Glossary of terms

Jump to:  A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z

A

Ambulance services

Medically necessary ambulance services.
Back to top ▲

At-home recovery

Coverage for at-home recovery paying up to $1,600 per year for short-term, at-home assistance with activities of daily living (bathing, dressing, personal hygiene, etc.) for those recovering from an illness, injury or surgery.
Back to top ▲

B

Basic benefits

Basic benefits include both Medicare-covered benefits (except hospice services) and additional benefits.
Back to top ▲

Benefit Period

The way that Original Medicare measures 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. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods.
Back to top ▲

C

Catastrophic coverage

Period of Part D prescription drug coverage that you reach after your yearly out-of-pocket prescription drug costs (including copayments, coinsurance and covered drug costs during the coverage gap) reach $4,550. During catastrophic coverage, you pay no more than 5% of the cost of each prescription filled.
Back to top ▲

Coinsurance

The amount you must pay for a health care service or product. Coinsurance is a percent of the Medicare-approved amount, e.g., 20% coinsurance for most Part B services.
Back to top ▲

Copayment

The amount you must pay for a health care service or product. A copayment is a set amount of cost-sharing, e.g., $10 for generic prescription drugs.
Back to top ▲

Cost Plan

Medicare Cost plans are offered by private insurance companies that contract with Medicare to provide you with health care coverage in addition to your Original Medicare benefits. If enrolled in a Medicare Cost plan, you retain your Original Medicare benefits, and the health plan provides additional benefit coverage through their contracted provider network.
Back to top ▲

Coverage start date

This is the date from which you are covered for the services outlined in your plan.
Back to top ▲

Coverage gap (Donut hole)

The period in Medicare Part D coverage between the point where your total drugs costs have reached $2,830 and your out-of-pocket spending reaches $4,550 in 2010.
Back to top ▲

Chiropractic services

Manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers.
Back to top ▲

Creditable Coverage

Most often related to Medicare Prescription Drug Coverage, Part D, creditable coverage is a term used to describe prescription drug coverage you may have that meets or exceeds the coverage offered under Part D. Individuals who have creditable coverage do not have to enroll in Part D. If they later lose their creditable coverage (e.g., upon retiring), they can enroll in Part D with no penalty.
Back to top ▲

D

Dental

Oral Exams, cleanings, dental X-rays.
Back to top ▲

Dental services

Oral Exams, cleanings, dental X-rays.
Back to top ▲

Deductible

The amount an individual is responsible to pay out-of-pocket before Medicare, a Part D plan, or a Medicare Advantage plan will pay claims.
Back to top ▲

Diabetes self-monitoring training and supplies

Includes coverage for glucose monitors, test strips, lancets, screening tests and self-management training.
Back to top ▲

Doctor office visit

Services that are prescribed by a doctor and often administered in a provider's office.
Back to top ▲

Doctor and hospital choice

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
Back to top ▲

Dual Eligible

Medicare beneficiaries who are also entitled to Medicaid benefits. Dual eligible beneficiaries are automatically eligible for Extra Help with Part D.
Back to top ▲

Durable medical equipment

Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds.
Back to top ▲

E

Enrollment period

Designated periods of time when you can enroll in, disenroll from, or otherwise change your Medicare coverage choices. Enrollment periods are different for the different parts of Medicare coverage.
Back to top ▲

Emergency care

You can go to any emergency room if you reasonably believe you need emergency care.
Back to top ▲

Extra Help

This program helps certain people with limited income and resources pay for the costs of a Medicare prescription drug plan, Part D. You can apply by calling the Social Security Administration at 1-800-772-1213.
Back to top ▲

F

Foreign travel emergency

80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.
Back to top ▲

Formulary

A list of drugs covered by a Part D plan. Drugs on the formulary will generally cost less than drugs not on the plan’s formulary. If your doctor believes you need a drug not on your plan’s formulary, you or your doctor can ask your plan for a formulary exception, which, if approved, would provide you coverage for that needed drug.
Back to top ▲

G

Gap coverage

The gap in Medicare Part D coverage when you have between $2,830 and $4,550 in total drug costs in a year.
Back to top ▲

H

Health Maintenance Organization (HMO)

HMOs are a type of Medicare Advantage plan that operates through a network of health care providers. HMOs contract with hospitals, physicians, laboratories, and other providers to create provider networks. Most HMOs require people who enroll in the plan to choose a primary care provider (PCP). The PCP is often a physician who is expected to act as a gatekeeper to health care services. HMO plan members, or “enrollees,” generally must contact their PCP to obtain referrals to see specialists or to receive some services, such as expensive diagnostic procedures.
Back to top ▲

Hearing services

Hearing aids, exam, test, and fitting evaluations.
Back to top ▲

Home health care

Services covered by Medicare that include: part-time or periodic skilled nursing care; home health aide services; physical therapy; occupational therapy; speech-language therapy; medical social services; durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers); medical supplies; and other services.
Back to top ▲

Hospice

Services covered by Medicare Part A for individuals with a terminal illness. Services may include prescriptions for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in an individual’s home; however, Medicare may cover some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
Back to top ▲

I

Immunizations

Flu vaccine, Hepatitis B vaccine, Pneumonia vaccine.
Back to top ▲

Initial coverage period

The period in Medicare Part D coverage after you have paid any deductible until your total drug costs have reached $2,830 in 2010.
Back to top ▲

Inpatient hospital care

Services covered by Medicare Part A that include a semiprivate room, meals, general nursing, and other hospital services and supplies.
Back to top ▲

Inpatient mental health care

Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.
Back to top ▲

L

Late enrollment penalty

An extra amount that you may have to pay if you do not have health or drug coverage for a certain amount of time. There are late enrollment penalties associated with Medicare Part A, B and D.

Part A: if you aren’t eligible for premium-free Part A, you may be able to buy it. However, if you don’t buy Part A when you are first eligible, your premium may go up 10% for twice the number of years you could have had Part A but didn’t join. For example, if you were eligible for Part A, but didn’t join for two years, you will have to pay the higher premium for four years.

Part B: If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare.

Part D: You may owe a Part D late enrollment penalty if one of the following is true: You didn’t join a Medicare drug plan when you were first eligible, and you didn’t have other creditable prescription drug coverage; or, you had a break in your Medicare prescription drug coverage or other creditable coverage of at least 63 days in a row.
Back to top ▲

Link to formulary

A formulary is a list of drugs that a health plan covers.
Back to top ▲

Link to in-network pharmacies

A list of in-network pharmacies.
Back to top ▲

M

Medicare Advantage plans

A Medicare Advantage plan is a health coverage choice you may make as part of Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA” plans, are offered by Medicare-approved private insurance companies. MA plans provide all Part A (Hospital Insurance) and Part B (Medical Insurance) services. MA plans are structured in several ways, including HMO, PPO, or PFFS plans. All plan types cover emergency and urgent care. Medicare Advantage plans must cover all of the services that Original Medicare covers except hospice care.
Back to top ▲

Medicare-approved amount

In Original Medicare, this is the amount a doctor or supplier can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.
Back to top ▲

Medicare prescription drug (Part D) plan

Medicare prescription drug coverage (Part D) is available to everyone with Medicare. Medicare drug coverage is offered through plans run by insurance companies or other private companies approved by Medicare. Each plan can vary in cost and drugs covered.

There are two types of Medicare prescription drug plans:

Medicare Prescription Drug Plans: These plans (sometimes called “PDPs”) add drug coverage to Original Medicare and, in very limited situations, some Medicare Advantage plans.

Medicare Advantage Plans with Drug Coverage: These plans (sometimes called “MA-PDs”) offer all of your Part A and Part B coverage, as well as Part D prescription drug coverage.
Back to top ▲

Medicare Savings Programs

These state-based programs provide assistance to help certain individuals with limited income and resources pay for the costs of Medicare. People in Medicare Savings Programs are automatically eligible for Extra Help with Part D.
Back to top ▲

Medicare Supplement Insurance

Medicare Supplement Insurance, or Medigap, is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare plan coverage. Medicare supplement policies help pay some of the health care costs that Original Medicare doesn’t cover. If you are in Original Medicare and have a Medicare Supplement policy, then Medicare and your Medicare Supplement policy will both pay their share of covered health care costs.
Back to top ▲

O

Original Medicare

Original Medicare, also called Part A and Part B, includes the two traditional, fee-for-service components that make up the Original Medicare program. Original Medicare is the default coverage option for beneficiaries who do not enroll in Medicare Advantage.
Back to top ▲

One month supply of non-preferred drugs

Drugs that are not on a plan-approved drug list.
Back to top ▲

One month supply of specialty drugs

Specialty and non self-administered injectables.
Back to top ▲

Out-of-pocket Limit

An amount that certain Medicare Advantage plans set for enrollees’ yearly out-of-pocket expenses. Above this amount, enrollees do not have to pay cost-sharing for services they receive.
Back to top ▲

Outpatient mental health

Programs that provide diagnostic and treatment services for individuals whose psychiatric problems or other emotional difficulties are not severe enough to require twenty-four hour care but who can benefit from regular consultation and therapy with a mental health professional.
Back to top ▲

Outpatient rehabilitation services

Occupational Therapy, Physical Therapy, Speech and Language Therapy.
Back to top ▲

Outpatient services and surgery

Medicare covered visits to an outpatient hospital facility or ambulatory surgical center.
Back to top ▲

Outpatient substance abuse care

Treatment for alcoholism and drug abuse on an ambulatory basis in the outpatient department of a hospital or in a clinic or other medical facility, including a physician’s or other health practitioner’s office.
Back to top ▲

P

Part A deductible

Covers the Medicare Part A (Hospital services) deductible for that year.
Back to top ▲

Part B deductible

Covers the Medicare Part B (Doctor services) deductible for that year.
Back to top ▲

Part B excess

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 amount Medicare will reimburse.
Back to top ▲

Pharmacy network

A list of pharmacies that participate with Part D plans. Except in certain situations, enrollees must fill prescriptions at pharmacies in their plan’s network. Within a network, a Part D plan also may have a list of “preferred” pharmacies, where enrollees can purchase prescription drugs for the lowest price.
Back to top ▲

Physical exams

One time physical exam.
Back to top ▲

Podiatry services

Medically necessary foot care, including care for medical conditions affecting the lower limbs.
Back to top ▲

Preferred Provider Organization (PPO) Plan

O plans are a type of Medicare Advantage plan that operates through a network of health care providers. Unlike HMOs, PPOs generally pay for out-of-network care. Also, they do not require enrollees to choose a primary care provider (PCP) nor do they require referrals to see specialists or receive certain types of health services. Enrollees in PPOs usually pay lower cost-sharing amounts for services provided by the PPO’s network of “preferred” health care providers. Even in routine circumstances, PPOs provide coverage for services received out-of-network, but cost-sharing (deductibles and copayments) is generally higher for out-of-network care.
Back to top ▲

Prescription drugs

Drugs covered under Medicare Part B and Part D.
Back to top ▲

Prescription drug coverage

Identifies whether the plan covers prescription drugs. If the plan does not cover prescription drugs you may want to consider adding a Part D Prescription drug plan.
Back to top ▲

Premium

The amount you must pay (generally monthly) to maintain enrollment in certain types of coverage. There are premiums associated with Medicare Part A (for some people), Part B (for most people), Medicare Advantage (for most people), Part D (for most people), and Medigap (for all people).
Back to top ▲

Preventive care NOT covered by Medicare

The preventive medical care benefit pays up to $120 per year for such things as a physical examination, serum cholesterol screening, hearing test, diabetes screenings and thyroid function test.
Back to top ▲

Primary Care Doctor

In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.
Back to top ▲

Private Fee for Service (PFFS) Plan

PFFS plans are a type of Medicare Advantage plan. PFFS plans resemble Original Medicare in that the plans pay providers for each service delivered to plan enrollees. They are also similar in that enrollees are not limited to a network of health care providers and do not need referrals to see a specialist. PFFS plan service areas are nationwide—not limited to a particular MA region or to a county. Unlike Original Medicare, PFFS plans set their own payment rates for health care providers. Thus, enrollees may see any provider who agrees to accept the plan’s payment terms. PFFS plans do not require providers to accept these terms. Because of this, it is critical to know that any Medicare provider, including physicians, home health agencies, and equipment suppliers, may choose to accept, or not accept, the terms of the PFFS plan each time a patient visits the provider.
Back to top ▲

Prosthetic devices

Includes braces, artificial limbs and eyes, etc.
Back to top ▲

S

Skilled nursing

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

Skilled nursing facility

Services that include a semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies. Medicare covers skilled nursing facility care after the individual has been in the hospital for 3 days.
Back to top ▲

Skilled nursing facility co-insurance

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

Special Needs Plan (SNP)

SNPs are a type of Medicare Advantage plan that exclusively provides coverage for Medicare beneficiaries with special medical needs or health care situations. An SNP may serve one of the following three subgroups of Medicare beneficiaries: institutionalized individuals, dual-eligible individuals, or individuals with a chronic or disabling condition.
Back to top ▲

T

Three month supply of non-preferred brand drugs

Drugs that are not on a plan-approved drug list.
Back to top ▲

Three month supply of specialty drugs

Specialty and non self-administered injectables.
Back to top ▲

U

Urgently needed care

This is NOT emergency care.
Back to top ▲

V

Vision

Medicare covered eye exams and glasses.
Back to top ▲

Vision services

Medicare covered eye exams and glasses.
Back to top ▲

Glossary of terms