Glossary

In Medicare Part B, a doctor "accepts assignment" when he or she agrees to take payment of the Medicare-approved amount as payment in full for a service. If a doctor accepts assignment, your share of the cost is limited to your coinsurance payment (usually 20% of the Medicare-approved amount).
See Medicare-approved amount.

The time period each year during which you may enroll in Medicare prescription drug plans (Part D) and Medicare Advantage (Part C) plans. The Annual Enrollment Period (AEP) is October 15 through December 7 every year.

In Medicare Part B, doctors who do not accept assignment may use this method to bill you for an additional payment. Another name for balance billing is "excess charges." A doctor cannot bill you more than 15% of the Medicare-approved amount. In some states, balance billing may be limited to less than 15% or may not be allowed at all.  

In Medicare Part A, a period of time that begins when you enter a hospital for an overnight stay and ends when you have been out of the hospital for 60 days in a row.

A prescription drug that is sold under a trademarked brand name.
See generic drugs.

In a Medicare Part D prescription drug plan, the time period in which you pay only a small coinsurance or small copay for a covered drug, and your plan pays the rest of the cost for the remainder of the year. In 2012, you reach catastrophic coverage once you, or another individual on your behalf, have spent $4,700 in total out-of-pocket costs for your covered drugs in a single year.

In Medicare Advantage (Part C), this refers to a kind of health care plan that links providers and services to deliver efficient, cost-effective patient care. Plan members usually have to use doctors and hospitals that are within the plan's network. These plans are also referred to as "managed care plans." 

A term for the way Medicare shares your health care costs with you. The most common types of cost sharing are deductibles, copays and coinsurance.

The cost-sharing stage of a Medicare Part D plan in which you pay most of the plan's discounted cost for your covered medications. In 2012, you will pay 86% of the price for generic drugs and 50% of the price (plus the dispensing fee) for brand-name drugs during the coverage gap. You enter the coverage gap when you, others on your behalf and the plan together have paid a pre-set amount for your drugs. This amount is determined by the plan, but Medicare establishes a maximum. The maximum for 2012 is $2,930. You remain in the coverage gap stage until you have spent your plan's out-of-pocket limit in a single year. Deductibles, copays, coinsurance and other payments count toward the out-of-pocket limit, but premiums do not. Once you are through the coverage gap stage, you enter the cost-sharing stage called “catastrophic coverage

In a Medicare Part D prescription drug plan, the time period in which you pay only a small coinsurance or small copay for a covered drug, and your plan pays the rest of the cost for the remainder of the year. In 2012, you reach catastrophic coverage once you, or another individual on your behalf, have spent $4,700 in total out-of-pocket costs for your covered drugs in a single year.

.” In this stage, you pay a small copay for your drugs for the rest of that year.

Prescription drug coverage from a health plan other than a Medicare Part D standalone plan or a Medicare Advantage plan that includes prescription drug coverage and that meets certain Medicare standards. If you are currently enrolled in a health plan that gives you prescription drug coverage, your plan can tell you if it meets the Medicare requirements to be considered creditable drug coverage.

Care that provides help with the activities of daily living, like eating, bathing or getting dressed. Most long-term care is considered custodial care.

A person who is eligible for both Original Medicare (Parts A and B) and Medicaid.

A list of the prescription drugs that are covered by a specific Medicare Part D plan.

Prescription drugs that have the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as their brand-name equivalent.
See brand-name drug.

A feature of Medicare supplement insurance (Medigap) plans. A "guaranteed renewable" plan must be renewed by the company automatically each year, so long as you pay the premium and have truthfully completed your Medicare supplement insurance application.

A type of Medicare Advantage plan in which you must use doctors and hospitals in the plan's network for your care. If you go outside the network, other than for emergency care, for urgent care or for out-of-area renal dialysis, you are responsible for paying for your own care.

A health insurance plan in which you pay a significant deductible (usually more than $1,000) before the plan begins to help with your costs.
See Medical Savings Account (MSA) plans.

In Original Medicare, skilled nursing care and therapy, such as speech therapy or physical therapy, provided on a part-time or intermittent basis to those who cannot leave the home.

Care for those who are terminally ill. Hospice care typically focuses on controlling symptoms and managing pain. In Part A, hospice care also includes support services for both patient and caregivers.
Part A covers both hospice care received at home and care received in a hospice outside the home.

When you first become eligible to enroll in Medicare or a Medicare plan. For most, it's the seven-month period that begins three months before the month you turn 65 and ends three months after the month you turn 65.

Care you receive in a hospital when you are admitted for an inpatient stay.

As part of Medicare Part A, you'll receive 60 lifetime reserve days. You can choose to use lifetime reserve days anytime you stay in a hospital longer than 90 days. A lifetime reserve day cannot be replaced. When it is used up, it is gone.

Care that gives help with the activities of daily life, like eating, dressing and bathing, over a long period of time. Most long-term care is custodial care.

A limit that Medicare Advantage plans set on the amount of money you will have to spend out of your own pocket in a plan year. In Medicare Part D, this is the maximum amount of money you will have to spend out of your own pocket before catastrophic coverage begins for the remainder of the year.

A program that pays for medical assistance for certain individuals and families with limited incomes and resources. Medicaid is jointly funded by the federal and state governments and managed by the states. Medicaid includes programs that help eligible persons pay Medicare premiums and cost sharing.
See dual eligible and Medicare Savings Plan.

A type of Medicare Advantage plan that combines a special bank savings account for your medical expenses with a high-deductible Medicare Advantage plan.
See high-deductible Medicare Advantage plans.

Services or supplies that are needed to diagnose or treat a medical condition, according to the accepted standards of medical practice.

A federal government health program for:

• People age 65 or older
• People under age 65 with certain disabilities
• People of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or kidney transplant)

A type of plan offered by a private company. In Medicare Advantage plans, a single plan provides you with both hospital and doctors' care. Many Medicare Advantage plans also include prescription drug coverage.

If you enroll in a Medicare Advantage plan during the AEP from October 15 through December 7, then you have until February 14 of the following year to disenroll. If you disenroll, then you will return to Original Medicare automatically.
If prescription drug coverage was included in your Medicare Advantage plan, you can enroll in a Medicare Part D prescription drug plan during this time.

Medicaid program that helps eligible people pay some or all of their Medicare premiums and deductibles.

A special type of Medicare supplement insurance plan that requires you to use specific hospitals, and in some cases, specific doctors, to get your full insurance benefits (except in an emergency).

A plan provided by a private insurance company that pays for some or all of the cost sharing, or gaps in coverage, such as deductibles, copays and coinsurance, in Original Medicare coverage. Medicare supplement insurance plans are available in standard types or plans. Each plan is named with a letter of the alphabet. Don't confuse Plans A, B, C and D with Medicare Parts A, B, C and D.

The amount of money that Medicare has approved as the total amount that a doctor or hospital should be paid for a particular service. The total amount includes what Medicare pays, plus any cost sharing you pay.
See accepting assignment.

A term sometimes used to refer to Medicare supplement insurance.
See Medicare supplement insurance.

The group of health care providers, such as hospitals, doctors and pharmacies, that agrees to provide care to the members of a Medicare Advantage coordinated care plan or Medicare Part D prescription drug plan. These providers are called "network providers" and "network pharmacies."

You are guaranteed the right to buy any Medicare supplement insurance plan available where you live during the six months after you are enrolled in Medicare Part B at age 65 or older. Many states also provide an OEP for beneficiaries under age 65, which begins the month you enroll in Medicare Part B and ends six months later. This six-month period is called your Open Enrollment Period (OEP). During this time, the insurer cannot refuse to sell you a plan or charge a higher premium due to your medical history or current health.
Important: Some states have additional Open Enrollment Periods. Call your State Health Insurance Assistance Program (SHIP) to learn about your state's rules.

Indicates the amount you pay or others pay on your behalf toward the cost of your prescription drugs, including deductible, copays, coinsurance and payments made in the coverage gap. Premiums do not count toward out-of-pocket costs.

Care you receive as a hospital patient if you are not admitted for an inpatient stay, or care you receive in a freestanding clinic or surgery center as an outpatient. 

The part of Original Medicare that provides help with the cost of hospital stays, skilled nursing services following a hospital stay and some other kinds of skilled care. Don't confuse this with a Medicare supplement insurance Plan A, which is a type of Medicare supplement insurance plan.

The part of Original Medicare, offered by the federal government, that provides help with the cost of doctor visits and other medical services that don't involve overnight hospital stays. Don't confuse this with a Medicare supplement insurance Plan B, which is a type of Medicare supplement insurance plan.

Known as Medicare Advantage, this part of Medicare allows private insurance companies to offer plans that combine help paying for hospital costs, doctor visits and other medical services all in one plan. Many Medicare Advantage plans also include prescription drug coverage. Don't confuse this with a Medicare Supplement Insurance Plan C, which is a type of Medicare supplement insurance plan.

This part of Medicare allows private insurance companies to offer plan that help with the cost of prescription drugs. You can get Medicare Part D coverage as a standalone prescription drug plan or as part of a Medicare Advantage plan. Don't confuse this with a Medicare supplement insurance Plan D, which is a type of Medicare supplement insurance plan.

A type of Medicare Advantage HMO plan that allows members the ability to visit doctors and hospitals outside their network for some covered services, usually for a higher copayment or coinsurance. Some POS plans do not require referrals for specialty services.

When you are applying for an insurance plan, a name for an illness or medical condition you currently have.

A type of Medicare Advantage plan in which you can use either doctors and hospitals in the plan's network, or go to doctors and hospitals outside the network. If you go outside the network, you'll usually pay a larger share of the cost of your care.

A fixed amount you have to pay to participate in a plan or program; in private insurance, the price you pay for a plan, usually as a monthly payment.

A standalone Medicare Part D insurance plan that helps with the cost of prescription drugs.

Care that is meant to keep you healthy, or to find illness early, when treatment is most effective. Examples of preventive care are flu shots, screening mammograms and diabetes screenings.

A type of Medicare Advantage plan that allows you to visit any Medicare-eligible doctor, hospital or other health care service provider who is willing to accept the plan's payment terms and conditions.

A person or organization that provides medical services and products, such as a doctor, hospital, pharmacy, laboratory or outpatient clinic.

Group health insurance coverage offered through an employer or other plan sponsor to retired employees.

In Medicare Advantage, the area in which a plan offers service. A service area is typically a county, state or region.

Nursing care that should be provided only by a licensed nurse.

A type of Medicare Advantage plan that serves people with special health care needs.

In Medicare Part D, a special procedure you and your doctor must follow before you can use certain drugs. You must first try a less expensive drug to see if it works for you. You may "step up" to a more expensive drug that treats the same condition only if you and your doctor can show that the less expensive drug didn't work for you.

In Medicare Part D, a drug plan formulary that divides drugs into groups. Each group, or tier, has a different level of cost sharing. For example, a generic version of a drug may have a lower copay than a brand-name version of the drug. The details of the cost sharing vary from plan to plan.