Glossary

Glossary - A

Advance Beneficiary Notice of Noncoverage (ABN)

A term pertaining to Original Medicare, a notice that a doctor or supplier (provider) gives a person with Medicare before furnishing an item or service if the provider thinks Medicare may not pay.

In this situation, if you are not given an ABN before you get the item or service, and Medicare denies payment, then you may not have to pay for it. If you are given an ABN, and you sign it, you will likely have to pay for the item or service if Medicare denies payment.

Advance Coverage Decision

A notice a person receives from a Medicare Advantage Plan letting them know in advance whether it will cover a medical service.

Advance Directive

A written document stating how a person wants medical decisions to be made in the case of a loss of the ability to make these decisions for themselves. This document may include a living will and a durable power of attorney specifically for health care.

ALS

Amyotrophic lateral sclerosis, a.k.a. Lou Gehrig's disease.

Ambulatory Surgical Center

A facility where surgeries are performed for patients who are not expected to need more than 24 hours of care.

Annual Election Period (AEP)

Medicare's annual election period is October 15 - December 7. During this period, anyone with Medicare can change their Medicare health plans and prescription drug coverage for the following year to better meet their needs.

Appeal

An appeal is the action a person can take if they disagree with a coverage or payment decision made by Medicare, their Medicare health plan, or their Medicare Prescription Drug Plan.

The person can appeal if Medicare or the health plan denies one of these:

  • A request for a health care service, supply, item, or prescription drug that the person thinks should be able to receive
  • A request for payment for a health care service, supply, item, or prescription drug the person already received
  • A request to change the amount a person must pay for a health care service, supply, item, or prescription drug.

The person can also appeal if Medicare or their plan stops providing or paying for all or part of a service, supply, item, or prescription drug the person believes they still need

Assignment

An agreement by a doctor, provider, or supplier to be paid directly by Medicare. This provider also agrees to accept the payment amount Medicare approves for the service, and not to bill the patient for any more than the Medicare deductible and coinsurance.

A common question to providers prior to service is to ask “Do you accept Medicare assignment?”

Glossary - B

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

A group of doctors and other health care experts (known as a Quality Improvement Organization or QIO, under contract with Medicare) that uses doctors and other health care experts to review complaints and quality of care for people with Medicare.

While ensuring local factors/needs are taken into consideration, the BFCC-QIO makes sure there is consistency in the case review process including medical necessity and general quality of care.

Benefit Period

The way Original Medicare measures the use of hospital and skilled nursing facility (SNF) services.

A benefit period begins the day a patient is admitted as an inpatient in a hospital or facility.

The benefit period ends when the patient has not received inpatient hospital care (or skilled care in a SNF) for 60 concurrent days.

If someone goes into a hospital or a SNF after one benefit period has ended, a new benefit period begins. This means the patient would be responsible to pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.

Benefits Coordination & Recovery Center (BCRC)

This would be the company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have.

Additionally, the company determines whether the coverage pays before or after Medicare.

This company acts for Medicare to obtain repayment when Medicare makes a conditional payment, when the other payer is determined to be primary.

Glossary - C

CHAMPVA

A health care program specifically for dependents of qualifying veterans.

Claim

A request for payment that beneficiaries submit to Medicare or private health insurance when receiving services or goods that are covered by either the health plan or Medicare.

Clinical Breast Exam

An exam by a doctor or other health care provider to check for breast cancer by feeling and looking at the breasts. This exam is not the same as a mammogram and is usually done in the doctor's office during the annual Pap test and pelvic exam.

Co-insurance

The amount beneficiaries may be required to pay as their share of the cost for services after paying any deductibles.

To help differentiate between Co-insurance and Co-Pay, Co-insurance is usually a percentage (for example, 20%) as opposed to a fixed dollar amount.

Comprehensive Outpatient Rehabilitation Facility

A facility that provides services on an outpatient basis (including physicians' services, physical therapy, rehabilitation, and social or psychological services).

Co-payment

The amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug.

To help differentiate between Co-Pay and Co-insurance, Co-Pay is usually a fixed dollar amount (for example, $20 for a doctor's visit or prescription drug) as opposed to a percentage.

Coverage determination (Part D)

The initial decision made by a Medicare drug plan about drug benefits. This decision is not made by the pharmacy.

Decisions can include:

  • If a particular drug is covered
  • Whether beneficiaries have met all the requirements for getting a requested drug
  • How much is required to pay for a drug
  • Exceptions to a plan rule when beneficiaries request it

The drug plan must give you a prompt decision within 72 hours for standard requests and 24 hours for expedited requests.

If the determination by the plan is not acceptable, the beneficiary is allowed to appeal the decision.

Coverage gap

A period in which beneficiaries pay higher cost sharing for prescription drugs until the amount spent is enough to qualify for catastrophic coverage.

The coverage gap (sometimes it is called the donut hole, but much less fun that actual donut holes) starts when beneficiaries and the insurance plan have paid a set dollar amount for prescription drugs during that plan year.

Creditable coverage (Medigap)

Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.

Creditable prescription drug coverage

Prescription drug coverage (for example, from a union or employer health plan) that's expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.

Beneficiaries who have coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.

Critical Access Hospital (CAH)

Typically, this is in rural areas and is a smaller facility that provides outpatient services as well as inpatient services on a limited basis.

Custodial Care

Non-skilled personal care to assist a patient with the activities of daily living (ADL) like getting in or out of a chair or bed, dressing, eating, bathing, moving around, and using the bathroom.

This could also include health care that most people do themselves, like eye drops. Typically, Medicare doesn't pay for custodial care.

Glossary - D

Deductible

This is the amount beneficiaries pay for prescriptions or health care before Original Medicare, a Prescription Drug Plan (PDP), or other insurance (Medicare Supplement or Medicare Advantage plans) begins to pay.

Demonstrations

These ae usually limited time projects, sometimes called "research studies” or "pilot programs," that test improvements in Medicare quality of care, payment, or coverage.

Durable medical equipment (DME)

Medical equipment, like a wheelchair, hospital bed, or walker that is ordered by doctors for use in the home.

Durable power of attorney

A legal document that names someone else to make health care decisions for the beneficiary.

Glossary - E

End-Stage Renal Disease (ESRD)

Kidney failure (Permanent) that requires a kidney transplant or a regular course of dialysis.

Exception

A determination of a Medicare prescription drug coverage plan.

A formulary exception is a drug plan's decision to waive a coverage rule or cover a drug that's not on its drug list.

A tier exception is a drug plan's decision to charge the beneficiary a lower amount for a drug that's on its non-preferred drug tier.

The beneficiary or the prescriber must request an exception, and a doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.

Excess charge

On Original Medicare, the amount a health care provider or a doctor is permitted by law to charge a higher price than the Medicare-approved amount. This difference is called the excess charge.

Extra Help

A Medicare program to help people with limited resources and income pay Medicare prescription drug program costs. This can include premiums, coinsurance, and deductibles.

Glossary - F

Formulary

A drug list of prescription drugs covered by a Prescription Drug Plan (PDP) or another insurance plan offering prescription drug benefits (For instance, some Medicare Advantage plans offer drug coverage.).

Glossary – G

Grievance

A criticism or complaint about the way a Medicare drug plan or Medicare health plan is providing care. For example, you may file a grievance if you have a problem calling the plan or if you're unhappy with the way a staff person at the plan has behaved towards you.

Completely separate, if you have a complaint about the plan's refusal to cover a supply, service, or prescription, that is when you would file an appeal.

Group health plan

Generally speaking, this is a type of health plan that is offered by an employee organization (think employer) that provides health coverage to employees and their families.

Guaranteed issue rights (also called "Medigap protections")

A protective law where someone who has an insurance policy when insurance companies are required by law to offer a Medigap policy or are required to sell under certain circumstances.

In these situations, an insurance company cannot deny a Medigap policy or put certain conditions on a Medigap policy. For instance, exclusions for pre-existing conditions, or trying to charge more for a Medigap policy because of present or past health conditions.

Guaranteed renewable policy

An insurance policy that the insurance company cannot terminate unless policy holders commit fraud, make untrue statements to the insurance company, or don't pay policy premiums.

There is typically a grace period and alerts by the insurance company to prevent the loss of coverage.

Medigap policies issued since 1992 are considered guaranteed renewable.

Glossary - H

Health care provider

An organization or person that is licensed to give health care.

Doctors, nurses, and hospitals are examples.

Health Insurance Marketplace

An online resource that helps people shop for and enroll in “affordable” health insurance.

The federal government operates the Marketplace, available at HealthCare.gov, for most states. In other cases, some states have their own Marketplace.

The Health Insurance Marketplace (also known as the “Marketplace” or “exchange”) provides health plan shopping and enrollment services through websites and in-person help in requested.

Home health agency

A group or organization that provides home health care.

Home health care

Health care supplies and services a doctor decides you may get in a patient’s home under a plan of care established by their doctor.

This service is only covered by Medicare on a limited basis and must be ordered by a doctor.

Hospice

A methodology of caring for people who are terminally ill.

Hospice care involves a team-oriented approach that addresses the following areas for a patient:

  • Medical
  • Physical
  • Social
  • Emotional
  • Spiritual needs

Some support is also given for patient’s caregiver or family.

Glossary – I

Independent reviewer

This is often referred to Independent Review Entity or IRE – a group or organization that has no connection to a patient’s Medicare Prescription Drug Plan or a patient’s Medicare health plan.

The IRE is contracted with Medicare to review a patient’s case if the plan doesn't make a timely appeals decision appeal or regarding the plan's payment or coverage decision.

Inpatient rehabilitation facility

A hospital, or part of a hospital, that provides an rehabilitation program for inpatients.

Glossary – J

(Dad) Jokes

Something that is considered funny by older men and typically nobody else. Not much interesting starting with J in Medicare-land.

Glossary – K

Kickstand

That thing on a bicycle that you kick down to keep the bike upright when you walk away. In other words, there doesn’t seem to be anything relevant to Medicare starting with K!

Glossary - L

Large Group (Health) Plan

An employee’s health plan supplied by the employer – comprised of more than 100 employees.

Lifetime Reserve Days

Pertaining to Original Medicare, additional days that Medicare pays for when you're in a hospital for more than 90 days.

Patients have 60 reserve days that can be used during their lifetime.

Medicare pays all covered costs except for a daily coinsurance.

Limiting Charge

Pertaining to Original Medicare, this is the highest amount of money a patient will be charged for service covered by doctors (also health care suppliers) who don't accept assignment (See above).

This charge is limited to 15% over Medicare's approved amount.

The limiting charge doesn't apply to supplies or equipment and only applies to certain services.

Living Will

A legal document (written), also known as an "advance directive” or sometimes a "medical directive.”

This document explains what type of treatments a patient wants or don’t want in case that patient cannot speak, like whether life support is wanted.

Typically, this document only comes into effect during the patient being unconscious.

Long-Term Care

Services that include medical and non-medical care given to patients who are unable to perform basic activities of daily living, like bathing, toileting, or dressing.

Long-term supports and services can be provided at home, in the community, nursing homes, or in assisted living. Individuals may need long-term supports and services at any age.

Medicare and most health insurance plans don’t pay for long-term care, but is a separate policy type that can be purchased.

Long-Term Care Hospital

Acute care hospitals that gives treatment to patients whose average stay is more than 25 days.

Most patients are transferred from an intensive or critical care unit.

Services provided include respiratory therapy, rehabilitation (comprehensive), pain management, and head trauma treatment.

Glossary – M

Medicaid

A sort of hybrid federal and state program that helps with medical costs for people with limited income and resources.

Medicaid programs have different names from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medical Underwriting

How an insurance company uses to decide, based on your medical history, whether to add a waiting period for pre-existing conditions (state law allowable), whether to take your application for insurance, and how much to charge you for that insurance.

With Medicare supplements, you can skip underwriting the first time you qualify but that’s about it unless you qualify for a Special Enrollment Period, a.k.a. an SEP.

Medically Necessary

Health care supplies or services needed to diagnose or treat an illness, condition, injury, disease, or its symptoms and that meet accepted standards of medicine.

No Medicare does not cover cosmetic surgery, not considered “medically necessary” unless related to an accident or something like that.

Medicare

What this whole website is about.

Medicare Advantage Plan (Part C)

One of the options to receive a Medicare health plan offered by a private company that contracts with Medicare.

Medicare Advantage Plans provide all of your Part A and Part B benefits, excluding hospice.

Medicare Advantage Plans include:

  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Private Fee-for-Service Plans (PFFS, rare)
  • Special Needs Plans (SNP, very useful for chronic conditions)

Most Medicare Advantage Plans have prescription drug coverage; thus, we refer to them as MAPD. Having this coverage allows the member to avoid the Part D penalty for not having drug coverage.

Medicare-approved amount

In Original Medicare, this is the amount a supplier or doctor/hospital that accepts assignment can be paid.

It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference, or your insurance depending on which type of plan you choose.

Medicare-certified provider

A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that's been approved by Medicare.

Providers are approved or "certified" by Medicare if they've passed an inspection conducted by a state government agency.

Medicare only covers care given by providers who are certified, so don’t use dodgy providers.

Medicare Cost Plan

A type of Medicare health plan available in some areas, no idea what these are still around for - except to be a pest on the annual exam we Medicare Insurance brokers have to pass each year.

Medicare Health Maintenance Organization (HMO) Plan

A type of Medicare Advantage Plan (Part C) available in some areas, dictated by county.

In a typical HMO, members of the plan can only go to doctors, specialists, or hospitals on the plan's list except in an emergency.

Most HMOs also require you to get a referral from your primary care physician (PCP), but some are starting not to require this.

Medicare Part A (Hospital)

Original Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility (SNF), some home health care, and hospice care.

Medicare Part B (Medical)

Original Medicare Part B covers doctor services, medical supplies, outpatient care, and preventive services.

Medicare plan

Any way other than Original Medicare that you can get your Medicare health or prescription drug coverage.

This term includes all Medicare health plans and Medicare Prescription Drug Plans.

Medicare Supplement is quite different from Medicare Advantage, know the difference by asking us what is the fit for your budget and medical situation.

Medicare Preferred Provider Organization (PPO) Plan

A type of Medicare Advantage Plan (Part C) available in some areas by county, in which you pay less if you use doctors, hospitals, and other health care providers that belong to the network of the plan.

For an additional cost within the plan, you can use doctors, hospitals, and providers outside of the network.

Medicare prescription drug coverage (Part D)

Optional benefits for prescription drugs available to all people with Medicare for an additional charge. Having “creditable’ Prescription Drug coverage avoids the Part D penalty.

This Medicare approved coverage is offered by private insurance companies.

Medicare Prescription Drug Plan (Part D)

There is a Part D component of prescription drug coverage added to:

  • Original Medicare
  • Medicare Medical Savings Account Plans
  • Some Medicare Private-Fee-for-Service Plans

Private insurance companies offer these plans and are approved by Medicare.

Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

Medicare Private Fee-For-Service (PFFS) Plan

A type of Medicare Advantage Plan (Part C) in which members can generally go to any doctor or hospital they could go to if on Original Medicare if the hospital or doctor agrees to treat the patient.

The plan determines how much it will pay doctors and hospitals, and how much they must pay when the patient receives care.

A Private Fee-For-Service Plan is very different than Original Medicare, and the member must follow the plan rules carefully when going for health care services.

When in a Private Fee-For-Service Plan, members may pay more or less for Medicare-covered benefits than in Original Medicare.

Medicare Savings Program

A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, coinsurance, and deductibles. Medicare Special Needs Plan (SNP)

A specialized Medicare Advantage Plan (Also known as Part C) that provides more focused and specialized health care for specific groups of people.

Examples of this would be those who live in a nursing home, who have both Medicare and Medicaid, or have certain chronic medical conditions (example – Diabetes).

Medicare Summary Notice (MSN)

A notice you get after the health care provider (example, a doctor) or supplier files a claim for Part A/Part B services in Original Medicare.

It explains what the doctor, other health care provider, or supplier billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

Medigap (Medicare Supplement) Open Enrollment Period

A one-time only, 6-month period when federal law allows you to buy any Medigap (also known as a Medicare Supplement) policy you want that's sold in your state regardless of health condition.

It starts in the first month that you're covered under Part B and you're age 65 or older.

During this period, you can't be denied a Medigap policy or charged more due to past or present health problems.

Some states may have additional open enrollment rights under state law.

Medigap policy

Medicare Supplement Insurance sold by private insurance companies to fill "gaps" in Original Medicare coverage.

Multi-employer plan

In general, a group health plan that's sponsored jointly by 2 or more employers.

Glossary - N

Nada

As in, there is nada starting with the letter N of interest in Medicare land.

Glossary - O

Original Medicare

Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

Out-of-pocket costs

Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.

Glossary - P

Penalty

An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don't join when you're first eligible.

You pay this higher amount as long as you have Medicare. There are some exceptions.

Point-of-service option

In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.

Power of attorney

A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care.

This type of advance directive also may be called a health care proxy, appointment of health care agent, or a durable power of attorney for health care.

Pre-existing condition

A health problem you had before the date that new health coverage starts.

Premium

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Preventive services

Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).

Primary care doctor

The doctor you see first for most health problems.

He or she makes sure you get the care you need to keep you healthy.

He or she also may talk with other doctors and health care providers about your care and refer you to them.

In many Medicare Advantage Plans (usually HMOs), you must see your primary care doctor before you see any other health care provider.

Prior authorization

Approval that you must get from a Medicare drug plan before you fill your prescription for the prescription to be covered by your plan.

Your Medicare drug plan may require prior authorization for certain drugs.

Glossary - Q

Qualified Beneficiary, QMB, QMB-26, LIS, etc.

In Medicare-land, some of the acronyms that describe the level of financial assistance the program provides. Mostly incomprehensible and subject to a lot of “huh?” – when in doubt contact social security to see if you qualify… er, and at what level.

Glossary - R

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services.

In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor.

If you don't get a referral first, the plan may not pay for the services.

Rehabilitation services

Health care services that help you keep, get back, or improve skills and functioning for daily living that you've lost or have been impaired because you were sick, hurt, or disabled.

These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Respite care

Temporary care provided in a nursing home, hospice inpatient facility, or hospital so that a family member or friend who is the patient's caregiver can rest or take some time off.

Glossary - S

Secondary payer

The insurance policy, plan, or program that pays second on a claim for medical care.

This could be Medicare, Medicaid, or other insurance depending on the situation.

Service area

A geographic area where a health insurance plan accepts members if it limits membership based on where people live.

For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services.

The plan may disenroll you if you move out of the plan's service area.

Skilled nursing care

Care like intravenous injections that can only be given by a registered nurse or doctor.

Skilled nursing facility (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Skilled nursing facility (SNF) care

Skilled nursing care and rehabilitation services provided daily, in a skilled nursing facility (SNF).

Examples of SNF care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

State Health Insurance Assistance Program (SHIP)

A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

State Insurance Department

A state agency that regulates insurance and can provide information about Medigap policies and other private health insurance.

State Medical Assistance (Medicaid) office

A state or local agency that can give information about, and help with applications for,

Medicaid programs that help pay medical bills for people with limited income and resources.

State Pharmaceutical Assistance Program (SPAP)

A state program that provides help paying for drug coverage based on financial need, age, or medical condition.

State Survey Agency

A state agency that oversees health care facilities that participate in the Medicare and/or Medicaid programs by, for example, inspecting health care facilities and investigating complaints to ensure that health and safety standards are met.

Step therapy

A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.

Supplemental Security Income (SSI)

A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older.

SSI benefits aren't the same as Social Security retirement or disability benefits.

Supplier

Generally, any company, person, or agency that gives you a medical item or service, except when you're an inpatient in a hospital or skilled nursing facility.

Glossary - T

Telemedicine

Medical or other health services given to a patient using a communications system (like a computer, phone, or television) by a practitioner in a location different than the patient's.

Tiers

Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

TTY

A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment.

People who don't have a TTY can communicate with a TTY user through a message relay center (MRC).

An MRC has TTY operators available to send and interpret TTY messages.

Glossary - U

Urgently needed care

Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away but isn’t life threatening.

If it’s not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.

Glossary – V

Voilà!

In view, a humble vaudevillian veteran, cast vicariously as both victim and villain by the vicissitudes of Fate. This visage, no mere veneer of vanity, is a vestige of the vox populi, now vacant, vanished. However, this valorous visitation of a by-gone vexation, stands vivified and has vowed to vanquish these venal and virulent vermin vanguarding vice and vouchsafing the violently vicious and voracious violation of volition. The only verdict is vengeance; a vendetta, held as a votive, not in vain, for the value and veracity of such shall one day vindicate the vigilant and the virtuous. Verily, this vichyssoise of verbiage veers most verbose, so let me simply add that it's my very good honor to meet you.

In fewer words, nothing Medicare related beginning with V.

Glossary – W

Wiff

That sound the racquet makes when you completely miss the tennis ball. Nothing W in Medicare however.

Glossary – X

Xavier, Charles

Guy with a shaved head, putts around in a hovering wheelchair. The big brain who runs the X-men. Regarding Medicare, nothing interesting starting with the letter X.

Glossary – Y

Yabba

Large Jamaican earthenware or wooden vessel. You guessed it, nothing to do with Medicare starting with Y!

Glossary – Z

Zorro

That guy who runs around in a black mask and hat, carving a big Z in the walls, doors, and sometimes uniforms of the guards.

In other words, nothing interesting from a Medicare standpoint starting with the letter Z! Thanks for reading our glossary