Medicare Glossary

Accreditation

A process where external organizations (or “accrediting bodies”) evaluate health care facilities’ policies, procedures, and performance to make sure they are meeting predetermined criteria.

Advance Beneficiary Notice

In Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage., a notice that a doctor, supplier, or provider gives a Medicare beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payment. In this situation, if you aren’t given an ABN before you get the item or service, and Medicare denies payment, then you may not have to pay for it. If you are given an ABN, and you sign it, you will probably have to pay for the item or service if Medicare denies payment.

Advance Coverage Decision

A notice you get from a Medicare Advantage Plan letting you know in advance whether it will cover a particular service.

Advance Directive

A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.

Ambulatory Surgical Center

A facility where simpler surgeries are performed for patients who aren’t expected to need more than 24 hours of care.

Appeal

An appealAn appeal is an action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan, or your Medicare Part D plan. is an action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan.

Assignment

An agreement by your doctor (or other healthcare providers) to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. .

Beneficiary

A person who has health care insurance through the Medicare or MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. programs.

Benefit Period

The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit periodA benefit period is a method used in Original Medicare to measure a beneficiaries use of hospital and skilled nursing facility (SNF) services. With each new benefit period, the beneficiary is charged a new benefit... begins the day you’re admitted as an inpatient in 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.

Centers for Medicare & Medicaid Services (CMS)

The Federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs.

Claim

A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.

Coinsurance

An amount you may be required to pay as your share of the cost for services after you pay any deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.. Coinsurance is usually a percentage (for example, 20%).

Comprehensive Outpatient Rehabilitation Facility

A facility that provides a variety of services on an outpatient basis, including physicians’ services, physical therapy, social or psychological services, and rehabilitation.

Coordination of Benefits

A way to figure out who pays first when two or more health insurance plans are responsible for paying a medical claimA request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered..

Copayment

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, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.

Cost Sharing

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, hospital outpatient visit, or prescription drug. This amount can include copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., coinsurance, and/or deductibles.

Coverage Determination (Part D)

The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including the following:

• Whether a particular drug is covered
• Whether you’ve met all the requirements for getting a requested drug
• How much you’re required to pay for a drug
• Whether to make an exceptionIn a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... to a plan rule when you request it

If the drug plan doesn’t give you a prompt decision and you can show that the delay would affect your health, the plan’s failure to act is considered to be a coverage determinationA coverage determination is the first decision made by a Medicare Part D plan (not the pharmacy) about a plan member's drug benefits.. If you disagree with the coverage determination, the next step is an appeal.

Coverage Gap (Medicare Prescription Drug Coverage)

A period of time in which you pay higher cost sharingAn amount patients pay for their share of the cost of medical service or supply, like a doctor’s visit, hospital inpatient visit, or prescription drug. for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gapA period of time in which you pay higher cost-sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

Creditable Coverage

See Creditable CoverageCreditable coverage refers to health insurance or prescription drug benefits that meet Medicare's minimum qualifications necessary to avoid a penalty. (Medigap) or Creditable Prescription Drug Coverage.

Creditable Coverage (Medigap)

Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.

Creditable Prescription Drug Coverage

Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.

Custodial Care

Non-skilled 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 the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial careNon-skilled 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..

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.

Deemed Status

A provider or supplier earns this when they have been accredited by a national accreditation program (approved by the Centers for Medicare & Medicaid Services) that they demonstrate compliance with certain conditions.

Department of Health and Human Services (HHS)

A Federal agency that administers programs for protecting the health of all Americans, including the Medicare, Medicaid, and Children’s Health Insurance Programs.

DME Medicare Administrative Contractor (MAC)

A private company that contracts with Medicare to pay bills for durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds..

Drug List

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This list is also called a formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered..

Durable Medical Equipment

Certain medical equipment, such as a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.

Durable Power of Attorney

A legal document that enables you to designate another person to act on your behalf in the event you become disabled or incapacitated.

Employer or Union Retiree Plans

Plans that give health and/or drug coverage to employees, former employees, and their families. These plans are offered to people through their (or a spouse’s) current or former employer or employee organization.

End-Stage Renal Disease (ESRD)

Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Exception

A type of Medicare prescription drug coverage determination. You must request an exception, and your doctor or another prescriber must send a supporting statement explaining the medical reason for the exception.

Excess Charge

If you have Original Medicare, and the amount a doctor or other health care providerA person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers. is legally permitted to charge is higher than the Medicare-approved amountA Medicare-approved amount is what Medicare will pay for a covered service. Healthcare providers that agree to Medicare assignment accept the approved amount without excess charges. What Does Medicare-Approved Amount Mean? A Medicare-approved amount is..., the difference is called the excess chargeA Medicare Part B excess charge is the difference between a health care provider’s actual charge and Medicare’s approved amount for payment..

Extra Help

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. , deductibles, and coinsurance.

Federally-Qualified Health Center

Federally-funded nonprofit health centers or clinics that serve medically under-served areas and populations. Federally-qualified health centers provide primary care services even if you can’t afford them. Services are provided on a sliding scale fee based on your ability to pay.

Formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.

Generic Drug

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugsA generic drug is a prescription medication that has the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Grievance

A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievanceA grievance is a complaint about the way your Medicare Advantage health plan or Medicare Part D drug plan is giving care. A beneficiary may file a grievance if they have a problem calling the... if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan’s refusal to cover a service, supply, or prescription, you file an appeal.

Group Health Plan

In general, a health plan offered by an employer or employee organization that provides health coverage to employees, former employees, and their families.

Guaranteed Issue Rights (also called “Medigap Protections”)

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre-existing conditionsA pre-existing condition is any health problem that occurred before enrolling in a health plan. The Affordable Care Act law made it illegal for health plans to or charge more due to a pre-existing condition...., and can’t charge you more for a Medigap policy because of a past or present health problem.

Guaranteed Renewable Policy

An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.

Health Care Provider

A person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

High-Deductible Medigap Policy

A type of Medigap policy that has a high deductible but a lower premium. You must pay the deductible before the Medigap policy pays anything. The deductible amount can change each year.

Homebound

To be homeboundHomebound refers to a person who is unable to leave their home due to a medical condition. Homebound individuals can still leave home for brief periods for non-medical reasons such as graduation, family reunions, funerals, and... means:

• Leaving your home isn’t recommended because of your condition.
• Your condition keeps you from leaving home without help (like using a wheelchair or walker, needing special transportation, or getting help from another person).
• Leaving home takes a considerable and taxing effort.

You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health careHealth 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... if you attend adult day care.

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

Hospital Care (Inpatient)

Treatment you get in an acute care hospital, critical access hospital, inpatient rehabilitation facility, long-term carea variety of services that help people with their medical and non-medical needs over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including... hospital, inpatient careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition. as part of a qualifying research study, and mental health care.

Hospital Outpatient Setting

A part of a hospital where you get outpatient services, like an emergency department, observation unit, surgery center, or pain clinic.

Hospital-Related Medical Condition

Any condition that was treated during your qualifying 3-day inpatient hospital stay, even if it wasn’t the reason you were admitted to the hospital.

Independent Reviewer

An organization (sometimes called an Independent Review Entity or IRE) that has no connection to your Medicare health plan or Medicare Prescription Drug Plan. Medicare contracts with the IRE to review your case if you appeal your plan’s payment or coverage decision or if your plan doesn’t make a timely appeals decision.

Initial Coverage Limit

Once you have met your yearly deductible, you will pay a copayment or coinsurance for each covered drug until you reach your plan’s out-of-pocket maximum (or initial coverage limitOnce you have met your yearly deductible, you will pay a copayment or coinsurance for each covered drug until you reach the initial coverage limit. You will then enter your plan’s coverage gap (aka, “donut...). You will then enter your plan’s coverage gap (sometimes called the “donut hole”).

In-Network

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. In some insurance plans, your care is only covered if you get it from in-networkDoctors, hospitals, pharmacies, and other healthcare providers that agree to health plan members' services and supplies at a set price are in-network providers. With some health plans, your care is only covered if you get... doctors, hospitals, pharmacies, and other health care providers.

Inpatient Care

Health care that you get when you’re admitted to a health care facility, like a hospital or skilled nursing facility.

Inpatient Hospital Services

Services you get when you’re admitted to a hospital, including bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.

Inpatient Rehabilitation Facility

A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.

Lifetime Reserve Days

In Original Medicare, these are additional days that Medicare will pay for when you are in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

Limiting Charge

In Original Medicare, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignmentAn agreement by your doctor to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.. The limiting chargeThe highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept Medicare-assignment. is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.

Long-Term Care

A variety of services that help people with their medical and non-medical needs over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care you need.

Long-Term Care Hospital

Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

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.

Medicaid-Certified Provider

A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that has been approved by Medicaid. Providers are approved or “certified” if they have passed an inspection conducted by a state government agency.

Medical Emergency

When you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death.

Medically Necessary

Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.

Medicare

The Federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal DiseaseEnd-Stage Renal Disease (ESRD), also known as kidney failure, is a condition that causes you to need dialysis or a kidney transplant. People with ESRD are eligible for Medicare coverage regardless of age. (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medicare Administrative Contractor (MAC)

A company that processes claims for Medicare.

Medicare Advantage Plan (Part C)

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. benefits. Medicare Advantage PlansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.

Medicare Advantage Prescription Drug (MA-PD) Plan

A Medicare Advantage plan that offers Medicare prescription drug coverage (Part D), Part A, and Part B benefits in one plan.

Medicare-Approved Amount

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

Medicare-Approved Supplier

A company, person, or agency that has been certified by Medicare to give you a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.

Medicare-Certified Provider

A health care provider that has been approved by Medicare. Providers are approved or “certified” by Medicare if they have passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified.

Medicare Coordination of Benefits Contractor

The company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have, and determines whether the coverage pays before or after Medicare.

Medicare Cost Plan

A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).

Medicare Health Maintenance Organization (HMO) Plan

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.

Medicare Health Plan

A plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).

Medicare Medical Savings Account (MSA) Plan

MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible.

Medicare Part A (Hospital Insurance)

Coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)

Coverage for certain doctors’ services, outpatient careOutpatient Care is medical care that does not require an overnight stay at the hospital. Medicare Part B provides coverage for Outpatient Care., medical supplies, and preventive services.

Medicare Plan

Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug PlansMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each....

Medicare Preferred Provider Organization (PPO) Plan

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.

Medicare Prescription Drug Coverage (Part D)

Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

Medicare Prescription Drug Plan (Part D)

A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These 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.

Medicare Private Fee-For-Service (PFFS) Plan

A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had Original Medicare, if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when you get care. A Private Fee-For-Service Plan is very different than Original Medicare, and you must follow the plan rules carefully when you go for health care services. When you’re in a Private Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits than in Original Medicare.

Medicare Savings Program

A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.

Medicare SELECT

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Medicare Special Needs Plan (SNP)

A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.

Medicare Summary Notice (MSN)

A notice you get after the doctor or provider files a claim for Part A or Part B services in Original Medicare. It explains what the doctor or provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

Medigap Basic Benefits

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.

Medigap Open Enrollment Period

A one-time-only, 6-month period when Federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems.

Medigap Policy

Medicare Supplement InsuranceMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. sold by private insurance companies to fill “gaps” in Original Medicare coverage.

Multi-Employer Plan

In general, a group health planA group health plan is a health plan offered by an employer or employee organization that provides health coverage to employees, their families, and retirees. that’s sponsored jointly by two or more employers.

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 only covered if you get them filled at network pharmacies.

Non-Preferred Pharmacy

A pharmacy that’s part of a Medicare drug plan’s network but isn’t a Preferred Pharmacy. You may pay higher out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. if you get your prescription drugs from a Non-Preferred Pharmacy instead of a Preferred Pharmacy.

Occupational Therapy

Treatment that helps you return to your usual activities (like bathing, preparing meals, and housekeeping) after an illness.

Optional Supplemental Benefits

Services that Medicare doesn’t cover, but that a Medicare health plan may choose to offer.

Original Medicare

Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A and/or Part B benefits.

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 of 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 as an inpatient. 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.

Penalty

An amount added to your monthly premium for Part B or a Medicare 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.

Pharmacy Network

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 only covered if you get them filled at network pharmacies.

Point-of-Service Option

In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.

Prior Authorization

Approval from a Medicare drug plan that may be required before you fill your prescription in order for the prescription to be covered by your plan.

Pre-existing Condition

A health problem you had before the date that a new insurance policy starts.

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 (for example, 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. He or she 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.

Programs of All-Inclusive Care for the Elderly (PACE)

A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically-necessary care and services based on your needs as determined by an interdisciplinary team.

Qualified Disabled and Working Individuals (QDWI) Program

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

Qualified Individual (QI) Program

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

Qualified Medicare Beneficiary (QMB) Program

A state program that helps pay Part A premiums, Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments) for people who have Part A and limited income and resources.

Recovery Contractor

A company that acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary.

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Rehabilitation Services

Services that help you regain abilities, such as speech or walking, that have been impaired by an illness or injury. These services are given by nurses, and physical, occupational and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.

Respite Care

Temporary care provided in a nursing home, hospice inpatient facility, or hospital so that a family member or friend who is the patient’s caregiver can rest or take some time off.

Rural Health Clinic

A Federally Qualified Health Center (FQHC) that provides health care services in rural areas where there is a shortage of health care services.

Secondary Payer

The insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.

Service Area

A geographic area where 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 the plan’s 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.

Skilled Nursing Facility (SNF) Care

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Specified Low-Income Medicare Beneficiary (SLMB) Program

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

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.

State Insurance Department

A state agency that regulates insurance and can provide information about Medigap policies and other private health insurance.

State Medical Assistance Office

A state agency that’s in charge of the State’s Medicaid program and can give information about programs that help pay medical bills for people with limited income and resources.

State Pharmacy Assistance Program (SPAP)

A state program that provides help paying for drug coverage based on financial need, age, or medical condition.

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 prescribed drug.

Supplemental Security Income (SSI)

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 aren’t the same as Social Security retirement or disability benefits.

Tiers

Groups of drugs that have a different cost for each group. A drug in a lower tier will cost you less than a drug in a higher tier.

TRICARE

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

TRICARE FOR LIFE

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

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 the care.