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Activities of Daily Living (ADL)

Activities of daily living (ADL) are activities in which most people take part on a daily basis. Eating, bathing, dressing, toileting, and moving from one place to another are some examples.

Acute Illness

An acute illness is a disease or condition that comes on rapidly and severely, but that can—with proper treatment—be cured, such as pneumonia or a broken bone.

Administrative Law Judge (ALJ)

An Administrative Law Judge (ALJ) is a hearing officer who presides over appeals to Medicare by people with Medicare or their providers. The ALJ level follows the reconsideration level for all appeals for Medicare coverage.

Advance Beneficiary Notice (ABN)

An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice health care providers and suppliers are required to give a person with Original Medicare when they believe that Medicare will not cover their services or items and the person has no reason to know that Medicare will not cover these services or items. If your provider does not give you an ABN to sign and you have no reason to know the procedure is not covered, then you do not have to pay. If you sign an ABN before you get the service or item and Medicare does not pay for it, you generally pay for it (although there are a few exceptions). Providers are not required to give you an ABN for services or items Medicare never covers.

Advance Coverage Decision

An advance coverage decision is a Private Fee-For-Service (PFFS) plan’s determination about whether or not it will pay for a certain service. Note: this is completely unrelated to an Advance Beneficiary Notice (ABN), which only applies to people with Original Medicare.

Advance Directive

An advance directive is a legal document that outlines how you want medical and financial decisions made if you can no longer communicate your wishes. A health care advance directive may include a health care proxyliving will, and a health care power of attorney.

Advanced Illness

An advanced illness is a serious disease or condition that has progressed too far to be cured, such as cancer that has spread throughout the body.

Affordable Care Act

Affordable Care Act (also known as the Health Care Law)

Signed by President Obama on March 23, 2010, the Affordable Care Act (ACA) includes provisions to expand health coverage to eligible Americans, control health care costs, and improve the health care delivery system. The ACA closes the Medicare Part D donut hole/coverage gap and expands coverage of preventive services for people with Medicare. The Act also creates state-specific Marketplaces, where individuals can go to purchase health insurance. Generally, those with Medicare should not buy health insurance in the Marketplace.

ALS / Lou Gehrig’s Disease

ALS (Amyotrophic Lateral Sclerosis)/Lou Gehrig’s Disease

ALS (Amyotrophic Lateral Sclerosis) is a disease that affects the motor nerve cells of the spinal cord and causes their degeneration. Patients with this disease can qualify for Medicare coverage regardless of age.

Ambulette

An ambulette is a wheelchair-accessible van that provides non-emergency transportation for people with disabilities.

Annual Coordinated Election Period (ACEP)

Fall Open Enrollment, also known as the Annual Coordinated Election Period, is the span of time from October 15 through December 7. During this period you can change your Medicare private drug plan (Part D) and/or your Medicare health plan choice (Original Medicare or a Medicare Advantage plan) for the following year. This is also the time you can enroll in Part D for the first time if you did not enroll during your Initial Enrollment Period. (You may have to pay a premium penalty if you enroll during this time unless you have had other creditable coverage.) Your new coverage will begin January 1.

Annual Notice of Change (ANOC)

The Annual Notice of Change (ANOC) is the notice you receive from your Medicare Advantage or Part D plan in late September. This notice gives a summary of any changes in the plan’s cost and coverage that will take effect January 1 of the next year. Review this notice to see if your plan will continue to meet your health care needs in the following year. If you do not receive an ANOC from your plan, you should contact your plan. The ANOC is typically mailed with the plan’s Evidence of Coverage (EOC), which is a more comprehensive list of the plan’s cost and benefits for the upcoming year.

Annual Wellness Visit

The Annual Wellness Visit is a once a year visit covered by Medicare in which you can meet with your doctor to develop a prevention plan based on your needs. It will give you an opportunity to create and update a medical history a list of your medications and a list of your current providers and suppliers. During this visit your provider will record your weight, height, blood pressure, and BMI, as well as screen for cognitive issues and depression and your ability to function safely at home. The provider should give you a 5 to 10 year screening schedule or checklist and health advice and referrals to health education or preventive counseling services or programs aimed at reducing identified risk factors and at promoting wellness.

Appeal

An appeal is a formal request for review of an official decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare regarding payment for or coverage of health care. Federal regulations and law specify appeals deadlines, processes for handling cases, decision notification requirements, and multiple levels of review in the appeals process.

Approved Amount

The approved amount, also known as the Medicare-approved amount, is the fee that a health insurance plan sets as as the amount a provider or supplier should be paid for a particular service or item. Original Medicare calls this assignment. See also: Take AssignmentParticipating Provider, and Non-Participating Provider.

Area Agency on Aging (AAA)

Area Agencies on Aging (AAA) are agencies that coordinate and offer services such as Meals-on-Wheels, homemaker assistance, and similar programs that help older adults remain independent in their home and community.

Assets

Assets are resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate.

Assignment

Assignment is Medicare’s approved amount for a service or item. Original Medicare will cover 80 percent of this amount and you (or your supplemental insurance) are responsible for the remaining coinsurance. See also: Take AssignmentParticipating Provider, and Non-Participating Provider.

Assisted Living Facility

Assisted living facilities, also known as group homes, are facilities designed to assist people with activities of daily living who can otherwise take care of themselves. They are different from nursing homes, which also provide skilled care. Medicare does not cover a stay in an assisted living facility.

Assistive Technology

Assistive technology is any item, piece of equipment, or system that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. For example, Closed Circuit Television is an assistive technology that Medicare will cover if medically necessary. Simple items like grabbers and reachers are not covered by Medicare.

Balance Billing

Balance billing is when doctors and hospitals charge you more than the approved amount for the service.

Benchmark

Extra Help, also known as the Low-Income Subsidy (LIS), is a federal program administered by Social Security that helps people with Medicare who have low incomes and assets to pay for their Medicare prescription drug coverage (Part D), including coinsurance, deductibles, and premiums. There are different levels of Extra Help. You may get full Extra Help or partial Extra Help, depending on your income.

Beneficiary

A beneficiary is a person who receives benefits. (If you are a member of a health plan, like a group health planOriginal Medicare, or Medicaid, and receive benefits from that plan, you are a health plan beneficiary).

Benefit Period

The benefit period is the amount of time during which Medicare pays for hospital and skilled nursing facility (SNF) services. A benefit period begins the first day you enter the hospital or SNF and ends when you no longer receive hospital care or skilled care in a SNF for 60 days in a row. With each new benefit period, you pay a new deductible. Your coinsurance is determined by the number of days you have been in the facility during each benefit period.

Bereavement Services

Bereavement services are a hospice service that provides counseling for the family up to a year after the patient passes away.

Brand-Name Drug

A brand-name drug is a drug marketed under a proprietary, trademark-protected name. (Definition from the U.S. Food and Drug Administration)

Calendar Quarters

A calendar quarter is a three-month period of time ending with March 31, June 30, September 30, or December 31. Social Security counts each calendar quarter that you work and pay into Social Security and Medicare taxes toward your eligibility for premium-free Part A.

Capped Rental Item

A capped rental item is durable medical equipment (DME) (such as a wheelchair) that Medicare covers initially for rental, rather than for purchase, often because of its high cost. Medicare pays the rental fees for these items in monthly installments. You can keep a capped rental item as long as it is medically necessary and elect to buy it. After you rent for 13 months, ownership will automatically transfer to you. (Note: If you have been renting an item of DME since before January 1, 2006, you can continue to rent that item without purchasing if you choose.)

Care Manager

A care manager is a nurse or specially trained educator or doctor who will assess your needs and advise you on how to best manage your health conditions.

Caregiver

A caregiver is anyone who provides help and support to someone who is either temporarily or permanently unable to function or someone who can function but not optimally. Most caregivers are unpaid, and are often a family member, friend, or neighbor. Formal caregivers are paid care providers or volunteers associated with a service system.

Carrier

A carrier is a private company that has a contract with Medicare to process Part B claims.

Catastrophic Coverage

Insurance designed to protect you from having to pay very high out-of-pocket costs. Catastrophic coverage usually begins after you have spent a pre-determined amount on your health care. Original Medicare Part A and Part B do not offer catastrophic coverage. They always pay the same amount regardless of how much you have spent. The Medicare prescription drug benefit (Part D) does offer catastrophic coverage. After you have spent a certain amount out-of-pocket, you will only pay five percent of the cost of each prescription drug (in addition to your monthly plan premium). Medicare private plans, like regional PPOs (Prefered Provider Organizations), may also have catastrophic coverage or caps on out-of-pocket costs, but these caps may exclude certain high cost services. Also, Medicare Medical Savings Accounts (MSAs) must pay all or most of your Medicare Part A and B costs after you have met your deductible.

Catastrophic Limit

The catastrophic limit, also known as the out-of-pocket limit, is the highest amount of money you have to pay out-of-pocket during a given period of time for certain services. After you have reached the catastrophic limit of your insurance plan, a higher level of coverage begins.

Center for Health Dispute Resolution (CHDR)

Maximus, formerly known as the Center for Health Dispute Resolution (CHDR), is and organization that handles Medicare Advantage Plan appeals. They serve as the Qualified Independent Contractor (QIC) level of appeals for Medicare Advantage Plans and for Medicare private drug plans (Part D).

Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), is the United States government agency responsible for administering Medicare, Medicaid, SCHIP (State Children’s Health Insurance), HIPPA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs.

Certificate of Medical Necessity (CMN)

A certificate of medically necessity (CMN) is documentation from a doctor which Medicare requires before it will cover certain durable medical equipment (DME). The CMN states the patient’s diagnosis, prognosis, reason for the equipment, and estimated duration of need.

Chronic Illness

A chronic illness is a disease or condition, such as diabetes or asthma, that lasts for a long period of time or is marked by frequent recurrence.

Claim

A claim is a bill that asks for payment for services or benefits you received. Medicare Part A claims are processed by fiscal intermediaries and Part B claims are processed by Medicare carriers. Medicare Advantage Plan and Medicare private drug plan (Part D) claims are processed by the plans. See also: Medicare Administrative Contractors (MACs) and DME MAC (Durable Medical Equipment Medicare Administrative Contractor).

COBRA

COBRA (Consolidated Omnibus Budget Reconciliation Act)

COBRA is a federal law guaranteeing employees and their families at risk of losing health insurance—due to termination of employment, death, divorce, or other circumstances—the right to purchase continued coverage under the employer’s group health plan for limited periods of time.

Coinsurance

The coinsurance is the portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of an approved amount. In Original Medicare, the coinsurance is usually 20 percent of Medicare’s assignment.

Competitive Bidding

Competitive bidding was phased in starting January 2011 in select locations. It requires you to get most of your durable medical equipment from certain Medicare-certified suppliers. The suppliers must accept the Medicare approved amount in full and can only bill you for 20 percent of the Medicare approved amount.

Comprehensive Outpatient Rehabilitation Facility (CORF)

A Comprehensive Outpatient Rehabilitation Facility (CORF) is a medical facility that provides outpatient diagnostic, therapeutic, and restorative services for the rehabilitation of an injury, disability, or sickness.

Continuous Open Enrollment

Continuous open enrollment is a consumer’s right to buy private insurance at any time, regardless of age or health status.

Conversion Policy

A conversion policy is an employer-sponsored group health plan that can be converted to an individual policy with the same insurance company. These policies are usually very expensive.

Coordination of Benefits

Coordination of benefits is the sharing of costs by two or more health plans, based on their respective financial responsibilities for medical claims. Your primary insurance and secondary insurance must coordinate benefits in order to pay claims.

Coordination Period, 30-Month

The 30-month coordination period, for people with End-Stage Renal Disease (ESRD), is the period of time during which a group health plan pays first and Medicare pays second. Medicare may pay the remaining costs if your group health plan does not pay 100 percent of your health care bills during the coordination period.

Copayment

A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $5 or $35).

Cost Plan

A cost plan is a private health plan sponsored by a Health Maintenance Organization (HMO), through which you can get your Medicare benefits. A cost plan is not a Medicare Advantage Plan. It allows you to go out of network to get care. If you get out-of-network care from a provider that accepts Medicare as payment, your costs will be covered by Original Medicare.

Cost Sharing

Cost sharing is the portion of medical care that you pay yourself, such as a copaymentcoinsurance or deductible, if you have health coverage. See also: Out-Of-Pocket Costs.

Cost Tiers

Cost tiers, also known as tiers, are a system that Medicare private drug plans use to price prescription drugs. Generic drugs are generally on the first, least expensive tier (Tier 1), followed by brand-name drugs (Tier 2), and then specialty drugs (Tiers 3 and above), with each subsequent tier requiring higher out-of-pocket costs.

Coverage Gap

The coverage gap, also known as the donut hole, is a gap in Medicare prescription drug coverage (Part D). During this coverage period your drug costs may increase. As a result of health reform, the coverage gap is gradually being phased out. It will be completely phased out in 2020, at which point you will pay no more than 25 percent of the cost of your drugs throughout the entire year.

Coverage Restrictions

Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to restrict their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy.

Creditable Coverage

Creditable coverage is:

  • Any health insurance coverage you had within 63 days of securing a new insurance policy that can be used to shorten the waiting period for pre-existing conditions.
  • Prescription drug coverage that is considered to be as good as or better than the Medicare prescription drug benefit (Part D) in monetary value.
Crossover

A crossover is a billing arrangement between your Medigap supplemental insurance and Original Medicare, which allows your Medigap to be automatically billed for its share of the cost of your health care services so that you do not have to pay up front and later seek reimbursement from the Medigap.

Curative Care

Curative care is the treatment of a patient with the intent of curing the patient’s disease or condition. For example, chemotherapy treatments to cure breast cancer.

Currently Working

You are considered to be currently working as long as you have employment rights at your company even if you do not work on a regular basis, are on sick leave, are a seasonal worker, or have been temporarily laid-off. You are not considered to be currently working if you receive Social Security Disability Insurance (SSDI), have received disability benefits from your employer for more than six months, or if you receive your employer insurance through COBRA.

Custodial Care

Custodial care, also known as homemaking services or housekeeping services, is non-medical care, such as cooking, cleaning, and shopping. Medicare generally does not cover custodial care.

Deductible

The deductible, also known as the elimination period in long-term care, is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year.

Demand Bill

A demand bill is a demand that a provider continue to bill Medicare for the given services even though the provider does not think that Medicare will cover them. You may demand bill after you receive an Advance Beneficiary Notice (ABN), a Home Health Advance Beneficiary Notice (HHABN), or Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) from a health care provider. In order to demand bill, you must sign the ABN and agree to pay for the services in full if Medicare denies coverage.

Denial of Coverage

A denial of coverage is a refusal by Original Medicare, a Medicare Advantage Plan, or Medicare private drug plan (Part D) to pay for medical services.

Department of Veterans Affairs (VA)

The Department of Veterans Affairs (VA) is a government agency that provides federal benefits to veterans and their families. These benefits include (but are not limited to) pensions, educational stipends, and health care services. See also: VA Benefits.

Detailed Explanation of Non-Coverage (DENC)

A Detailed Explanation of Non-Coverage (DENC) is a notice that is given to you by a home health agency (HHA), skilled nursing facility (SNF)comprehensive outpatient rehabilitation facility (CORF), or hospice agency when you appeal its decision to end your care to the Quality Improvement Organization (QIO). The DENC explains why the services will no longer be provided and any applicable Medicare coverage rules.

Detailed Notice of Discharge

A Detailed Notice of Discharge is a notice given to you by a hospital after you have requested a Quality Improvement Organization (QIO) review of the hospital’s decision that you be discharged. (You would have been notified that the hospital wanted to discharge you in the Important Message from Medicare notice.) The Detailed Notice of Discharge explains why services will no longer be covered, provides a description of Medicare coverage restrictions, and explains how those rules apply to your case. Once you request QIO review of a discharge decision, the hospital must provide you this notice in all cases (whether you in are in Original Medicare or in a Medicare Advantage Plan).

Dialysis

Dialysis is the technique used to artificially cleanse your blood of toxins when your kidneys no longer work either temporarily or permanently.

Disability

A disability is a restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being. The Social Security Administration (SSA) judges disability—and whether you qualify for financial assistance—based on whether you can work. (Definition from the World Health Organization)

Discharge

Discharge is the end to your stay as an inpatient in a medical institution such as a hospital or skilled nursing facility (SNF).

Discharge Plan

discharge plan is a plan for post-hospitalization care intended to identify an individual’s need for medical and social services and resources available to help prevent re-hospitalization. A discharge plan must involve

  • input from you and your representatives about your preferences and care needs after hospitalization;
  • information and instructions to you and your caregivers about post-hospitalization care you need; and
  • arrangement of necessary post-hospital services, transfers, and referrals to appropriate services and facilities.
Disenrollment

Disenrollment is leaving a private health plan or Medicare private drug plan.

DMEPOS

DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies)

Durable medical equipment (DME), also known as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) is equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment, and hospital beds. To be covered by Medicare, durable medical equipment must be prescribed by a doctor. Many types of adaptive equipment are not covered.

Donut Hole

The coverage gap, also known as the donut hole, is a gap in Medicare prescription drug coverage (Part D). During this coverage period your drug costs may increase. As a result of health reform, the coverage gap is gradually being phased out. It will be completely phased out in 2020, at which point you will pay no more than 25 percent of the cost of your drugs throughout the entire year.

Drug Class

A drug class is a group of drugs that treat the same symptoms or have similar effects on the body. For example, people with Medicare often use statin class drugs, which are used for reducing cholesterol. Drugs in this class include (but are not limited to) Lipitor, Zocor, Pravachol, Zetia, and Vytorin.

Drug Tiers

Cost tiers, also known as tiers, are a system that Medicare private drug plans use to price prescription drugs. Generic drugs are generally on the first, least expensive tier (Tier 1), followed by brand-name drugs (Tier 2), and then specialty drugs (Tiers 3 and above), with each subsequent tier requiring higher out-of-pocket costs.

Dual Eligible

A dual eligible individual is a person who has both Medicare and Medicaid.

Durable Medical Equipment (DME)

Durable medical equipment (DME), also known as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) is equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment, and hospital beds. To be covered by Medicare, durable medical equipment must be prescribed by a doctor. Many types of adaptive equipment are not covered.

DME MAC

Durable Medical Equipment Medicare Administrative Contractor (DME MAC)

A Durable Medical Equipment Medicare Administrative Contractor (DME MAC) is a private insurance company that has a contract with Medicare to process durable medical equipment (DME) claims. DME MACs follow Medicare national guidelines to decide on a local level what types of equipment should be covered on a case-by-case basis and how much Medicare will pay for the equipment. See also: Medicare Administrative Contractors (MACs).

DMERC

Durable Medical Equipment Regional Carrier (DMERC)

Durable Medical Equipment Regional Carrier (DMERC) is the former name of DME MACs (Durable Medical Equipment Medicare Administrative Contractors). The change occurred in 2007.

Durable Power of Attorney

A durable power of attorney is a legal document that lets you (the principal) appoint another person(s) (your agent or attorney in fact) to make decisions about your personal affairs (property, financial matters including health insurance, and other legal decisions) on your behalf. Making the document durable allows the agent(s) to act if you become ill or cannot otherwise act or your own behalf.

Earned Income

Earned income is money you get because you work, such as wages from work or earnings from self-employment.

Elimination Period See

The deductible, also known as the elimination period in long-term care, is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year.

Employer Group Health Plan

Group health plans, also known as employer group health plans, are employer or union-based health insurance administered to current or former employees of a company or organization through a private insurance company. This insurance may be primary or secondary to Medicare coverage depending on the size of the company and whether or not you are currently working.

End-Stage Renal Disease (ESRD)

End-Stage Renal Disease (ESRD) is kidney failure that requires you to be on dialysis or have a kidney transplant. Patients with this disease can qualify for Medicare coverage regardless of age.

Enrollment

Enrollment is joining Original Medicare or becoming a member of a Medicare Advantage Plan or Medicare private drug plan (Part D).

Enrollment Periods

Enrollment periods are certain periods of time when you can join the Original Medicare program, or elect a Medicare Advantage Plan, Medicare private drug plan (Part D), or supplemental insurance plan (Medigap). See also: Fall Open Enrollment Period, Medicare Advantage Open Enrollment Period, General Enrollment PeriodInitial Coverage Election PeriodInitial Enrollment PeriodInitial Open Enrollment Period, Open Enrollment Period, Special Election Period, and Special Enrollment Period.

Evidence of Coverage (EOC)

Evidence of Coverage (EOC) is the list of Medicare Advantage or Part D plan costs and benefits that will take effect on January 1 of the following year. You should receive an EOC from your plan in the fall. Review the EOC to see if the plan will meet your health care needs for the following year. The EOC is typically mailed with the plan’s Annual Notice of Change (ANOC), which is a notice informing you of plan changes that will take effect the following year.

Exception Request

An exception request is a formal, written request to your Medicare private drug plan (Part D) asking that it pay for a drug you need that is not on its list of covered drugs (formulary) or asking it to lower the price of a drug you need that is on its formulary but it costs too much.

Excess Charges

The excess charge is the difference between a doctor’s or other health care provider’s actual charge and Medicare’s approved amount for payment.

Expedited Appeal

An expedited appeal is a fast appeal of a Medicare Advantage Plan’s or Medicare private drug plan’s denial of coverage when a person’s “life, health, or ability to regain maximum function” is in jeopardy. These appeals may take up to 72 hours.

Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is the notice you get from Medicare after receiving medical services from a doctor, hospital, or other health care provider if you are enrolled in a Medicare Advantage Plan. It tells you what the provider billed Medicare, Medicare’s approved amount, the amount Medicare paid, and what you have to pay. It is not a bill. See also: Medicare Summary Notice (MSN).

Extra Help

Extra Help, also known as the Low-Income Subsidy (LIS), is a federal program administered by Social Security that helps people with Medicare who have low incomes and assets to pay for their Medicare prescription drug coverage (Part D), including coinsurance, deductibles, and premiums. There are different levels of Extra Help. You may get full Extra Help or partial Extra Help, depending on your income.

Extra Help Premium Amount

The Extra Help Premium Amount, also known as the benchmark, is the amount of money that full Extra Help will pay for the monthly premium of a Medicare private drug plan (Part D) that offers basic benefits.

Fall Open Enrollment

Fall Open Enrollment, also known as the Annual Coordinated Election Period, is the span of time from October 15 through December 7. During this period you can change your Medicare private drug plan (Part D) and/or your Medicare health plan choice (Original Medicare or a Medicare Advantage plan) for the following year. This is also the time you can enroll in Part D for the first time if you did not enroll during your Initial Enrollment Period. (You may have to pay a premium penalty if you enroll during this time unless you have had other creditable coverage.) Your new coverage will begin January 1.

Federal District Court

The federal district court is:

  • The general trial court of the United States court system. Each federal judicial district has at least one courthouse, and most districts have more than one. Each state has at least one judicial district.
  • The level in the Medicare process of appeals that comes after the Medicare Appeals Council (MAC) level. This is the final level of the Medicare appeals process.
FEHBP

Federal Employee Health Benefit Program (FEHBP)

The Federal Employee Health Benefit Program (FEHBP) is health insurance for full-time permanent civilian employees and retirees of the United States Government, offered through private health plans.

Federal Poverty Level (FPL)

The Federal Poverty Level (FPL) is the federally set level of income that an individual or family can earn below which it is recognized that they can not afford necessary services. The FPL is used in eligibility criteria of many programs, including Extra Help and Medicaid. The FPL changes every year and varies depending on the number of people in your household. It is higher in Alaska and Hawaii.

Federally Qualified Health Center (FQHC)

Federally Qualified Health Centers (FQHCs) are health centers located in medically under-served areas which provide low-cost health care. Medicare will pay for some health services in FQHCs that it generally does not cover, such as routine check-ups. FQHCs include community health centers, migrant health centers, and health centers for the homeless.

Fee-for-Service

Fee-for-service is payment to providers for each service they provide, as in Original Medicare.

Fiscal Intermediary

A fiscal intermediary, also known as an intermediary, is a private company that has a contract with Medicare to process Medicare Part A claims.

Formulary

The formulary is the list of prescription drugs for which a Medicare Advantage Plan that offers drug coverage—Medicare Advantage Prescription Drug Plan (MAPD)—or Medicare private drug plan (Part D) will help pay. Drugs not on the formulary are generally not covered by private plans.

Formulary Restrictions

Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to restrict their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy.

Free Look

A free look is a period of time when you can try out a Medicare supplemental insurance (Medigap) policy. During this time (usually 30 days), you can cancel the policy and get a full refund.

Gaps in Coverage

Gaps in coverage are services or costs that are not covered under the Original Medicare health insurance plan, such as prescription drugs, deductibles, and coinsurance.

Gatekeeper

Gatekeepers are the primary care physician (PCP) in managed care plans, who oversee your care and decide when to refer you to a specialist.

General Enrollment Period

The General Enrollment Period is the time period between January 1 and March 31 of every year when you can enroll in Medicare Part B for the first time. If you enroll during this period (and it is after your Initial Enrollment Period), your coverage will begin on July 1.

Generic Drug

A generic drug is a copy of a brand-name drug that is regulated by the Food and Drug Administration to be identical in dosage, safety, strength, how it is taken, quality, performance and intended use (Definition from the U.S. Food and Drug Administration). Generics generally work just as well as the brand-name version but are cheaper because they are not patented.

Grievance

A grievance is a complaint or dispute filed with your Medicare Advantage Plan or Medicare private drug plan (Part D) about any part of the plan’s operations, behavior, or activities. You must file a grievance orally or in writing within 60 days of the event or incident. For example, you may file a grievance if you are dissatisfied with the condition of a health care facility or the facility’s operating hours, or if you have a complaint about the behavior of those working for the facility or the private health or drug plan, itself. An appeal, not a grievance, is the appropriate way to complain about a denial of coverage. However, Medicare Advantage Plans and drug plans must respond to grievances within 24 hours if they involve the plan’s failure to grant an expedited appeal (and in the case of a drug plan, you have not yet purchase the medication). A Medicare drug plan must notify you of its decision about other grievances within 30 days of receiving them (but can extend that time up to 14 calendar days).

Group Health Plan

Group health plans, also known as employer group health plans, are employer or union-based health insurance administered to current or former employees of a company or organization through a private insurance company. This insurance may be primary or secondary to Medicare coverage depending on the size of the company and whether or not you are currently working.

Guaranteed Issue

Guaranteed issue is a consumer protection that gives people the right to buy Medigap supplemental insurance. Because of this right, which is in effect during certain times, an insurance company cannot deny you insurance coverage or place conditions on a policy, must cover your pre-existing conditions, and cannot charge you more for a policy because of your health status.

Health Care Financing Administration (HCFA)

See Centers for Medicare and Medicaid Services (CMS).

Health Care Power of Attorney

A health care power of attorney directive is a legal document that lets you (the principal) appoint another person(s) (your agent or attorney in fact) to make health care decisions for you if you become too sick or disabled to make them yourself. State law determines whether Medicare plan enrollment is a health care decision that your health care agent can carry out for you.

Health Care Provider

A health care provider is an individual or facility, such as a doctor or hospital, which provides health care services. See also: Provider.

Health Care Proxy

A health care proxy is a legal document that allows you to appoint another person (a proxy or agent) to make health care decisions for you if you can not speak for yourself.

Health Insurance

Health insurance is insurance that protects you against loss from illness, generally through compensation for medical expenses. Programs like Medicare and Medicaid are government-sponsored forms of health insurance. Health insurance can also be administered by private companies that offer individual policies, group health plans, and supplemental insuranceMedicare Advantage Plans and Medicare private drug plans (Part D) are examples of government-sponsored health insurance that is administered by private companies.

Hill-Burton Program/Facilities

The Hill-Burton Program/Facilities are hospitals and clinics that offer free or reduced-cost care to patients who meet qualifying income limits. These vary in what types of services they offer and do not provide services that are covered by a patient’s health insurance.

HIPAA

HIPAA amended the Employee Retirement Income Security Act (ERISA) to provide new rights and protections for members of group health plans. HIPAA contains protections both for health coverage offered in connection with employment (group health plans) and for individual insurance policies sold by insurance companies.

HMO (Health Maintenance Organization)

A HMO (Health Maintenance Organization) is a type of managed care plan that generally covers only the care you get from providers that are in the HMO’s network. People with Medicare can choose to get their Medicare benefits through an HMO. HMO members must choose a primary care physician (PCP) who coordinates their care and acts as a gatekeeper to their care. See also: Medicare Advantage Plan.

Home Health Agency

A home health agency is an organization that provides home care services, such as skilled nursing, physical therapyoccupational therapyspeech/language pathology, and personal care.

Home Health Aide

A home health aide is a worker who helps a patient at home with activities of daily living. Medicare does not pay separately for aides to perform custodial care, but they may do light housekeeping related to personal care during the visit. Medicare will not pay for home health aide services unless they are accompanied by a need for skilled care.

Home Health Care

Home health care is care provided at home to treat an illness or injury. Medicare will only cover care in the home if the person has a need for skilled care.

Homebound

Homebound is the state of having a condition such that there exists a normal inability to leave home and leaving home requires “a considerable and taxing effort.” A person does not have to be confined to bed to be considered homebound by Medicare. Leaving home for short periods of time for special non-medical events such as a family reunion, funeral, or graduation would not exclude someone from being considered homebound. A doctor must certify this condition.

Homemaking Services

Custodial care, also known as homemaking services or housekeeping services, is non-medical care, such as cooking, cleaning, and shopping. Medicare generally does not cover custodial care.

Hospice

Hospice is comprehensive care for people who are terminally ill that includes pain management, counseling, respite careprescription drugs, inpatient care and outpatient care, and services for the terminally ill person’s family.

Hospital Insurance

Part A, also known as Hospital Insurance, is the part of Medicare that covers most medically necessary hospital care, skilled nursing facility (SNF) care, home health care, and hospice care.

Hospital-Issued Notice of Non-Coverage (HINN)

A Hospital-Issued notice of Non-Coverage (HINN) is a written notice which explains:

  • That Original Medicare probably will not cover your hospital stay;
  • What you will have to pay if you decide to go ahead with your care anyway; and
  • Your rights to an immediate QIO appeal of the hospital’s decision.
Housekeeping Services

Custodial care, also known as homemaking services or housekeeping services, is non-medical care, such as cooking, cleaning, and shopping. Medicare generally does not cover custodial care.

Important Message from Medicare

An Important Message from Medicare is a notice given to you by the hospital whether you are in Original Medicare or in a Medicare Advantage Plan when you are going to be discharged that explains your rights as a patient. It also tells you how to ask for an expedited review of the discharge decision by the Quality Improvement Organization (QIO). This is the same document you should have been asked to sign within two days of being admitted to the hospital.

In-Network

In-network means part of a managed care plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and equipment suppliers that are in your private health plan’s or Medicare private drug plan’s network, you will generally pay less than if you go to out-of-network providers.

Independent Review Entity (IRE)

An Independent Review Entity (IRE) is an separate organization with which Medicare contracts to handle the second level of appeals of a denial of coverage (except for of hospital care) if you are in a Medicare Advantage Plan or Medicare private drug plan (Part D).

Individual Policy

An individual policy is a private health plan that covers an individual person as opposed to a group (such as a group of employees covered by an employer group health plan). It is separate from Medicare coverage.

Initial Coverage Election Period

The Initial Coverage Election Period (ICEP) is a period of time that begins the three months immediately before you are entitled to Medicare Part A and enrolled in Part B and ends either the last day of the month before you are entitled to Part A and enrolled in Part B or three months after the month of your 65th birthday or the 25th month of receiving Social Security Disability Insurance (SSDI). If you choose to join a Medicare Advantage Plan during this period, the plan must accept you, unless it has reached its member limit.

Initial Enrollment Period

The Initial Enrollment Period (IEP) is the first chance you have to enroll in Part APart B or Part D if you do not get it automatically. If you enroll during this time, which begins three months before you first meet the eligibility requirements for Medicare and continues for seven months, you do not pay a premium penalty.

Initial Open Enrollment Period

The Initial Open Enrollment Period is a six month period beginning the month you enroll in Part B during which you can buy any Medigap supplemental insurance plan you want. If you are 65 or older, you are guaranteed this enrollment period in all states. Only a few states extend this enrollment period to people who are under 65. If you enroll during this time, the insurance company cannot

  • deny you Medigap coverage or make you wait for coverage to start; or
  • charge you more for a policy because of past or present health problems.
Inpatient

An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance).

Inpatient Care

Inpatient care is care received when you have been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance).

Intermediary

A fiscal intermediary, also known as an intermediary, is a private company that has a contract with Medicare to process Medicare Part A claims.

Intermediate Care Facility for the Mentally Retarded (ICF/MR)

Intermediate Care Facilities for the Mentally Retarded (ICF/MRs) are skilled nursing facilities specifically designed to provide “active treatment” to people with mental retardation.

Language Therapy

Speech/Language Pathology, also known as speech therapy and language therapy, is the therapeutic treatment of speech impairments (such as lisping and stuttering) or speech difficulties that result from illness.

Lifetime Reserve Days

Lifetime reserve days, also known as reserve days, are for when you are in the hospital for more than 90 days. Medicare will pay for 60 additional reserve days that you can only use once in your lifetime. They are not renewable once you use them.

Limiting Charge

A limiting charge is an upper limit on how much doctors who do not accept Medicare’s approved amount as payment in full can charge to people with Medicare. Federal law sets the limit at 15 percent more than the Medicare-approved amount. Some states limit it even further. For example, in New York doctors can only charge 5 percent more than Medicare’s approved amount for certain services. This charge is in addition to 20 percent coinsurance (45 percent for mental health services). Providers who opt-out of Medicare are not subject to these limiting charges and can charge as much as they want, if the patient signs an agreement with them prior to receiving care.

Living Will

Living wills, also called directive to physicians, health care declaration, or medical directive, describe the type of care you want to receive as you near the end of your life in specific circumstances. In some states it only goes into effect only when your doctor certifies your health condition and that you are no longer capable of making decisions (incapacitated). It is narrow in scope and works best as a guide for your physicians and the person you have legally named to make health care decisions on your behalf using a health care proxy.

Long-Term Care

Long-Term Care is custodial care given at home or in a nursing homeMedicare does not cover long-term care. See also: Long-Term Care Insurance.

Long-Term Care Insurance

Long-Term Care Insurance is provided by private insurance companies. It covers some of the costs of long-term care and can help you preserve your assets, but is often very expensive and is not a good option for most people.

Long-Term Care Ombudsman

The Long-Term Care Ombudsman is an independent advocate for nursing home and assisted living facility residents who provides information about how to find a facility and how to get quality care. Every state is required to have an Ombudsman Program that addresses complaints and advocates for improvements in the long-term care system.

Low-Income Subsidy (LIS)

Extra Help, also known as the Low-Income Subsidy (LIS), is a federal program administered by Social Security that helps people with Medicare who have low incomes and assets to pay for their Medicare prescription drug coverage (Part D), including coinsurance, deductibles, and premiums. There are different levels of Extra Help. You may get full Extra Help or partial Extra Help, depending on your income.

Maintenance Care

Maintenance care is care given to people with chronic illnesses to keep them from getting worse. For example, exercise and physical therapy can minimize abnormal or painful positioning of the joints and may prevent or delay curvature of the spine in a person with Muscular Dystrophy.

Managed Care Plan

A managed care plan is any arrangement for health care in which an organization, such as an insurance company, acts as an intermediary between the person seeking care and the medical care provider. In Medicare, you have the choice to get your benefits through the federal government (Original Medicare) or a private managed care plan that receives a set amount of money from the government to provide Medicare-covered benefits. See also: Medicare Advantage Plan.

MAPD (Medicare Advantage Drug Plan)

MAPD (Medicare Advantage Drug Plan) is a Medicare Advantage Plan that offers Medicare prescription drug coverage (Part D).

Marketing Fraud

Marketing fraud is when Medicare private plans deceive you—through marketing materials or through a person mis-representing the plan—about what the plan offers and how much it costs. See also: Medicare Fraud.

Marketplaces (also known as Exchanges)

The Marketplace is a shopping forum, created by the Affordable Care Act, where individuals and small business owners can compare and purchase health insurance plans. Each state chooses how the Marketplace will operate in its own state. Beginning in October 2013, almost all U.S. citizens and lawfully present residents will be able to enroll into health insurance plans through the online Marketplaces, with earliest possible coverage beginning January 1, 2014. People who have Medicare will not be able to get Medicare coverage in the Marketplaces. Medicare Advantage and Medigap plans will not be sold in the Marketplaces.

Maximum Out-of-Pocket Cost (MOoP)

The Maximum Out-of-Pocket Cost (MOoP) is a limit on how much you can spend out-of-pocket for a Medicare Advantage Plan. Once you reach this amount, you have no more copays for Parts A and B services. All Medicare Advantage Plans have been required to have an out-of-pocket maximum since January 1, 2011.

Maximus

Maximus, formerly known as the Center for Health Dispute Resolution (CHDR), is and organization that handles Medicare Advantage Plan appeals. They serve as the Qualified Independent Contractor (QIC) level of appeals for Medicare Advantage Plans and for Medicare private drug plans (Part D).

Medicaid

Medicaid is a state-run program that covers medical expenses for people with low or limited incomes.

Medicaid Buy-In

The Medicaid Buy-In is a state-run Medicaid program that allows people with disabilities under the age of 65 to work and still get the comprehensive benefits of Medicaid. The program allows people who are not eligible for traditional Medicaid—because their income or assets are too high—to buy in to the program for a small percentage of their income. Not all states have Medicaid Buy-In.

Medicaid Spend-Down

The Medicaid spend-down is a state-run Medicaid program for people whose income is higher than would normally qualify them for Medicaid, but who have high medical expenses that reduce their incomes to the Medicaid eligibility level. Not all states have Medicaid spend-down.

Medical Insurance

Part B, also known as Medical Insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, durable medical equipment (DME), hospital outpatient care, laboratory tests, x-rays, mental health, and some home health care and ambulance services.

Medical Social Services

Medical Social Services are services generally intended to help a patient and family cope with the logistics of daily life with an advanced illness. Medical social services include assessing social and emotional factors related to the patient’s illness and care; evaluating the patient’s home situation, financial resources, and availability of community resources; and helping the patient access community resources to assist in recovery. The social worker may also provide counseling to the patient and family to address emotions and issues related to the illness.

Medical Supplies

Medical supplies under Medicare are items that are covered if used by home health agency staff to fulfill the plan of care, such as wound dressings.

Medically Necessary

Medically necessary refers to procedures, services, or equipment that meet good medical standards and are necessary for the diagnosis and treatment of a medical condition.

Medicare

Medicare is a federal government health insurance program that gives you health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months due to a severe disability, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD), no matter your income. You can receive health coverage directly through the federal government (see: Original Medicare) or administered through a private company (see: Medicare Advantage Plan).

Medicare Administrative Contractor (MAC)

Beginning in 2008, Medicare Administrative Contractors (MACs) became Medicare’s replacement for fiscal intermediaries, carriers, and Regional Home Health Intermediaries. These MACs will process claims for both Medicare Part A and Part B in assigned regions. To find who you should call with billing issues, and whether your state has already been assigned to a MAC region, call 1-800-MEDICARE.

Medicare Advantage

Medicare Advantage, also known as Part CMedicare Private Health Plan, or Managed Care Plan, and formerly known as Medicare+Choice, is the part of Medicare concerning private health plans. It lets you get your Medicare benefits from a private health plan contracted by the government to provide this coverage. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs and coverage restrictions. Some plans (MAPDs—Medicare Advantage Prescription Drug Plans) offer Part D drug coverage as part of their benefits packages. You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Medicare Advantage Plans include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFFS (Private Fee-for-Service) plans, SNPs (Special Needs Plans) and MSAs (Medical Savings Accounts), and may have a POS (Point-of-Service) option. See also: Private Plan Card

Medicare Appeals Counsel (MAC)

The Medicare Appeals Counsel is the second highest level of Medicare appeals in the Medicare appeals process.

Medicare Card

Everyone who enrolls in Medicare also receives a Medicare card, also know as the red, white, and blue card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare claim number, which is the same as your Social Security number and identifies you in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say “Railroad Retirement Board” at the top. If you choose to get your Medicare benefits from a Medicare Advantage Plan, you will use your plan’s card instead of the Medicare card. See also: Private Plan Card.

Medicare Fraud

Medicare fraud is when doctors or other health care providers deceive Medicare into paying when it should not or into paying more than it should. See also: Marketing Fraud.

Medicare Prescription Drug Benefit

Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. The benefit is optional to most and provided only by private companies. You can get Part D coverage either through a stand-alone prescription drug plan (PDP) or a Medicare Advantage Prescription Drug Plan (MAPD)—a Medicare private health plan (Part C) that offers Medicare prescription drug coverage. You must choose Part D coverage that works with your Medicare health benefits. People who enroll in Part D pay a monthly premium in addition to their Part B premium. See also: Private Plan Card.

Medicare Private Drug Plan

Medicare private drug plan is a drug plan run by a private a company through which people with Medicare can get Medicare prescription drug coverage (Part D). A stand-alone Medicare private drug plan, which generally works with Original Medicare, is called a PDP (Prescription Drug Plan). A Medicare Advantage Plan that offers prescription drug coverage is called an MAPD (Medicare Advantage Prescription Drug Plan).

Medicare Private Health Plan

Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Managed Care Plan, and formerly known as Medicare+Choice, is the part of Medicare concerning private health plans. It lets you get your Medicare benefits from a private health plan contracted by the government to provide this coverage. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs and coverage restrictions. Some plans (MAPDs—Medicare Advantage Prescription Drug Plans) offer Part D drug coverage as part of their benefits packages. You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Medicare Advantage Plans include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), PFFS (Private Fee-for-Service) plans, SNPs (Special Needs Plans) and MSAs (Medical Savings Accounts), and may have a POS (Point-of-Service) option. See also: Private Plan Card

Medicare Savings Programs (MSP)

Medicare Savings Programs (MSPs), also known as Medicare Buy-In programs, help pay your Medicare premiums and sometimes also coinsurance and deductibles. There are three main Medicare Savings Programs, with different eligibility limits: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) program. The Qualified Disabled Working Individual (QDWI) program is a less common MSP for people who are under 65, have a disabling impairment, and continue to work.

Medicare SELECT

Medicare SELECT is a type of Medigap policy that will generally give you full coverage as long as you go to doctors and hospitals in its network.

Medicare Summary Notice (MSN)

A notice you get in the mail from Original Medicare that lists services you received over the previous three months from doctors, hospitals or other health care providers. It tells you what the provider billed Medicare, Medicare’s approved amount for the service, the amount Medicare paid, and what you have to pay. The MSN is not a bill. See also: Explanation of Benefits (EOB).

Medicare-Approved Amount

The approved amount, also known as the Medicare-approved amount, is the fee that a health insurance plan sets as as the amount a provider or supplier should be paid for a particular service or item. Original Medicare calls this assignment. See also: Take Assignment, Participating Provider, and Non-Participating Provider.

Medicare-Certified

Medicare-certified means offering services at a level of quality approved by Medicare. Medicare will not pay for services received from a health care provider that is not Medicare-certified.

Medicare+Choice

Medicare is a federal government health insurance program that gives you health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months due to a severe disability, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD), no matter your income. You can receive health coverage directly through the federal government (see: Original Medicare) or administered through a private company (see: Medicare Advantage Plan).

Medigap

A Medigap is a supplemental insurance policy that is sold by private insurance companies to fill “gaps” in Medicare. This insurance policy is usually available in the form of twelve different plans labeled A through L and works only with Original Medicare.

MSA (Medical Savings Account)

A MSA (Medical Savings Account) is a type of managed care plan included in the choices offered through Medicare Advantage Plan that combines a savings account and a very high-deductible health plan. Medicare deposits a certain amount of money you can use towards the deductible. The amount deposited each year is generally much lower than the deductible. MSAs cannot offer Medicare prescription drug coverage (Part D).

National Coverage Determination (NCD)

A National Coverage Determination (NCD) is a decision about particular treatments that Medicare will or will not cover for particular conditions. Medicare contractors are required to follow NCDs.

Network

A network is a group of doctors, hospitals, and pharmacies that contract with a managed care plan to provide health care services to plan members. Generally, managed care plan members may only receive covered services from providers in the plan’s network. Networks may be made up of both preferred and non-preferred providers.

Non-Participating Provider

In Original Medicare, a non-participating provider is a health care provider that does not routinely take assignment. When you see such a provider, you may pay up to 15 percent of Medicare’s approved amount for the service or item on top of the Medicare coinsurance. In addition, the provider can request full payment up front and you must submit the bill to Medicare for reimbursement. See also: Participating Provider.

Non-Preferred Provider/Care

A non-preferred provider/care is a health care provider or service covered by a private health plan or Medicare private drug plan (Part D) for which the plan will pay lower reimbursement rates. You will pay more for non-preferred services or services given at a non-preferred provider than for preferred providers and services.

Notice of Medicare Non-Coverage (NOMNC)

If you are enrolled in a Medicare Advantage Plan, a Notice of Medicare Non-Coverage (NOMNC) is a notice that tells you when care you are receiving from a home health agency (HHA), skilled nursing facility (SNF), or comprehensive outpatient rehabilitation facility (CORF) is ending and how you can contact a Quality Improvement Organization (QIO) to appeal.

NOMPNC

Notice of Medicare Provider Non-Coverage (NOMPNC)

If you have Original Medicare, a Notice of Medicare Provider Non-Coverage (NOMPNC) tells you when care you are receiving from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) or hospice agency is ending and how you can contact a Quality Improvement Organization (QIO) to appeal.

Nursing Home

A nursing home, also called a convalescent home, long-term care facility, skilled nursing facility, is a residential facility for persons with chronic illness or disability, particularly older people who have mobility and eating problems. Nursing homes may provide skilled care. If you meet certain health criteria, Medicare covers a limited stay in a Medicare-certified skilled nursing facility. While a skilled nursing facility is a nursing home, not all nursing homes are Medicare-certified skilled nursing facilities.

Observation Stay

An observation stay is an outpatient hospital stay in which an individual receives medical services to help the doctor decide whether he/she should be admitted to the hospital as an inpatient or should be discharged. Observation stays may occur when patients go to the emergency room and have symptoms that require hospital physicians to monitor them. Observation stays can last as little as a few hours, but may also last longer.

Occupational Therapy

Occupational therapy is therapy using meaningful activities of daily living to assist people who have difficulty acquiring or performing meaningful work due to impairment or limitation of physical or mental function.

Off-Label

Off-label is the prescribed use of a particular drug for a reason other than the use approved by the U.S. Food and Drug Administration.

Opt-Out

Doctors can opt-out of Medicare by notifying the Medicare carrier that they will not accept Medicare payments and telling their patients–in writing before treating them–that Medicare will not pay for their services and that the patients must pay for the care themselves. Doctors who have opted-out can charge as much as they want, and their patients have to pay the entire bill themselves. The only time a doctor who has opted out can receive payment from Medicare is when the doctor provides a patient emergency or urgent care services and the patient does not have a contract with that doctor. If the doctor did not provide a written contract before the patient received the services, the patient is not liable for payment.

Original Medicare

Original Medicare, also known as Traditional Medicare, is the federal health insurance program, created in 1965, under which the government pays providers directly for each service a person receives (on a fee-for-service basis). Almost all doctors and hospitals in the United States accept Original Medicare. The majority of people with Medicare are enrolled in Original Medicare, as opposed to a Medicare Advantage Plan.

Out-of-Network

Out-of-network means not part of a managed care plan’s network of health care providers. If you get services from an out-of-network doctor, hospital or pharmacy, it usually means that you likely will have to pay the full cost out of your own pocket for the services you received.

Out-of-Pocket Costs

Out-of-pocket costs are health care costs that you must pay because Medicare or other health insurance does not cover them.

Out-of-Pocket Limit

The catastrophic limit, also known as the out-of-pocket limit, is the highest amount of money you have to pay out-of-pocket during a given period of time for certain services. After you have reached the catastrophic limit of your insurance plan, a higher level of coverage begins.

Outpatient

An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (Medical Insurance).

Outpatient Care

Outpatient care is care that you receive when you have not been formally admitted into the hospital by a doctor as an inpatient. Outpatient care may include emergency room visits, doctor’s office visits, or observation stays.

Outpatient Prospective Payment System (OPPS)

The Outpatient Prospective Payment System (OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. The rate of reimbursement varies with the location of the hospital or clinic.

Over-the-Counter Drug

An over-the-counter drug is a drug that you can buy, without a prescription, at your local pharmacy or drug store. These drugs are not covered by the Medicare prescription drug benefit (Part D).

Palliative Care

Palliative care is the care of patients with a terminal illness, with the intent of trying to relieve them of their symptoms, not trying to cure them. Palliative care consists of relief of pain and nausea, as well as psychological, social, and spiritual support services.

Part A

Part A, also known as Hospital Insurance, is the part of Medicare that covers most medically necessary hospital care, skilled nursing facility (SNF) care, home health care, and hospice care.

Part B

Part B, also known as Medical Insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive caredurable medical equipment (DME), hospital outpatient care, laboratory tests, x-rays, mental health, and some home health care and ambulance services.

Part C

Medicare is a federal government health insurance program that gives you health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months due to a severe disability, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD), no matter your income. You can receive health coverage directly through the federal government (see: Original Medicare) or administered through a private company (see: Medicare Advantage Plan).

Part D

Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. The benefit is optional to most and provided only by private companies. You can get Part D coverage either through a stand-alone prescription drug plan (PDP) or a Medicare Advantage Prescription Drug Plan (MAPD)—a Medicare private health plan (Part C) that offers Medicare prescription drug coverage. You must choose Part D coverage that works with your Medicare health benefits. People who enroll in Part D pay a monthly premium in addition to their Part B premium. See also: Private Plan Card.

Participating Provider

A participating provider is a health care provider who agrees to always take assignment. Participating providers may not charge you more than Medicare’s approved amount, even if they charge non-Medicare patients more for the service. You will still pay a coinsurance or copayment of the cost for a visit or service—usually 20 percent of the Medicare-approved amount, if you have Original Medicare. See also: Non-Participating Provider.

Pastoral Care

Pastoral care is counseling or comfort provided by religious leaders (ministers, rabbis, etc.) to members of their group (church, congregation, etc). This can range from home visitation, to formal counseling by pastors who are licensed to provide pastoral counseling.

Patient Assistance Program

A patient assistance program is a  program typically run by a pharmaceutical company that offers low-cost or free drugs manufactured by that company to people with low incomes.

PDP (Prescription Drug Plan)

A PDP (Prescription Drug Plan) is a stand-alone Medicare prescription drug plan (Part D) offered through a private insurance company that only offers prescription drug benefits. PDPs work with Original MedicareMSA (Medical Savings Account) plans, Cost Plans, and PFFS (Private Fee-For-Service) plans without drug coverage.

Personal Care

Personal care, also known as unskilled care, is assistance with activities of daily living. Providers of personal care (home health aides) are not required to undergo medical training. Medicare only covers personal care if you are homebound and receiving skilled care.

PFFS (Private Fee-for-Service)

PFFS is a type of managed care plan that allows you to use any doctor or hospital anywhere in the country as long as that provider accepts the plan’s terms and conditions. People with Medicare can choose to get their Medicare benefits through a PFFS plan. You may pay more for Medicare benefits, many providers will not take PFFS plans, and you cannot buy a Medigap plan to fill gaps in coverage. See also: Medicare Advantage Plan.

Pharmacotherapy

Pharmacotherapy is the use of drugs to treat a disease or condition.

Physical Therapy

Physical therapy is exercise and physical activities used to condition muscles and improve levels of activity. It is helpful for those with physically debilitating illness.

Plan of Care

A plan of care is a doctor’s written plan describing the type and frequency of services and care a particular patient needs.

POS (Point-of-Service) Option

The POS (Point-of-Service) option is the right of managed care plan members to partial coverage for certain services they get outside the managed care plan’s network of providers. People with Medicare can choose to get their Medicare benefits through a private managed care plan; some of these plans offer the POS option. See also: Medicare Advantage Plan.

PPO (Preferred Provider Organization)

A PPO (Preferred Provider Organization) is a type of managed care plan. To get full coverage, you must use providers in the plan’s network, but you should also have partial coverage of care you get from out-of-network providers. People with Medicare can choose to get their Medicare benefits through a PPO. See also: Medicare Advantage Plan.

Pre-Approval

Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by private health plans and Medicare private drug plans. If a service or medication is covered with “prior authorization,” your doctor must get special permission from the plan to prescribe the service or medication to you before it will be covered. If you fail to get prior authorization before you get a service, your plan generally will not cover it.

Pre-Authorization

Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by private health plans and Medicare private drug plans. If a service or medication is covered with “prior authorization,” your doctor must get special permission from the plan to prescribe the service or medication to you before it will be covered. If you fail to get prior authorization before you get a service, your plan generally will not cover it.

Pre-Existing Condition

A pre-existing condition is a condition or illness with which you were diagnosed or for which you received treatment before your new health care coverage began. Some health plans may impose a waiting period on coverage of any pre-existing conditions you have.

Preferred Provider/Care

A preferred provider/care is a health care provider that is part of a private health plan’s network or a service that is covered by that private health plan for which the plan will pay its highest reimbursement rates. See also: Non-Preferred Provider/Care.

Premium

A premium is the amount that an individual must pay to a Medicare or other health insurance plan for coverage. Generally paid on a monthly basis.

Premium Penalty

premium penalty is an amount that you must pay to Medicare in addition to the regular monthly premium for late enrollment in Part B or Part D. The Part B premium is an additional 10 percent of the premium for each year you delay enrollment that you did not have coverage from a current employer. Part D will have a premium penalty of at least 1 percent for every month you delay enrollment that you were without creditable coverage.

Prescription

A prescription is an order for a health care service or drug written by a qualified health care professional.

Prescription Drug

prescription drug is a drug that can be obtained only by means of a prescription from a provider. Prescription drugs cannot be bought over-the-counter.

Prescription Drug Insurance

Prescription drug insurance is health coverage that helps you pay for prescription drugs. With a prescription drug insurance plan, you generally pay a copayment or coinsurance for each prescription drug you get that is covered by your plan (on its formulary). If you have Medicare, you can get prescription dug insurance through Part D, the Medicare prescription drug benefit.

Preventive Care

Preventive care is care to keep you healthy or prevent illness, such as routine checkups, flu shots, and tests like prostate cancer screenings and yearly mammograms.

Primary Care Physician (PCP)

The primary care physician (PCP) is the doctor that manages your health care and gives you a referral to consult a specialist if you need it. A managed care plan requires you to have a PCP. If you do not consult your PCP before seeing a specialist, your managed care plan will generally not cover your care.

Primary Insurance

Primary Insurance is health insurance that pays first on a claim for medical and hospital care. In most cases, Medicare is your primary insurer. See also, Secondary Insurance.

Prior Authorization

Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by private health plans and Medicare private drug plans. If a service or medication is covered with “prior authorization,” your doctor must get special permission from the plan to prescribe the service or medication to you before it will be covered. If you fail to get prior authorization before you get a service, your plan generally will not cover it.

Private Duty Nursing

Private duty nursing is direct, comprehensive care on an hourly or live-in basis.

Private Health Plan

Private health plans, also known as a managed care plans, are any arrangement for health care in which a private company acts an intermediary between the person seeking care and the physician. In Medicare, you have the choice to get your benefits through the federal government (Original Medicare) or a private health plan that receives a set amount of money from the government to provide Medicare-covered benefits. See also: Medicare Advantage Plan.

Private Plan Card

The private plan card is the membership card your Medicare private health plan (Part C) or Medicare private drug plan (Part D) sends to you to get health services or prescription drugs covered. You will use this instead of an Original Medicare “red, white and blue card.” It will generally include your name, the name of your insurance policy and the name of the company that sponsors it, as well as your member ID number. It may also list specific copayment or coinsurance amounts for your primary care physician (PCP) and specialist visits, and show what benefits your insurance plan includes (health, dental, prescription drug coverage, etc.). See also, Medicare Card.

PACE

Program of All-Inclusive Care for the Elderly (PACE) serves individuals who are age 55 or older who are certified by their state to need nursing home care to be able to live safely in the community at the time of enrollment and who live in a PACE service area. The philosophy of PACE states that it is better for the well being of seniors with chronic illness care needs and their families to be served in the community (rather than in a living facility) whenever possible.

Provider

In the field of health care, a provider is an individual or facility (such as a doctor, hospital or durable medical equipment (DME) supplier), that provides health care services and/or items.

PSO (Provider-Sponsored Organization)

Provider-Sponsored Organization (PSO) is a type of managed care plan that is operated by a group of doctors and hospitals that form a network of providers within which you must stay to receive coverage for your care. People with Medicare can choose to get their Medicare benefits through a PSO. This type of plan is not available in most parts of the country. See also: Medicare Advantage Plan.

QDWI (Qualified Disabled Working Individual)

QDWI is a less common Medicare Savings Program (MSP) administered by each state’s Medicaid program. It pays the Medicare Part A premium for people who are under 65, have a disabling impairment, continue to work, and are not otherwise eligible for Medicaid.

QI (Qualifying Individual)

QI is a federal program administered by each state’s Medicaid program that pays the Medicare Part B premium for people with Medicare who have low income.

QIO Review

The QIO Review is the initial step in making an appeal to a denial of coverage (either barring admittance to or discharge from a hospital, home health agency (HHA), skilled nursing facility (SNF)comprehensive outpatient rehabilitation facility (CORF) or hospice). See also: Quality Improvement Organization (QIO).

QMB (Qualified Medicare Beneficiary)

QMB is a federal program administered by state Medicaid programs that helps people with Medicare who have low income pay their coinsurance, deductibles, and premiums.

Qualified Health Plan (QHP)

Qualified Health Plans (QHPs) are health insurance policies that meet protections and requirements set by the Affordable Care Act (ACA). QHPs are sold through the individual Health Insurance Marketplace.

Qualified Independent Contractor (QIC)

A Qualified Independent Contractor (QIC) is an independent entity with which Medicare contracts to handle the reconsideration level of an Original Medicare (Part A or Part Bappeal.

Quality Improvement Organization (QIO)

A Quality Improvement Organization (QIO), formerly known as Peer Review Organization, is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. QIOs must review your complaints about the quality of care you get and appeals for care in inpatient hospitals, hospital outpatient care departments, hospital emergency rooms, skilled nursing facilities (SNFs), home health agencies (HHAs), Private Fee-for-Service (PFFs) plans, and ambulatory surgical centers. QIOs also contract with Medicare to conduct appeals. For example, QIOs review expedited appeals when a Medicare private health plan (Part C) denies coverage or terminates services from a hospital, home health agency, SNF, or comprehensive outpatient rehabilitation facility (CORF), or Original Medicare denies coverage of home health care, SNF care, hospice care or CORF care.

Quantity Limit

A quantity limit is a restriction used by private health plans and Medicare private drug plans that limits coverage of a particular drug to a specific amount (such as 30 pills a month each year).

Railroad Medicare Carrier

A Railroad Medicare Carrier is a private company that provides Medicare coverage for railroad retirement beneficiaries.

Railroad Retirement Board

The Railroad Retirement Board is an independent agency in the executive branch of the federal government that administers comprehensive retirement-survivor and unemployment-sickness benefit programs for the nation’s railroad workers and their families, under the Railroad Retirement Act and Railroad Unemployment Insurance Act.

Reconsideration

Reconsideration is:

  • In the Original Medicare (Part A and Part B) appeals process, the second level of appeal, where your appeal is reviewed by a Qualified Independent Contractor (QIC).
  • In a Medicare private health plan (Part C) appeals, there are two “reconsideration” phases.
  • Reconsideration by the Medicare private health plan. The first step in the appeal of a denial of coverage or denial of payment, in which the plan reviews its initial denial.
  • Reconsideration by the Independent Review Entity (IRE). If the plan upholds its initial decision in the redetermination, the appeal is automatically forwarded to the IRE for reconsideration.
  • In a Medicare private drug plan (Part D), a review of the plan’s redetermination of its decision to deny coverage or payment. Reconsiderations are conducted by the Independent Review Entity.
Red, White and Blue Card

Everyone who enrolls in Medicare also receives a Medicare card, also know as the red, white, and blue card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare claim number, which is the same as your Social Security number and identifies you in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say “Railroad Retirement Board” at the top. If you choose to get your Medicare benefits from a Medicare Advantage Plan, you will use your plan’s card instead of the Medicare card. See also: Private Plan Card.

Redetermination

Redetermination is:

  • The first step in the Original Medicare process of appeals once you have received a Medicare Summary Notice (MSN) giving you notice of a denial of coverage.
  • The first step in the Part D appeals process after the plan denies your coverage or exception request.
Referral

Referrals are authorizations that Medicare private health plans (Part C) usually require for services not provided by your primary care physician (PCP). For instance, HMOs generally require you to get a referral from your primary care doctor in order to see a specialist or get an eye exam.

Rehabilitative Care

Rehabilitative care is the treatment of patients with the intent of curing, improving or preventing a worsening of their condition. For example, physical therapy after hip replacement surgery to resume walking, or occupational therapy to prevent carpal tunnel syndrome.

Request for Reconsideration of Part B Premium Amount

The request for reconsideration of the Part B premium amount is the first level of appeal to the Social Security Administration if you think that Social Security has overestimated your income and is charging you a higher Part B premium than the standard amount. The next level of appeal is to the Administrative Law Judge (ALJ).

Reserve Days

Lifetime reserve days, also known as reserve days, are for when you are in the hospital for more than 90 days. Medicare will pay for 60 additional reserve days that you can only use once in your lifetime. They are not renewable once you use them.

Respite Care

Respite care is a hospice service that provides relief for caregivers of hospice patients by arranging a brief period (up to five days) of inpatient care for the patient.

Retiree Insurance

Retiree insurance is health insurance provided by employers to former employees who have retired. Retiree insurance always pays secondary to Medicare. See also: Supplemental Insurance.

Retroactive Disenrollment

Retroactive disenrollment is a way to discontinue enrollment in a Medicare private health plan (Part C) or Medicare private drug plan (Part D) that you mistakenly joined or joined due to marketing fraud, effective back to the date you joined. You will be disenrolled from your Medicare private health or drug plan as if you had never joined it.

Secondary Insurance

Secondary insurance is health insurance that covers your health care after the primary insurance on a claim for medical or hospital care. It usually pays for all or some of the costs that the primary insurer did not cover, but may not cover services not covered by the primary insurer. See also, Supplemental Insurance.

Semiprivate Room

A semiprivate room is a hospital room that contains two or more beds (generally just two), usually with a curtain separating the beds.

Service Area

The service area is the area within which a private health plan or Medicare private drug plan provides medical services to its members. In many private health plans, the area where your network of providers is located.

SHIP

State Health Insurance Assistance Programs (SHIPs) are federally-funded programs in each state that answer questions about Medicare, free of charge.

Skilled Care

Skilled care is medically necessary care performed by a skilled nurse or therapist. If a home health aide (someone who provides help with activities of daily living) or other person can perform the service, it is not considered skilled care. Skilled nursing includes care from Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). Skilled therapy includes care from licensed physical, occupational and speech therapists.

Skilled Nursing Facility (SNF)

Skilled nursing facilities are Medicare-approved facilities that provide short-term post-hospital extended care services, at a lower level of care than provided in a hospital.

Skilled Nursing Services

Skilled nursing services are services from a registered nurse, which include administration of medications; tube feedings; catheter changes; wound care; teaching and training activities; observation and assessment of a patient’s condition; and management and evaluation of a patient’s plan of care.

Skilled Therapy Services

Skilled therapy services are services from licensed physical, speech/language, and occupational therapists (if originally accompanied by physical therapy or speech/language pathology services). Physical therapy services which qualify people for home health care include: assessment; therapeutic exercises; gait training; range of motion tests; ultrasound, shortwave, and microwave diathermy treatments; teaching services; and development, implementation, management, and evaluation of a patient plan of careMaintenance care is covered if a physical therapist’s skills are necessary for the safe and effective provision of repetitive services which use complex, sophisticated procedures.

SLMB

SLMB (Specified Low-Income Medicare Beneficiary Program) is a Federal program administered by each state’s Medicaid program that pays the Part B premium for people with Medicare with low incomes.

SNP (Special Needs Plan)

Special Needs Plans are Medicare private health plans (Part C) that exclusively or primarily serve members who have a particular special need. A SNP may serve people who have both Medicare and Medicaid (dual-eligibles); people who have a specific chronic illness, like diabetes; or people who are in long-term care facilities or require an institutional level of care. Some SNPs may serve more than one type of special need.

Social Security Administration (SSA)

The Social Security Administration is the United States government agency responsible for advancing the economic security of Americans through shaping and managing various programs, including Medicare, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI) and Extra Help.

Special Election Period

The Special Election Period is a set period of time from October 1 through December 31 of every year when you can switch to another Medicare private health plan (Part C) if your plan is closing and another one is available in your area. During this time, Medicare private plans must enroll individuals who apply whose private plans are closing.

Special Enrollment Period (SEP)

The Special Enrollment Period (SEP) is a period of time outside of the general enrollment periodFall Open Enrollment Period or Medicare Advantage Disenrollment Period triggered by specific circumstances, during which you can enroll in Medicare Part BPart D, or a private health plan (Part C). SEPs may also allow you to switch or disenroll from Part D and private health plans. In Part B, an SEP absolves you from having to pay a premium penalty. Your Part B SEP begins the month after your or your spouse’s employment or group health plan coverage ends (whichever comes first). In Part D and private health plans, you are eligible for an SEP in many situations; for example, if you were to lose any type of drug coverage that was considered creditable coverage or you were to move out of your plan’s service area. Only two Part D SEPs absolve you from the premium penalty: getting Extra Help and receiving inadequate information about the creditability of your drug coverage.

Specialist

A specialist is a doctor who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems.

Speech Therapy

Speech/Language Pathology, also known as speech therapy and language therapy, is the therapeutic treatment of speech impairments (such as lisping and stuttering) or speech difficulties that result from illness.

Speech/Language Pathology

Speech/Language Pathology, also known as speech therapy and language therapy, is the therapeutic treatment of speech impairments (such as lisping and stuttering) or speech difficulties that result from illness.

SSDI

Social Security Disability Insurance (SSDI) is a monthly benefit provided through the United States Social Security Administration for people who lose their ability to work because of a severe medical impairment (disability). People who receive SSDI for 24 months are eligible for Medicare.

SSI

Supplemental Security Income is a monthly benefit for people with low incomes and assets who are 65 or older, blind, or have a disability.

SPAP

State Pharmaceutical Assistance Programs (SPAPs) are state-subsidized programs that provide assistance in paying for prescription drug costs. SPAPs vary by state.

Step Therapy

Step therapy is a coverage restriction placed on drug coverage by private health plans and Medicare private drug plans. Before your plan will cover some (generally more expensive) drugs, you must try other (generally less expensive) drugs that treat your condition to see if they will be effective for you.

Supplemental Insurance

Supplemental insurance fills gaps in Original Medicare coverage by helping to pay for the portion of health care expenses that Original Medicare does not pay for, such as deductibles and coinsurances. Supplemental insurance includes Medigap plans and retiree insurance from a former employer. Supplemental insurance may offer additional benefits that Medicare does not cover. See also: Secondary Insurance.

Supplier

A supplier is a person or business from whom you can buy medical equipment, like a walker or wheelchair. See also Provider and Durable Medical Equipment (DME).

Take Assignment

Take assignment is a term used to describe an agreement by a doctor to accept Medicare’s approved amount for a service or item as payment in full. See also, Participating Provider and Non-Participating Provider.

Temporary First Fill

A transition policy, also known as a temporary first-fill, allows new members of Medicare private drug plans (Part D) to get temporary coverage of drugs they were taking when they joined if those medications are not covered by their new plan.

Terminal Illness

A terminal illness is a disease or condition that cannot be cured or adequately treated, and is expected to result in eventual death.

Therapy Caps

Therapy caps are limits on the amount of physical therapyoccupational therapy and speech/language pathology that Medicare will cover in a given year.

Tiers

Cost tiers, also known as tiers, are a system that Medicare private drug plans use to price prescription drugs. Generic drugs are generally on the first, least expensive tier (Tier 1), followed by brand-name drugs (Tier 2), and then specialty drugs (Tiers 3 and above), with each subsequent tier requiring higher out-of-pocket costs.

Transition Policy

A transition policy, also known as a temporary first-fill, allows new members of Medicare private drug plans (Part D) to get temporary coverage of drugs they were taking when they joined if those medications are not covered by their new plan.

TRICARE

TRICARE is the Department of Defense’s health insurance program for active duty and retired military personnel and their family membters. TRICARE consists of several different programs, including TRICARE for Life (TFL), a retiree benefit that acts as supplemental insurance to Medicare. TRICARE also offers coverage to reserve force members who are on active duty for 30 days or more.

TRICARE for Life

TRICARE for Life is the health insurance program for military retirees who have served honorably for at least 20 years. They must be enrolled in Part B to receive the benefits. It pays secondary to Medicare and covers out-of-pocket costs including deductibles and coinsurance. People who qualify can receive free or low-cost medications from military treatment facilities, TRICARE network and out-of-network pharmacies, and the National Mail Order Pharmacy.

Unearned Income

Unearned income is money you get from sources other than current employment. Includes Social Security benefits, Veterans benefits, pensions, annuities and other regular payments you receive, such as alimony and workers’ compensation.

Unskilled Care

Personal care, also known as unskilled care, is assistance with activities of daily living. Providers of personal care (home health aides) are not required to undergo medical training. Medicare only covers personal care if you are homebound and receiving skilled care.

Urgent Care

Urgent care is immediate medical attention for a sudden illness or injury that is not life threatening.

Utilization Management Tools

Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to restrict their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy.

Veterans Administration (VA) Benefits

Veterans Administration benefits are benefits given by the federal government to people who have been in “active” service in the military, naval, or air service (veterans, not career officials) and, under certain conditions, to their family members. These benefits include pensions, educational stipends and health care, among others. Veterans can receive VA health care services only at VA facilities. See also, Department of Veteran’s Affairs.

Waiting Period

The waiting period is the time between signing up for a Medigap or Medicare private health plan (Part C) and the start of coverage. Waiting periods for Medicare-related benefits are most often imposed if you have a pre-existing condition and have not had creditable coverage for a certain amount of time.

Waiver of Liability

An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice health care providers and suppliers are required to give a person with Original Medicare when they believe that Medicare will not cover their services or items and the person has no reason to know that Medicare will not cover these services or items. If your provider does not give you an ABN to sign and you have no reason to know the procedure is not covered, then you do not have to pay. If you sign an ABN before you get the service or item and Medicare does not pay for it, you generally pay for it (although there are a few exceptions). Providers are not required to give you an ABN for services or items Medicare never covers.

Work Credits

Work Credits are the unit of measurement that determines when you are eligible to receive Social Security benefits, including Social Security Disability Insurance (SSDI). How many work credits you earn during a year (up to a maximum of four) depends on how much money you make during that year. The Social Security Administration (SSA) determines the amount that you must earn to receive one work credit.

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