Medicare & You 2006 | Medicare Supplement  Quote | Glossary  | 
Medicare Glossary        

Appeal-  A special kind of complaint you make if you disagree with certain kinds of decisions made by Medicare or your health plan. You can appeal if you request a health care service, supply or prescription that you think you should be able to get, or you request payment for health care you already received, and Medicare or a health plan denies the request. You can also appeal if you are already receiving coverage and the plan stops paying. There is a specific process your Medicare Advantage Plan, other Medicare Health Plan, Medicare drug plan, or the Original Medicare Plan must use when you ask for an appeal.

Benefit Period --The way that the Original Medicare Plan measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row.  If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

Coinsurance -The amount you may be required to pay for services after you pay any plan deductibles. In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare approved amount. You have to pay this amount after you pay the deductible for Part A and/or  Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent.

Copayment -In some Medicare health and prescription drug plans, the amount you pay for each medical service, like a doctor's visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor's visit or prescription. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.

Creditable Prescription Drug  Coverage-Prescription drug coverage (like from an employer or union), that is, on average, at least as good as the Medicare standard prescription drug coverage.

Deductible - The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan or other insurance begins to pay. For example, in Original Medicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year.

Formulary- A list of certain kinds of prescription drugs that a Medicare drug plan will cover subject to limits and conditions.

Health Maintenance Organization Plan- A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the planýs list except in an emergency. Your costs may be lower than in the Original Medicare Plan.

Institution-A facility that meets Medicareýs definition of a long-term care facility, such as a ursing home or skilled nursing facility. Doesn't include assisted or adult living facilities, or residential homes.

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

Medicaid- A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medically Necessary- Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and arenýt mainly for the convenience of you or your doctor.

Medicare Advantage Plan-A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. A Medicare Advantage Plan can be an HMO, PPO, or a Private Fee-for-Service Plan.

Medicare-approved Amount-In the Original Medicare Plan, this is the amount a doctor or supplier can be paid, including what Medicare pays and any deductible, coinsurance, or copayment that you pay.

Medicare Cost Plan- A Medicare Cost Plan is a type of HMO. In a Medicare Cost Plan,  if you get services outside of the plan's network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan, except your plan pays for emergency services, or urgently needed services outside the service area.

Medicare Health Plan - A Medicare Advantage Plan (such as an HMO, PPO, or Private Fee-for-Service Plan) or other plan such as a Medicare Cost Plan. Everyone who has Medicare Part A and Part B is eligible for a plan in their area, except those who have End-Stage Renal Disease (unless certain exceptions apply).

Medicare Prescription Drug Plan- A stand-alone drug plan, offered by insurance and other private companies to add prescription drug coverage to the Original Medicare Plan, Medicare Private Fee-for-Service Plans that donýt have prescription drug coverage, and Medicare Cost Plans.

Medigap Policy -Medicare supplement insurance sold by private insurance companies to fill 'gaps' in Original Medicare Plan coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 standardized plans labeled Plan A through Plan L. Medigap policies only work with the Original Medicare Plan.

Original Medicare Plan-A fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Penalty-An amount added to your monthly premium for Medicare Part B, or for a Medicare drug plan, if you don't join when you're first able. You pay this higher amount as long as you have Medicare. There are some exceptions.

Point-of-Service- An HMO option that lets you use doctors and hospitals outside the plan for an additional cost.

Preferred Provider Organization Plan- A type of Medicare Advantage Plan in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Premium-The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.

Private Fee-for-Service Plan-A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the planýs payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesnýt cover.92

Referral- A written OK from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you donýt get a referral first, the plan may not pay for your care.

Skilled Nursing Facility Care- This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, canýt be provided on an outpatient basis. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.

Special Needs Plan-  A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, or those who reside in a nursing home.

State Health Insurance Assistance Program-  A State program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

Telemedicine-Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site.

TTY-A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who donýt have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.