Medicare Glossary – Reference Medicare Terms and Definitions

A process where an accredited organization evaluates health care facilities’ policies, performance and procedures. This ensures integrity and high standards are met.

This is a notice given by a doctor, supplier or health care provider to a Medicare beneficiary before providing a service or product for which Medicare may deny payment. If you are not given an ABN before you receive the product or service and Medicare denies payment, you may not have to pay for that product or service.

If you accept an ABN by signing it and Medicare denies payment, you will probably have to pay for the product or service.

ABN’s only apply if the beneficiary is enrolled in Original Medicare Parts A and B.

If you are covered under a Medicare Advantage Plan (Part C), this notice will inform you in advance whether or not you are covered for a particular service.

This is not related to an ABN which only applies to Original Medicare.

ALS stands for amyotrophic lateral sclerosis – a degenerative disease also known as Lou Gehrig’s disease.

A public or private facility where certain procedures may be performed for patients who need less than 24 hours of care.

Chest pain caused by insufficient blood flow to the heart.

A procedure used to open or treat a blocked artery.

You can appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare Prescription Drug Coverage or your Medicare health plan.

An agreement where Medicare pays your doctor, supplier or provider directly – they have accepted the approved Medicare payment amount and will not bill you more than the deductible and coinsurance.

Medicare Glossary – PMB Senior Services

A person Medicare or Medicaid health care insurance.

The benefit period begins the day you are admitted as a hospital or skilled nursing facility inpatient. The period ends when you have not received this care for 60 days in a row.

You must pay the hospital deductible for each benefit period – there is no limit to the number of benefit periods.

Covered items or services under a health insurance plan. Benefits you are entitled to are contained in the insurance plan/policy documents.

The CMS is a federal agency responsible for administering Medicare, Medicaid and Children’s Health Insurance Programs.

Refer to the Medicare-certified-provider definition below in this Medicare glossary.

Health care benefits for dependents of qualifying veterans.

A payment request submitted to Medicare or other health insurance providers for covered services.

An examination to check for breast cancer. This exam is done by look and feel and is not the same as a mammogram. It is usually performed during your Pap test and pelvic exam.

After you have paid deductibles, you may be required to pay a coinsurance as well. This can be covered under a Medigap plan.

An outpatient services facility that includes physician services, physical therapy, rehabilitation and social/psychological services.

A sharing-of-costs mechanism to decide who pays first when two or more health insurance plans are responsible for paying the same claim.

An amount you have to pay as part of your share of the cost for medical services or product (like prescription drugs). Copayments are usually set amounts and can also be covered with a Medigap plan.

An inserted tube to treat coronary heart disease and keep an artery open.

An amount you may have to pay as your share of medical services or supply. This can include deductibles, copayments and coinsurance costs.

The first decision made by your Medicare drug plan about drug benefits;

• Is a particular drug covered?
• Have you met all the requirements for obtaining that drug?
• How much you are required to pay for that drug?

You are entitled to a prompt decision about the drug and you can appeal an unfavorable decision.

You are advised to call or write to your provider in this regard.

This gap – also known as the donut hole – is the period of time in which you pay higher cost sharing for prescription drugs until you qualify for catastrophic coverage.

This requirement will be completely phased out in 2020 – at this stage you will pay no more than 25% of the costs of your drugs throughout the entire year. 

This Medicare Glossary term refers to previous health insurance coverage used to shorten pre-existing condition waiting periods under a Medigap (Medicare Supplement Insurance) policy.

If you have prescription drug coverage from an employer or union that is considered “creditable” – you can keep this coverage without paying a penalty if you decide to enroll in Part D later.

For people living in rural area this is a small facility that provides outpatient services as well as limited inpatient services.

This Medicare Glossary term refers to non-skilled personal care, for example, help with eating, bathing, dressing etc.

Medicare does not cover custodial care.

Medicare Glossary – PMB Senior Services

If you do not have a Medigap policy that covers your deductible – this is the amount you have to pay before your Original Medicare benefits pay. This also applies to prescription drugs.

A provider or supplier who has been accredited by the Centers for Medicare and Medicaid Services.

These are special projects designed to test improvements for Medicare coverage.

Benefits that help pay the cost of dental care.

The federal agency that oversees and administers programs for protecting the health of all Americans.

Visit the HHS website.

A breast X-ray screening.

A privately contracted company to ensure greater Medicare efficiency regarding Durable Medical Equipment.

Also known as a formulary – a list of prescription drugs covered by a prescription drug plan.

DME is covered by Original Medicare Part B under home health services – this is special equipment prescribed by a doctor for use inside the home, for example, a wheelchair, walker, hospital bed etc.

This can be an important document and is helpful if you are unable to make your own decisions – a legal agreement that designates and names someone else to make health care decisions for you.

Your decision to join or leave Original Medicare or Medicare Advantage.

Plans that are offered by current or former employers or employee organizations (or a spouse’s).

Permanent kidney failure that requires regular dialyses or a kidney transplant.

Also known as a formulary exception – a drug plan’s decision to cover a drug that is not on its drug list. The insurer can therefor decide to waive their coverage rule.

When applying for an exception, you or the prescriber must get a supporting statement from your doctor.

The excess charged (if you have Original Medicare) where a doctor or health care provider can legally charge higher than the Medicare approved amount.

Medicare Glossary – PMB Senior Services

For people of lower income who qualify – Medicare will help with costs for prescription drug costs (Part D) like premiums, deductibles and coinsurance.

For the Medicare Glossary definition – refer to Drug List above.

A drug that is identical to the brand-name drug according to the Food and Drug Administration (FDA) regulations. These drugs usually cost less than the brand-name.

You can file a grievance if you have a complaint. For example, if you are unhappy with your interaction with your plan provider’s staff.

If you have an issue about service coverage, prescription or supply, you must file an appeal – refer to the Medicare Glossary; Appeal.

Offered by an employer or employee organization that provides health coverage to employees and their families.

In certain situations a health insurance company cannot deny or place conditions on a Medigap policy that you are entitled to. For example, pre-existing health conditions, and not being able to charge you more for a Medigap policy because of past or present health issues.

All Medigap policies issues since 1992 are guaranteed renewable – these policies cannot be terminated unless you make untrue statements to the insurer, commit fraud, or fail to pay your premiums.

A person or organization licensed to provide health care.

Generally under contract with a health insurance company or a government health program (like Medicare), you have a legal entitlement for payment or reimbursement of your health care costs. You are subject to the contract and conditions contained therein.

The Marketplace is a wide resource where you can obtain all information about your healthcare needs – visit HealthCare.gov

The so called Privacy Rule assures that your health information is adequately protected – while at the same time allowing for health information needed to provide and promote high quality health care.

Because of a lower premium, this policy has a higher deductible that you have to pay before the Medigap policy pays you. Be aware that the deductible amount can change each year.

A person who has been confined to their home due to illness or injury – you can leave your house for short or infrequent periods of time.

Medicare Glossary – PMB Senior Services

An organization providing home health care and services.

Care for people who are terminally ill.

Hospital outpatient services that include an emergency department, observation facilities, a pain clinic and surgery center.

Any condition that was treated during your inpatient hospital stay – it does not have to be the same reason as your initial admittance.

Sometimes called an Independent Review Entity – this is an organization that has no connection to your Medicare health plan or prescription drug plan. This an independent organization contracted with Medicare to review an appeal made by you.

Part D – when you have met your annual deductible, you will be liable to pay a copayment or coinsurance for each covered drug until you reach your plan’s out-of-pocket maximum. You will then enter the plan’s coverage gap or donut hole.

The donut hole requirement will be phased out in 2020.

In-network refers to a group of doctors, hospitals, pharmacies and other health care providers who have agreed to provide members of a certain health insurance plan with discounted prices. Some insurance plans require that you must use in-network providers to be covered.

Healthcare you receive when admitted to a hospital or skilled nursing facility.

Treatment you receive in an acute care hospital, mental health care facility, critical access hospital, long-term care hospital, inpatient rehabilitation facility.

On admission to hospital, these services include bed and board, nursing services, medical or surgery, diagnostic or therapeutic services.

Where hospitals have contracted with Medicare to provide acute inpatient care and accept a predetermined rate as full payment.

A hospital facility that provides intensive rehabilitation services to inpatients.

Refers to a group health plan that has at least 100 employees.

Applicable to Original Medicare (Part A and Part B) – when you are hospitalized for more than 90 days, these are additional days Medicare will pay for. You have a total of 60 reserve days that can be used during your lifetime. Medicare covers all reserve day costs except for a coinsurance.

For Original Medicare this is the highest amount you can be charged for a covered doctor service and other health care suppliers who do not accept assignment (see above). The limiting charge is 15% over the Medicare approved amount. The limiting charge does not apply to equipment or supplies.

A living will is a written legal document – when you cannot speak for yourself this serves as a directive for treatments you do, and do not want. You can specify whether you do or do not want life-support treatment. This directive usually comes into effect when you are unconscious.

These are services provided to you when you are unable to perform basic daily living activities like dressing and bathing. These services can be provided at home, in the community, in nursing homes and assisted living facilities. Long-term care assistance can be provided to people of any age.

Medicare does not pay for long-term care. You can purchase long-term insurance from private insurance companies.

Acute care hospitals that provide treatment for patients who stay, on average, longer than 25 days – most patients are transferred from a critical care or intensive care unit.

Services provided include;

• rehabilitation
• therapy
• respiratory
• head trauma treatment
• pain management

An independent advocate who works to resolve problems between residents and nursing homes or assisted living facilities.

An ombudsman is usually a good resource to find information about your rights and protections and local health agencies.

A federal and state program that helps with medical costs for people with low income and resources. See Medicaid.gov.

Certified providers have passed an inspection conducted by a state government agency and are approved by Medicare.

Where people with lower incomes and resources can get information and assistance with Medicaid applications.

An insurance company adopts an underwriting process that enables them to decide, based on your medical history, whether to accept your application for insurance. They access the risk and decide whether to add a waiting period for pre-existing conditions (if allowed by your state), and how much you will have to pay for that insurance.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

A company that processes claims for Medicare.

Medicare Glossary – PMB Senior Services

A Part C plan is a Medicare approved insurance plan from private insurance carriers. Part C provides you with all the benefits of Original Medicare Part A and Part B. Part C includes HMO’s PPO’s etc.

Most Medicare Advantage plans include prescription drug coverage (Part D) and other benefits.

A Medicare Advantage plan that offers Parts A, B, and D (prescription drugs) in one plan.

In Original Medicare, when a doctor or supplier accepts assignment (see Assignment above), this is the amount that can be paid.

A company, person, and agency that’s been certified by Medicare to give you medical supplies and services.

A Medicare approved health care provider – providers are approved or certified by Medicare if they have met and passed state government agency inspection. Medicare only covers care by certified providers.

If you receive services outside of the plan’s network without a referral, Medicare covered services will still be paid under Original Medicare. The Cost Plan pays for emergency or urgently needed services.

These types of plans are available in some areas.

Available in a Medicare Advantage plan (Part C) in some areas – with most HMO’s, you can only go to doctors or hospitals specified on the plan’s list (except in an emergency).

Most HMO’s require you to get a referral from your primary care doctor.

A plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits – additional benefits like prescription drug coverage (Part D) can also be offered.

A MSA plan combines a high deductible Part C (Medicare Advantage plan) and a bank account. Money is deposited from Medicare into the account. You are entitled to use the money to pay for your health care costs, however, only Medicare covered expenses count towards your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.

Part A covers inpatient hospital stays, skilled nursing care facilities, hospice care and some home health care.

Part B covers certain doctor’s services, preventive services, medical supplies and outpatient care.

Any plan other than Original Medicare (Part A and Part B) where you can get your Medicare health or prescription drug coverage.

This coverage is offered by private insurance companies approved by Medicare. Plan types vary and it is important to study and become familiar with plan details.

Part D adds prescription drug coverage to Original Medicare. These plans are offered by private companies approved by Medicare.

A type of Medicare Advantage Plan (Part C) – you can visit any doctor or hospital as if you had Original Medicare if they agree to treat you. The plan determines how much they will pay for these services and what your sharing costs will be. A PFFS plan is however very different to Original Medicare and you must ensure that you carefully follow the plan’s rules.

Costs may be more or less than in Original Medicare.

This is a Medicaid program for people with limited income and resources – the program helps pay for some or all of their Medicaid costs.

A type of Medigap (supplement) policy – you may be required to use in-network hospitals and doctors to receive benefits.

This plan provides more focused and specialized health care for specific groups of people, for example, those who have both Medicare and Medicaid, who have certain chronic illnesses and who live in a nursing home.

It is a Medicare Advantage (Part C) type of plan,

You will receive this notice after your doctor, supplier or other health care provider files a claim for Original Medicare (Part A and Part B) services. It will explain all the billing details and the amount you are liable for.

Benefits that all Medigap policies must cover, including Part A and Part B coinsurance amounts, blood, and additional hospital benefits not covered by Original Medicare.

This is a one-time-only, 6-month enrollment period when federal law allows you to purchase any Medigap policy that’s sold in your state.

The enrollment period starts in the first month that you are covered under Part B and you are 65 years old or older.

During this enrollment period you cannot be denied a Medigap plan or be charged more due to past or present health conditions.

Enrollment right can vary state-by-state.

These are Medicare Supplement insurance policies sold by private insurance companies to pay for coverage that Original Medicare does not.

A group health plan that is sponsored by 2 or more employers.

The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

When deciding and choosing your plan, it is important to consider the network.

Network pharmacies who have agreed to provide discounted prices to members of certain Medicare plans. With some Medicare plans, your prescriptions will only be covered if you get them filled at network pharmacies.

If a pharmacy is part of a Medicare plan but considered non-preferred, you may pay higher out-of-pocket costs for your prescription drugs.

Treatment that helps you return to normal activity after an illness.

This is a benefit that Medicare does not cover, but a Medicare health plan may choose to offer – you may choose to purchase these services and will pay for them directly; usually in the form of premium, copayment and/or coinsurance.

Medicare Glossary – PMB Senior Services

Original Medicare consists of two parts;

• Part A – hospital insurance
• Part B – medical insurance

It is a fee-for-service health plan.

Applies to a Medicare Advantage plan (Part C) – out-of-network benefits may cost you more than in-network provider services.

Costs that are not covered by Medicare or other health insurance – you will be liable to pay these costs.

Medical or surgery care you receive when your doctor has not admitted you to hospital as an inpatient. Note: this care may still be considered outpatient even if you spend the night at the hospital.

A test to check for cancer of the cervix.

A medical device used to lift you from a bed or wheelchair.

If you do not join a Medicare drug plan (Part D) or join Part B when you are first eligible, a penalty amount will be added to your monthly premium. You will pay this higher amount as long as you have Medicare although there are some exceptions.

Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price.

With some Medicare plans, prescriptions will only be covered if they are filled at network pharmacies.

Includes treatments like massage, exercise, heat and light treatments.

For an additional cost, this Health Maintenance Organization (HMO) option allows you to use doctors and hospitals outside of the plan.

A medical Power of Attorney allows you to designate someone that you trust to make medical care decisions on your behalf.

Like a Living Will, it may be an important document to consider.

A health problem you had before the date that new health coverage starts.

You will pay lower out-of-pocket costs for prescription drugs using a pharmacy that is part of a Medicare drug plan’s network.

The premium is the periodic payment – usually monthly – to pay for health services from Medicare or private insurance companies.

Health care to prevent or detect illness at an early stage, for example, mammograms, flu shots etc.

The doctor you see first as your primary physician. In many Part C plans, you must see your primary care doctor before you see any other health care provider and get a referral.

Approval you must obtain from a Medicare drug plan before you have the prescription filled – your drug plan may require prior authorization for certain drugs.

A special type of health plan determined by an interdisciplinary team to provide care and services covered by Medicare and Medicaid based on your needs. PACE serves frail older adults who need nursing home services but are capable of living in the community.

PACE combines medical, social, and long-term care services and prescription drug coverage.

Also known as loss of protective sensations – for example, nerve damage caused by diabetes can cause loss of feeling in the foot or leg. This condition may result in skin loss, ulcers and blisters.

For people who have limited income and resources, this is a state program that helps pay Part A (Original Medicare) premiums.

A state program for people who have limited resources and income – this helps pay Part B premiums.

This state program helps individuals pay their Part A and Part B (Original Medicare) premiums if they have low income and resources. QMB may also help with deductibles, copayments and coinsurance.

With many HMO’s you will need a written order from your primary care doctor to see a specialist or get certain medical services. If you do not get this referral prior to seeing a specialist or obtaining certain medical services, the plan might not pay for the services.

If you have been sick, hurt or disabled, these services will help you recover from those injuries.

Services could include;

• Physical and occupational therapy
• Psychiatric rehabilitation
• Speech and language pathology

Services can be conducted in an inpatient and/or outpatient setting.

A facility that provides non-medical health care items and services to people who need hospital or skilled nursing facility care, but for whom that care would be inconsistent with their religious beliefs.

Medicare Glossary – PMB Senior Services

If you have a family member or friend who is your caregiver, temporary respite care can give them some rest  – can be obtained in a nursing home, inpatient facility, hospice or hospital.

Where there is a shortage of health care services in rural areas, a federally qualified health center can provide those services.

A medical procedure to check for breast cancer.

The policy, plan or program that pays second on a medical claim – this is dependent on the situation.

If a health insurance plan limits membership based on an area where people live, this is defined by the geographic service area. If your plan is limited geographically, you might be disenrolled if you move out of that area.

Only a doctor or registered nurse can give certain kinds of care, for example, intravenous injections.

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility (SNF).

For individuals who have Part A (Original Medicare) and have low income and resources, this program will help pay Part B premiums.

Therapeutic speech treatments resulting from illness.

A federal funded government program to give free health insurance counseling to Medicare recipients.

A state regulatory agency – regulates insurance, provides information about Medigap policies and other private health insurance.

A state regulatory authority that provides information about, and assists with Medicaid applications.

A state program that assists with help for paying drug coverage based on financial need, age and medical condition.

This agency inspects health care facilities and investigates complaints to ensure that health and safety standards are met for both Medicare and Medicaid.

Some Medicare prescription drug plans require you to try similar, lower cost drugs for treatment, before the plan will cover the actual prescribed drug.

Medicare Glossary – PMB Senior Services

When one or more bones of your spine move out of position.

SSI is a monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits are not the same as Social Security retirement or disability benefits.

A practitioner who provides medical and other health services to a patient via electronic means; phone, computer or television.

Cost pricing of drugs in different groups or tiers. Generally, a lower group drug should cost less.

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

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

A communication device (teletypewriter) used by people who are deaf, hard-of-hearing, or have severe speech impairment.

Non life threatening care that you receive outside of your Medicare health plan’s service area for a sudden illness or injury. As it is not safe to wait until you return home before you receive this care, your health plan must pay for this.

An insurance plan that employers must have to cover employees who get sick or injured on the job.

Medicare Glossary – PMB Senior Services