed with the plan’s Evidence of Coverage (EOC), which is a more comprehensive list of the plan’s costs and benefits for the upcoming year.
- Annual Wellness Visit (AWV) The Annual Wellness Visit (AWV), which is covered by Medicare, is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. The AWV is not the same as a head-to-toe physical. During your Annual Wellness Visit, your provider will record your height, weight, blood pressure, and BMI; give you a health risk assessment; and screen for cognitive impairment, depression, and your ability to function safely at home. The provider will note your medical history and make a list of your current providers, suppliers, and medications. The provider should also create a 5-10 year screening schedule or checklist and provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness.
- Appeal An appeal is a formal request for review if you disagree with an official health care coverage or payment decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare. Federal regulations and law specify appeals deadlines, processes for handling appeals, what information must be included in a decision, and the levels of review in the appeals process.
- Approved Amount The approved amount, also known as the Medicare-approved amount, is the fee that Medicare sets as how much a provider or supplier should be paid for a particular service or item. Original Medicare also calls this assignment. See also: Take Assignment, Participating Provider, and Non-Participating Provider.
- Area Agency on Aging (AAA) Area Agencies on Aging (AAA) are agencies that coordinate and offer services such as Meals-on-Wheels, homemaker assistance, and similar programs that help older adults in their home and community.
- Assets Assets are resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate.
- Assignment Assignment is Medicare’s approved amount for a service or item. Original Medicare pays 80% of this amount and you (or your supplemental insurance) are responsible for the remaining 20%, called a coinsurance. See also: Take Assignment, Participating Provider, and Non-Participating Provider.
- Assisted Living Facility Assisted living facilities are long-term care facilities designed to assist people with activities of daily living who can otherwise take care of themselves. They are different from nursing homes, which also provide skilled care. Medicare does not cover room and board in an assisted living facility.
- Assistive Technology Assistive technology is any item, piece of equipment, or system that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. Medicare covers some assistive technology if medically necessary, such as speech generating devices. Simple items like grabbers and reachers are not covered by Medicare.
B
- Balance Billing Balance billing is when doctors and hospitals charge more than the approved amount for a service. It can also refer to when a provider charges cost-sharing to a person with QMB, but note that this practice is also called improper billing.
- Benchmark The Extra Help benchmark amount, also known as the Extra Help Premium Amount, is the amount of money that full Extra Help will pay for the monthly premium of a Part D plan that offers basic benefits. Benchmarks vary by state, and if you enroll in a Part D plan with a monthly premium above your state’s benchmark amount, you will have to pay the difference.
- Beneficiary A beneficiary is a person who receives benefits. If you are a member of a health plan, like a group health plan, Original Medicare, or Medicaid, and receive benefits from that plan, you are a health plan beneficiary.
- Benefit Period The benefit period is the amount of time during which Medicare pays for hospital and skilled nursing facility (SNF) services. A benefit period begins the day you are admitted to a hospital as an inpatient, or to a SNF, and ends the day you have been out of the hospital or SNF for 60 days in a row. With each new benefit period, you pay a new deductible. Your coinsurance is determined by the number of days you have been in the facility during each benefit period.
- Bereavement Services Bereavement services are covered by Medicare’s hospice benefit and provide counseling for the family up to a year after the patient passes away.
- Brand-Name Drug A brand-name drug is a drug marketed under a proprietary, trademark-protected name. (Definition from the U.S. Food and Drug Administration)
C
- Calendar Quarters A calendar quarter is a three-month period of time ending with March 31, June 30, September 30, or December 31. Social Security counts each calendar quarter that you work and pay into Social Security and Medicare taxes toward your eligibility for premium-free Part A. Calendar quarters can also refer to the time periods when people with Extra Help have a Special Enrollment Period (SEP) to change their Part D or Medicare Advantage drug coverage, which is once per quarter in the first three calendar quarters of the year.
- Capped Rental Item A capped rental item is durable medical equipment (DME) (such as a wheelchair) that Medicare covers initially for rental, rather than for purchase, often because of its high cost. Medicare pays the rental fees for these items in monthly installments. You can keep a capped rental item as long as it is medically necessary. After you rent for 13 months, you will automatically own the item. (Note: If you have been renting an item of DME since before January 1, 2006, you can continue to rent that item without purchasing if you choose.)
- Care Manager A care manager is a nurse, specially trained educator, or doctor who will assess your needs and advise you on how to best manage your health conditions.
- Caregiver A caregiver is anyone who provides help and support to someone who is either temporarily or permanently unable to function or someone who can function but not optimally. Most caregivers are unpaid, and are often a family member, friend, or neighbor. Formal caregivers are paid care providers or volunteers associated with a service system.
- Catastrophic Coverage Catastrophic coverage is a phase of coverage designed to protect you from having to pay very high out-of-pocket costs for prescription drugs. It usually begins after you have spent a pre-determined amount on your health care. For example, Part D prescription drug plans offer catastrophic coverage. After you have spent a certain amount out of pocket, you owe no cost-sharing for the cost of your covered drugs for the remainder of the year.
- Centers for Medicare & Medicaid Services (CMS) The Centers for Medicare & Medicaid Services (CMS) is the United States government agency responsible for administering Medicare, Medicaid, CHIP (Children’s Health Insurance Program), HIPAA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs.
- Certificate of Medical Necessity (CMN) A certificate of medical necessity (CMN) is 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.
- Chronic Illness A chronic illness is a disease or condition, such as diabetes or asthma, that lasts for a long period of time or is marked by frequent recurrence.
- Claim A claim is a bill that health care providers submit to Medicare to ask for payment for services you received. Medicare Part A and Part B claims are processed by Medicare Administrative Contractors (MACs). Medicare Advantage Plan and Part D plan claims are processed by those private plans. See also: Medicare Administrative Contractor (MAC) and Durable Medical Equipment Medicare Administrative Contractor (DME MAC).
- COBRA (Consolidated Omnibus Budget Reconciliation Act) COBRA is a federal law that lets employees, their spouses, and their dependents keep group health plan (GHP) coverage for 18 to 36 months after they leave their job or lose coverage for certain other reasons, as long as they pay the full cost of the premium.
- Coinsurance The coinsurance is the portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of the approved amount or negotiated amount. In Original Medicare, the coinsurance is usually 20% of Medicare’s assignment.
- Competitive Bidding The Medicare durable medical equipment (DME) competitive bidding program selects DME suppliers—called contract suppliers—who agree to provide DME in certain categories at the rate Medicare sets. For Original Medicare beneficiaries who live in a competitive bidding area and are prescribed DME affected by the program, they are required to purchase from contract suppliers. These suppliers can only charge 20% coinsurance for Medicare-covered DME after you meet the Part B deductible.
- Comprehensive Outpatient Rehabilitation Facility (CORF) A Comprehensive Outpatient Rehabilitation Facility (CORF) is a medical facility that provides outpatient diagnostic, therapeutic, and restorative services for the rehabilitation of an injury, disability, or illness.
- Continuous Open Enrollment Continuous open enrollment is a consumer’s right to buy or sign up for insurance at any time, regardless of age or health status.
- Conversion Policy A conversion policy is an employer-sponsored group health plan that can be converted to an individual policy with the same insurance company. These policies are usually very expensive.
- Coordination of Benefits Coordination of benefits is how Medicare and other health insurance share responsibility for paying claims. Your primary insurance and secondary insurance must follow particular rules to coordinate benefits and pay claims.
- Coordination Period, 30-Month The 30-month coordination period, for people with End-Stage Renal Disease (ESRD), is the period when a group health plan (GHP) pays first and Medicare pays second for health care costs. The coordination period begins when your eligibility for ESRD Medicare begins, even if you haven’t enrolled for ESRD Medicare yet. Even though your GHP pays primary during this period, you may want to enroll in ESRD Medicare, as it may cover remaining costs.
- Copayment A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $35 for a doctor’s visit).
- Cost Plan A Medicare Cost Plan is a type of Medicare health plan available in certain, limited areas of the U.S. It is not a Medicare Advantage Plan. Cost Plans have networks, but they provide for coverage outside of the network through Original Medicare. If you get out-of-network care from a Medicare provider, Original Medicare will cover the services. You will pay the Part A and Part B deductibles and coinsurances for any services covered by Original Medicare.
- Cost Tiers Cost tiers, also known as tiers, are a system that Part D plans use to price 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 higher tier generally requiring higher out-of-pocket costs or percentages.
- Cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs.
- Coverage Gap The coverage gap, also known as the Medicare Part D donut hole, is the phase of Part D coverage after your initial coverage period. As a result of the Affordable Care Act (ACA), the coverage gap was phased out in 2020. Your drug costs may still change when you enter the coverage gap, after your initial coverage period, but you will pay no more than 25% of the cost of your drugs in the coverage gap.
- Coverage Restrictions Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to limit their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy.
- Creditable Coverage Creditable coverage is used in two different ways. In general, it is coverage that gives you the right to buy or switch health insurance coverage without penalty, restriction, or waiting period. Different types of health insurance have different creditable coverage requirements. For Medigap policies, certain health insurance coverage you had within 63 days of securing a new policy can be used to shorten the waiting period for pre-existing conditions. This type of coverage that shortens the waiting period would be called creditable coverage. For Part D, creditable coverage is prescription drug coverage that is evaluated by an actuary and determined to be as good as or better than the basic Part D benefit. If you have creditable drug coverage, you can delay enrollment without penalty. Medicare Part A and Part B enrollment is NOT affected by prior creditable coverage.
- Curative Care Curative care is the treatment of a patient with the intent of curing the patient’s disease or condition. For example, chemotherapy treatments to cure breast cancer.
- Current Work One of the qualifications for the Part B Special Enrollment Period is to be currently working. You are considered to be currently working as long as you have employment rights at your company even if you do not work on a regular basis, are on sick leave, are a seasonal worker, or have been temporarily laid-off. You are not considered to be currently working if you receive Social Security Disability Insurance (SSDI), have received disability benefits from your employer for more than six months, or if you receive your employer insurance through COBRA.
- Custodial Care Custodial care, also known as homemaker services, is non-medical care including light housekeeping, laundry, and meal preparation. Medicare generally does not cover custodial care except as incidental to covered home health care.
D
- Deductible The deductible is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year.
- Demand Bill A demand bill is a request for a provider to continue billing Medicare for the given services even though the provider does not think that Medicare will cover them. You may demand bill after you receive an Advance Beneficiary Notice (ABN), a Home Health Advance Beneficiary Notice (HHABN), or a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) from a health care provider. In order to demand bill, you must sign the ABN and agree to pay for the services in full if Medicare denies coverage. You may file an appeal if Medicare denies coverage.
- Denial of Coverage A denial of coverage is a refusal by Original Medicare, a Medicare Advantage Plan, or a Part D plan to pay for health services, prescription drugs, or durable medical equipment.
- Department of Veterans Affairs (VA) The Department of Veterans Affairs (VA) is a federal government agency that provides benefits to veterans and their families. These benefits include (but are not limited to) pensions, educational stipends, and health care services. See also: Veterans Affairs (VA) Benefits.
- Detailed Explanation of Non-Coverage (DENC) A Detailed Explanation of Non-Coverage (DENC) is a notice that is given to you by a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice agency when you appeal its decision to end your care to the Quality Improvement Organization (QIO). The DENC explains why the services will no longer be provided and lists any Medicare coverage rules related to your case.
- Detailed Notice of Discharge A Detailed Notice of Discharge is a notice given to you by a hospital after you have requested a Quality Improvement Organization (QIO) review of the hospital’s decision that you be discharged. (The hospital would have notified you of this decision in the Important Message from Medicare notice.) Once you request QIO review of a discharge decision, the hospital must provide you the Detailed Notice of Discharge in all cases, whether you are in Original Medicare or a Medicare Advantage Plan. This notice explains why your hospital care is ending and lists any Medicare coverage rules related to your case.
- Dialysis Dialysis is the treatment used to artificially cleanse your blood of toxins when your kidneys no longer work.
- Disability A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities and interact with the world around them. The Social Security Administration (SSA) determines disability—and eligibility for Social Security Disability Insurance benefits (SSDI)—based on whether you can work and whether your disability is likely to be permanent. (Definition from the World Health Organization)
- Discharge Discharge is the end to your stay as an inpatient in a medical institution such as a hospital or skilled nursing facility (SNF).
- Discharge Plan A discharge plan is a plan for post-hospitalization care intended to identify an individual’s need for medical and social services and resources available to help prevent re-hospitalization. A discharge plan must involve information and instructions to you and your caregivers, including a list of medications, referrals for other care (for example, skilled nursing facilities or home health agencies), and details about Medicare coverage of post-hospitalization services. The plan should be developed with input from you and your representatives about your preferences and care needs.
- Disenrollment Disenrollment is leaving a Medicare Advantage Plan or Part D plan.
- DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) See Durable Medical Equipment (DME).
- Donut Hole See Coverage Gap.
- Drug Class A drug class is a group of drugs that treat the same symptoms or have similar effects on the body. For example, people with Medicare often take statin class drugs, which are used for reducing cholesterol. Drugs in this class include (but are not limited to) Lipitor, Zocor, Pravachol, and Vytorin.
- Drug Tiers See Cost Tiers.
- Dual Eligible A dually eligible individual is a person who has both Medicare and Medicaid.
- Durable Medical Equipment (DME) Durable medical equipment (DME), also known as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) is equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment, and hospital beds. Medicare only covers DME if your provider says it is medically necessary for use in the home.
- Durable Medical Equipment Medicare Administrative Contractor (DME MAC) A Durable Medical Equipment Medicare Administrative Contractor (DME MAC) is a private insurance company that has a contract with Medicare to process durable medical equipment (DME) claims. DME MACs are required to follow Medicare national guidelines to decide what equipment should be covered on a case-by-case basis and how much Medicare will pay for the equipment. See also: Medicare Administrative Contractor (MAC).
E
- Earned Income Earned income is money you get because you work, such as wages from work or earnings from self-employment.
- Elimination Period See Deductible.
- Employer Group Health Plan See Group Health Plan.
- End-Stage Renal Disease (ESRD) End-Stage Renal Disease (ESRD) is a kidney disease that requires you to be on dialysis or have a kidney transplant. Patients with ESRD may qualify for Medicare coverage regardless of age.
- Enrollment Enrollment is joining Original Medicare or becoming a member of a Medicare Advantage Plan or Part D plan.
- Enrollment Periods Enrollment periods are certain periods of time when you can join the Original Medicare program, or enroll in a Medicare Advantage Plan, Part D plan, or supplemental insurance plan (Medigap). See also: Fall Open Enrollment, Medicare Advantage Open Enrollment Period, General Enrollment Period, Initial Coverage Election Period, Initial Enrollment Period, Medigap Open Enrollment Period, and Special Enrollment Period.
- Evidence of Coverage (EOC) Evidence of Coverage (EOC) is a notice you receive from your Medicare Advantage or Part D plan in late September. It lists the plan’s costs and benefits that will take effect on January 1 of the upcoming year. Review the EOC to see if the plan will meet your health care needs in the next year. The EOC is typically mailed with the plan’s Annual Notice of Change (ANOC), which is a notice informing you of plan changes that will take effect the upcoming year.
- Exception Request An exception request is a formal written request to your Part D plan asking that it pay for a drug you need. For example, you can file an exception request to pay for a drug that is not on the plan’s list of covered drugs (formulary), or you can ask the plan to lower the cost of an expensive drug on the formulary (see Tiering Exception).
- Excess Charge The excess charge is the difference between a health care provider’s actual charge and Medicare’s approved amount for payment. See also: Non-Participating Provider.
- Expedited Appeal An expedited appeal is a fast appeal of an Original Medicare, Medicare Advantage, or Medicare Part D plan’s denial of coverage when a person’s “life, health, or ability to regain maximum function” is in jeopardy.
- Explanation of Benefits (EOB) An Explanation of Benefits (EOB) is the notice that your Medicare Advantage Plan or Part D prescription drug plan typically sends you after you receive medical services or items. It tells you how much your provider billed Medicare, the Medicare-approved amount your plan will pay, and how much you have to pay the provider. An EOB is not a bill. See also: Medicare Summary Notice (MSN).
- Extra Help Extra Help, also known as the Part D Low-Income Subsidy (LIS), is a federal program administered by Social Security that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage, including coinsurances, deductibles, and premiums. People with Medicare who have income and assets below specified limits are eligible for Extra Help, which has different levels. Depending on your income and assets, you may qualify for either full Extra Help or partial Extra Help. People may also be automatically enrolled in Extra Help if they have certain other types of coverage, even if their income and assets are above the set levels.
F
- Fall Open Enrollment Fall Open Enrollment, also known as the Annual Election Period, occurs each year from October 15 through December 7. During this period, you can change your Medicare coverage, and these changes will take effect January 1 of the following year. You can switch between Original Medicare (with or without a Part D plan) and Medicare Advantage; join a new Medicare Advantage Plan; and enroll in Part D for the first time if you did not enroll during your Initial Enrollment Period. (You may have to pay a Part D late enrollment penalty if you newly enroll in Part D during this time, unless you have had other creditable drug coverage.)
- Federal District Court The Federal District Court is the final level of the Medicare appeals process, following an unfavorable decision at the Medicare Appeals Council level.
- Federal Employees Health Benefits (FEHB) The Federal Employees Health Benefits (FEHB) program provides health insurance through private health plans for current employees and retirees of the United States government.
- Federal Poverty Level (FPL) The Federal Poverty Level (FPL) is the federally set measure of income that is used to determine eligibility for certain programs, including Extra Help and some Medicaid programs. The FPL changes every year and varies depending on the number of people in your household. It is higher in Alaska and Hawaii.
- Federally Qualified Health Center (FQHC) Federally Qualified Health Centers (FQHCs) are located in medically underserved areas and provide low-cost health care. They provide Medicare-covered medical services as well as some preventive services that Medicare does not cover, such as routine check-ups, and may provide dental and vision care. FQHCs include community health centers, migrant health centers, and health centers for the homeless.
- Fee-for-Service Fee-for-service is payment to providers for each service they provide, as in Original Medicare.
- Formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket.
- Formulary Restrictions See Coverage Restrictions.
- Free Look Period A free look period is the 30-day period that starts when you switch to a new Medicare supplemental insurance (Medigap) policy. During this time, you can decide if you want to keep the new Medigap policy. You will need to pay both premiums for one month. If you decide to switch, do not cancel your first Medigap policy until you have decided to keep the second Medigap policy.
G
- Gaps in Coverage Gaps in coverage are services or costs that are not covered by Original Medicare, such as vision, dental, and hearing care, as well as deductibles and coinsurance.
- Gatekeeper Gatekeepers are primary care providers (PCP) in some managed care plans. They oversee your care and decide when to refer you to a specialist.
- General Enrollment Period (GEP) The General Enrollment Period (GEP) is the time period every year from January 1 to March 31 when you can enroll in Medicare Part B for the first time if you missed your Initial Enrollment Period (IEP) and do not qualify for the Part B Special Enrollment Period (SEP). When you enroll during the GEP, coverage begins the first of the month after you enroll, and you may have to pay a Part B late enrollment penalty.
- Generic Drug A generic drug is a medication created to be the same as a brand-name drug that is approved by the Food and Drug Administration. It is the same in dosage, safety, strength, how it is taken, quality, performance, and intended use (definition from the U.S. Food and Drug Administration). Generic drugs generally work just as well as the brand-name version but are less expensive.
- Grievance A grievance is a formal complaint that you file with your Medicare Advantage or Part D plan if you are dissatisfied with it for any reason. For example, you may file a grievance if your plan has poor customer service, or you face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund). It is not an appeal, which is a request for your plan to cover a service or item it has denied. You must file a grievance within 60 days of the event by contacting your plan over the phone or ideally by sending a letter to your plan’s Grievances and Appeals department. Your plan must investigate your grievance and respond within 30 days. If your request is urgent, your plan must respond within 24 hours.
- Group Health Plan (GHP) Group health plans (GHPs), also known as employer group health plans, are health insurance offered by an employer or employee organization (such as a union) for current or former employees and their families. This insurance may be primary or secondary to Medicare coverage depending on the size of the company and whether or not you are currently working.
- Guaranteed Issue Right A guaranteed issue right is a consumer protection that gives people age 65 or older the right to buy Medigap supplemental insurance within 63 days of losing or ending certain kinds of health coverage. Because of this right, an insurance company must sell you a Medigap policy at the best available rate regardless of your health status, cannot deny you insurance coverage, and cannot impose a waiting period for coverage of pre-existing conditions.
H
- Health Care Provider A health care provider is an individual or facility (such as a doctor, hospital, or durable medical equipment (DME) supplier) that provides health care services and/or items.
- Health Care Proxy A health care proxy is a legal document that names someone you trust as your proxy, or agent, to express your wishes and make health care decisions for you if you are unable to speak for yourself.
- Health Insurance Health insurance (sometimes called health coverage) pays for some or all of the cost of health services you receive, like doctors’ visits and hospital stays. Programs like Medicare and Medicaid are public health insurance offered through the government. Health insurance can also be administered by private companies that offer individual policies, group health plans, and supplemental insurance.
- Health Maintenance Organization (HMO) A Health Maintenance Organization (HMO) is a type of private insurance plan. Some Medicare Advantage Plans are HMOs. Generally, people enrolled in an HMO must see in-network providers to receive coverage, except in emergencies or urgent care situations. HMO members must choose a primary care provider (PCP) who coordinates their care. See also: Medicare Advantage.
- Hill-Burton Program The Hill-Burton program offers free or reduced cost care at Hill-Burton facilities to patients who meet qualifying income limits. Each facility chooses which services it will provide, and services that are fully covered by other types of insurance (like Medicare or Medicaid) are not eligible for Hill-Burton coverage.
- Home Health Agency (HHA) A home health agency (HHA) is an organization that provides home care services, such as skilled nursing, physical therapy, occupational therapy, speech-language pathology, and personal care.
- Home Health Aide A home health aide provides personal care services for a patient at home, including help with bathing, toileting, and dressing. Medicare pays in full for an aide if you require skilled care (skilled nursing or therapy services) and meet other requirements. Medicare will not pay for an aide if you only require personal care and do not need skilled care.
- Home Health Care Home health care is care provided at home to treat an illness or injury. Medicare will only cover home health care if you are homebound and have a need for skilled care, including skilled nursing and/or skilled therapy services.
- Homebound Medicare considers you homebound if: you need the help of another person or medical equipment (such as a walker or wheelchair) to leave your home, or your doctor believes that your health could get worse if you leave your home; and it is difficult for you to leave your home and you typically cannot do so. A doctor must evaluate and certify this condition. Leaving your home for medical treatment, religious services, and special non-medical events such as a family reunion or funeral does not mean that you are not homebound.
- Homemaking Services See Custodial Care.
- Hospice Hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. Medicare’s hospice benefit includes inpatient care and outpatient care, respite care, prescription drugs, counseling, and social services.
- Hospital Insurance See Part A.
- Hospital-Issued Notice of Non-Coverage (HINN) A Hospital-Issued Notice of Non-Coverage (HINN) is a written notice that hospitals provide if they determine that Medicare will not cover your inpatient stay. The HINN includes what you will have to pay if you decide to receive this care, as well as your rights to an immediate Quality Improvement Organization (QIO) appeal of the hospital’s decision.
I
- Important Message from Medicare An Important Message from Medicare is a notice you receive from the hospital and sign within two days of being admitted as an inpatient. This notice explains your rights as a patient, and you should receive another copy up to two days, and no later than four hours, before you are discharged. If you disagree with the hospital’s discharge decision, this notice tells you how to file an expedited appeal to the Quality Improvement Organization (QIO).
- In-Network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers.
- Independent Review Entity (IRE) An Independent Review Entity (IRE) is an outside organization with which Medicare contracts to handle the second level of appeals for denial of coverage in a Medicare Advantage Plan or Part D plan.
- Individual Policy An individual policy is a private health plan that covers an individual person as opposed to a group (such as a group of employees covered by an employer group health plan). It is separate from Medicare coverage.
- Initial Coverage Election Period The Initial Coverage Election Period (ICEP) is the period when you can enroll in a Medicare Advantage Plan for the first time. Your ICEP begins three months before you are enrolled in both Parts A and B and ends either the last day of the second month after the month in which you are first entitled to Part A and enrolled in Part B, or the last day of your Part B Initial Enrollment Period, whichever is later.
- Initial Enrollment Period (IEP) The Initial Enrollment Period (IEP) is the first chance you have to enroll in Medicare Part A and Part B. You can also enroll in Part D for the first time during your IEP. This seven-month period includes the three months before, the month of, and the three months following your 65th birthday. If you enroll during this time, you do not pay a late enrollment penalty.
- Inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance).
- Inpatient Care Inpatient care is care received when you have been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance).
- Integrated Care Integrated care in the context of health insurance refers to the coordination of benefits for dually eligible individuals. This coordination is primarily accomplished through private plans that pay for and deliver an individual’s Medicare and Medicaid services. Examples of these private plans include Dual-eligible Special Needs Plans (D-SNPs), Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs), Highly Integrated Dual-Eligible Special Needs Plans (HIDE SNPs), and Medicare-Medicaid Plans (MMPs).
- Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) are nursing facilities specifically designed to provide active treatment to individuals with intellectual disabilities and other related conditions.
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- Language Therapy See Speech-Language Pathology.
- Late Enrollment Penalty A late enrollment penalty is an amount you must pay to Medicare in addition to the regular monthly premium for late enrollment in Part B or Part D. The Part B premium penalty is 10% of the Part B premium for each 12-month period you delayed enrollment without insurance from your or your spouse’s current work. The Part D premium penalty is 1% of the Part D premium for each month you delayed enrollment without creditable drug coverage.
- Lifetime Reserve Days Lifetime reserve days are for when you are in the hospital for more than 90 days. Medicare will cover 60 additional reserve days, and you will pay a coinsurance for each day. You can only use these 60 days once in your lifetime, but they do not have to be applied toward the same hospital stay.
- Limiting Charge A limiting charge is the amount above the Medicare-approved amount that non-participating providers can charge. These providers accept Medicare but do not accept Medicare’s approved amount for health care services as full payment. They can charge up to 15% more than the Medicare-approved amount, which you pay in addition to the 20% coinsurance. Some states restrict the limiting charge further. For example, in New York providers can only charge 5% more instead of 15% for most services. Providers who opt out of Medicare are not subject to these limiting charges and can charge as much as they want, if they maintain their opt-out status and give the patient a private contract that meets Medicare’s rules.
- Living Will A living will is a written record of the type of medical care you would want in specific circumstances. It can be used to make treatment decisions if you can no longer communicate your wishes because you are incapacitated by a temporary or permanent injury or illness. Living wills usually take effect after your doctor certifies that you are incapacitated and nearing the end of life. If you have appointed a health care proxy, they should use your living will to make medical decisions on your behalf.
- Long-Term Care Insurance Long-term care insurance is provided by private insurance companies. It generally covers nursing home stays and can limit your health care costs, but the policies are often very expensive and may be subject to medical underwriting or provide limited benefits.
- Long-Term Care Ombudsman The Long-Term Care Ombudsman is an independent advocate for nursing home and assisted living facility residents who provides information about how to find a facility and how to get quality care. Every state is required to have an Ombudsman Program that addresses complaints and advocates for improvements in the long-term care system.
- Long-Term Services and Supports (LTSS) Long-term services and supports (LTSS) refers to a range of services and supports that help you perform everyday activities. LTSS can be provided in a nursing home, assisted living facility, or other setting, and may include medical care, therapy, 24-hour care, personal care, and custodial care (homemaker services). Medicare usually does not cover long-term services and supports. See also: Long-Term Care Insurance.
- Low-Income Subsidy (LIS) See Extra Help.
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- Maintenance Care Maintenance care is care given to people with chronic illnesses to maintain or slow a decline in their health or function. For example, exercise and physical therapy can minimize abnormal or painful positioning of the joints and may prevent or delay curvature of the spine in a person with muscular dystrophy.
- Managed Long-Term Care (MLTC) Managed long-term care (MLTC) health plans provide services for New Yorkers who have both Medicare and Medicaid and require long-term care services and supports. Covered services can include home care, adult day health care, durable medical equipment, non-emergency medical transportation, and more.
- Marketing Violations Marketing violations occur when Medicare private plans deceive you—through marketing materials or a person presenting misleading information—about what the plan offers and how much it costs. See also: Medicare Fraud.
- Marketplaces (also known as Exchanges) The Marketplace is a shopping forum, created by the Affordable Care Act, where individuals and small business owners can compare and purchase health insurance plans. Each state chooses how the Marketplace will operate in its own state. Marketplaces do not sell any type of Medicare coverage.
- Maximum Out-of-Pocket (MOOP) The maximum out-of-pocket (MOOP) is an annual limit on your out-of-pocket costs for Medicare Advantage Plans. Once you reach this amount, you will not owe cost-sharing for Part A or Part B covered services for the remainder of the year. All Medicare Advantage Plans are required to set a maximum out-of-pocket.
- MAXIMUS MAXIMUS is an independent entity that contracts with Medicare to review appeals for Original Medicare, Medicare Advantage, and Part D plans.
- Medicaid Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets.
- Medicaid Buy-In The Medicaid Buy-In is a state-run program that allows people with disabilities under the age of 65 to work and still receive Medicaid benefits. The program allows people who would otherwise not be eligible for Medicaid—because their income or assets are too high—to buy in to the program by paying a premium. Not all states have Medicaid Buy-In.
- Medicaid Spend-Down The Medicaid spend-down is a state-run program for people whose income is higher than would normally qualify them for Medicaid, but who have high medical expenses that reduce their income to the Medicaid eligibility level. Not all states have Medicaid spend-down.
- Medical Insurance See Part B.
- Medical Supplies Medical supplies under Medicare are items that are covered if used by home health agency staff to fulfill the plan of care, such as wound dressings.
- Medically Necessary Medically necessary refers to procedures, services, or equipment that meet accepted medical standards and are necessary for the diagnosis and treatment of a medical condition.
- Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage).
- Medicare Administrative Contractor (MAC) Medicare Administrative Contractors (MACs) are private companies that process Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Original Medicare beneficiaries. Each MAC serves a defined geographic area. To find the MAC in your region, call 1-800-MEDICARE.
- Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. 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. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs).
- Medicare Advantage Drug Plan Medicare Advantage Drug Plan is a term sometimes used to refer to Medicare Advantage Plans that include Medicare prescription drug coverage. These plans are sometimes also called MAPDs.
- Medicare Advantage Open Enrollment Period (MA OEP) The Medicare Advantage Open Enrollment Period (MA OEP) is the time when you can switch from one Medicare Advantage Plan to another, or switch from a Medicare Advantage Plan to Original Medicare with or without a Part D plan. The MA OEP occurs each year from January 1 through March 31, and changes take effect on the first of the month following the month you enroll. You can only make one change during the MA OEP.
- Medicare Advantage Plan Card If you are enrolled in a Medicare Advantage Plan, you will use your Medicare Advantage Plan card when you go to the doctor or hospital instead of the Original Medicare red, white, and blue card. The Medicare Advantage Plan card will generally include your name, member ID number, and the name of your plan and insurance company. See also: Medicare Card.
- Medicare Appeals Council (Council) The Medicare Appeals Council (Council) is the second highest level of Medicare appeals in the appeals process.
- Medicare Card Everyone who enrolls in Medicare receives a red, white, and blue Medicare card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare number, which serves as an identification number in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say “Railroad Retirement Board” at the bottom. If you are enrolled in a Medicare Advantage Plan, you will also have a card from that plan (see Medicare Advantage Plan Card).
- Medicare Fraud Medicare fraud occurs when someone knowingly deceives Medicare to receive payment when they should not, or to receive higher payment than they should. See also: Marketing Violations.
- Medicare Medical Savings Account (MSA) Medicare Medical Savings Account (MSA) plans are a type of Medicare Advantage Plan that includes both a high deductible health plan and a bank account to help pay your medical costs. The plan deposits funds into the bank account once each year to use for your medical expenses, but the amount is generally lower than the full deductible. MSA plans cannot offer Medicare prescription drug coverage (Part D).
- Medicare Prescription Drug Benefit See Part D.
- Medicare Private Drug Plan See Part D.
- Medicare Private Health Plan See Medicare Advantage.
- Medicare Savings Program (MSP) Medicare Savings Programs (MSPs), also known as Medicare Buy-In programs, help pay your Medicare costs if you have limited income and savings. There are three main MSPs, each with different benefits and eligibility limits: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) program. The Qualified Disabled Working Individual (QDWI) program is a less common MSP for people who are under 65, have a disabling impairment, and continue to work.
- Medicare SELECT Medicare SELECT is a type of Medigap policy sold in some states that has a plan network.
- Medicare Summary Notice (MSN) The Medicare Summary Notice (MSN) is a notice from Original Medicare that lists the health care services and items you received during the previous three months. It tells you what the provider billed to Medicare, the amount Medicare paid, and the amount you have to pay. The MSN is not a bill. See also: Explanation of Benefits (EOB).
- Medicare Supplement See Medigap.
- Medicare-Approved Amount See Approved Amount.
- Medicare-Certified Medicare-certified means offering services at a level of quality approved by Medicare. Medicare will not pay for services received from a health care provider that is not Medicare-certified.
- Medigap A Medigap is a supplemental health insurance policy that is sold by private insurance companies and works only with Original Medicare. Medigaps pay part or all of certain remaining costs after Original Medicare pays first. Depending on where you live and when you became eligible for Medicare, you have up to 10 different Medigap policies to choose from, each with a different set of standardized benefits.
- Medigap Open Enrollment Period The Medigap Open Enrollment Period is a six-month period beginning the month you are 65 or older and enrolled in Part B. During this period, you can buy any Medigap supplemental insurance plan, and Medigap companies must sell you a policy at the best available rate regardless of your health status. If you enroll during this time, insurance companies cannot deny you Medigap coverage.
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- National Coverage Determination (NCD) A National Coverage Determination (NCD) is a decision about particular treatments that Medicare will or will not cover for particular conditions. Medicare contractors are required to follow NCDs.
- Network A network is a group of doctors, hospitals, and pharmacies that contract with a Medicare Advantage Plan to provide health care services. Generally, plan members will have the lowest costs when using providers and facilities in the plan’s network. Networks may be made up of both preferred and non-preferred providers.
- Non-Participating Provider In Original Medicare, a non-participating provider is a health care provider that accepts Medicare but does not take assignment in all cases. You may pay up to 15% of Medicare’s approved amount for the service, in addition to the 20% Medicare coinsurance. The provider can request full payment up front, then submit the bill to Medicare for reimbursement. See also: Participating Provider.
- Notice of Medicare Non-Coverage (NOMNC) A Notice of Medicare Non-Coverage (NOMNC) is a notice that indicates when your care is set to end from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice. It includes information for how to appeal the provider’s decision to a Quality Improvement Organization (QIO).
- Nursing Home A nursing home, also called a long-term care facility, is a residential facility for people with chronic illness or disability. Nursing home services include room and board, nursing care, personal care, and therapy services. A skilled nursing facility (SNF) is a nursing home that provides skilled care, but not all nursing homes are SNFs. Medicare does not cover the cost of nursing homes that are not SNFs.
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- Observation Stay An observation stay is an outpatient hospital stay during which an individual receives medical services to help the doctor decide whether they should be admitted as an inpatient or discharged. Observation stays may occur when patients go to the emergency room and have symptoms that require hospital physicians to monitor them.
- Occupational Therapy Occupational therapy is therapy that helps you regain the ability to do usual daily activities by yourself, such as eating and putting on clothes.
- Off-Label Off-label is the prescribed use of a particular drug for a reason other than the use approved by the U.S. Food and Drug Administration or listed in certain medical reference books.
- Opt-Out Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. They can charge whatever they want for services, and Medicare will not pay for care you receive from an opt-out provider (except in emergencies). The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.
- Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare.
- Out-of-Network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received.
- Out-of-Pocket Costs Out-of-pocket costs are health care costs that you must pay because Medicare or other health insurance does not cover them.
- Out-of-Pocket Limit See Maximum Out-of-Pocket (MOOP).
- Outpatient An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (medical insurance).
- Outpatient Care Outpatient care is care received when you have not been formally admitted into the hospital by a doctor as an inpatient. Outpatient care may include emergency room visits, observation stays, or same-day surgeries.
- Outpatient Prospective Payment System (OPPS) The Outpatient Prospective Payment System (OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care provided to patients with Medicare. The rate of reimbursement varies with the location of the hospital or clinic.
- Over-the-Counter Drug An over-the-counter drug is a drug that you can buy, without a prescription, at your local pharmacy or drug store. These drugs are not covered by Medicare Part D.
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- Palliative Care Palliative care is the care of patients with a terminal illness, with the intent of providing relief from their symptoms, not trying to cure them. Palliative care includes support for physical needs such as pain relief, as well as psychological, social, and spiritual support services.
- Part A Part A, also known as hospital insurance, is the part of Medicare that covers most medically necessary hospital inpatient care, skilled nursing facility (SNF) care, home health care, and hospice care.
- Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services.
- Part C See Medicare Advantage.
- Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan.
- Participating Provider In Original Medicare, a participating provider is a health care provider who accepts Medicare and always takes assignment. They may not charge you more than Medicare’s approved amount. If you have Original Medicare and see a participating provider, you will pay a 20% coinsurance for Medicare-covered services. See also: Non-Participating Provider.
- Pastoral Care Pastoral care is counseling or comfort provided by religious leaders (ministers, rabbis, etc.) to patients. This can range from home visitation to formal counseling by licensed pastors.
- Patient Assistance Program (PAP) A patient assistance program (PAP), for people with limited incomes, is a program that offers free or low-cost drugs directly from the pharmaceutical company that makes them.
- Personal Care Personal care, also known as unskilled care, is assistance with activities of daily living. Providers of personal care (home health aides) are not required to undergo medical training. Medicare only covers personal care if you are homebound and receiving skilled care.
- Pharmacotherapy Pharmacotherapy is the use of drugs to treat a disease or condition.
- Physical Therapy Physical therapy is exercise and physical activities used to condition muscles and regain movement and strength in a body area. It is helpful to improve or restore physical function for those with debilitating illness or injury.
- Plan of Care A plan of care is a doctor’s written plan describing the type and frequency of health services a particular patient needs.
- Point-of-Service (POS) Option The Point-of-Service (POS) option is offered in some Health Maintenance Organization (HMO) plans. Most HMOs only cover care from in-network providers, except in case of emergency. The POS option allows you to receive coverage for certain services out of network, but usually at a higher cost.
- Power of Attorney A power of attorney is a legal document that lets you (the principal) appoint another person(s) (your agent or attorney in fact) to make decisions on your behalf. The specific terms of the power of attorney will describe what types of decisions the agent can make, including decisions about property, financial matters, health care, etc. The terms also determine how long the power of attorney lasts—a durable power of attorney is one that remains in effect if you are incapacitated.
- Pre-Existing Condition A pre-existing condition is a condition or illness you were diagnosed with or received treatment for before your new health care coverage began. Some health plans, such as Medigaps, may impose a waiting period on coverage of your pre-existing conditions.
- Pre-existing Condition Waiting Period The waiting period is the time between signing up for a Medigap and the start of coverage. This waiting period is generally imposed if you have a pre-existing condition and have not had prior creditable coverage for a certain amount of time.
- Preferred Pharmacy Many Part D plans have preferred and non-preferred pharmacies in their network. You typically pay less for your prescription drugs at preferred pharmacies.
- Preferred Provider Organization (PPO) A Preferred Provider Organization (PPO) is a type of private insurance plan. Some Medicare Advantage Plans are PPOs. People enrolled in a PPO can see any provider, but you generally pay more when seeing out-of-network providers. See also: Medicare Advantage.
- Prescription A prescription is an order for a health care service or drug written by a qualified health care professional.
- Prescription Drug A prescription drug is a drug that can be obtained only if you have a prescription from a provider. Prescription drugs cannot be bought over the counter.
- Prescription Drug Insurance Prescription drug insurance is health coverage that helps you pay for prescription drugs. You generally pay a copayment or coinsurance for each drug that is covered by your plan (on its formulary). If you have Medicare, you can get prescription drug insurance through a Part D plan or a Medicare Advantage Plan with drug coverage.
- Prescription Drug Plan (PDP) A prescription drug plan (PDP) is a stand-alone plan that offers Medicare prescription drug coverage (Part D) through a private insurance company. PDPs work with Original Medicare, Medical Savings Account (MSA) plans, Cost Plans, and Private Fee-For-Service (PFFS) plans without drug coverage.
- Preventive Care Preventive care is care intended to prevent illness, detect medical conditions, and keep you healthy. Medicare Part B covers many preventive services, such as routine checkups, flu shots, and tests like prostate cancer screenings and yearly mammograms.
- Primary Care Provider (PCP) The primary care provider (PCP) is the doctor or other health care worker who manages your health care and gives you a referral to consult a specialist if you need it. In Medicare Advantage, many Health Maintenance Organizations (HMOs) require you to select a PCP and get their permission or referral before seeing a specialist. Preferred Provider Organizations (PPOs) and Private Fee-for-Service (PFFS) plans do not have this requirement.
- Primary Insurance Primary insurance is health insurance that pays first on a claim for medical and hospital care. In most cases, Medicare is your primary insurer. See also: Secondary Insurance.
- Private Duty Nursing Private duty nursing is direct, comprehensive care on a continuous or live-in basis. Medicare does not cover private duty nursing.
- Private Fee-for-Service (PFFS) plan A Private Fee-for-Service (PFFS) plan is a type of private insurance plan. Some Medicare Advantage Plans are PFFS plans. PFFS plans have provider networks, and you pay less for your care when using in-network providers or facilities. All PFFS plans must also cover out-of-network care, but you may pay a higher cost. See also: Medicare Advantage.
- Private Health Plan See Medicare Advantage.
- Program of All-Inclusive Care for the Elderly (PACE) Program of All-Inclusive Care for the Elderly (PACE) is a program available in some states to people with Medicare and Medicaid who need a nursing home level of care. It provides comprehensive medical and social services to help people live in the community instead of going to a facility. To qualify for PACE, individuals must be age 55 or older, certified by their state to need a nursing home level of care, able to live safely in the community, and living in a PACE service area.
- Provider See Health Care Provider.
- Provider-Sponsored Organization (PSO) A Provider-Sponsored Organization (PSO) is a type of Medicare Advantage Plan that is operated by a group of doctors and hospitals that form a network of providers within which you must stay to receive coverage for your care. This type of plan is not available in most parts of the country.
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- QIO Review QIO Review is the initial step in filing an appeal when your care is ending at a hospital, skilled nursing facility (SNF), Comprehensive Outpatient Rehabilitation Facility (CORF), hospice, or home health agency. See also: Quality Improvement Organization (QIO).
- Qualified Disabled Working Individual (QDWI) Qualified Disabled Working Individual (QDWI) is a less common Medicare Savings Program (MSP) administered by each state’s Medicaid program. It pays the Medicare Part A premium for people who are under 65, have a disabling impairment, continue to work, and are not otherwise eligible for Medicaid.
- Qualified Health Plan (QHP) Qualified Health Plans (QHPs) are health insurance policies that meet protections and requirements set by the Affordable Care Act (ACA). QHPs are sold in federal- or state-run forums, known as Marketplaces or Exchanges. People who are eligible for Medicare should generally not buy a QHP.
- Qualified Independent Contractor (QIC) A Qualified Independent Contractor (QIC) is an independent entity with which Medicare contracts to handle the reconsideration level of an Original Medicare (Part A or Part B) appeal.
- Qualified Medicare Beneficiary (QMB) Qualified Medicare Beneficiary (QMB) is a Medicare Savings Program (MSP) administered by each state’s Medicaid program. It helps people with Medicare who have limited income and assets pay their premiums, deductibles, and coinsurances. If you have QMB, you should not be billed for any Medicare-covered services you receive from Original Medicare providers or providers in your Medicare Advantage Plan’s network.
- Qualifying Individual (QI) Qualifying Individual (QI) is a Medicare Savings Program (MSP) administered by each state’s Medicaid program. It pays the Medicare Part B premium for people with Medicare who have limited income and assets.
- Quality Improvement Organization (QIO) A Quality Improvement Organization (QIO) is a group of practicing doctors and health care experts organized to improve the quality of care given to Medicare beneficiaries. QIOs address complaints about quality of care and review appeals for both Original Medicare and Medicare Advantage when you disagree with a provider’s decision to end your care. You have the right to file a fast (expedited) appeal to the QIO to extend your care when Medicare denies coverage or terminates the services you are receiving from a hospital, skilled nursing facility (SNF), Comprehensive Outpatient Rehabilitation Facility (CORF), hospice, or home health agency.
- Quantity Limit A quantity limit is a restriction used by Part D plans and Medicare Advantage Plans. It limits coverage of a drug to a certain amount over a certain period of time, such as 30 pills per month.
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- Railroad Medicare Carrier A Railroad Medicare Carrier is a private company that provides Medicare coverage for railroad retirement beneficiaries.
- Railroad Retirement Board The Railroad Retirement Board (RRB) is an independent agency in the executive branch of the federal government that administers comprehensive retirement, survivor, unemployment, and sickness benefits for U.S. railroad workers and their families. If you receive Railroad Retirement benefits or railroad disability annuity checks, the RRB processes your Medicare enrollment and collects your Medicare premiums.
- Reconsideration Reconsideration is a level of appeal in Medicare appeals processes. In Original Medicare (Part A and B), reconsideration is the second level, where your appeal is reviewed by a Qualified Independent Contractor (QIC). In Medicare Advantage, there are two reconsideration phases: the plan first reviews its denial of coverage or payment, and if it upholds the initial decision, the second level is reconsideration by the Independent Review Entity (IRE). In Part D plans, reconsideration is also the second level of appeal, conducted by the IRE.
- Red, White, and Blue Card See Medicare Card.
- Redetermination Redetermination is the first step in the Original Medicare appeals process once you have received a Medicare Summary Notice (MSN) with a denial of coverage or payment. It also refers to the first step in the Part D appeals process after the plan denies your coverage determination or exception request.
- Referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam.
- Rehabilitation Therapy Rehabilitation therapy is treatment to improve or restore your ability to function, or to prevent your condition from getting worse. Examples include physical therapy after hip replacement surgery to resume walking, or occupational therapy to prevent carpal tunnel syndrome.
- Reserve Days See Lifetime Reserve Days.
- Respite Care Respite care provides relief for caregivers of hospice patients by arranging a brief period (up to five days) of inpatient care for the patient. Medicare only covers respite care under the hospice benefit.
- Retiree Insurance Retiree insurance is health insurance provided by employers to former employees who have retired. Retiree insurance almost always pays secondary to Medicare. See also: Secondary Insurance.
- Retroactive Disenrollment Retroactive disenrollment is a way to discontinue enrollment in a Medicare Advantage Plan or Part D plan that you joined by mistake or due to incorrect or misleading information. You will be disenrolled from the plan back to the date you joined.
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- Secondary Insurance Secondary insurance is health insurance that pays after primary insurance on a claim for medical or hospital care. It usually pays for some or all of the costs left after the primary insurer has paid (e.g., deductibles, copayments, coinsurances). If your primary insurance denies coverage, or if you do not have primary insurance, your secondary insurance may make little or no payment for your health care costs. See also: Primary Insurance.
- Service Area The service area is the geographic area where a Medicare Advantage Plan or Part D plan provides medical services to its members. In many plans, the service area is where your network of providers is located.
- SHIP (State Health Insurance Assistance Program) State Health Insurance Assistance Programs (SHIPs) are federally funded programs in each state that provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers.
- Skilled Care Skilled care is medically necessary care that must be performed by a skilled professional, or under their supervision. Skilled nursing includes care from registered nurses and licensed practical nurses. Skilled therapy includes care from licensed physical, occupational, and speech therapists.
- Skilled Nursing Facility (SNF) Skilled nursing facilities (SNFs) are Medicare-approved facilities that provide short-term post-hospital extended care services.
- Skilled Nursing Services Skilled nursing services are services performed by or under the supervision of a licensed or certified nurse to treat your injury or illness. Services may include administration of medications, tube feedings, catheter changes, wound care, observation and assessment of your condition, and management and evaluation of your plan of care.
- Skilled Therapy Services Skilled therapy services include physical, speech, and occupational therapy services necessary for treating illness or injury, and performed by or under the supervision of a licensed therapist. See also: Physical Therapy, Speech-Language Pathology, and Occupational Therapy.
- Special Election Period See Special Enrollment Period (SEP).
- Special Enrollment Period (SEP) Special Enrollment Periods (SEPs) are periods of time outside normal enrollment periods when you can enroll in Medicare or change your health and/or drug coverage. One example is the Part B SEP, which allows you to enroll in Part B without penalty while you have job-based insurance and for eight months after you lose the insurance or stop working. SEPs triggered by specific circumstances may also allow you to switch or disenroll from Part D and Medicare Advantage Plans. For example, if you moved out of your plan’s service area, you would receive an SEP to switch to another plan.
- Special Needs Plan (SNP) Special Needs Plans (SNPs) are Medicare Advantage Plans designed to meet specific care needs. You can only join a SNP if you fit the special needs category the plan serves. A SNP may serve people who have both Medicare and Medicaid (dual-eligibles); people who have specific chronic conditions, like diabetes; or people who live in an institution, such as a long-term care facility.
- Specialist A specialist is a doctor who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems.
- Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary (SLMB) is a Medicare Savings Program (MSP) administered by each state’s Medicaid program. It pays the Medicare Part B premium for people with Medicare who have limited income and assets.
- Speech Therapy See Speech-Language Pathology.
- Speech-Language Pathology Speech-language pathology, also known as speech therapy and language therapy, is treatment to regain and strengthen speech and language skills.
- State Pharmaceutical Assistance Program (SPAP) State Pharmaceutical Assistance Programs (SPAPs) are state-subsidized programs that provide assistance in paying for prescription drug costs. SPAPs vary by state, but they generally help pay for the Part D premium and any cost-sharing.
- Step Therapy Step therapy is a restriction placed on drug coverage by Part D plans and Medicare Advantage Plans. Before your plan will cover a drug, you must first try a different or less expensive drug that treats your condition to see if it will be effective for you.
- Supplemental Security Income (SSI) Supplemental Security Income is a monthly benefit for people with limited incomes and assets who are 65 or older, blind, or have a disability.
- Supplier A supplier is a person or business from whom you can buy medical equipment, like a walker or wheelchair. See also: Health Care Provider and Durable Medical Equipment (DME).
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- Take Assignment Take assignment is a term that means a provider accepts Medicare’s approved amount for a service or item as full payment. See also: Participating Provider and Non-Participating Provider.
- Terminal Illness A terminal illness is a disease or condition that cannot be cured or adequately treated, with a life expectancy of six months or fewer.
- Tiering Exception A tiering exception is a type of exception request through the Part D appeal process. You can request lower cost-sharing for a prescription on a higher tier if you show that similar drugs on the formulary at lower tiers are ineffective or harmful for you. If your plan approves the tiering exception, your drug will be covered at the lower cost that applies in the lower tier. You cannot request a tiering exception for drugs in the specialty tier.
- Tiers See Cost Tiers.
- Transition Refill A transition refill, also known as a transition fill, is typically a one-time, 30-day supply of a drug that you were already taking. It lets you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions. You can get a transition refill when you switch to a different Part D plan (either stand-alone or through Medicare Advantage) that does not cover your drug, or when your current plan changes its coverage at the start of a new calendar year.
- TRICARE TRICARE is the Department of Defense’s health insurance program for active duty and retired military personnel and their family members. TRICARE consists of many different programs, including TRICARE for Life (TFL), a retiree benefit that acts as supplemental insurance to Medicare.
- TRICARE for Life (TFL) TRICARE for Life (TFL) is the health insurance program for Medicare-eligible military retirees and their dependents. They must be enrolled in Part A and Part B to receive the benefits. It pays secondary to Medicare and covers out-of-pocket costs including deductibles, coinsurances, and copayments. TFL also offers a pharmacy program that provides creditable drug coverage.
U
- Unearned Income Unearned income is money you get from sources other than current employment. This includes Social Security benefits, Veterans benefits, pensions, annuities, and other regular payments you receive, such as alimony and workers’ compensation.
- Unskilled Care See Personal Care.
- Urgent Care Urgent care is immediate medical attention for a sudden illness or injury that is not life threatening.
- Utilization Management Tools See Coverage Restrictions.
V
- Veterans Affairs (VA) Benefits Veterans Affairs benefits are administered by the federal government for people who served on active duty in the U.S. Armed Forces for a required period of time and received an honorable discharge or release. VA benefits do not coordinate with Medicare, though you can be enrolled in both. Veterans can receive VA covered health care services only at VA facilities. See also: Department of Veterans Affairs.
W
- Waiver of Liability See Advance Beneficiary Notice (ABN).