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N O P Q R S T U V W X Y Z

A

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 Prescription Drug Plan.

B

Beneficiary

A beneficiary is a person who has Medicare health care coverage.

Benefits

Benefits are items or services that are covered under a health insurance plan. Benefits that are covered or excluded are defined in the health insurance plan’s coverage documents.

C

Catastrophic Coverage

Once you get out of the coverage gap of a Prescription Drug Plan, you automatically get catastrophic coverage. It assures you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.

Centers for Medicare & Medicaid Services (CMS)

CMS is the federal agency that runs Medicare, Medicaid and Children’s Health Insurance Programs.

Claim

A request for payment that you submit to Medicare when you get items and services that you believe are covered.

Coinsurance

Coinsurance is the amount you may be required to pay as your share of the cost of services after you pay any deductibles. It is typically a set percentage.

Copayment

A copayment is an amount you may be required to pay as your share of the cost for a medical service or supply. It is typically a set dollar amount.

Coverage Gap

The coverage gap (also called the “donut hole”) is 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 starts when you and your plan have paid a set dollar for prescription drugs during that year.

D

Deductible

The amount you must pay for health care or prescriptions before Medicare, your Prescription Drug plan or other insurance begins to pay.

Dental Coverage

Benefits that help pay for the cost of dental visits for basic and preventative services.

E

Employer Plans

A plan offered to people through their employer that gives health and/or drug coverage to employees or former employees and their families.

End-Stage Renal Disease (ESRD)

ESRD is permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

F

Formulary

A list of prescription drugs that are covered by a Prescription Drug Plan or another insurance plan that offers drug benefits.

G

Generic Drug

A generic prescription drug that has the same active ingredient formula as a brand name drug. Generic drugs usually cost less and are deemed to be as safe and effective as brand name drugs.

Group Health Plan

A group health plan is generally offered by an employer or organization that provides health insurance coverage to employees and their families.

H

Health Maintenance Organization (HMO)

A HMO is a type of Medicare health plan that is available in most major metropolitan 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 plan's list except in an emergency

Home Health Care

Health care services and/or supplies that a physician decides you may receive in your home.

Hospice

Hospice is a special way of caring for people who are terminally ill. Hospice services are covered by Medicare Part A.

I

Inpatient Hospital Care

Inpatient hospital care is covered by Medicare Part A that includes services you receive when you’re admitted to a hospital.

J

K

L

Long Term Care

Long term care at hospitals provide treatment for patients who stay, on average, more than 25 days.

M

Medicaid

Medicaid is a federal and state government program that helps with medical costs for some people with limited income and resources.

Medicare

The Medicare is federally provided health insurance program for people over the age of 65, of certain people with disabilities, and people with End Stage Renal Disease (ESRD).

Medicare Advantage Plan (Part C)

A Medicare Advantage (MA) plan is a type of Medicare health insurance plan offered by a Medicare-approved private insurance companies that covers Part A and Part B Medicare benefits. Most Medicare Advantage plans offer prescription drug coverage.

Medicare Advantage Prescription Drug (MAPD) Plan

A MAPD plan is Medicare Advantage plan that offers Prescription Drug coverage (Part D), Part A and Part B benefits in one plan.

Medicare Supplement Plan (Medigap)

A Medicare plan that is sold by a Medicare-approved private insurance company to fill gaps in Original Medicare coverage.

Medigap Policy

Medigap is also known as Medicare Supplement, which is insurance sold by Medicare-approved private insurance companies to fill gaps in Original Medicare coverage.

N

Network

A network refers to facilities, providers and suppliers that your health insurance plan has contracted with.

O

Original Medicare

Original Medicare consists of Part A and Part B. It is a fee-for-service coverage under which the federal government pays your health care providers directly for your benefits.

Outpatient Hospital Care

Outpatient hospital care is medical or surgical care you get from a hospital without admitting you to the hospital as an inpatient.

P

Part A (Hospital Insurance)

Part A is the part of Medicare that pays for inpatient hospital stays, skilled nursing facility care, hospice and some home health care.

Part B (Medical Insurance)

Part B is the part of Medicare that helps pay for doctor services, outpatient hospital care and some medical services that aren’t covered by Part A.

Pharmacy Network

Pharmacies that have agreed to provide members with prescriptions at a discounted price for certain Medicare and Part D plans.

Preferred Pharmacy

A preferred pharmacy is one that is part of a Prescription Drug Plan’s network. You pay lower out-of-pocket costs if you get your drugs from a preferred pharmacy instead of a non-preferred pharmacy.

Preferred Provide Organization (PPO)

A type of Medicare Advantage plan in which you pay less if you use doctors, hospitals, and providers that belong to their network. You can use services outside of the network for an additional cost.

Premium

The amount of money you must pay periodically to Medicare, an insurance company, health care plan or drug plan.

Prescription Drug Plan (Part D)

Medicare offers prescription drug coverage to everyone with Medicare. These plans are run by Medicare-approved insurance companies.

Preventative Services

Preventative services are health care to prevent illness or detect illness at an early stage.

Private Fee-for-Service (PFFS)

A PFFS plan is a type of Medicare Health Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan's 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 Original Medicare doesn't cover.

Q

R

Referral

A referral is a written order from your primary care doctor for you to see a specialist or get certain medical services. A referral is generally required for most HMO plans.

S

Skilled Nursing Care

Skilled nursing care administers care such as intravenous injections that can only be given by a registered nurse or doctor.

Special Needs Plan (SNP)

SNPs are a type of Medicare Advantage plan that limits membership to people with specific diseases and tailors their benefits, provider choices, and drug formularies to meet their specific needs. Also, SNPs are a type of plan available to those beneficiaries who have both Medicare and Medicaid.

T

U

Urgent Care

Urgent Care is care that you get outside of your Medicare health plan’s service area for a sudden illness or injury that needs immediate medical care but is not life threatening. Urgent care is not the same as emergency care.

V

W

X

Y

Z

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