Glossary of Medicare Terms & Definitions

Appeal

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan.

You have the right to appeal if Medicare, your Medicare health plan, or your Medicare drug plan denies one of these:

A request for a healthcare service, supply, item, or prescription drug that you think you should be able to get
A request for payment of a healthcare service, supply, item, or prescription drug you already got
A request to change the amount you must pay for a healthcare service, supply, item, or prescription drug

You can also appeal if Medicare, your Medicare health plan, or your Medicare drug plan stops providing or paying for all or part of a healthcare service, supply, item, or prescription drug you think you still need.

Benefit period

The way that original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Claim

A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.

Co-insurance

An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Co-insurance is usually a percentage (for example, 20%).

Coordination of benefits

A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.

Co-payment

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription. A co-payment is usually a set amount, rather than a percentage. (For example, you might pay $10 or $20 for a doctor’s visit or prescription.)

Cost sharing

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. This amount can include co-payments, co-insurance, and/or deductibles.

Coverage determination (Part D)

The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:

Whether a particular drug is covered
Whether you have met all the requirements for getting a requested drug
How much you’re required to pay for a drug
Whether to make an exception to a plan rule when you request it

The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests). If you disagree with the plan’s coverage determination, the next step is an appeal.

Coverage gap (Medicare prescription drug coverage)

A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

Creditable coverage (Medigap)

Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.

Creditable prescription drug coverage

Prescription drug coverage (for example, from an employer or union) that’s 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.

Deductible

The amount you must pay for healthcare or prescriptions before original Medicare, your prescription drug plan, or your other insurance begins to pay.

Department of Health and Human Services (HHS)

The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).

Drug list

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This list is also called a formulary.

Durable medical equipment

Certain medical equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.

Employer or union retiree plans

Plans that give health and/or drug coverage to employees, former employees, and their families. These plans are offered to people through their (or a spouse’s) current or former employer or employee organization.

End-Stage Renal Disease (ESRD)

Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Exception

A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision to charge a lower amount for a drug that’s on its non-preferred drug tier. You must request an exception, and your doctor or other prescriber must send a written supporting statement explaining the medical reason for the exception.

Extra Help

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

Formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

Generic drug

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Grievance

A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan’s refusal to cover a service, supply, or prescription, you file an appeal.

Group health plan

In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Guaranteed issue rights (also called "Medigap protections")

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, like exclusions for pre-existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.

Healthcare provider

A person or organization that’s licensed to give healthcare. Doctors, nurses, and hospitals are examples of healthcare providers.

Home health agency

An organization that provides home healthcare.

Home healthcare

Healthcare services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home healthcare on a limited basis as ordered by your doctor.

Hospice

A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver.

Hospital care (inpatient)

Treatment you get in an acute care hospital, critical access hospital, inpatient rehabilitation facility, long-term care hospital, inpatient care as part of a qualifying research study, and mental healthcare.

Hospital outpatient setting

A part of a hospital where you get outpatient services, like an emergency department, observation unit, surgery center, or pain clinic.

Independent reviewer

An organization (sometimes called an Independent Review Entity or IRE) that has no connection to your Medicare health plan or Medicare Prescription Drug Plan. Medicare contracts with the IRE to review your case if you appeal your plan’s payment or coverage decision or if your plan doesn’t make a timely appeals decision.

Initial coverage limit

Once you’ve met your yearly deductible, you’ll pay a copayment or coinsurance for each covered drug until you reach your plan’s out-of-pocket maximum (or initial coverage limit). You’ll then enter your plan’s coverage gap (also called the “donut hole”).

In-network

Doctors, hospitals, pharmacies, and other healthcare providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network doctors, hospitals, pharmacies, and other healthcare providers.

Inpatient care

Healthcare that you get when you’re admitted to a healthcare facility, like a hospital or skilled nursing facility.

Inpatient hospital services

Services you get when you’re admitted to a hospital, including bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.

Inpatient rehabilitation facility

A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.

Long-term care

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, like dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living, or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

Long-term care hospital

Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

Long-term care ombudsman

An independent advocate (supporter) for nursing home and assisted living facility residents who works to solve problems between residents and nursing homes or assisted living facilities. They may be able to provide information about home health agencies in their area.

Medicaid

A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.

Medical emergency

When you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death.

Medically necessary

Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

Medicare

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medicare Advantage Plan (Part C)

A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.

Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.

If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Advantage Prescription Drug (MA-PD) Plan

A Medicare Advantage plan that offers Medicare prescription drug coverage (Part D), Part A, and Part B benefits in one plan.

Medicare-approved amount

In original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

Medicare-approved supplier

A company, person, or agency that’s been certified by Medicare to give you a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.

Medicare-certified provider

A healthcare provider (like a home health agency, hospital, nursing home, or dialysis facility) that’s been approved by Medicare. Providers are approved or “certified” by Medicare if they’ve passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified.

Medicare Coordination of Benefits Contractor

The company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have, and determine whether the coverage pays before or after Medicare.

Medicare Cost Plan

A type of Medicare health plan available in some areas. 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 original Medicare (your Cost Plan pays for emergency services or urgently needed services).

Medicare Health Maintenance Organization (HMO) Plan

A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Most HMOs also require you to get a referral from your primary care physician.

Medicare health plan

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

Medicare Medical Savings Account (MSA) Plan

MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your healthcare costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.

Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.

Medicare Part B (Medical Insurance)

Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Medicare plan

Any way other than original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug Plans.

Medicare Preferred Provider Organization (PPO) Plan

A type of Medicare Advantage Plan (Part C) available in some areas of the country in which you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare prescription drug coverage (Part D)

Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

Medicare Prescription Drug Plan (Part D)

Part D adds prescription drug coverage to original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

Medicare Private Fee-For-Service (PFFS) Plan

A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had original Medicare, if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when you get care. A Private Fee-For-Service Plan is very different than original Medicare, and you must follow the plan rules carefully when you go for healthcare services. When you’re in a Private Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits than in original Medicare.

Medicare Savings Program

A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.

Medicare SELECT

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Medicare Special Needs Plan (SNP)

A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized healthcare for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.

Medicare Summary Notice (MSN)

A notice you get after the doctor or provider files a claim for Part A or Part B services in original Medicare. It explains what the doctor or provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

Medigap basic benefits

Benefits that all Medigap policies must cover, including Part A and Part B coinsurance amounts, blood, and additional hospital benefits not covered by original Medicare.

Medigap Open Enrollment Period

A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.

Medigap policy

Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in original Medicare coverage.

Multi-employer plan

In general, a group health plan that’s sponsored jointly by 2 or more employers.

Network pharmacies

Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are only covered if you get them filled at network pharmacies.

Non-preferred pharmacy

A pharmacy that’s part of a Medicare drug plan’s network, but isn’t a preferred pharmacy. You may pay higher out-of-pocket costs if you get your prescription drugs from a non-preferred pharmacy instead of a preferred pharmacy.

Optional supplemental benefits

Services that Medicare doesn’t cover, but that a Medicare health plan may choose to offer. If you enroll in a plan with these services, you may choose to buy the services. If you choose to buy these benefits, you’ll pay for them directly, usually as a premium, copayment, and/or coinsurance. These services may be offered individually or as a group of services, and they may be different for each Medicare health plan.

Original Medicare

Original Medicare is fee-for-service coverage under which the government pays your healthcare providers directly for your Part A and/or Part B benefits.

Out-of-network

A benefit that may be provided by your Medicare Advantage plan. Generally, this benefit gives you the choice to get plan services from outside of the plan’s network of healthcare providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.

Out-of-pocket costs

Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.

Outpatient hospital care

Medical or surgical care you get from a hospital when your doctor hasn’t written an order to admit you to the hospital as an inpatient. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests, or x-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.

Over the Counter

Over the Counter (OTC) items are medications and health related items that are safe and effective for use by the general public without seeking treatment by a health professional. Popular examples of OTC are non-prescription pain relievers, vitamins, cough and cold medicines, and first aid supplies.

Penalty

An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don’t join when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

Pharmacy network

Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are only covered if you get them filled at network pharmacies.

Point-of-service option

In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.

Pre-existing condition

A health problem you had before the date that new health coverage starts.

Preferred pharmacy

A pharmacy that’s part of a Medicare drug plan’s network. You pay lower out-of-pocket costs if you get your prescription drugs from a preferred pharmacy instead of a non-preferred pharmacy.

Premium

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

Preventive services

Healthcare to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).

Primary care doctor

The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and healthcare providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other healthcare provider.

Prior authorization

Approval from a Medicare drug plan that may be required before you fill your prescription for the prescription to be covered by your plan.

Programs of All-inclusive Care for the Elderly (PACE)

A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Religious nonmedical healthcare institution

A facility that provides nonmedical healthcare items and services to people who need hospital or skilled nursing facility care, but for whom that care would be inconsistent with their religious beliefs.

Secondary payer

The insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.

Service area

A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.

Skilled nursing care

Care like intravenous injections that can only be given by a registered nurse or doctor.

Skilled nursing facility (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Skilled nursing facility care

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility (SNF).

State Health Insurance Assistance Program (SHIP)

A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

State Pharmacy Assistance Program (SPAP)

A state program that provides help paying for drug coverage based on financial need, age, or medical condition.

Step therapy

A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.

Telemedicine

Medical or other health services given to a patient using a communications system (like a computer, phone, or television) by a practitioner in a location different than the patient’s.

Tiers

Groups of drugs that have a different cost for each group. A drug in a lower tier will cost you less than a drug in a higher tier.

TRICARE

A healthcare program for active-duty and retired uniformed services members and their families.

TTY

A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment. People who don’t 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.

Urgently needed care

Care that you get outside of your Medicare health plan’s service area for a sudden illness or injury that needs medical care right away but isn’t life threatening. If it’s not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.

Glossary of Terms