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Medicare Glossary
A
Actuarial Equivalent
Plans must provide a prescription drug plan that is actuarially (the statistical calculation of risk) the same or better than the Medicare Part D prescription plan.
Any Willing Doctor
A hospital, physician, or health care provider that accepts the plan’s terms and conditions in regards to payment. The plan also agrees to meet the requirements for coverage.
Appeal
A complaint that is made when one disagrees with the decisions made by Original Medicare or other health care plan. For example, one can appeal if Medicare denies a request that should otherwise be granted. However, there is a process when appealing to Medicare, or other health care providers.
Assignment
When a physician or supplier agrees to accept Medicare coverage as full payment.
Authorization
When the receipt of care requires approval by a Managed Care Organization (MCO).
B
Beneficiary
One who has health insurance through Medicare or Medicaid.
Benefit Period
A duration that begins at the time of admittance to a hospital or skilled nursing facility (SNF) and ends when one has not received hospital care for 60 days in a row.
C
Carrier
A company that has a contract with Medicare and agrees to pay Medicare Part B and physician bills.
Catastrophic Coverage Stage
The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,700 in covered drugs during the covered year.
Certificate of Creditable Coverage
A written document issued by a health plan, or health insurance issuer that shows the amount of time that the plan covered.
Children’s Health Insurance Program
A low cost health insurance program for uninsured children under the age of 19. These children belong to families who earn too much to qualify for Medicaid, but not enough to get private coverage. For more information, you may call 1-877-KIDS-NOW (1-877-543-7669), or go to www.insurekidsnow.gov.
CMS Hearing Officer
A person who is designated to conduct the appeals processes for claims disputes.
Coinsurance
The amount that may be required to pay after plan deductibles are paid. Amounts may vary depending on how much has been spent.
Comprehensive Outpatient Rehabilitation Facility (CORF)
A facility that mainly provides rehabilitation services for illnesses and injuries. This includes services such as physician services, physical therapy, outpatient rehabilitation, social, and psychological services.
Coordination of Benefits
The financial responsibilities for a medical claim that two or more health care plans process. This is also called a cross-over.
Copayment
The amount that one has to pay for specific services.
Cost Sharing
The amount one pays for health care and prescriptions.
Covered Employee
A person who is/was provided health care through a group plan.
Creditable Coverage
Past health coverage, such as, Medicare, Medicaid, an HMO, group plan, or individual plan that was never interrupted by a break in coverage.
Creditable Coverage (Medigap)
Types of past health coverage that can help shorten the wait for a pre-existing condition.
Creditable Prescription Drug Coverage
Prescription drug coverage that pays out as much as or more than Medicare’s prescription drug coverage.
Critical Access Hospital
A facility that gives limited services in rural areas.
Custodial Care
Personal care assistance that does not require skill. These include help with everyday tasks, such as, bathing, dressing, or using the restroom. In most cases, Medicare does not cover Custodial Care.
D
Deductible (Medicare)
The amount that must be paid for health care or prescriptions before Medicare or an insurance plan pays for coverage. Amounts for deductibles are subject to change every year.
Drug List
Often called a formulary, this shows which prescription drugs are covered by the plan.
Durable Medical Equipment Regional Carrier (DMERC)
A private company that has a contract through Medicare to pay for medical equipment.
E
Election
Joining or leaving a Medicare plan.
Electronic Data Interchange (EDI)
The sending of standard business transactions from one computer to another.
Electronic Funds Transfer (EFT)
The transferring of monies from one financial institution to another.
End Stage Renal Disease (ESRD)
Failure of the kidneys that requires a transplant or a course of dialysis.
Enrollment and Payment Systems (EPS)
All activities involved with the Retiree Drug Subsidy Program (RDS) including enrollment, payments, appeals, etc.
Excess Charges
The difference between a doctor’s or health care provider’s charge and the Medicare approved payment amount.
Expedited Organization Determination
A quick decision made by Medicare+Choice to determine whether it will cover a health service. Beneficiaries whose life, health, or ability to function may be jeopardizes may be able to receive a decision within 72 hours.
Extra Help
A Medicare program which helps limited income beneficiaries with resources to pay for prescription drug programs costs, premiums, deductibles, and coinsurance.
F
Fiscal Intermediary
A company who is contracted through Medicare Part A and some Part B bills.
Formulary
The prescription drug list that is covered by the plan.
G
Grievance
A complaint about the way that care is given through a Medicare plan. A grievance may be filed if a complaint is made about a staff member or an issue of service. However, some stipulations do apply when filing a grievance. See Appeal for other complaints.
Group Health Plan
A plan through an employer or group of employers that provides health care for current employees, former employees, and their families.
Guaranteed Issue Rights (Also Called Medigap Protection)
The rights you have in certain situations in which a Medigap policy is required to offer a policy. In these situations, insurance companies cannot deny or place conditions on a policy.
Guaranteed Renewable
The right that requires an insurance company to renew a Medigap policy provided that the beneficiary did not lie to the insurance company, commit fraud, or neglect to pay premiums.
H
Health Insurance Portability and Accountability Act (HIPPA) of 1996
A federal law that allows people to qualify for comparable health insurance coverage when changing employment relationships.
Health Maintenance Organization (HMO)
A Medicare Advantage Plan that is available in some areas in some states. Plans must cover Medicare Part A and Part B. In some HMO plans, costs are cheaper than Original Medicare.
Hemodialysis
A treatment for cleaning out the blood through the use of filters.The treatment is usually done in a dialysis facility with a filter that is called a dialyzer.
Home Health Care
Nursing care and at home health aide services such as, physical therapy, speech language pathology, medical social services, durable medical equipment, and other services.
Hospice Care
Treatment for the terminally ill that includes medical, physical, social, emotional, and spiritual support to the patient and their family.
I
Inpatient Care
Health care or treatment that one receives while in the hospital or skilled nurse facility.
Institution
A facility that provides long term or short term health care. These include skilled nursing facilities, rehabilitation hospitals, and nursing homes.
L
Lifetime Reserve Days
The 60 days that Original Medicare pays for when a beneficiary is in the hospital for over 90 days. Once these 60 days are used, they cannot be offered again.
Limiting Charge
The highest amount of money a beneficiary can be charged for Medicare covered services by doctors who do not accept fully paid Medicare.
Long-Term Care
Services that assist people through everyday living over a long period of time. These include nursing homes and assisted living facilities. Medicare does not cover long-term care for beneficiaries.
M
Medicaid
A federal and state program for limited income people that assists with medical costs.
Medical Underwriting
The process in which an insurance company decides whether or not to accept an application, how much to charge for the insurance, and if they are going to place the recipient on a waiting list for pre-existing conditions.
Medically Necessary
Services or supplies that are needed in order to diagnose.
Medicare Advantage Plan
A plan offered by a company that has a contract through Medicare to provide Part A and B benefits. Medicare Advantage Plans include HMOs, PPOs, or Private Fee-for-Service Plans.
Medicare Advantage Prescription Drug (MA-PD) Plan
A Medicare Advantage Plan that covers Medicare Prescription Drug benefits Part A and B in one plan.
Medicare Coordinated Care Plan
A Medicare Advantage PPO or HMO.
Medicare Cost Plans
A certain type of HMO that contracts as a Medicare Health Plan. However, the plan only pays for services outside of its designated service area under emergency circumstances.
Medicare Coverage
Coverage made up of Part A (which covers hospital insurance) and Part B (which covers medical insurance).
Medicare Health Plan
A plan that contracts with Medicare and is offered by a private company to provide Part A and/or B benefits. Medicare Health Plans include Medicare Advantage plans, Medicare Cost Plans, PACE plans, and special needs plans.
Medicare Managed Care Plan
A specific type of Medicare Advantage Plan that is only available in certain areas in the country. Some managed care plans cover Part A and B, with additional benefits, like prescription drugs. The cost may be lower than in Original Medicare.
Medicare Plan
Any way other than Original Medicare in which one is able to receive Medicare health or prescription drug coverage.
Medicare Prescription Drug Coverage
Optional coverage that is available to all beneficiaries who have received Medicare through insurance companies or private companies.
Medicare Select
A Medigap policy that may require beneficiaries to use hospitals and doctors within its network in order to receive full benefits.
Medicare Summary Notice
A notice given to beneficiaries after the provider files a claim for Part A and B in Original Medicare. The notice includes what the provider billed, the amount that Medicare approved, how much Medicare paid, and how much the beneficiary is to pay.
Medicare-Approved Amount
The amount that the doctor or supplier can be paid when they accept assignment. It includes the amount that Medicare pays, any deductible, coinsurance, or copayment that needs to be paid.
Medigap Open Enrollment Period
A one-time-only six month period when all Medigap policies are available to buy within a beneficiary’s state. The period begins when beneficiaries have reached an age of 65 or older and are in the first month of their coverage under Medicare Part B.
Medigap Policy
Medicare supplement insurance that is sold by private insurance companies in order to bridge the “gap” in Original Medicare coverage.
N
O
Original Medicare
A fee-for-service health plan that allows beneficiaries to go to any health care provider, hospital, or supplier who accepts Medicare and new Medicare patients. Deductible must be paid. Medicare pays for the approved amount and the beneficiary pays the coinsurance.
Outpatient Hospital Care
Medical or surgical care that a hospital has offered, but the beneficiary has not been admitted as an inpatient. The hospital records will state that the beneficiary is an outpatient. In some cases, observation may be considered as outpatient care.
P
Penalty
An amount that is added to a beneficiary’s premium if they do not enroll at the appropriate time. These amounts are added for Medicare Part B and for the Medicare Prescription Plan.
Physician Services
Services provided by a person who is licensed under state law to practice medicine or osteopathy. Services that are given while in the hospital that are on the bill are not included.
Plan Administrator
The person who is designated to manage the plan. If the plan does not specify, then the plan sponsor is generally the plan administrator.
Plan Sponsor
The employee organization or employer that maintains the benefit plan.
Point-of-Service (POS) Option
An option given by HMOs that allows beneficiaries to use doctors and hospitals outside the plan for an additional cost.
Pre-existing Condition
A health problem that existed prior to the start date of the new insurance policy.
Preferred Provider Organization (PPO) Plan (Medicare)
A Medicare Advantage Plan that costs less when beneficiaries use doctors, hospitals and providers who belong to the network. For an additional cost, beneficiaries may use out of network providers.
Premium
The consistent payment to Medicare, insurance companies, or health care plans for health care or prescription coverage.
Preventive Services
Services that are meant to prevent illness.
Primary Care Doctor
The doctor who is seen first for basic care purposes. The doctor may contact other health care professionals to ensure that you get all the care that is needed.
Private Fee-for-Service Plan
A Medicare Advantage Plan that allows beneficiaries to go to any hospital or doctor that is approved by Medicare but also accepts the plan’s payment. The insurance plan decides how much is paid by the plan and how much is paid by the beneficiary.
Programs of All Inclusive Care for the Elderly (PACE)
PACE combines medical, social, and long-term services for people to stay active within their communities for as long as possible. PACE is only available in states that offer the program under Medicaid.
Q
Quality Improvement Organization
Groups of practicing doctors and health care experts who check and improve the care given to Medicare patients. These doctors review complaints provided by health plan providers. They also review fast-track termination decisions with outpatient service providers.
R
Referral
A written order from a primary care physician for the patient to see a specialist for certain services. In order for the plan to pay for specialist services, beneficiaries must see their primary care doctor for a referral first.
Regional Home Health Intermediary (RHHI)
A company that contracts with Medicare and pays home health and hospice bills. This company also checks on the quality of home health care.
Rehabilitation
Services ordered by a physician to help patients recover from illness or injury. These services are given by nurses and therapists.
Retiree-for the RDS Program
A person who receives benefits after they have retired.
Risk Adjustment
A change in a health plan to reflect a person’s health status.
S
Second Opinion
When another doctor gives their advice on how a patient should be treated.
Secondary Payer
Insurance plans, policies, or programs that pay second on claims for care.
Service Area
The specific area in which health plans may accept members. For plans that offer services with doctors and hospitals, this is also the area where treatment is provided. If a beneficiary moves out of the area, they may have to disenroll from the plan.
Service Area (Private Fee-For-Service)
Where a Medicare Private-Fee-For-Service plan may accept members.
Service Category Definition
A description of services provided located under the service name.
Side Effect
When a treatment causes a medical problem.
Significant Break in Coverage
Generally a time period of 63 days when an individual is without creditable coverage. The period may be longer if coverage is provided by an insurance policy or HMO. Period length is also dependant on the state that the beneficiary lives in.
Skilled Care
Health care that is given when a beneficiary needs skilled nursing staff to evaluate, manage, and observe their care.
Skilled Nursing Care
Care that includes services that can only be performed safely by a licensed or registered nurse.
Skilled Nursing Facility (SNF)
A facility with staff and equipment to provide skilled nursing care, skilled rehabilitation, and other health services.
Skilled Nursing Facility Care
Daily care that is required of nursing or rehabilitation staff. Examples of skilled nursing facility include physical therapy and intravenous injections. The need for assistance with daily living tasks (such as bathing and dressing) cannot, in itself qualify a beneficiary for coverage in a skilled nursing facility.
Social Health Maintenance Organization
A health plan that provides all Medicare benefits offered by Medicare HMOs and includes other services such as: prescription drug and chronic care benefits, respite care, short-term nursing home care, personal care services, medical transportation, eyeglasses, hearing aids, and dental benefits.
Special Election Period
A time when beneficiaries are able to change their health plans or return to Original Medicare. These changes can be made under the following circumstances: a service area change, Medicare contract violation, the organization fails to renew a contract with CMS, and other exceptions determined by CMS. The Special Election Period differs from the Special Enrollment Period (SEP).
Special Enrollment Period
A time when beneficiaries may sign up for Medicare Part B because they could not enroll during the Initial Enrollment Period due to their employment status. For example, if an individual or their spouse was working under a group health plan through an employer or union at the time of enrollment, then the beneficiary could not receive Medicare Part B. However, based on employment status, one may sign up at anytime.
Special Needs Plan
A plan that provides focused health care for certain groups of people. These groups include people who have both Medicare and Medicaid, who live in a nursing home, or who have chronic medical conditions.
Specialist
A doctor who treats certain health problems, body parts, or specific age groups.
Specified Disease Insurance
Insurance that pays benefits for one specific disease.
Specified Low Income Medicare Beneficiaries (SLMB)
A Medicaid program that pays premiums for Medicare Part B. This is available for individuals who have Medicare Part A, a low monthly income, and limited resources.
Speech-Language Therapy
Treatment to assist individuals with their verbal communication skills.
Sponsor
An person or group, such as an employer or union that helps or supports health plans.
State Children’s Health Insurance Program
Low cost or free insurance that is available for uninsured children under the age of 19. These programs are assist children with families who earn too much to qualify for Medicaid, but not enough to qualify for private insurance.
State Health Insurance Assistance Program (SHIP)
A state program that provides free health care counseling to Medicare beneficiaries.
State Insurance Department
A state agency that regulates insurance policies and provides information about private insurance.
State Medical Assistance Office
A state agency that regulates state Medicaid and provides information about programs that help people with low incomes pay their medical bills.
State Pharmacy Assistance Program
A state program that provides assistance for people who need help paying for drug coverage. The program provides assistance based on age, medical condition, or financial need.
State Survey Agency
An agency that inspects dialysis facilities to ensure that Medicare standards are met.
Subsidized Senior Housing
A program available through specific states and the Federal Department of Housing to help people with low incomes pay for housing.
Subsidy
A government grant that is paid to an individual or company to assist an enterprise that contributes to the public as a whole.
Supplier
Any agency, company, or person who supplies beneficiaries with medical items or services.
T
Telemedicine
An interactive telecommunications system service given to patients by a practitioner from a distant site.
Tiers
A plan’s system of categorizing to create lower costs. Different plans can have different ways of forming tiers. For example, prescription drugs can often be categorized by lowest to highest price.
Treatment
Assistance with a health complication. For example, surgery and medicine are treatments.
Treatment Options
A beneficiary’s choices when there is more than one way to care for a health problem.
Tricare
A health care program available for uniformed services and their families.
Tricare for Life (TFL)
Expanded medical coverage for Medicare eligible uniformed service retirees who have reached age 65 or older. This coverage is also available for their family members.
TTY
A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have speech impairments. TTYs consist of a modem, display screen, and keyboard. TTY messages travel over telephone lines. A person who does not have a TTY can communicate with a TTY user by using a message relay center (MRC). MRCs have TTY operators available to send and receive messages.
U
Unassigned Claim
A claim for a supply or service when the provider does not accept assignment.
Urgently Needed Care
Care for a sudden illness or injury that needs immediate attention, but is not life threatening. Urgently needed care is generally provided through a primary care physician if one has Medicare benefits.
V
Validation
Ensuring that the correctness of data is established. Validation processes may occur directly after a single data item is collected, or after a complete set of data is collected.
W
Waiting Period
A length of time that should pass before an employee or dependent can enroll in a group health plan. If the employee or dependent enrolls late or on a special enrollment date, any period before those times are not considered a waiting period.
Workers Compensation
The insurance that employers carry in order to cover employees who get sick or injured on the job.
Y0007_MKT602 (H5416), (H7179) CMS Approved (10/07/2011)