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. 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 Original Medicare must use when you ask for an appeal.
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. Medicare will pay their portion and you will pay your portion for the Medicare covered service.
BENEFIT PERIOD: 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 consecutive days. 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.
CARRIER: A private company that has a contract 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
CO-INSURANCE: An amount you may be required to pay as your share of the costs for services after you pay any deductibles.
CO-PAYMENT: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit or a prescription. It is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
CUSTODIAL CARE: 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.
DEDUCTIBLE: The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or any 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 requiring dialysis or a kidney transplant.
FORMULARY: A list of drugs covered by a plan. Also referred to as drug list.
GUARANTEED ISSUE RIGHTS: Also called “Medigap Protections” Rights you have in certain situations when insurance companies are required by law to offer you certain Medigap policies even if you have health problems and must cover any pre-existing conditions. An insurance company must sell you a Medigap policy, cover all your pre-existing health conditions, and can’t charge you more for a Medigap policy because of past or present health problems.
HIPAA: HIPAA initials stand for Health Insurance Portability and Accountability Act of 1996. A Federal law passed in 1996 that allows individuals 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.
HEALTH MAINTENANCE ORGANIZATION (HMO): A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, you 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.
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 limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
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: Also known as Part C. A type of Medicare health plan offered by a private company that contract with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage
MEDIGAP POLICY: A Medicare supplements health insurance sold by private insurance companies to fill ‘gaps’ in Original Medicare. Medigap policies can help pay share or cover certain benefits Medicare doesn’t cover. There are 11 standardized Medigap policies (Plan A, B, C, D, F, F+, G, K, L, M, N), that individuals can chose from that offer basic as well as detailed additional benefits per plan.
ORIGINAL MEDICARE: A Federal run health insurance program for people 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD). Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
PRE-EXISTING CONDITION: Any prior medical conditions for which the applicant should have received medical care within a reasonable amount of time prior to the effective date of a policy.
PREFERRED PROVIDER ORGANIZATION (PPO): A type of Medicare Advantage Plan (Part C) available in some areas of the country in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
PREMIUMS: A payment or periodic payments made by the policy owner to keep an insurance policy in effect.
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 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.
SPECIALIST: A doctor who treats only certain areas of the body, certain health problems, or 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 time period when you are not covered by insurance for a specific