Don’t speak Medicare? Here’s a brief glossary

Brief glosary

Medicare Open Enrollment started yesterday (October 15th) so this is as good a time as any to brush up on your Medicare lingo.

·         Accountable care organization. Groups of physicians, hospitals, and other healthcare providers that coordinate care for Medicare participants to improve care in a cost-effective manner.

·         Advantage plan. Also known as Part C. See Medicare health plan.

·         Assignment. When your doctor, provider, or supplier agrees to be paid the Medicare-approved amount for the service directly by Medicare, and bill you only the Medicare deductible and coinsurance.

·         Benefit period. A benefit period starts the day that you are admitted in a hospital or skilled nurse facility (SNF) as an impatient, and ends when you have not received any inpatient hospital or SNF care for 60 consecutive days. If you go into a hospital or SNF after the 60 days, that counts as a new benefit period. You have to pay the inpatient hospital deductible for each benefit periods. There is no limit to the number of benefit periods.

·         Coinsurance. An amount you may have to pay as your share of the cost for services after paying any deductibles. Usually a percentage (e.g. 20%).

·         Copayment. An amount you may have to pay as your share of the cost for a medical service or supply such as a doctor’s visit, hospital outpatient visit, or prescription drug. Usually a fixed amount (e.g. $10).

·         Creditable prescription drug coverage. Drug coverage – employer-sponsored, from a union, or otherwise – that is expected to pay on average at least as much as standard prescription coverage from Medicare. People who have this coverage when they become eligible for Medicare can usually keep it without being penalized if they chose to enroll in Medicare prescription drug coverage later.

·         Critical access hospital. A small medical facility in a rural area that offers outpatient services and limited inpatient services.

·         Custodial care. Non-skilled personal care such as help with daily activities (bathing, dressing, eating, getting in and out of a bed or chair, moving around, using the bathroom). It may also refer to health-related care that can be done by oneself, such as administering eye drops. Not covered by Medicare.

·         Deductible. The amount you must pay for healthcare or prescriptions before your insurance (Original Medicare, Medicare Advantage Plan, prescription drug plan, or other) starts to pay.

·         Demonstrations. Special pilot programs or research studies that gauge improvements in Medicare coverage, payment, and care quality for a limited time and for a specific group in a specific area.

·         Durable medical equipment. Walkers, wheelchairs, hospital beds, and other equipment prescribed by a physician for use at home.

·         Extra help. Medicare programs that help low-income individuals to pay premiums, deductibles, coinsurance and other Medicare prescription drug plan expenses.

·         Formulary. A list of prescription drugs covered by a prescription drug plan or any other insurance that offers prescription drug benefits.

·         Health maintenance organization (HMO). A type of plan you may only get care and services from doctors, hospitals, and other providers within the plan’s network, unless it’s an emergency. In certain HMOs you can go outside of the network but you might have to pay more.

·         Inpatient rehabilitation facility. A hospital or part of one that offers patients intensive rehabilitation programs.

·         Institution. A facility that offers short- or long-term care, for example a nursing home, SNF, or rehabilitation hospitals. For Medicare purposes, private residences such as assisted living facilities or group homes are not considered institutions.

·         Lifetime reserve days. A total of 60 additional days during which Original Medicare will pay all covered expenses – except daily coinsurance – when you’re in a hospital for more than 90 days during your lifetime.

·         Long-term care. Medical and non-medical care services provided at home, in the community, in assisted living, or nursing homes to people of any age who can’t perform basic daily activities such as dressing or bathing. Not covered by Medicare.

·         Long-term care hospital. Acute care hospitals that provide comprehensive rehabilitation, respiratory trauma, head trauma treatment, pain management and similar services to patients who stay an average of more than 25 days, usually transferred from an intensive or critical care unit.

·         Medically necessary. Services or supplies required to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted medicine standards.

·         Medicare-approved amount. The amount a doctor or supplier that accepts assignment can be paid. It may be less than what the doctor or supplier actually charges. Original Medicare pays part and the rest is your responsibility.

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

·         Medicare plan. Describes any way to get Medicare health or prescription drug coverage other than Original Medicare. Includes all Medicare health plans and Medicare prescription drug plans.

·         Original Medicare. Refers to Part A and Part B which cover hospital and nursing home care, doctor’s visits, and outpatient care. Medicare Advantage Plans (Part C) are not included.

·         Premium. The periodic payment to Medicare, insurance company, or health care plan in exchange for health or prescription drug coverage.

·         Preventive services. Intended for the early detection or prevention of illness (e.g. Pap tests, flu shots, screening mammograms).

·         Primary care practitioner. A physician with a primary specialty in family, internal, geriatric, or pediatric medicine, or a nurse practitioner, clinical nurse specialist, or physician assistant.

·         Quality improvement organization (QIO). A group of doctors and experts the federal government pays to assess and enhance the care given to Medicare enrollees.

·         Referral. A written order from a primary care practitioner for the patient to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs) medical services from anyone other than your primary care practitioner are predicated on getting referral; otherwise the plan may not pay for the services.

·         Service area. The geographic area where a health insurance plan that limits membership based on where people live accepts members. Also the area where you can get routine, non-emergency services if the your plan limits which hospitals and doctors you can use. You may be disenrolled from the plan if you move out of the area.

·         Skilled nursing care. Intravenous injections and other care that can only be administered by a registered nurse or doctor.

·         Skilled nursing facility (SNF). A nursing facility that has staff and equipment qualified for nursing care, and more often than not, skilled rehabilitative services and other related services. 

·         Skilled nursing facility care. Skilled nursing care and rehabilitation services given on a continuous, daily basis, in a SNF.

·         TTY. A teletypewriter; a communication device used by individuals who are deaf, hard-of-hearing, or have a severe speech impediment. Non-TTY users can communicate with TTY users by way of a message relay center (MRC) that employs TTY operators to interpret and send TTY messages.

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