Appeal—An appeal is a special kind of complaint insureds can make if they disagree with any decision about their health care services—for example, if Medicare doesn’t pay at all or doesn’t pay enough for a service the insured received or would like to receive. This complaint is made to the Medicare health plan or to the Original Medicare plan. There is a special process that must be used to make the complaint.
Approved amount—The fee Medicare sets as reasonable for a covered medical service. It may be less than the actual amount charged. Approved amount is sometimes called “approved charge.”
Benefit period—The way that Medicare measures insureds’ use of hospital and skilled nursing facility services. A “benefit period” begins the day the insured goes into a hospital or skilled nursing facility. The benefit period ends when the insured has not received inpatient hospital or skilled nursing care for 60 consecutive days in a row. If the insured goes into the hospital after one benefit period has ended, a new benefit period begins. the insured must pay the inpatient hospital deductible required for each new benefit period. There is no limit on how long a benefit period can be or on the number of benefit periods; however, the inpatient hospital deductible is required for each new benefit period.
Centers for Medicare and Medicaid Services (CMS)—The federal agency that provides oversight and the administration of Medicare.
Coinsurance—The percent of the Medicare-approved amount that insureds must pay after they pay the deductible for Part A and/or Part B. In the Original Medicare plan, the coinsurance payment is a percentage of the cost of the service (like 20 percent).
Co-payment (Co-pay)—In some Medicare health plans, the amount that insureds pay for each medical service, like a doctor’s visit. A co-payment is usually a set amount paid for a service—for example, $10 to $40 for a doctor visit. Co-payments are also used for some hospital outpatient services in the Original Medicare plan.
Coverage gap—Official description of the period in Medicare Part D plans, where coverage was not available through the plan. Considerable changes occurred to this “donut hole” concept by 2016, with 55 percent coverage for brand-name drugs and 58 percent coverage for generic drugs being introduced.
Deductible—The amount that must be paid for health care before Medicare begins to pay, either for each benefit period for Part A, or for each year for Part B. These amounts can change every year.
Donut hole—Outdated, but publicly understood, definition of the coverage gap in Part D plans.
Durable medical equipment (DME)—Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds.
End stage renal disease (ESRD)—This is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. Beneficiaries may become entitled to Medicare based on ESRD.
Fiscal intermediary (also called intermediary)—A private company that has a contract with Medicare to pay Part A and some Part B bills.
Formulary—A formulary is associated with Medicare Part D and is the list of drugs the plan covers. vGeneral enrollment period (GEP)—The time period to enroll in Medicare for those who were not automatically enrolled and did not sign up for Medicare during their initial enrollment period. The general enrollment period takes place every year, from January 1 through March 31. Medicare coverage begins on July 1 for those who enroll during a GEP.
Grievance—A complaint about the way a Medicare health plan is giving care. For example, insureds may file a grievance if they have problems with the health care facility (such as cleanliness), staff behavior, or operating hours. Likewise, insureds many file a grievance if they have problems calling the plan. Note that a grievance is not the same as an appeal, which is the way to deal with a complaint about a treatment decision or a service that is not covered (see the definition of appeal).
Guaranteed issue rights (also called “Medigap protections”)—Rights that insureds have in certain situations when insurance companies are required by law to sell or offer them a Medigap policy. In these situations, an insurance company can’t deny insureds insurance coverage or place conditions on a policy; it must cover them for all pre-existing conditions and cannot charge them more for the policy because of past or present health problems.
Health Maintenance Organization (HMO)—A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. Typically, a member of HMO must use the services of a contracted provider in order for the services to covered by the plan.
Health savings account (HSA)—A health savings account, or HSA, is a special purpose financial account that allows employees to save and pay for qualifying medical expenses on a triple tax-favored basis: funds are deposited in the account are not subject to tax; interest that accrues within the account is not taxable; and withdrawals taken from the account are not taxable if used to pay for qualifying medical expenses. The HSA owner uses the account in a manner similar to a checking or debit account to cover his or her (or his or her family’s) medical expenses.
High deductible health plan (HDHP)—A high-deductible health plan is reflective of a certain insurance principle: the higher a plan’s deductible, the lower the plan’s premium. Those covered by an HDHP pay a higher deductible—a greater share of their own health care costs—before the plan pays any benefits.
Homebound—Normally unable to leave one’s home. Leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as a trip to the barber. Home health agency—An organization that provides home care services, including skilled nursing care, physical therapy, occupational therapy, speech therapy, and care by home health aides.
Home health care—Skilled nursing care and certain other health care that a person gets in his or her home for the treatment of an illness or injury.
Hospital Insurance (Medicare Part A) (HI)—It helps to cover the costs of inpatient care in a hospital, skilled nursing facility care (but not for custodial or long-term care), hospice care, some home health care, and inpatient care in a religious nonmedical health care institution.
Initial enrollment period (IEP)—This is the first opportunity to actively sign-up for Medicare. The IEP is the seven-month period that begins three months before one turns 65, includes the birth month, and ends three months after the birth month. Inpatient care—Health care that a person gets when admitted to a hospital.
Lifetime reserve days—Sixty days that Medicare will pay for when an insured is in a hospital for more than 90 days. These 60 reserve days can be used only once during a lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Limiting charge—The highest amount of money an insured can be charged for a covered service by doctors and other health care providers who don’t accept assignment. The limit is 15 percent over Medicare’s approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.
Long-term care—A variety of services that help people with health or personal needs and activities of daily living over a certain period. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare does not pay for this type of care.
Medicaid—A joint federal and state program that helps with medical costs for some people with low incomes. Programs vary from state to state, but most health care costs are covered if insureds qualify for both Medicare and Medicaid.
Medicare—A health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD) (people with permanent kidney failure who need dialysis or a transplant). Medicare Advantage (Medicare Part C) (MA)—An alternative to Original Medicare, this component of the Medicare program “bundles” the provisions and benefits of Medicare Part A and Part B (and often Part D) in an all-inclusive plan sold by private insurance companies.
Medicare Advantage plan (MA)—A Medicare program that gives the Medicare recipient more choices among health plans. Everyone who has Medicare Part A and Part B is eligible, except those who have end-stage renal disease (unless certain exceptions apply). Medicare Advantage plans were formerly called Medicare+Choice plans.
Medicare Advantage Prescription Drug Plan (MAPD)—A Medicare Advantage plan that includes prescription drug coverage in the plan.
Medicare Advantage (Medicare Part C) (MA)—An alternative to Original Medicare, this component of the Medicare program “bundles” the provisions and benefits of Medicare Part A and Part B (and often Part D) in an all-inclusive plan sold by private insurance companies.
Medicare Part D (PD)—This is the component of the Medicare program that provides coverage and benefits for prescription drugs. Part D coverage is provided by private insurance companies in the form of a separate plan that beneficiaries can purchase or as part of a Medicare Advantage plan in which beneficiaries can enroll.
Medicare-approved amount—The fee Medicare sets as reasonable for a covered medical service. This is the amount that the insured and Medicare pay a doctor or supplier for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the “approved charge.”
Medicare carrier—A private company that contracts with Medicare to pay Part B bills.
Medicare+Choice plans—Alternatives to the Original Medicare plan, these plans are health care plans, such as Medicare managed care plans or Medicare private fee-for-service plans, offered by a private company and approved by Medicare. The name of these plans changed to Medicare Advantage by MMA 2003.
Medicare managed care plan—Health care choices (like HMOs) in some areas of the country. In most plans, insureds can only go to doctors, specialists, or hospitals on the plan’s list. Plans must cover all Medicare Part A and Part B health care. Some plans cover extras, like prescription drugs. Insureds’ costs may be lower than in the Original Medicare plan.
Medicare private fee-for-service plan—A private insurance plan that accepts people with Medicare. Insureds can go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what insureds pay for the services they get. Insureds may pay more for Medicare-covered benefits. They may also have extra benefits the Original Medicare plan does not cover.
Medicare Summary Notice—A notice that insureds get after the doctor files a claim for Part A and Part B services in the Original Medicare plan. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get a notice called a Notice of Utilization.
Medigap policy—A Medicare supplement insurance policy sold by private insurance companies to fill “gaps” in Original Medicare plan coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are ten standardized plans labeled Plan A through Plan N. Medigap policies only work with the Original Medicare plan.
MOON—Medicare Outpatient Observation Notice—A new way of informing hospital patients that they are in the hospital coded under an “observation” status, rather than an “admitted” status, and why they are coded as “observational.” Observation status means that the patient loses the extended care benefits of skilled care in a skilled care facility. Previously, hospitals did not have to notify patients of this coding, but as of October 1, 2015, they must now notify patients who are in the hospital more than 24 hours.
Open enrollment period (Medigap)—A one-time only, six-month period after insureds enroll in Medicare Part B. Insureds must be age 65 or older, at which time they can buy any Medigap policy they want. They cannot be denied coverage or charged more due to health history during this time.
Open enrollment period (Medicare)—Effective January 2019, the annual period during which a Medicare Advantage enrollee can change MA plans or return to Original Medicare and purchase a non-guaranteed Medicare supplement plan. The period runs from January 1 through March 31 every year.
Original Medicare plan—A pay-per-visit health plan that lets an insured go to any doctor, hospital, or other health care provider who accepts Medicare. The insured pays the deductible. Medicare pays its share of the Medicare-approved amount, and the insured pays his or her share of this amount (coinsurance). The Original Medicare plan has two parts—Part A (Hospital Insurance) and Part B (Medical Insurance).
Out-of-pocket (OOP)—These are expenses associated with medical care costs that are not covered by insurance and that an insured must pay for directly "out of pocket." Out-of-pocket expenses include deductibles, coinsurance, copayments, and any services that are not covered by the plan.
Personalized Prevention Plan Services (PPPS)—A feature of Medicare introduced in 2011, which allowed for an annual wellness and prevention doctor visit with no charge to the Medicare beneficiary.
Preferred provider organization (PPO)— A type of managed care health plan that provides health care to its members through a network of contracted health care providers, (except for an emergency) similar to an HMO. Unlike an HMO, services that are delivered to a PPO member from out-of-network providers are typically covered, but at higher rates than in-network providers.
Premium—The periodic payments to Medicare, to an insurance company, or to a health care plan for health care coverage.
Prescription Drug Plan (PDP)—A stand-alone prescription drug plan that includes only Part D benefits.
Preventive services—Health care to keep an insured healthy or to prevent illness, such as Pap tests, pelvic exams, yearly mammograms, and flu shots. MIPPA 2008 and PPACA 2010 expanded these preventive services benefits.
Primary care doctor—A doctor who is trained to give an insured basic care. The primary care doctor is the doctor an insured sees first for most health problems. The doctor makes sure that insureds get the care they need to stay healthy. The primary care doctor may also talk with other doctors and health care providers about the insured’s care and refer the insured to them. In many Medicare managed care plans, insureds must see their primary care doctor before they can see any other health care provider.
Private-fee-for-service—Original Medicare, wherein Medicare pays doctors directly for their services.
Private-fee-for-service plans—A type of Medicare Advantage plan, which until MIPPA 2008 allowed the enrollee to use any provider for services. MIPPA 2008 ordered MA plans to develop networks, which resulted in a large decrease in the number of enrollees in PFFS plans because of the reduction of PFFS plan offerings by the MA companies.
Skilled nursing care—This is a level of medical care or medical services that that only a trained medical professional can perform. Individuals who only need and receive assistance with the activities of daily living, such as bathing, eating, dressing, walking, and so on, are receiving custodial care, not skilled nursing care.
Skilled nursing facilities—A level of care that must be given or supervised by registered nurses. All of an insured’s needs are taken care of with this type of service. Examples of skilled nursing care are intravenous injections, tube feeding, oxygen, and changing sterile dressings on a wound. Any service that could be safely done by an average nonmedical person (or the insured him-or herself) without the supervision of a registered nurse is not considered skilled care.
Supplemental benefits—These are benefits that extend beyond what Original Medicare offers and are provided through Medicare Advantage plans. Supplementary Medical Insurance (Medicare Part B) (SMI)—A component of Medicare, Part B covers medical services and supplies that are considered medically necessary. Such services can include outpatient care, preventive services, ambulance services, and durable medical equipment. It also covers part-time or intermittent home health and rehabilitative services, such as physical therapy, if ordered by a doctor.
Urgently needed care (also called urgent care)—Care that an insured gets for a sudden illness or injury that needs medical care right away but that is not life threatening. The insured’s primary care doctor generally provides urgently needed care if the insured is in a Medicare health plan other than the Original Medicare plan. If the insured is out of the plan’s service area for a short time and cannot wait until he or she returns home for care, then the health plan must pay for urgently needed care.
“Welcome to Medicare” physical—a benefit of Medicare that allows a new enrolled to receive a Medicare paid-for visit to a doctor within 12 months of being enrolled. The physical is designed as a wellness feature to alert both enrollee and physician about the need for preventive care in several instances.
