Administrative law judge: court officer who makes judgements on Medicare appeal proceedings made by current or potential Medicare participants who do not agree with a Medicare decision or have a dispute with a Medicare provider.
Advanced beneficiary notice, also called a “waiver of liability”: a notice given to Medicare participants by Medicare providers or suppliers when the participant requests services not covered by Medicare.
Advance directive: the individual assigned to make medical decisions for a person if he/she is physically or mentally unable to make medical decisions themselves.
Affiliated provider: medical professional or health care facility covered to provide medical services under your health care plan.
Affordable Care Act (ACA): health reform legislation signed into law in March 2010 by President Barack Obama and intended to offer coverage to all uninsured Americans, improve system efficiency, lower health care costs and prevent private insurance companies from denying medical coverage based on pre-existing conditions.
Aging in place: the choice to not enter skilled-nursing care, but to instead stay at home.
Ambulatory care: medical services that do not include a hospital stay.
Amyotrophic lateral sclerosis
(ALS) or “Lou Gehrig’s disease”: a disease that attacks the motor nerve cells in a person’s spinal cord. Individuals with ALS are eligible for Medicare at any age.
Ancillary services: services such as X-rays, prescription drug pick-up, laboratory testing, etc. provided by a hospital or inpatient health care facility.
Annual Election Period from October 15 through December 7 every year is also known as the “Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage and “Fall Open Enrollment”: annual period of time when Medicare participants can decide to change their coverage under Original Medicare (Part A, B), Medicare Advantage (Part C) or Medicare Part D. During this period, a Medicare participant can change, drop and add coverage across the three plans.
Appeal: a formal claim to dispute an official decision made regarding a Medicare payment or policy.
Assigned claim: a claim made by an approved provider for payment after health care services have been received.
Assignment: an agreement by a health care provider, doctor, or supplier to receive direct payment from Medicare, to accept the payment amount Medicare approves for the service received by an individual, and to not bill the individual for an amount more than the Medicare coinsurance and deductible.
Assistive technology: devices used by disabled persons to help them function. Not all devices are covered by, but some may be covered is a physician determines the tool medically necessary.
Balance billing: a process in which physicians or health care providers bill patients for costs that exceed the amount covered by Medicare. Participating Medicare physicians and health care providers are not allowed to engage in this process.
Beneficiary: individual who receives benefits through Medicare or Medicaid insurance.
Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO): an organization of health care service providers who contract with Medicare that uses doctors and health care experts to review quality of care and complaints from individuals receiving Medicare coverage. Its purpose is to ensure consistency within the process of reviewing cases and providing care, considering local needs and unique attributes, such as medical necessity and overall quality of care, when reviewing these items.
Benefits Coordination & Recovery Center: the company contracted to act on Medicare’s behalf when collecting and managing information on additional types of health insurance policies an individual may be covered under to figure out whether the coverage pays before Medicare or after. The company also collects repayment a conditional payment be made by Medicare when the other payer is found to be the primary payer.
Beneficiary encrypted file: file requiring an individual’s authorization before it can be read or used by health care professionals.
Benefit period: period of time beginning the day an individual enters a hospital or health care facility for care and ending 60 days after he/she receives care.
Bereavement services: Services, such as hospice counseling, offered to families of Medicare participants for up to a year after the participant has passed away.
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Catastrophic coverage: the point when the cost for an individual’s prescription drugs reach a set maximum level ($4,700 in 2015) within any given calendar year. Prescription drug coverage kicks in at this point to cover most prescription drug expenses, asking individuals to pay the higher of $2.65 for generic drugs and $6.60 for brand names, or 5% of the total cost.
Certificate of medical necessity: documentation required to be signed and submitted by a physician before a Medicare participant can receive coverage for certain medical equipment.
Children’s Health Insurance Program (CHIP): type of insurance program, which covers low-income children and pregnant women (in certain states) with a family income that is too high to be eligible for Medicaid, but who cannot afford a private health care insurance policy.
Claim: an application to utilize benefits provided by your health plan. A claim must be filed before your medical provider can be reimbursed.
Clinical breast exam: a type of exam performed by a doctor or alternate health care professional, usually in a doctor’s office during a pelvic exam or Pap test, with the purpose of checking for breast cancer by looking and feeling the breasts for signs of the disease.
Coinsurance: a percentage of the Medicare-approved cost of your health care services that an individual must pay on top of plan deductibles.
Comprehensive outpatient rehabilitation facility: a health care service facility that offers multiple outpatient services, such as rehabilitation, doctor’s services, social and psychological services and physical therapy.
Coordination of benefits: a method to figuring out which entity pays first when more than one health insurance plan covers the same medical claim.
Copayment: out-of-pocket dollar amount an individual is responsible for paying for the medical services he/she receives, such as prescriptions and doctor’s visits.
Cost plan: health care plan similar to a Medicare HMO, which gives participants access to a network of Medicare-approved doctors and hospitals and includes an option to get out-of-network care covered by Original Medicare.
Cost sharing: the portion an individual may be responsible for paying, which includes deductibles, coinsurance and/or copayments, for a medical supply or service, such as prescription drugs, a visit to the doctor or an outpatient hospital visit.
Cost tiers: system to rank prescription drugs according to their out-of-pocket cost to Medicare participants. Tier 1 (generic drugs) are the cheapest, Tier 2 (brand-name drugs are more expensive and Tier 3 (specialty drugs) are the most expensive.
Coverage determination (Part D): a decision made by your Medicare drug plan about the coverage of your benefits, which may answer how much you have to pay for a drug, whether or not you have met the requirements for receiving a requested drug.
or “donut hole”: the point where an individual’s prescription drug costs exceed the initial coverage limit of their Part D coverage.
Creditable prescription drug coverage: a type of prescription drug coverage that usually pays at least as much as Medicare’s standard drug coverage. In general, an individual who has this level of coverage can keep it without being charged a penalty fee if they choose to enroll in prescription drug coverage offered by Medicare later on.
Critical access hospitals: health care facilities providing limited inpatient and outpatient services in rural areas.
Cross-over: a claim for a dual eligibility to be covered by both Medicare and Medicaid. Claims payments must be approved by Medicare before being send on to Medicaid, which offers coverage toward the Medicare deductible and coinsurance.
Curative care: health care services that treat patients with a goal to cure them, rather than simply reducing their stress or pain.
Custodial care: activities of daily living such as putting on clothes, getting in and out of bed, going to the restroom, etc.). These activities are not covered by Medicare.
Daily living activities: things people do as part of their everyday lifestyle, including eating, bathing and going to the bathroom.
Deductible: a set out-of-pocket expense a Medicare participant must pay before his/her insurance begins covering payment of the health care service.
Denial of coverage: a situation in which Medicare denies paying for certain health care services.
Detailed explanation of non-coverage: document establishing the point when a Medicare provider established that an individual is no longer eligible for Medicare services.
Detailed notice of discharge: documentation of the full explanation for your hospital discharge and/or why Medicare will no longer cover the health care services an individual is receiving.
Determination: a decision by Medicare regarding a claim. Possible outcomes are to deny a claim, pay part of a claim or pay a claim in full.
Disabled enrollee is a person under 65 who qualifies for Medicare because of a disability, or is receiving benefits through Social Security or the Railroad Retirement system.
Disenrollment: the process of stopping Medicare coverage.
Dual eligible: an individual who is eligible for both Original Medicare and Medicaid coverage.
Durable medical equipment: a class of Medicare-approved equipment, such as oxygen, a wheelchair, a hospital bed, etc., authorized by a participant’s doctor.
Durable power of attorney: an individual’s formal appointment of a person to speak and make decisions on his/her behalf should the individual become unable to make decisions themselves.
Eldercare: care programs (Medicare, Social Security, private health insurance and other programs) created to meet the specific needs of older people.
End-stage renal disease: the point when an individual’s kidneys fail and the person has to receive a kidney transplant, or undergo dialysis treatments to survive. Individuals at this stage are automatically eligible for Medicare.
Enrollment period: a period of time set by Medicare during which you can sign up for a Medicare health insurance plan.
Exception request: formal written request to Medicare asking that a drug not on the approved list of prescription drugs be approved for coverage or that the cost of the drug be decreased.
Excess charge: the difference between a physician’s cost for service and the approved payment amount Medicare has designated for that service.
Expedited appeal: An appeal made by individual whose life is in serious danger and usually resolved within 3 days.
Extra Help program: program providing financial help to individuals with limited income and resources to help cover Medicare premium payments.
Federal poverty level (FPL): the income level, varying from year to year, below which necessary services are very hard to get access too. Only U.S. Citizens below this income level are eligible for Medicaid or Extra Help benefits.
Federally qualified health center: a community health care establishment offering complete primary and preventive care to patients, whether or not they can afford to pay for said services. Examples include homeless shelters or community centers or homeless shelters in “medically underserved areas” where people do not have access to these services.
Fee-for-service: a health care payment system that pays a provider for each specific service in a separate payment. One example of this type of payment system is Original Medicare
Fiscal intermediary: a privately-held agency holding a contract with Medicare to pay bills on the system’s behalf for Medicare Part A and Medicare Part B.
Grievance: formal complaint filed by Medicare participants who are dissatisfied with the treatment received through their health plan.
Guaranteed issue rights
of “Medigap protections”: insurance policy carriers are required to off Medicare participants by law. These policies prohibit carries from denying an individual coverage or charging more for coverage because of pre-existing health conditions.
Guaranteed renewable: a health plan that requires an insurance provider to renew the policy if the policy premiums have been paid in full and on time by the policy holder.
Health care provider: an organization or individual, such as a hospital, doctor or nurses, that is licensed to provide health care services.
Health coverage: a type of insurance that covers the payment or reimbursement for an individual’s health care costs. Plans are usually offered by a government program like Medicaid, Medicare or Children’s Health Insurance Program (CHIP), by a private insurance provider or by an employer through a group health plan.
Health Insurance Marketplace: a resource, run by the State of Federal government depending on location, that teaches families, individuals and small business owners about their health care coverage choices; allows comparison on health care coverage by benefits, costs and additional features; and gives options to pick and plan and enroll in coverage. It incentivizes competition among private health insurance providers and can be accessed online, over the phone and in person. This resource also offers details on programs to help low to moderate income individuals get health care coverage, including options to reduce out-of-pocket expenses and monthly premiums and information on government assistance programs like Medicaid, Medicare and Children’s Health Insurance Program (CHIP).
Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Standard for Privacy of Individually Identifiable Health Information or Privacy Rule: guideline ensuring personal health information is protected properly during the flow of health information, which promotes and provides top-notch health care services and protects the public’s well-being and health.
High-deductible Medigap policy: a type of Medigap insurance coverage with a lower premium and higher cost deductible than traditional Medigap plans. An individual is required to cover the deductible amount before the insurance policy pays for anything. The deductible amount may fluctuate each year.
Homebound: a state of physical condition meaning and individual is not readily able to leave his/her home without assistance, including help form another person, wheelchair, walker, crutches, cane or other special transport, due to an illness or injury OR an individual is not advised to leave his/her home due to the condition.
Home health agency: a business or organization that provides home health care.
Home health care: health care services provide inside the home of an individual by their friends and family or a professional caregiver. This type of care is covered under Medicare under certain circumstances.
Hospice care: health care and support services offered to individuals who are terminally ill, including drugs and pain relief. Medicare Part A covers this type of health care services for terminally ill individuals.
Hospital-related medical condition: a state or condition, even if it is not the reason for initially being admitted to the hospital, that was treated during an individual’s Medicare-qualified 3-day inpatient hospital stay
Independent reviewer or Independent Review Entity or IRE: an organization with no link to your Medicare health care coverage of Medicare Prescription Drug Plan that is contracted by Medicare to review an individual’s case should he/she appeal a Medicare coverage or payment determination or if Medicare does not make a prompt appeals decision.
Initial coverage limit: point when an individual has met their annual deductible and will be required to pay coinsurance or a copayment for each prescription drug covered until he/she reaches the plan’s out-of-pocket maximum and reaches his/her plan’s cover gap (donut hole).
In-network: any health care facility or professional, including hospitals, pharmacies, doctors and other health care providers, that have agreed to offer individuals covered under specific insurance policies with health care supplies and services at a discounted rate. Some insurance providers only cover care received in-network.
Inpatient care: medical treatment or health care services given to an individual requiring treatment in a health care facility or hospital.
Inpatient rehabilitation facility: a health care facility, offering intensive rehabilitative services and skilled nursing care, licensed under state laws.
Large group health plan: a type of insurance plan that covers employees of a company with at least 100 or more employees.
Lifetime reserve days: any days over 90 that an individual is hospitalized in a certain benefit period. Original Medicare will pay for up to 60 of these days, minus the daily coinsurance amount, during an individual’s lifetime
Limiting charge: rule that ensures an individual cannot be charged more than 15 percent over the approved amount for specific health care services when getting care from a medical services provider who hasn’t completed opted out of Medicare, but does not accept it for the treatment or services received. Equipment and medical supplies are not subject to this rule.
Living will or medical directive or advance directive: a written legal document noting the types of treatments an individual opts in or out of in case he/she cannot speak for him/herself, including decisions like whether or not you want to be on life support. This type of document is valid only when an individual is unconscious or unable to speak.
Long-term care: medical and non-medical care for individuals experience a disability or chronic illness. Services often include helping individuals with basic activities like going to the restroom, getting dressed and bathing or showering. Services are administered in-home or at health care facilities, assisted living facilities or assisted living communities. These services are traditionally covered by Medicare if individuals meet Medicare eligibility, but not covered by Medicare if services can be categorized as custodial care.
Long-term care hospital: a type of specific care hospital that provides treatment for patients staying for more than 25 days, on average. Most patients who end up at this type of facility come from a critical or intensive care unit. Services provided by this type of hospital include pain management, comprehensive rehabilitation, trauma treatment and respiratory therapy, to name a few.
Long-term Care Ombudsman: an individual who advocates on behalf of assisted living facility and nursing home residents, working to solve issue between residents and the facilities and possessing much knowledge about these types of facilities in the area they work in.
Medicaid: type of health care program for low-income individuals who are unable to afford health insurance from private insurance providers. Funds come from the federal government and state in which the individual lives.
Medical underwriting: a process used to determine whether or not to offer coverage to an individual or determine the cost of premiums for a health care policy. Used by insurance carriers, this process is implemented when individuals apply for Medigap plans during a time that is not part of the initial enrollment period or other enrollment periods offered.
Medically necessary: medical services or supplies that are needed in order for a health care professional to treat or diagnose a medical condition.
or Medicare Part
C: policy allowing Medicare participants to get benefits covered by Medicare through private health insurance policies, like a PPO, HMO, or private fee-for-service policy, rather than Original Medicare. This type of plan usually includes more benefits, such as prescription drug coverage, than what is included in Medicare Part A and Medicare Part B and is required to follow Medicare guidelines and be approved by the program.
Medicare Advantage prescription drug plan
(MA-PD): a choice for Medicare participants who desire enrollment in Medicare Part D prescription drug coverage. This coverage subsidizes prescription drug costs, while offering the benefits of Medicare Part A and Medicare Part B under the same plan.
Medicare cost plan: health care coverage similar to a Medicare HMO, which grants individuals access to a Medicare-approved network or hospitals and doctors. The difference being that policy holders are offered a choice to get coverage outside of the network is they choose and have the costs of his/her health care services paid through Original Medicare. Policies may include prescription drug coverage. Participants may enroll in this type of plan when it is accepting new applicants and re-enroll in Original Medicare at any time.
Medicare open enrollment or “annual election period” or “annual coordinated election period”: annual period of time when Medicare participants can decide to change their coverage under Original Medicare (Part A, B), Medicare Advantage (Part C) or Medicare Part D. During this period, a Medicare participant can change, drop and add coverage across the three plans.
Medicare Part A
or “hospital insurance”: a type of Medicare coverage that covers inpatient care, which includes stays at skilled nursing facilities and hospitals, as well as hospice and in-home health care.
Medicare Part B or “medical insurance”: a type of Medicare coverage that covers outpatient expenses for services that are medically necessary, including doctor and nursing costs, health care services such as diagnostic tests, renal dialysis, x-rays and some vaccinations and some equipment.
Medicare Part C or Medicare Advantage: a type of Medicare coverage that provides Medicare-covered benefits through private health insurance policies, rather than through Original Medicare. Benefits beyond those included in Medicare Part A and Medicare Part B like prescription drug coverage, are often included. Coverage may be restricted to certain providers because of these extra benefits.
Medicare Part D: a Medicare program for prescription drug coverage that subsidizes a Medicare participant’s prescription drugs costs. Participants choose this type of coverage by enrolling in a Medicare Advantage Plan, which medical expenses and prescription drugs, or a prescription drug plan (PDP), which covers prescription drugs only. Fees include a prescription co-pay for each drug, monthly premium and annual deductible.
Medicare Select: a type of supplemental Medicare policy offered by certain states. To receive full benefits, the participant must use a pre-determine network of hospitals and sometimes doctors to receive services.
Medicare Summary Notice (MSN): documentation received by Medicare participants when he/she receives a health service covered by Medicare. The notices report all services and supplies receive by the individual, how much is covered by Medicare and how much the individual owes the provider. They are mailed every three months.
Medicare supplement insurance or Medigap: type of private insurance plans offering supplemental benefits to fill gaps in Original Medicare coverage. This type of coverage includes a mix of benefits, which cover costs for a wide range of things, such as copayments, deductibles, preventative care and even emergency foreign travel expenses. Within the first 6 months of turning 65 and receiving coverage from Medicare Part B, you are qualified for a Medigap policy without the possibility of being denied by the insurance company. If you do not choose to enroll during this time, the coverage guarantee goes away and you may be denied.
Medigap protections or guaranteed issue rights: requirements enforced by law that insurance providers offer a Medigap coverage plan and do not deny coverage or charge a premium for any reason, including pre-existing conditions to individuals who enroll in a Medigap plan during their initial enrollment period or during special enrollment periods, which occur after particular qualifying events.
Network: all of the health care suppliers, facilities and professional contracted by a health insurance provider to provide health care services under a health insurance plan.
Network pharmacies: all of the pharmacies contracted by a health insurance provider to provide health care services and supplies at a discounted rate under a health insurance plan. Some Medicare plans only cover prescription drugs filled in-network.
Non-preferred pharmacy: any pharmacy that is part of Medicare’s drug plan network, but is not a preferred pharmacy. Individuals may pay more out-of-pocket for drug prescriptions filled at a non-preferred pharmacy.
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Optional supplemental benefits: services, offered individually or as a group, that are not cover by Medicare that a Medicare health coverage plan may offer to participants. Participants may choose to purchase these services, paying for them directly as a coinsurance, copayment or premium, if they enroll in a plan that offers them.
Original Medicare or traditional Medicare: fee-for-service health care coverage, which includes Medicare Part A and Medicare Part B, that is paid for by the government. This type of coverage allows a covered individual to being seen by any doctor who accepts Medicare coverage anywhere in the U.S.
Out-of-network: any health care supplier, facility and professional not contracted by a health insurance provider to provide health care services under a health insurance plan. A plan may allow an individual to receive care out of network by out-of-pocket costs will likely be higher than with care received in-network.
Out-of-pocket costs: amount paid by an individual for health care supplies or services that is not covered by an individual’s health insurance plan.
Outpatient hospital care: medical or surgical services an individual receives from a hospital during a time when a doctor has not ordered inpatient admittance into a hospital, even if the individual stays overnight in the facility. Health care services received may include outpatient surgery, X-rays, lab tests, emergency room services and medical observation.
Patient Protection and Affordable Care Act (PPACA)
or Affordable Care Act (ACA): legislation reform the American health care system signed into law in 2010 by President Barack Obama. Included in the legislation is health-care related provisions rolled out over 4 years after being signed into law. Provisions offer health care coverage to millions of previously uninsured Americans and seek to decrease health care costs and improve the efficiency of the health care system. Under this legislation, insurance providers can no longer deny coverage because of pre-existing conditions.
Pre-existing condition: a medical condition that began before health insurance coverage was obtained and may be excluded from coverage since it existed before coverage began.
Preferred provider organization (PPO): a Medicare Advantage plan that offers individuals covered under these plans an incentive to use the in-network health professionals and hospitals in exchange for lower out-of-pocket expenses.
Prescription drug coverage
or Medicare Part D: a type of Medicare coverage that subsidizes the costs of both generic and brand name prescription drugs for Medicare participants. Individuals can choose a Medicare Advantage plan, covering other expenses along with the drugs or a prescription drug plan (PDP), which covers the drugs alone. Those who opt-in will pay a copay for his/her prescription along with a monthly premium and a yearly deductible. Individuals may qualify for financial assistance depending on their income.
Prescription drug plan (PDP): is one option for individuals who want to enroll in the Medicare Part D prescription drug coverage, which subsidizes the costs of prescription drugs for enrollees. A prescription drug plan (PDP) is a stand-alone plan, covering only prescription drugs. Enrollees who choose the option of prescription drug coverage through a Medicare Advantage plan would also have coverage for other medical expenses as part of that plan.
Enrollees pay a co-pay for each prescription, a monthly premium and an annual deductible.
Preventive services: medical services offered to keep an individual rom becoming ill or developing chronic health conditions before they begin to form. Examples include vaccinations, mammograms, pelvic exams and Pap tests.
Primary care doctor: the physician an individual consults first when a health issue arises. Primary care doctors are responsible for giving specialist recommendations should they be needed.
Private fee-for-service plans: a type of Medicare Advantage plan that lets an individual get health care from any physician or hospital that takes the plan’s coverage. When it comes to paying for the health services received, the plan is not required to follow Medicare guidelines and may cost more than Medicare. This type of coverage often offers more benefits than Original Medicare and may include prescription drug coverage. If the plan does not include prescription drug coverage, an individual may choose to enroll in a separate drug prescription plan, which is not true for other Medicare Advantage plans.
Programs of all-inclusive care for the elderly (PACE): a type of health care program offering comprehensive health services and care to older adults over the age of 55. Care is funded by Medicaid and Medicare funds and administered by a team of health care professionals. To be eligible, PACE participants must be certified as eligible by the state agency, live in the PACE service area, be healthy enough to live safely in the community and meet the age requirement for the program.
Quality improvement organization: a group of health care professionals and doctors who monitor the quality of care Medicare participants receive. They are paid for their expertise and tasked with critiquing the decision-making policies of Medicare health care providers as well as the quality of Medicare health care facilities and investigating complaints.
Qualified Individual (QI) Program: a state health care program designed to help individuals with limited income and resources who are also enrolled in Medicare Part A pay Medicare Part B premiums.
Qualified Medicare Beneficiary (QMB) Program: a state health care program for individuals with limited income and resources that helps these individuals with the cost of Medicare Part A and Medicare Part B premiums and other cost-sharing, such as coinsurance, copays and deductibles.
Referral: a recommendation made by a primary care doctor before an individual is authorized to receive care from another doctor or health care provider. If a referral is not obtained before care is received, the health care insurance plan may not pay for the care.
Regional home health intermediary: a private company contracted by Medicare to examine the quality of home health care services and to pay bills for home health care and hospice under the provisions of Original Medicare.
Rehabilitation services: a type of health care service that help an individual improve, keep or get back skills and function for daily living lost or impaired because of injury, sickness or disability. Services may include physical therapy, speech-language pathology, occupational therapy and psychiatric rehabilitation services in a multitude of inpatient and/or outpatient settings.
Religious nonmedical health care institution: a health care facility offering nonmedical health care supplies and service to individuals in need of skilled nursing facility care or hospital care, but who do not believe in receiving such care for religious reasons.
Respite care: a type of temporary care offered in a hospital, nursing home or hospice inpatient facility that allows an individual’s family member, friend or other primary caregiver to take time off or rest without a lapse in the individuals care.
Rural health clinic:
A federally qualified health center (FQHC) that provides health care services in rural areas where there’s a shortage of health care services.
Secondary payer: the health program, plan or insurance policy that pays a claim for medical care after another health program, plan or insurance policy. Depending on the situation, this could be Medicaid or Medicare or other insurance policy.
Service area: a defined area within which certain services covered under your health care coverage may be limited to. If an individual moves outside of the service area, he/she will be automatically disqualified from that specific plan.
Silver Sneakers: the growing group of seniors over the age of 65, also called Baby Boomers. The term is also used to describe senior-focused programming from workshops to fitness classes as well as some senior discount programs. Many health care insurance providers are beginning to offer “Silver Sneakers” Medicare Advantage plans.
Skilled nursing care: a type of health care, which may be covered by Medicare, Medicare, or other health plans, provided by a licensed practical nurse or registered nurse
Skilled nursing facility: a type of health care facility that provides the equipment and staff to provide skilled nursing care, rehabilitation services or other health care services.
Social health maintenance organization: a type of health care insurance plan that offers a wide range of benefits and coverage, including medical transportation services, prescription drug and chronic care benefits, dental care, short-term nursing home care, personal care services and hearing aids. This type of plan costs more, but offers participants many more services than Original Medicare.
Special election period: a set period of time during which Medicare participants have the option of changing their health care plan or re-enroll in Medicare. Individuals may choose to adjust coverage because a plan provider has violated policy terms, the individual moved from the coverage area of their current plan or another reason approved by the Centers for Medicare and Medicaid Services.
Special enrollment period: an 8-month period of time beginning the month after an individual or his/her spouses job ends, or when former group health coverage ends, whichever happens first, during which an individual who missed his/her first opportunity to sign up for Medicare Part B because he/she or his/her spouse was still working at age 65 and covered by an employer–paid group health plan at that time.
Medicare special needs plan (SNP): a type of Medicare Advantage plan that provides Medicare Part A and Medicare Part B health services and care to individuals who require care management of multiple diseases, special care for chronic illnesses, and focused care management. This type of plan may be limited to people in certain types of health care facilities, such as nursing homes, or beneficiaries who have specific chronic or disabling conditions or who are dual eligible.
Specified Low-Income Medicare Beneficiaries: a type of Medicaid program the covers Medicare Part B premiums for individuals with income below the poverty line and limited resources who are enrolled in Medicare Part A.
State Health Insurance Assistance Program: a national health care program that provides fee-free assistance and counseling to Medicare participants and their families.
State medical assistance office: office located in each state, usually at multiple locations, that provides Medicaid, Medicare and other helpful information to low-income residents.
State Pharmaceutical Assistance Program (SPAP): a state health care program the offers help to individuals who need assistance paying for prescription drug coverage.
Eligibility is based on age, medical condition and/or financial need.
Step therapy: a coverage guideline implemented under certain Medicare Prescription Drug Plans requiring an individual try one or more similar but lower cost prescription drugs before the plan will cover the higher cost prescribed drug.
Supplier: any agency, company or person that gives an individual a medical service or supply, except when he/she is an inpatient in a skilled nursing facility or hospital.
Telemedicine: health related services provided to a patient over the phot, computer or television or other communications system by a health care professional in another location.
Tiers: segments of prescription drugs that are grouped by cost. In general, cost increases as the tiers get higher.
TRICARE: a type of health care coverage for retired and active duty military service members and their families.
TRICARE FOR LIFE (TFL): a type of health care coverage for retired military service members over 65 who are also eligible for Medicare, their eligible family members, survivors and certain previous spouses.
TTY or teletypewriter: a device used by the deaf or hard-of-hearing or those with severe speech impediments to communicate. Individuals without a device can communicate with a person using a TTY with a message relay center (MRC), which has individuals familiar with TTY available to send and interpret messages.
Urgently needed care: medical supplies or services that are needed immediately, but are not life-threatening. This type of care is covered from an individual’s primary care doctor if he/she is enrolled in any Medicare plan aside form Original Medicare. If he/she is out of the service area when care is needed, care will be covered in the location where it’s received.
Waiting period: period of time potential participants must wait to be eligible for enrollment and coverage under certain health care plans.
Workers’ compensation: a type of insurance coverage required to be carried by employers than covers employees who are injured or get sick on the job.
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