Medicare Insurance Glossary
APPEAL: A special kind of complaint you make if you disagree with certain kinds of decisions made by Original Medicare or by your health plan. You can appeal if you request a health care service, supply or prescription that you think you should be able to get from your health plan, or you request payment for health care you've already received, and Medicare or the health plan denies the request.
ASSIGNMENT: In Original Medicare, this means a doctor or supplier agrees to accept the Medicare-approved amount as full payment. If you are in Original Medicare, it can save you money if your doctor accepts assignment. BENEFICIARY: The person who has health care insurance through the Medicare or Medicaid program.
BENEFIT PERIOD: A "benefit period" begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven't received any hospital care for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods.
CARRIER: A private company that has contracted with Medicare to pay your physician and most other Medicare Part B bills.
CERTIFICATE OF CREDITABLE COVERAGE: A written certificate issued by a group health plan or health insurance issuer (including an HMO) that states the period of time you were covered by your health plan. COINSURANCE: The amount you may be required to pay for services after you pay any plan deductibles. In Original Medicare, this is a percentage (like 20%) of the Medicare approved amount.
CO-PAYMENT: A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor's visit or prescription. Co-payments are also used for some hospital outpatient services in Original Medicare. COST SHARING: The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and or deductibles.
CUSTODIAL CARE: Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. In most cases, Medicare will not pay for custodial care.
DEDUCTIBLE: The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or other insurance begins to pay.
DRUG LIST: A list of drugs covered by a plan. This list is also called a formulary.
DURABLE MEDICAL EQUIPMENT (DME): Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.
ELECTION: Your decision to join or leave Original Medicare or a Medicare Advantage plan.
END-STAGE RENAL DISEASE (ESRD): Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
FORMULARY: A list of drugs covered by a plan. Also referred to as drug list.
GUARANTEED ISSUE RIGHTS: Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can't deny you a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can't charge you more for a policy because of past or present health problems.
HIPAA: A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. HIPPA stands for Health Insurance Portability and Accountability Act of 1996.
HEALTH MAINTENANCE ORGANIZATION (HMO): A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan's list except in an emergency. Your costs may be lower than in Original Medicare.
HOME HEALTH CARE: Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
INPATIENT CARE: Health care that you receive when you are admitted to a hospital or skilled nursing facility.
MEDICAID: A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources.
MEDICALLY NECESSARY: Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren't primarily for the convenience of you or your doctor.
MEDICARE ADVANTAGE PLAN: A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare.
MEDIGAP POLICY: Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare coverage. Medigap policies only work with Original Medicare. There are 12 standardized plans labeled Plan A through Plan L, Except in Massachusetts, Minnesota, and Wisconsin.
ORIGINAL MEDICARE: A fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
PRE-EXISTING CONDITION: A health condition that you had before the date that a new insurance policy starts.
PREFERRED PROVIDER ORGANIZATION (PPO): A type of Medicare Advantage Plan in which you will pay less if you use doctors, hospitals, and providers that belong to the network.
PRIMARY CARE DOCTOR: A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health care. Your PCP may refer you to a specialist or other facility for specialized care. With most HMOs, you must see your primary care doctor before you can see any other health care provider.
SPECIALIST: A doctor who treats only certain parts of the body, certain health problems, or certain age groups.
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.
WAITING PERIOD: A period of time when you are not covered by insurance for a particular problem.