Medicare glossary

A

Annual enrollment period (specific to Medicare Advantage Plans and Medicare Advantage Prescription Drug Plans (Part D)): This is the period from Oct. 15 to Dec. 7 each year when you can make plan changes or add prescription drug coverage if you don't currently have it. This six-week period is also referred to as the annual election period. Any changes you make to your coverage during this time will go into effect Jan. 1 of the following year.

Appeal: An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan or your Medicare drug plan. You have the right to appeal if Medicare, your Medicare health plan or your Medicare drug plan denies one of these:

  • A request for a health care service, supply, item or prescription drug that you think you should be able to get
  • A request for payment of a health care service, supply, item or prescription drug you already received
  • A request to change the amount you must pay for a health care service, supply, item or prescription drug

You also can appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need.

B

Beneficiary: A person with health insurance through Medicare or Medicaid programs.

Benefit period: The way that a health plan and Original Medicare measure your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care or skilled care in a SNF 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. There is no limit to the number of benefit periods. For a skilled nursing facility, the plan covers up to 100 days each benefit period. For a hospital, there is no limit to the number of days covered by the plan each benefit period.

Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents.

C

Centers for Medicare & Medicaid Services (CMS): The federal agency that runs the Medicare, Medicaid and Children's Health Insurance programs as well as the federally facilitated marketplace.

Claim: A request for payment that you or your health care provider submits to Medicare or other health insurance when you receive items and services that you think are covered.

Co-insurance: An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Co-insurance is usually a percentage of the total cost.

Co-payment (co-pay): An amount you may be required to pay as your share of the cost for a medical service or supply, such as a doctor visit, hospital outpatient visit or prescription drug. A co-payment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.

Coverage determination (Part D): The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:
  • Whether a particular drug is covered
  • Whether you have met all the requirements for getting a requested drug
  • How much you're required to pay for a drug
  • Whether to make an exception to a plan rule when you request it

The drug plan must give you a prompt decision within 72 hours for standard requests and within 24 hours for expedited requests. If you disagree with the plan's coverage determination, the next step is to file an appeal.

Coverage gap (Medicare prescription drug coverage): A period of time in which you pay a greater share of the cost for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap, also called the "donut hole," starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

D

Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan or your other insurance begins to pay.

Drug list: See formulary.

Durable medical equipment: This refers to certain medical equipment, such as a walker, wheelchair or hospital bed, that's ordered by the doctor for use in your home.

E

End Stage Renal Disease (ESRD): Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Extra help: A Medicare program to help people with limited income and resources pay Medicare prescription drug costs, including premiums, deductibles and co-insurance.

F

Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan that offers prescription drug benefits. A formulary is also called a drug list.

G

Grievance: A complaint about the way your Medicare health plan or Medicare drug plan is providing care. For example, you may file a grievance if you have a problem calling your health plan or if you're unhappy with the way a staff member at the plan has behaved toward you. If you have a complaint about a plan's refusal to cover a service, supply or prescription, however, you will need to file an appeal.

H

Health Insurance Portability and Accountability Act of 1996 (HIPAA): HIPAA's Standards for Privacy of Individually Identifiable Health Information (also called the "privacy rule") assures your health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care and to protect the public's health and well-being.

Home health care: Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.

Hospice: A special way of caring for people who are terminally ill. Hospice care involves a team oriented approach that addresses a patient's medical, physical, social, emotional and spiritual needs. Hospice also provides support to the patient's family or caregiver.

Hospital outpatient setting: The part of a hospital where you can receive outpatient services. This includes an emergency department, observation unit, surgery center or pain clinic.

I

In network: This refers to doctors, hospitals, pharmacies and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. With some insurance plans, your care is only covered if you receive it from doctors, hospitals, pharmacies and other health care providers in that health plan's network.

Inpatient care: Health care you receive when you're admitted to a health care facility such as a hospital or skilled nursing facility.

L

Long-term care: Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, such as dressing or bathing. Long-term support and services can be provided at home, in the community, in assisted living facilities or in nursing homes. Individuals may need long-term support and services at any age. Medicare and most health insurance plans don't pay for long-term care. 

Low-income subsidy: See extra help.

M

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.

Medicare: Medicare is a federal health insurance program for people who are age 65 or older, certain younger people with disabilities and people with End Stage Renal Disease (ESRD).

Medicare Health Maintenance Organization (HMO) Plan: A type of Medicare Advantage Plan (Part C) available in some areas of the country. With most HMOs, you can only receive care from 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.

N

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

Network pharmacies: Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are covered only if you get them filled at network pharmacies.

Non-preferred pharmacy: A pharmacy that's part of a Medicare drug plan network but that isn't a preferred pharmacy. You may pay higher out-of-pocket costs if you get your prescription drugs from a non-preferred pharmacy instead of a preferred pharmacy.

O

Occupational therapy: Treatment that helps you get back to usual activities such as bathing, preparing meals and housekeeping after an illness.

Out of network: A benefit that may be provided by your Medicare Advantage Plan. Generally, this benefit gives you the choice to get plan services from outside the plan's network of health care providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.

Out-of-pocket costs: Health or prescription drug costs that you must pay on your own because they aren't covered by Medicare or other insurance.

Outpatient hospital care: Medical or surgical care you get from a hospital when your doctor hasn't written an order to admit you to the hospital for inpatient care. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests or X-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.

P

Penalty: An amount added to your monthly premium for Part B or a Medicare Prescription Drug Plan (Part D) if you don't join when you're first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

Point-of-service option: In a health maintenance organization (HMO), this option lets you use doctors and hospitals outside of the plan's network for an additional cost.

Preferred pharmacy: A pharmacy that is part of a Medicare drug plan's network. You pay lower out-of-pocket costs if you get your prescription drugs from a preferred pharmacy instead of a non-preferred pharmacy.

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

Preventive services: Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best. Preventive services include Pap tests, flu shots and screening mammograms.

Primary care doctor: The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. Your primary care doctor also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.

Prior authorization: Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs.

R

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

S

Service area: A geographic area in which a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of its service area.

Skilled nursing care: Care such as intravenous injections that can only be given by a registered nurse or doctor.

Skilled nursing facility (SNF): A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Step therapy: A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower-cost drugs to treat your condition before the plan will cover the more costly drug originally prescribed.

T

Tiers: A tier refers to drugs grouped by cost. Generally, a drug in a lower tier will cost less than a drug in a higher tier.

TTY: A teletypewriter, or TTY for short, is a communication device used by people who are deaf, hard of hearing or severely speech impaired. People who don't have a TTY can communicate with a TTY user through a message relay center, or MRC. An MRC has TTY operators available to send and interpret TTY messages.

U

Urgently needed care: Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away but isn't life threatening. If it's not safe to wait until you get home to get care from a plan doctor, the health plan must pay for your care.

For more Medicare terms and definitions, go to www.medicare.gov/glossary