Glossary

A plan sponsor must offer a prescription drug plan that is actuarially (a term relating to the statistical calculation of risk) the same or better than the Medicare Part D prescription drug plan

A doctor, hospital, or other health care provider that agrees to accept the plan's terms and conditions related to payment and that meets other requirements for coverage.

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 already received, and Medicare or the health plan denies the request.  You can also appeal if you are already receiving coverage and Medicare or the plan stops paying.  There are specific processes your Medicare Advantage Plan, other Medicare Health Plan, Medicare drug plan, or the Original Medicare plan must use when you ask for an appeal. 

In the Original Medicare Plan, this means a doctor or supplier agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.

MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)

The name for a person who has health care insurance through the Medicare or Medicaid program.

A “benefit period” begins the day you go to a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF 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.

A private company that has a contract with Medicare to pay your physician and most other Medicare Part B bills.

Once your total drug costs reach the $5451.25 maximum, you pay a small coinsurance (like 5%) or a small co-payment for covered drug costs until the end of the calendar year.

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

An individual designated by CMS to conduct the appeals process for a claim dispute

The amount you may be required to pay for services after you pay any plan deductibles. In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare approved amount. You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent.

A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physician's services, physical therapy, social or psychological services, and outpatient rehabilitation.

Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.

In some Medicare health and prescription drug plans, the amount you pay for each medical service, like a doctor’s visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor’s visit or prescription. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.

In some Medicare health and prescription drug plans, the amount you pay for each medical service, like a doctor’s visit, or prescription. 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 the Original Medicare Plan.

The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and/or deductibles.

An individual who is (or was) provided coverage under a group health plan. See also Group Health Plan, Retiree.

Health coverage you have had in the past, such as group health plan (including COBRA continuation coverage), an HMO, an individual health insurance policy, Medicare or Medicaid, and this prior coverage was not interrupted by a significant break in coverage. The time period of this prior coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan. Proof of your creditable coverage may be shown by a certificate of creditable coverage or by other documents showing an individual had health coverage, such as a health insurance ID card. See also Certificate of Creditable Coverage.

Is health coverage that you had in the past that gives you certain rights when you apply for new coverage. 

Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy. (See pre-existing conditions.)

Prescription drug coverage (like from an employer or union), that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.

A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.

Nonskilled, 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. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or other insurance begins to pay. For example, in Original Medicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year.

A list of drugs covered by a plan. This list is also called a formulary.

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.

A private company that contracts with Medicare to pay bills for durable medical equipment.

Your decision to join or leave the Original Medicare Plan or a Medicare+Choice plan.

Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

A term used to describe the electronic transfer of monies from one financial institution to another.

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

A term used to cover all of the partner company activities involved in developing the Retiree Drug Subsidy Program (RDS) and administering its various aspects such as enrollment, payments, appeals, etc. ERISA - Employee Retirement Income Security Act of 1974 (ERISA)

If you are in the Original Medicare Plan, this is the difference between a doctor?s or other health care provider?s actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.

A fast decision from the Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.

A private company that has a contract with Medicare to pay Part A and some Part B bills (for example, bills from hospitals).  (Also called "Intermediary")

A list of drugs covered by a plan.

A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered (see Appeal).

A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.

An employee (or retiree) benefit plan established or maintained by an employer, an employee organization (such as a union), or a church group that provides medical care to employees and their dependents directly or through insurance (including and HMO), reimbursement or otherwise.

A number that will be assigned to all group health plans in the future by the CMS division administering the transactions, code sets, security and administrative simplification portions of the Health Insurance Portability and Accountability Act (HIPAA) GSA - General Services Administration

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.

A right you have that requires your insurance company to automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud or don’t pay your premiums.

A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS 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 information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.

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 the Original Medicare Plan.

This treatment is usually done in a dialysis facility but can be done at home with the proper training and supplies. HD uses a special filter (called a dialyzer or artifical kidney) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body (See dialysis and peritoneal dialysis.).

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.

A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver as well. Hospice care is covered under Medicare Part A (Hospital Insurance).

Health care that you get when you are admitted to a hospital or skilled nursing facility.

In the Original Medicare Plan, a total of 60 extra days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, you don't get any more extra days during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($456 in 2005).

In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.

A variety of services that help people with health or personal needs and activities of daily living over a period of time. 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 doesn’t pay for this type of care if this is the only kind of care you need.

A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.

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 mainly for the convenience of you or your doctor.

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.

A Medicare Advantage plan that offers Medicare Prescription Drug coverage and Part A and Part B benefits in one plan.

A Medicare Advantage HMO or PPO Plan.

Medicare cost plans are a type of HMO that contracts as a Medicare Health Plan. As with other HMOs, the plan only pays for services outside its service area when they are emergency or urgently needed services. However, when you are enrolled in a Medicare Cost Plan, if you get routine services outside of the plan's network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan, and you will be responsible for the Original Medicare deductibles and coinsurance.

Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).)

A plan offered by a private company that contracts with Medicare to provide you with your Medicare Part A and/or Part B benefits.Medicare Health Plans include Medicare Advantage plans (including HMO, PPO, or Private Fee-for-Service Plans); Medicare Cost Plans; PACE plans; and special needs plans.

A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care plans, you 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 managed care plans cover extras, like prescription drugs. Your costs may be lower than in the Original Medicare Plan.

Optional coverage available to all people with Medicare through insurance companies and other private companies.

A stand-alone drug plan, offered by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan; Medicare Private Fee-for-Service Plans that don’t offer prescription drug coverage; and Medicare Cost Plans offering Medicare prescription drug coverage.

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

A notice you get after the doctor or provider 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.

In the Original Medicare Plan, this is the amount a doctor or supplier can be paid, including what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount charged by a doctor or supplier.

A one-time-only six month period when you can buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can’t be denied coverage or charged more due to past or present health problems.

Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 standardized plans labeled Plan A through Plan L. Medigap policies only work with the Original Medicare Plan.

Drugs not on a plan-approved drug list.

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. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Medical or surgical care furnished by a hospital to you if you have not been admitted as an inpatient but are registered on hospital records as an outpatient. If a doctor orders that you must be placed under observation, it may be? considered outpatient care, even if you stay under observation overnight.

An amount added to your monthly premium for Medicare Part B, or for a Medicare Prescription Drug Plan, if you don’t join when you’re first able to. You pay this higher amount as long as you have Medicare. There are some exceptions.

Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included.

The person who is responsible for the management of the plan. The plan administrator is a person specifically designated by the terms of the plan. If the plan does not make such a designation, then the plan sponsor is generally the plan administrator.

Generally, the employer, the employee organization, (such as a union), or other entity that establishes or maintains an employee benefit plan, including a group health plan. See also Sponsor.

An HMO option that lets you use doctors and hospitals outside the plan for an additional cost.

A health problem you had before the date that a new insurance policy starts.

A type of Medicare Advantage Plan in which pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

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

Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms).

A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she may talk with other doctors and health care providers about your care and refer you to them. In many HMOs, you must see your primary care doctor before you can see any other health care provider.

A type of Medicare Advantage Plan in which you may 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 you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn’t cover.

PACE combines medical, social, and long-term care services for frail people to help people stay independent and living in their community as long as possible, while getting the high-quality care they need. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must

• be 55 years old or older,

• live in the service area of the PACE program,

• be certified as eligible for nursing home care by the appropriate state agency, and

• be able to live safely in the community.

Generally, qualified beneficiaries include covered employees, their spouses and their dependent children who are covered under the group health plan. In certain cases, retired employees, their spouses and dependent children may be qualified beneficiaries.

Quality is how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person—and getting the best possible results.

Groups of practicing doctors and other health care experts. They are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for-Service Plans, and ambulatory surgical centers. These doctors also review fast-track termination decisions in comprehensive outpatient rehabilitation facilities, skilled nursing facilities, and home health and hospice settings for people in Medicare Health Plans.

A written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for your care.

A private company that contracts with Medicare to pay home health and hospice bills under Original Medicare and check on the quality of home health care.

Rehabilitative services are ordered by your doctor to help you recover from an illness or injury. These services are given by nurses and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.

an individual who is provided coverage under a group health plan after that individual has retired.

The way that payments to health plans are changed to take into account a person's health status.

This is when another doctor gives his or her view about what you have and how it should be treated.

An 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.

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan?s service area.

The area where a Medicare Private Fee-for-Service plan accepts members.

A general description of the types of services provided under the service and/or the characteristics that define the service category.

A problem caused by treatment. For example, medicine you take for high blood pressure may make you feel sleepy. Most treatments have side effects.

Generally, a significant break in coverage is a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual’s coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage.

A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.

A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.

This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, can’t be provided on an outpatient basis. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.

A special type of health plan that provides the full range of Medicare benefits offered by standard Medicare HMOs, plus other services that include the following: prescription drug and chronic care benefits, respite care, and short-term nursing home care; homemaker, personal care services, and medical transportation; eyeglasses, hearing aids, and dental benefits.

A set time that a beneficiary can change health plans or return to the Original Medicare Plan, such as: you move outside the service area, your Medicare+Choice organization violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election Periods; Enrollment; Special Enrollment Period (SEP).)

A set time when you can sign up for Medicare Part B if you didn?t take Medicare Part B during the Initial Enrollment Period, because your or your spouse were working and had group health plan coverage through the employer or union. You can sign up at anytime you are covered under the group plan based on current employment status. The last eight months of the Special Enrollment Period starts the month after the employment ends or the group health coverage ends, whichever comes first.

A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.

This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance doesn?t fill gaps in your Medicare coverage.

A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

Treatment to regain and strengthen speech skills.

An entity that sponsors a health plan. This can be an employer, a union, or some other entity.

Free or low-cost health insurance is available now in your state for uninsured children under age 19. State Children?s Health Insurance Programs help reach uninsured children whose families earn too much to qualify for Medicaid, but not enough to get private coverage. Information on your state?s program is available through Insure Kids Now at 1-877-KIDS NOW (1-877-543-7669). You can also look at www.insurekidsnow.gov on the web for more information.

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

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

A state agency that is in charge of the state’s Medicaid program and can give information about programs that help pay medical bills for people with low incomes.

A state program that provides people assistance in paying for drug coverage, based on financial need, age or medical condition and not based on current or former employment status. These programs are run and funded by the states.

Agency that inspects dialysis facilities and makes sure that Medicare standards are met.

A type of program, available through the Federal Department of Housing and Urban Development and some States, to help people with low or moderate incomes pay for housing.

A monetary grant paid by the government to a private person or company to assist an enterprise deemed advantageous to the public

Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.

Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.

To have lower costs, many plans place drugs into different "tiers," which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers.

Example:

• Tier 1 - Generic drugs. Tier 1 drugs will cost you the least amount.
• Tier 2 - Preferred brand-name drugs. Tier 2 drugs will cost you more than Tier 1 drugs.
• Tier 3 - Non-preferred brand-name drugs. Tier 3 drugs will cost you more than Tier 1 and Tier 2 drugs.

Something done to help with a health problem. For example, medicine and surgery are treatments.

The choices you have when there is more than one way to treat your health problem.

A health care program for active duty and retired uniformed services members and their families.

Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.

A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. 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.

A claim submitted for a service or supply by a provider who does not accept assignment.

Care that you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than the Original Medicare Plan. If you are out of your plan's service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.

The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data is collected.

The period that must pass before an employee or dependent is eligible to enroll (becomes covered) under the terms of the group health plan. If the employee or dependent enrolls as a late enrollee or on a special enrollment date, any period before the late or special enrollment is not a waiting period. If a plan has a waiting period and a pre-existing condition exclusion, the pre-existing condition exclusion period begins when the waiting period begins. Days in a waiting period are not counted toward creditable coverage unless there is other creditable coverage during that time. Days in a waiting period are not counted when determining a significant break in coverage.

Insurance that employers are required to have to cover employees who get sick or injured on the job.

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