An ambulatory surgical center is the location or facility where specific surgeries can be performed for people who aren’t expected to need more than 24 hours of care.
An appeal is a chosen action people take if they disagree with a payment or coverage decision made by a Medicare health plan, Medicare Prescription Drug Plan or by Medicare. Appeals can be available if Medicare or your plan denies one of the following: A request for a prescription drug, health care service, supply, or...
An assignment is agreement by your provider, supplier or doctor to be reimbursed directly from Medicare, to receive the payment amount that Medicare approves for the service, and to not send you a bill for any more than Medicare’s coinsurance and deductible.
The benefit period is the way that Original Medicare calculates your use of skilled nursing facility (SNF) and hospital services. Benefit period starts the day of admission to a hospital or SNF as an inpatient. Benefit periods end when people haven’t received any skilled care in a SNF or hospital care for 60 days in...
A claim is a request for payment that people submit to health insurance or to Medicare when you receive services (or items) that you believe are covered.
A clinical breast exam is an exam conducted by your physician or other health care provider. It is done in order to check for breast cancer by looking at and physically examining an individual’s breasts. This exam is not a mammogram. Breast exams are typically done in a doctor’s office during a pelvic exam and...
Your coinsurance is the amount people may be required to pay as their share of the cost for services once they have paid any deductibles. Coinsurance is typically calculated as a percentage (i.e., 20%).
A copayment is the amount people are required to pay as their share of the cost for medical supplies or services. Examples include doctor visits, hospital outpatient visits, or prescription drugs. Copayments are typically a set amount (instead of a percentage). An example would be paying $15 or $25 for a visit to your doctor...
A coverage gap (also known as the “Donut Hole“) is the period of time that people will pay a higher cost sharing for their prescription drugs until they have spent enough to qualify for catastrophic coverage. It begins when you and your plan have spent a set dollar amount for your prescription drugs during that...
Creditable coverage is when you’ve had previous health insurance coverage that can be used to decrease a pre-existing condition waiting period under a Medicare Supplement policy.
Creditable prescription drug coverage is prescription drug coverage (i.e., employer or union coverage) that’s expected to pay (usually on average) at least as much as standard prescription drug coverage from Medicare. If you have have this type of coverage when you become eligible for Medicare, you can typically keep that coverage and not pay a...
A critical access hospital is small facility that offers outpatient services and inpatient services to people in rural areas on a limited basis.
With custodial care, you get non-skilled personal care and in most cases, Medicare will not pay for custodial care. Custodial care involves things like helping with activities of daily living. For example, getting in or out of a bed or chair, bathing, eating, dressing, using the bathroom, and moving around. It may also include the...
The deductible is the specific amount of money that you must pay for prescriptions or health care before Original Medicare, your drug plan or an insurance company will pay a claim.
A deductible is the dollar amount people must pay for prescriptions or health care before Original Medicare, other insurance, or your drug plan will begin to pay.
Durable medical equipment are specific types of medical equipment, like a hospital bed, wheelchair or walker that’s ordered by your physician for use in your home.
End-Stage Renal Disease is permanent kidney failure that will require a kidney transplant or a regular course of dialysis.
People who have Original Medicare, and the amount a health care provider or physician is legally permitted to charge is more than the Medicare-approved amount, the difference is called an excess charge. Part B Excess charges happen when a doctor overcharges Medicare more than the Medicare-approved amount. Physicians who accept “assignment” have agreed to accept...
A formulary is a list of prescription drugs that are covered by your prescription drug plan or other health insurance plans which provide prescription drug benefits.
A group health plan is typically a health plan that is offered by an employer or employee organization. It provides health care coverage to employees and their families.
Guaranteed Issue rights (also called “Medigap protections”) are the rights you have in certain situations. These situations occur when insurance companies are required by law to offer or sell you a Medigap policy. With these situations, an insurance company can’t deny you a Medicare Supplement policy. They also can’t place conditions on your Medicare Supplement...
A guaranteed renewable policy is one that can’t be terminated by the insurance carrier unless you don’t pay your premiums, commit fraud or provide untrue statements to the insurance company. All Medicare Supplement policies issued from 1992 to now are guaranteed renewable.
A health care provider is an organization or person that’s licensed to provide health care. Examples of health care providers are nurses, doctors, and hospitals.
An HMO is a type of MAPD (known as a Medicare Advantage Plan or Part C) that is available in specific areas of the country. Most HMOs, you will only be able to go to physicians, specialists, or hospitals on the MAPD plan’s list except for emergencies. Most HMOs will also require a referral from...
A home health agency is an organization that provides home health care.
Home health care are supplies and services a physician decides that you may receive in your home under a plan of care that is established by your physician. Medicare will only cover home health care on a limited basis as ordered by your physician.
Hospice is a special way of caring for people when they are terminally ill. Hospice care is provided in a team-oriented approach. It addresses the emotional, medical, social, physical, and spiritual needs of the terminally ill patient. It also provides support for the patient’s family or caregiver.
An inpatient rehabilitation facility is a hospital, or part of a hospital, that provides intensive rehabilitation services to inpatients.
The Insurance Department is a state by state agency that regulates insurance. They can provide info about Medigap policies as well as other private health insurance.
In Original Medicare, lifetime reserve days are extra days that Medicare pays for when people are in a hospital for more than 90 days. People have a total of 60 reserve days that can be used during an individual’s lifetime. For every lifetime reserve day, Medicare will pay for all covered costs except for a...
With Original Medicare, a Limiting Charge refers to the highest amount of money you can be charged (15% over Medicare’s approved amount) for a covered service by physicians and other health care suppliers who don’t accept assignment. This charge only applies to certain services and will not apply to equipment or supplies.
A Living Will is a written legal document (also known as an “advance directive” or “medical directive”) that shows the type of treatments you want authorized (or don’t want) in situations where you can’t speak for yourself. A common example is whether you want life support. The living will typically comes into effect only if...
Long-term care (or LTC) are services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living. Examples of these activities include dressing, bathing, feeding. LTC services can be provided in the community, at home, in assisted living, or in nursing homes. People may need LTC at...
A long-term care hospital is an acute care hospital that provides treatments for people who stay, on average, more than 25 days. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management. Most patients are transferred from an intensive or critical care unit.
Medicaid is the joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, which includes nursing home care and personal care services. Medicaid varies from state to state, but most health care costs are covered if you qualify...
Medically necessary is defined as the standard that Medicare uses to determine coverage of health care services or supplies used to diagnose or treat a disease, injury, condition, illness or its symptoms.
Medicare is the U.S. federal health insurance program for: Individuals who are 65 or older Certain people under 65 with disabilities Individuals with End-Stage Renal Disease
Medicare Advantage, also called Medicare Part C or MAPD; this type of Medicare health plan is offered by a private companies that contract with Medicare. MAPD plans provide all of your Part A and Part B benefits. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare Part A will cover inpatient hospital stays, hospice care, care in a skilled nursing facility, and some home health care.
Medicare Part B (Medical Insurance) covers certain doctors’ services, medical supplies, outpatient care, and preventive services.
The Medicare SELECT plan is a kind of Medigap policy that may require you to use hospitals and, in some situations, physicians within its network in order to be eligible for full benefits.
A Medicare Special Needs Plan (SNP) is a special type of Medicare Advantage Plan (Part C) that gives more focused and specialized health care for certain groups of people. For example, those who have both Medicaid & Medicare, have certain chronic medical conditions, or who reside in a nursing home.
Medicare-approved amount, with Original Medicare, this is the amount a physician or supplier that accepts assignment can be paid. It can be less than the dollar amount a physician or supplier charges. Medicare will pay part of this amount and you will be responsible for the difference.
Medigap (also called Medicare Supplement Insurance) is sold by private insurance companies to fill in the coverage “gaps” of Original Medicare.
Medigap Open Enrollment Period is a one-time only, 6-month period when federal law allows you to purchase any Medigap (Medicare Supplement) policy that’s sold in your state. It begins in the 1st month that you’re covered under Medicare Part B & you’re age 65 or older. During this period, you can’t be denied a policy...
Original Medicare is a fee-for-service health plan that is structured into two parts: Part A (Hospital Insurance) Part B (Medical Insurance). Once you pay a deductible, Medicare will pay its share of the Medicare-approved amount while you pay your share of the Medicare-approved amount (the coinsurance and deductibles).
Your out-of-pocket costs are your health care or prescription drug costs that you are required to pay on your own. These are the drug costs that will not be paid by Medicare or other insurance.
A Pap test is an exam to check for cancer of the cervix (the opening to a woman’s uterus). It’s completed by taking cells from the cervix. These cells are then prepared so they can be examined under a microscope.
Part D drug plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans. Part D adds prescription drug coverage to: Original Medicare Some Medicare Cost Plans Some Medicare Private-Fee-for-Service Plans Medicare Medical Savings...
A Pelvic exam is an examination to see if a female’s internal organs are normal. It is done by feeling the organ’s shape and size.
A Penalty is the dollar amount added to the monthly premium for your Part B or Part D Medicare drug plan if you don’t join when first eligible. You will have to pay this penalty amount as long as you have Medicare, however there are some exceptions.
A Medicare Preferred Provider Organization (PPO) Plan is a type of MAPD plan (Part C) which is available in some areas of the country. With a PPO, you pay less if you use the hospitals, physicians, and other health care providers that are on the plan’s network. For an additional cost, you may use physicians,...
A pre-existing condition is any health problems that occur before the date that new health coverage begins.
A premium is the periodic payment that you will pay to either Medicare, an insurance company, or a health care plan for prescription drug or health coverage.
A primary care physician (PCP) is the doctor people see first for the majority of health problems. The PCP objective is to make sure you’re getting the care you need in order to stay healthy. Your PCP may also communicate with other physicians and health care providers about your care and refer you to them....
A prior authorization is the approval that is required from a Medicare drug plan prior to filling a prescription. This is needed in order for your prescription to be covered by your PDP plan. The Medicare drug plan may request prior authorization for specific drugs.
The Medicare Private Fee-For-Service (PFFS) Plan is a type of Medicare Advantage Plan (Part C). This type of MAPD plan typically allows you to see any doctor or hospital you could go to if you had Original Medicare, if the doctor or hospital agrees to treat you. This plan will determine how much it will...
A referral is a written order from your primary care physician that is needed in order for you to get certain medical services or see a specialist. In the majority of Health Maintenance Organizations (HMOs), you are required to get a referral prior to receiving medical care from anyone except your primary care physician. If...
Rehabilitation services are categorized as health care services that help you retain, improve, or get back skills and functioning for daily living that have been impaired or lost because or illness, injury, or disability. Rehab services can include: Physical (PT) Occupational therapy (OT) Speech-language pathology (SLP or ST) Psychiatric rehabilitation services These rehab services can...
Respite care is the temporary care provided in a hospital, hospice inpatient facility, or nursing home. Respite care is available so that a family member or friend who is the patient’s caregiver can rest or take a little time off from providing care.
The secondary payer is the insurance policy, program, or plan that pays 2nd on a medical care claim. Medicare, Medicaid, or other insurance could be the secondary payer depending on the situation.
A service area is the geographic location where an insurance plan accepts members if it limits membership based on where people live. This plan may disenroll you if you move out of the plan’s service area. For plans that limit which hospitals and physicians you have access to, it’s also typically the area where you...
Skilled nursing care includes care that may only be provided by a physician or registered nurse (like intravenous injections).
A skilled nursing facility (SNF) is a nursing facility that has the staff and equipment needed to provide skilled nursing care. In most cases, they also provide skilled rehabilitative services & other related health services.
The State Health Insurance Assistance Program (SHIP) is a state program that receives money from the federal government to provide local health insurance counseling to people with Medicare at no cost.
Step therapy is defined as a coverage rule used by some Medicare Prescription Drug Plans. They require you to try 1 or more similar, but lower priced drugs to treat your health condition before the plan will cover the prescribed drug.
Supplemental Security Income (SSI) is a monthly benefit that is paid by Social Security. It’s paid to individuals with limited resources & income with disabilities, who are blind, or 65 years old or older. SSI benefits are different from Social Security retirement or disability benefits.
A supplier is typically any person, agency, or company that provides you a service or medical item, except for when you’re an inpatient in a skilled nursing facility or hospital.
Tiers are groups of drugs that have a different cost for each tiered group. Usually, a drug in a lower tier will be less expensive compared to a drug that’s in a higher tier.
Underwriting is the process that an insurer uses to decide, based on an applicant’s medical history, whether the insurance company can offer a policy, whether to add a waiting period for a pre-existing health condition (if your state law allows it), and how much your premium will cost for that insurance.
Urgently needed care is the type of care that people get outside of the Medicare health plan’s service area for a sudden injury illness that requires immediate medical care but isn’t life threatening. If it’s unsafe to wait until you get home to get care from your plan doctor, the health plan must pay for...
Workers’ compensation is an insurance plan that requires employers to cover employees who get injured or ill on the job.
