Glossary

Groups of doctors, hospitals and other health care professionals working together to give you high-quality, coordinated service and health care.¹

An agreement by your doctor, provider or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.¹

A person who has health care insurance through the Medicare or Medicaid programs.

The time frame Medicare uses to measure your inpatient hospital or skilled nursing care. It starts when you’re admitted and ends after 60 days in a row without inpatient care. You may have multiple benefit periods.

The 12-month period during which your insurance plan tracks benefits, deductibles and coverage limits. It may follow the calendar year (January–December) or start when your coverage begins.

The private insurance company that sells and manages your Medicare Supplement (Medigap) plan. While Medicare pays its share of covered services, the carrier handles the supplemental portion — like coinsurance, copayments or deductibles — based on your specific plan.

The Federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS works to make sure the beneficiaries in these programs are able to get high-quality health care.

The cost for medical care you pay yourself. Usually, the co-payment is a pre-determined dollar amount you pay each time you utilize a particular service (like $10 each time you fill a prescription or $20 each time you visit your doctor).

The percentage of the plan charge for services you may have to pay after you pay any plan deductibles. Usually, the payment is a percentage of the cost of the service (like 20%).

Prescription drug coverage (like from an employer or union) that is, on average, at least as good as the Part D standard prescription drug coverage.

A small, rural hospital that offers 24/7 emergency services and has 25 or fewer inpatient beds. These hospitals receive special Medicare funding to maintain care access in remote areas.¹

The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B and Part D. These amounts can change every year.

Temporary Medicare projects that test new ways to deliver or pay for care. They’re often limited to specific groups or locations.

Ending your coverage with a health plan.

Specific conditions, services or treatments that your insurance policy doesn’t cover. It’s important to review these carefully to avoid surprise costs.

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles and coinsurance.¹

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.²

Costs or services that are not covered under Medicare Parts A and B.

Rights you have in certain situations when insurance companies are required by law to sell or offer you coverage. The company can’t deny you coverage or place conditions on an insurance policy, must cover you for all old health problems and can’t charge you more because of past or present health problems.

A hospital or unit that provides intensive, specialized rehab care (like physical therapy) to inpatients recovering from serious conditions or injuries.²

In Original Medicare, these are additional days that Medicare will pay for when you're in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime.²

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.¹

A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Programs vary by state, but most medical costs are covered if you qualify for both Medicare and Medicaid.

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 aren’t mainly for the convenience of you or your doctor.

The Federal health insurance program for people 65 years of age or older, certain younger people with disabilities and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant).

A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits, with a few exclusions, for example, certain aspects of clinical trials which are covered by Original Medicare even though you’re still in the plan.

Medicare Advantage Plans include:

• Health Maintenance Organizations
• Preferred Provider Organizations
• Private Fee-for-Service Plans
• Special Needs Plans
• Medical Savings Account Plans

If you’re enrolled in a Medicare Advantage Plan:

• Most Medicare services are covered through the plan
• Most Medicare services aren’t paid for by Original Medicare
• Most Medicare Advantage Plans offer prescription drug coverage¹

If you have a Medicare Cost Plan, you may get services from the plan’s network of providers at a lower cost. You may also use providers who accept Medicare, and you’ll pay Original Medicare costs.

Generally, you can join a Medicare Cost Plan whenever the plan is accepting new members, even if you only have Part B. You can leave a Medicare Cost Plan at any time and return to Original Medicare.

Medicare Cost Plans are only available in certain, limited areas of the country.²

Plans offered by private companies that contract with Medicare to provide Part A, Part B and, in many cases, Part D benefits. Includes Medicare Advantage Plans and certain other types of coverage (like Medicare Cost Plans, PACE programs and demonstration/pilot programs).¹

An MSA is a type of consumer-directed Medicare Advantage Plan (Part C). These plans are similar to Health Savings Account (HSA) Plans like you’d get from an employer or the Marketplace.

With MSA Plans, you can choose your health care services and providers (these plans usually don’t have a network of doctors, other health care providers or hospitals).²

In general, Medicare Part A helps pay for inpatient care you get in hospitals, critical access hospitals and skilled nursing facilities. It also helps cover hospice care and some home health care.²

Medicare Part B (Medical Insurance) helps cover 2 types of services:

• Medically necessary services: Services or supplies that meet accepted standards of medical practice to diagnose or treat your medical condition.
• Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage when treatment is likely to work best.²

Also called a PDP (prescription drug plan), Medicare 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 drug plans.³

Any way other than Original Medicare that you can get your Medicare health or drug coverage. This term includes all Medicare health plans and Medicare drug plans.¹

A Medigap insurance policy sold by private insurance companies to supplement some of the “gaps” in Medicare coverage. There are 10 standardized plans (except in Minnesota, Massachusetts and Wisconsin). Medigap policies only work with Medicare Parts A and B.

The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the “approved charge.”

A group of doctors, hospitals, pharmacies and other health care experts contracted or hired by a health plan to take care of its members.

Commonly referred to as “Traditional Medicare”, is Fee-for-Service health insurance program that has 2 parts: Part A (Hospital Insurance) and Part B (Medical Insurance). You typically pay a portion of the costs for covered services as you get them. Under Original Medicare, you don’t have coverage through a Medicare Advantage Plan or another type of Medicare health plan.²

Health care costs you must pay on your own because they are not covered by Medicare or other insurance.

A type of Medicare Advantage plan in which you use providers that belong to the network. You can use providers outside of the network for an additional cost.

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.¹

Preventive services are services to prevent or detect illness at an early stage prior to the development of any symptoms. If symptoms are present or a diagnosis has been made, the treatment or procedure is not preventive.

Preventive services must also have been determined to be medically appropriate by an attending physician.

The doctor you go to first for most health problems. They may talk with other doctors and health care providers about your care and refer you to them.¹

A type of Medicare Advantage plan in which you use providers that belong to the network (unless certain exceptions apply). The health 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 Medicare Parts A and B don’t include.

Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.

PACE covers all Medicare- and Medicaid-covered care and services, and anything else the health care professionals in your PACE team decide you need to improve and maintain your health. This includes prescription drugs and any medically necessary care.²

A doctor, hospital, health care professional or health care facility.

A written ok from your primary care doctor for you to see a specialist or get certain services. In many Managed Care plans, you need a referral before you can get care from anyone except your primary care doctor. If you don’t get a referral, the plan may not pay for your care.

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. A plan may disenroll you if you move out of its service area.