Glossary of Medicare Health Plan Terms:
This glossary and definitions are provided to give you a general understanding of how words are used sometimes by Medicare and Medicare health insurance plans. Every health insurance plan has a complete list of benefits and coverages within the plan’s Medicare plans “Evidence of Coverage”.
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Annual Notice of Changes (ANOC) – Annual Notice of Changes is a booklet that explains to a member of a plan, how the benefits and costs of a plan will change next year from the current benefits. These changes of benefits and costs will take effect on January 1st of the next benefit year.
Appeal – An appeal is a complaint or notification of a problem regarding decisions about a plan members medical bills or health care. This process is used by a member of a Medicare health plan to request the health plan re-consider the denial of a previous authorization or a decision to deny a claim.
Assignment – Assignment means that your doctor or other medical provider has signed an agreement with Medicare to accept the Medicare approved amount as full payment for covered services
Allowable expense(s) – A medical health expense that is approved by the insurance company and part or all of which is covered under a health insurance plan.
Ambulatory Surgery – Surgical procedures that do not require an overnight hospital stay. These can be done inside a hospital or medical office. This is also referred to as outpatient surgery.
Approved Insurance plans – are those plans that are approved by the State Insurance Department and carry many coverage’s required by law.
Authorization – is the approval of a medical procedure prior to such procedure. This also called preauthorization or precertification. This is a good thing for a member to do.
Benefit – term used to indicate that there is coverage or protection under the terms of the health insurance plan for payment for medical services.
Benefit period – A Medicare benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received any hospital care or skilled nursing care for 60 days in a row.
Brand name drug – A prescription which is patented and protected by trademark registration.
Case management – The process of identifying members at high risk for problems associated with physical or mental health care needs and assessing opportunities to coordinate care to optimize the outcome and reduce expenses.
CMS – The Center for Medicare and Medicaid Services (CMS) is a branch of the United States Department of health and Human Services. CMS is the Federal Agency that administers the Medicare Program and “monitors” the Medicaid programs offered by each state.
Claim payment – payment of benefits for medical care services provided to a member by a medical provider.
Coinsurance – is the portion of the total medical expense that you may be required to pay for services after any plan deductibles are paid. This is usually a percentage (like 20%) of the Medicare approved amount.
Copayment – The dollar amount required to be paid by the plan member in connection with Medicare health plans and prescription drug plans. This amount is paid for each medical service like a doctor visit or prescription. A copayment is usually a set/fixed amount.
Covered benefits – is medical care that is approved and covered in whole or in part under a health insurance plan.
Creditable Prescription Drug Coverage – “This is prescription drug coverage for example from an employer that is expected to pay on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.” (Definition from CMS)
Custodial Care – Any type of care where the care provided is to attend to the member’s activities of daily living. This care does not require the attention of a licensed or trained medical provider. Some examples of this are: assistance in walking, getting in and out of bed, bathing oneself, dressing oneself, feeding oneself, using the toilet, and medicating oneself.
Deductible – the amount you must pay for a medical service or for a prescription before Original Medicare, a Medicare Health Plan, or your prescription drug plan. You also can have a combination of these conditions. For example, you can have a deductible for medical care and a deductible for prescriptions.
Diagnostic tests – are medical procedures to determine how a patients health is.
Drug Formulary – a list of prescription drugs created by the health insurance plan which includes generic drugs and brand name drugs. All Medicare health plans and prescription drug plans vary on the amount of copays and which drugs are included in the formulary..
Emergency Care – is when a member experiences sudden illness or injury perceived as life threatening and requiring immediate medical care.
End Stage Renal disease (ESRD) Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
Enrollee – is someone who has joined a Medicare health plan. This procedure is called enrolling a member and thus the term enrollee is used.
Evidence of Coverage (EOC) – is a booklet that tells you how to get yur Medicare medical care through a Medicare Advantage Plan. This booklet explains the enrolled members rights and responsibilities. It also explains what is covered and what the member must pay as an enrolled member in the plan.
Exclusions – are specific Medicare limitations that are placed on specific health conditions and specific circumstances where Medicare or the Medicare health plan provides no coverage or benefits. These exclusions are specified with Medicare and the health plan.
Formulary – a list of prescription drugs covered by a medicare health plan or prescription drug plan. This list is created by the health insurance plan which includes generic drugs and brand name drugs. Drugs not on these lists are called Non-formulary drugs.
Generic Drug – is a prescription drug which is not protected by trademark registration, and is sold as an equal to a Name Brand drug.
Grievance – is when a member expresses a dissatisfaction with any aspect of the operations, activities or behavior of a Medicare health Plan / Part D plan sponsor.
Health Plan – health insurance is referred to as HMOs, PPOs, PFFS, POS plans etc. which are all health plans. Each health plan defines the coverage’s or benefits offered and then takes away coverages through exclusions, limitations and conditions.
Health Insurance Portability and Accountability Act (HIPAA) – HIPAA is a federal law enacted in 1996. It was designated to improve availability and portability of health coverage by:
- Limiting exclusions for pre-existing conditions;
- Providing credit for prior health coverage;
- Allowing transmittal of the coverage information to a new insurer;
- Providing rights to allow individuals to enroll for health coverage when they lose their health coverage or have a new dependent;
- Prohibiting discrimination in enrollment/premiums
- Guaranteeing availability of health insurance coverage for small employers.
Health Maintenance Organization (HMO) – is a type of health insurance plan where the members of the health plans are able to go to the medical providers within the HMO network. HMO plans must cover all Medicare Part A and Part B services. Some HMOs cover extra benefits. Most HMOS require you to go to doctors, specialists or hospitals within the plan network. The exception to a HMO is in an emergency event.
Home health care – is a coverage or benefit that pays for skilled nursing and other services provided in a home setting.
Hospice Care – this is non-medical care, given to a terminally ill person as an inpatient or at home care. This care is to allow terminally ill patients to remain, for as long as they can, in the familiar surroundings of their home, before they die.
Hospital – is a business that offers inpatient and outpatient services. A hospital may be a general hospital, an acute care hospital, or a rehabilitation or specialty care hospital.
In-Network – is sometimes called an HMO and refers to the use of medical providers who participate in health plan’s provider network.
Inpatient Care – is when service is provided after the patient is admitted to the hospital and has a bed for the night.
Limitations – are restrictions within a health insurance plan that places a limit on the amount of coverage or benefits it will pay.
Managed Care – is when a health plan forms a network of providers at set fees and procedures and requires certification and pre authorization for certain services. This care also identifies members at high risk for problems associated with physical or mental health care needs and assesses opportunities to coordinate care and to optimize the outcome and reduce expenses.
Maximum Out of Pocket – is the maximum out of pocket amount that a member or enrollee will have to pay for expenses covered under the Medicare health plan. The maximum can be a coinsurance maximum or a copayment maximum.
Medicare Advantage Plan – is a health plan offered by a private company that contracts with Medicare to provide enrollees with all Medicare Part A and Part B benefits. Some of these plans include coverage for prescription drugs.
Medicare Part A – is hospital insurance that helps cover inpatient care in a hospital and skilled nursing facility, hospice care and home health care.
Medicare Part B – is medical insurance that helps cover doctor services, hospital outpatient care and home health care services. Some Preventative care is also provided to help maintain your health and to keep certain illnesses from getting worse.
Medicare Part C- is a health plan offered by a private company that contracts with Medicare to provide enrollees with all Medicare Part A and Part B benefits. Some of these plans include coverage for prescription drugs.
Medicare Part D – is a prescription drug option run by Medicare approved private insurance companies that help cover the cost of prescriptions drugs and may help lower your prescription drug costs.
Medicare Prescription Drug Plan (PDP) – is a standalone drug plan offered by insurance companies and other private companies.
Member – is the person who are enrolled in and covered by a Medicare health plan. Some companies refer to members as Medicare enrollees.
Mental disorder – is a medical condition for which coverage and benefits for medical care and treatment by a mental health professional such as a psychiatrist, a psychologist or a psychiatric social worker.
Network – Physicians, hospitals and other health care providers who agree to participate and provide medical services at reduced fees in a Medicare health insurance plan. Networks are also called a provider network.
Non-Participating Provider – is a term generally used to refer to medical providers who have not contracted with a health plan to provide services at reduced fees.
Occupational Therapy – is medical treatment to restore a person’s ability to perform activities of daily living such as bathing, dressing, walking, eating, and drinking.
Office Visits – coverage or benefits for costs incurred as a result of a vist to a doctors office.
Original Medicare – is a term for those members who are enrolled in Medicare’s Part A and Part B Plans from Medicare.
Out of Network – is when members use health care providers who have not contracted with the health plan to provide services.
Out of Pocket Maximum – is the maximum out of pocket amount that a member or enrollee will have to pay for expenses covered under the health plan. The maximum can be a coinsurance maximum or a copayment maximum. Once a member reaches the out of pocket maximum, the health plan pays 100% of covered medical care.
Outpatient Prescriptions – any prescription prescribed by a physician and dispensed by a pharmacist outside of a hospitalization.
Outpatient Surgery – is surgery that is performed on a member who is able to leave the hospital without an overnight stay in the hospital. This is also called ambulatory surgery.
Outpatient X-ray and Lab Tests – are medical services incurred for x-ray and lab tests that are not part of inpatient hospital fees.
Participating Provider – is a physician, a hospital, a skilled nursing facility, or other medical provider, who contracts with a health insurance plan, to provide medical services to members/enrollees.
PCP – is an acronym for Primary Care Physician.
Point of Service Plan (POS plan) – is a health insurance plan that provides coverage and benefits for medical care received from both participating and non-participating providers.
Preexisting condition – is a health problem or condition that existed prior to the date your health insurance plan became effective.
Preferred Provider Organization (PPO) – is a type of Medicare Advantage health plan which is available in a local or regional area in which you will pay less if you use doctors and other medical providers that belong to the PPO network.
Premium – The periodic payment to Medicare, an insurance company, or a health are plan for health care or prescription drug coverage.
Prescription – is a written order from a licensed provider for medical treatment. Medical treatment can be the usual prescription drug, or it could be for other medical care such as physical therapy.
Preventative Care – is medical care usually provided by a physician and is not medically necessary to address a medical problem or condition. What is included under preventative care varies greatly. Medicare mandates what preventative care will be covered for Medicare beneficiaries.
Primary Care Physician (PCP) – is usually your first contact for a medical problem. They are the local physicians such as a family care practitioner or an internist . Primary Care Physicians monitors your health, and diagnoses and treats minor health problems, and refers you to specialists if needed.
Private-Fee-For-Service (PFFS) is a type of Medicare Advantage plan in which you can go to any Medicare-approved doctor or hospital that accepts the plans payment.
The insurance plan decides how much it will pay and what you pay for the services you receive.
Prosthetic Devices – are a device which replaces all or a portion of a part of the human body. These devices are medically necessary because a part of the body is permanently damaged, is absent, or is malfunctioning.
Referral – some Medicare Advantage health plans requires a member to get a recommendation from their primary care physician before they see a specialist physician or have a non emergency surgery or hospital stay. In many HMOs, you must see your primary care doctor before you can see any other health care professional.
Service Area- the land area where a Medicare Advantage Health Plan accepts members. The plan may disenroll you if you move out of the plan’s service area.
Skilled Nursing Facility – is a Nursing facility with staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other health related health services.
Special Enrollment Period(SEP) – is a set time that a Medicare beneficiary can change health plans or return to Original Medicare. These times can be triggered by specific events like moving outside the service area, a plan leaving the area and other exceptional conditions which are determined by Center for Medicare and Medicaid Services.
A Physician who provides medical care for certain parts of the body, certain health problems or certain age groups.
Summary of Benefits – A document that explains some features of Medicare Health Plans. It doesn’t list every service that is covered or list every limitation or exclusion. A complete list of benefits is in a document called “Evidence of Coverage.”
Urgent Care – is medical care for an unexpected illness or injury that is not life threatening, but requires medical care right away to avoid complications and to stop unnecessary pain and suffering, such as a cut requiring stitches or a high fever.