Interactive Glossary - Section A-C
A-C D-F G-I J-L M-O P-R S-U V-W X-Z
A
Activities of Daily Living (ADL): Activities in which most people take part on a daily basis. Eating, bathing, dressing, toileting and moving from one place to another are some examples.
Acute Illness: A disease or condition that comes on rapidly and severely, but that can—with proper treatment—be cured, such as pneumonia or a broken bone.
Administrative Law Judge (ALJ): A hearing officer who presides over appeals to Medicareby people with Medicare or their providers. The ALJ level follows the reconsideration level for all appeals for Medicare coverage.
Advance Beneficiary Notice (ABN): Also known as a “waiver of liability.” A notice health careproviders and suppliers are required to give a person with Original Medicare when they believe that Medicare will not cover their services or items and the person has no reason to know that Medicare will not cover these services or items. If your provider does not give you an ABN to sign and you have no reason to know the procedure is not covered, then you do not have to pay. If you sign an ABN before you get the service or item and Medicare does not pay for it, you generally pay for it (although there are a few exceptions). Providers are not required to give you an ABN for services or items Medicare never covers.
Advance Coverage Decision: A Private Fee-For-Service (PFFS) plan’s determination about whether or not it will pay for a certain service. Note: this is completely unrelated to anadvance beneficiary notice (ABN), which only applies to people with Original Medicare.
Advance Directive: A legal document that outlines how you want medical and financial decisions made if you can no longer communicate your wishes. A health care advance directive may include a health care proxy, living will and a health care power of attorney.
Advanced Illness: A serious disease or condition that has progressed too far to be cured, such as cancer that has spread throughout the body.
ALS/Lou Gehrig’s Disease: A disease that affects the motor nerve cells of the spinal cord and causes their degeneration. Patients with this disease can qualify for Medicare coverage regardless of age.
Ambulette: A wheelchair-accessible van that provides non-emergency transportation for people with disabilities.
Annual Coordinated Election Period (ACEP): The period of time between November 15 and December 31 of every year when you can change your Medicare private drug plan (Part D) and/or your Medicare health plan choice (Original Medicare or a Medicare private health plan—Part C) for the following year. This is also the time you can enroll in Part D for the first time if you do not enroll during your Initial Enrollment Period. (You may have to pay a premium penalty if you enroll during this time unless you have had other creditable coverage.) Your new coverage will begin January 1.
Appeal: A formal request for review of an official decision made by a Medicare private health plan (Part C), a Medicare private drug plan (Part D), or Original Medicare regarding payment for or coverage of health care. Federal regulations and law specify appeals deadlines, processes for handling cases, decision notification requirements, and multiple levels of review in the appeals process.
Approved Amount: The fee that a health insurance plan sets as as the amount a provider or supplier should be paid for a particular service or item. Original Medicare calls this “assignment.” See also, Take Assignment, Participating Provider and Non-Participating Provider.
Area Agency on Aging (AAA): Agencies that coordinate and offer services such as Meals-on-Wheels, homemaker assistance, and similar programs that help older adults remain independent in their home and community.
Assets: Resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate.
Assignment: Medicare's approved amount for a service or item. Original Medicare will cover 80 percent of this amount (or 55 percent for most mental health services) and you (or yoursupplemental insurance) are responsible for the remaining coinsurance. See also, Take Assignment, Participating Provider and Non-Participating Provider.
Assisted Living Facility: Also known as a “group home.” Facilities designed to assist people with activities of daily living who can otherwise take care of themselves. They are different from nursing homes, which also provide skilled care. Medicare does not cover a stay in an assisted living facility.
Assistive Technology: Any item, piece of equipment, or system that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. For example, Closed Circuit Television is an assistive technology that Medicare will cover if medically necessary. Simple items like “grabbers” and “reachers” are not covered by Medicare.
B
Balance Billing: When doctors and hospitals charge you more than the approved amount for the service.
Benchmark: See Extra Help Premium Amount.
Beneficiary: A person who receives benefits. (If you are a member of a health plan, like agroup health plan, Original Medicare, or Medicaid, and receive benefits from that plan, you are a health plan beneficiary).
Benefit Period: The amount of time during which Medicare pays for hospital and skilled nursing facility (SNF) services. A benefit period begins the first day you enter the hospital or SNF and ends when you no longer receive hospital care or skilled care in a SNF for 60 days in a row. With each new benefit period, you pay a new deductible. Your coinsurance is determined by the number of days you have been in the facility during each benefit period.
Bereavement Services: A hospice service that provides counseling for the family up to a year after the patient passes away.
Brand-Name Drug: A drug marketed under a proprietary, trademark-protected name.(Definition from the U.S. Food and Drug Administration)
C
Calendar Quarters: A three-month period of time ending with March 31, June 30, September 30, or December 31. Social Security counts each calendar quarter that you work and pay into Social Security and Medicare taxes toward your eligibility for premium-free Part A.
Capped Rental Item: Durable medical equipment (DME) (such as a wheelchair) thatMedicare covers initially for rental, rather than for purchase, often because of its high cost. Medicare pays the rental fees for these items in monthly installments. You can keep a capped rental item as long as it is medically necessary and elect to buy it. After you rent for 13 months, ownership will automatically transfer to you. (Note: If you have been renting an item of DME since before January 1, 2006, you can continue to rent that item without purchasing if you choose.)
Caregiver: Anyone who provides help and support to someone who is either temporarily or permanently unable to function or someone who can function but not optimally. Most caregivers are unpaid, and are often a family member, friend or neighbor. Formal caregivers are paid care providers or volunteers associated with a service system.
Care Manager: A nurse or specially trained educator or doctor who will assess your needs and advise you on how to best manage your health conditions.
Carrier: A private company that has a contract with Medicare to process Part B claims.
Catastrophic Coverage: Insurance designed to protect you from having to pay very high out-of-pocket costs. Catastrophic coverage usually begins after you have spent a pre-determined amount on your health care. Original Medicare Part A and Part B do not offer catastrophic coverage. They always pay the same amount regardless of how much you have spent. TheMedicare prescription drug benefit (Part D) does offer catastrophic coverage. After you have spent a certain amount out-of-pocket, you will only pay five percent of the cost of each prescription drug (in addition to your monthly plan premium). Medicare private plans, like regional PPOs (Prefered Provider Organizations), may also have catastrophic coverage or caps on out-of-pocket costs, but these caps may exclude certain high cost services. Also, Medicare Medical Savings Accounts (MSAs) must pay all or most of your Medicare Part A and B costs after you have met your deductible.
Catastrophic Limit: The highest amount of money you have to pay out-of-pocket during a given period of time for certain services. After you have reached the catastrophic limit of your insurance plan, a higher level of coverage begins.
Center for Health Dispute Resolution (CHDR): See Maximus.
Centers for Medicare & Medicaid Services (CMS): Formerly known as the “Health Care Financing Administration (HCFA).” The United States government agency responsible for administering Medicare, Medicaid, SCHIP (State Children's Health Insurance), HIPPA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs.
Certificate of Medical Necessity (CMN): Documentation from a doctor which Medicarerequires before it will cover certain durable medical equipment (DME). The CMN states the patient’s diagnosis, prognosis, reason for the equipment, and estimated duration of need.
Chronic Illness: A disease or condition, such as diabetes or asthma, that lasts for a long period of time or is marked by frequent recurrence.
Claim: A bill that asks for payment for services or benefits you received. Medicare Part Aclaims are processed by fiscal intermediaries and Part B claims are processed by Medicarecarriers. Medicare private health plan (Part C) and Medicare private drug plan (Part D) claims are processed by the plans. See also, Medicare Administrative Contractors (MACs)and DME MAC (Durable Medical Equipment Medicare Administrative Contractor).
COBRA (Consolidated Omnibus Budget Reconciliation Act): A federal law guaranteeing employees and their families at risk of losing health insurance—due to termination of employment, death, divorce, or other circumstances—the right to purchase continued coverage under the employer’s group health plan for limited periods of time.
Coinsurance: The portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of an approved amount. In Original Medicare, the coinsurance is usually 20 percent of Medicare’s assignment.
Comprehensive Outpatient Rehabilitation Facility (CORF): A medical facility that providesoutpatient diagnostic, therapeutic and restorative services for the rehabilitation of an injury,disability or sickness.
Continuous Open Enrollment: A consumer's right to buy private insurance at any time, regardless of age or health status.
Conversion Policy: An employer-sponsored group health plan that can be converted to anindividual policy with the same insurance company. These policies are usually very expensive.
Coordination of Benefits: The sharing of costs by two or more health plans, based on their respective financial responsibilities for medical claims. Your primary insurance andsecondary insurance must coordinate benefits in order to pay claims.
Copayment: Also known as a “copay.” A set amount you are required to pay for each medical service you receive (like $5 or $35).
Coordination Period, 30-Month: For people with End-Stage Renal Disease (ESRD), the period of time during which a group health plan pays first and Medicare pays second. Medicare may pay the remaining costs if your group health plan does not pay 100 percent of your health care bills during the coordination period.
Cost Plan: A private health plan sponsored by a Health Maintenance Organization (HMO), through which you can get your Medicare benefits. A cost plan is not a “Medicare Advantage” (Part C) plan. It allows you to go out of network to get care. If you get out-of-network care from a provider that accepts Medicare as payment, your costs will be covered by Original Medicare.
Cost Sharing: If you have health coverage, the portion of medical care that you pay yourself, such as a copayment, coinsurance or deductible. See also, Out-Of-Pocket Costs.
Cost Tiers: A system that Medicare private drug plans use to price prescription drugs.Generic drugs are generally on the first, least expensive tier (Tier 1), followed by brand-namedrugs (Tier 2), and then specialty drugs (Tiers 3 and above), with each subsequent tier requiring higher out-of-pocket costs.
Coverage Gap: Also called a “Doughnut Hole.” A gap in Medicare prescription drugcoverage (Part D) during which you must pay all drug costs in full; followed by catastrophic coverage from the insurance plan.
Coverage Restrictions: Also called “Utilization Management Tools.” Restrictions that a health or drug plan may place on certain covered services to restrict their usage. Coverage restrictions include prior authorization, quantity limits and step therapy.
Creditable Coverage:
Curative Care: The treatment of patients with the intent of curing their disease or condition; for example, chemotherapy treatments to cure breast cancer.hyper
Currently Working: You are considered to be “currently working” as long as you have employment rights at your company even if you do not work on a regular basis, are on sick leave, are a seasonal worker, or have been temporarily laid-off. You are not considered to be “currently working” if you receive Social Security Disability Insurance (SSDI), have receiveddisability benefits from your employer for more than six months, or if you receive your employer insurance through COBRA.
Custodial Care: Non-medical care, such as cooking, cleaning, and shopping. Medicaregenerally does not cover custodial care.
Activities of Daily Living (ADL): Activities in which most people take part on a daily basis. Eating, bathing, dressing, toileting and moving from one place to another are some examples.
Acute Illness: A disease or condition that comes on rapidly and severely, but that can—with proper treatment—be cured, such as pneumonia or a broken bone.
Administrative Law Judge (ALJ): A hearing officer who presides over appeals to Medicareby people with Medicare or their providers. The ALJ level follows the reconsideration level for all appeals for Medicare coverage.
Advance Beneficiary Notice (ABN): Also known as a “waiver of liability.” A notice health careproviders and suppliers are required to give a person with Original Medicare when they believe that Medicare will not cover their services or items and the person has no reason to know that Medicare will not cover these services or items. If your provider does not give you an ABN to sign and you have no reason to know the procedure is not covered, then you do not have to pay. If you sign an ABN before you get the service or item and Medicare does not pay for it, you generally pay for it (although there are a few exceptions). Providers are not required to give you an ABN for services or items Medicare never covers.
Advance Coverage Decision: A Private Fee-For-Service (PFFS) plan’s determination about whether or not it will pay for a certain service. Note: this is completely unrelated to anadvance beneficiary notice (ABN), which only applies to people with Original Medicare.
Advance Directive: A legal document that outlines how you want medical and financial decisions made if you can no longer communicate your wishes. A health care advance directive may include a health care proxy, living will and a health care power of attorney.
Advanced Illness: A serious disease or condition that has progressed too far to be cured, such as cancer that has spread throughout the body.
ALS/Lou Gehrig’s Disease: A disease that affects the motor nerve cells of the spinal cord and causes their degeneration. Patients with this disease can qualify for Medicare coverage regardless of age.
Ambulette: A wheelchair-accessible van that provides non-emergency transportation for people with disabilities.
Annual Coordinated Election Period (ACEP): The period of time between November 15 and December 31 of every year when you can change your Medicare private drug plan (Part D) and/or your Medicare health plan choice (Original Medicare or a Medicare private health plan—Part C) for the following year. This is also the time you can enroll in Part D for the first time if you do not enroll during your Initial Enrollment Period. (You may have to pay a premium penalty if you enroll during this time unless you have had other creditable coverage.) Your new coverage will begin January 1.
Appeal: A formal request for review of an official decision made by a Medicare private health plan (Part C), a Medicare private drug plan (Part D), or Original Medicare regarding payment for or coverage of health care. Federal regulations and law specify appeals deadlines, processes for handling cases, decision notification requirements, and multiple levels of review in the appeals process.
Approved Amount: The fee that a health insurance plan sets as as the amount a provider or supplier should be paid for a particular service or item. Original Medicare calls this “assignment.” See also, Take Assignment, Participating Provider and Non-Participating Provider.
Area Agency on Aging (AAA): Agencies that coordinate and offer services such as Meals-on-Wheels, homemaker assistance, and similar programs that help older adults remain independent in their home and community.
Assets: Resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate.
Assignment: Medicare's approved amount for a service or item. Original Medicare will cover 80 percent of this amount (or 55 percent for most mental health services) and you (or yoursupplemental insurance) are responsible for the remaining coinsurance. See also, Take Assignment, Participating Provider and Non-Participating Provider.
Assisted Living Facility: Also known as a “group home.” Facilities designed to assist people with activities of daily living who can otherwise take care of themselves. They are different from nursing homes, which also provide skilled care. Medicare does not cover a stay in an assisted living facility.
Assistive Technology: Any item, piece of equipment, or system that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. For example, Closed Circuit Television is an assistive technology that Medicare will cover if medically necessary. Simple items like “grabbers” and “reachers” are not covered by Medicare.
B
Balance Billing: When doctors and hospitals charge you more than the approved amount for the service.
Benchmark: See Extra Help Premium Amount.
Beneficiary: A person who receives benefits. (If you are a member of a health plan, like agroup health plan, Original Medicare, or Medicaid, and receive benefits from that plan, you are a health plan beneficiary).
Benefit Period: The amount of time during which Medicare pays for hospital and skilled nursing facility (SNF) services. A benefit period begins the first day you enter the hospital or SNF and ends when you no longer receive hospital care or skilled care in a SNF for 60 days in a row. With each new benefit period, you pay a new deductible. Your coinsurance is determined by the number of days you have been in the facility during each benefit period.
Bereavement Services: A hospice service that provides counseling for the family up to a year after the patient passes away.
Brand-Name Drug: A drug marketed under a proprietary, trademark-protected name.(Definition from the U.S. Food and Drug Administration)
C
Calendar Quarters: A three-month period of time ending with March 31, June 30, September 30, or December 31. Social Security counts each calendar quarter that you work and pay into Social Security and Medicare taxes toward your eligibility for premium-free Part A.
Capped Rental Item: Durable medical equipment (DME) (such as a wheelchair) thatMedicare covers initially for rental, rather than for purchase, often because of its high cost. Medicare pays the rental fees for these items in monthly installments. You can keep a capped rental item as long as it is medically necessary and elect to buy it. After you rent for 13 months, ownership will automatically transfer to you. (Note: If you have been renting an item of DME since before January 1, 2006, you can continue to rent that item without purchasing if you choose.)
Caregiver: Anyone who provides help and support to someone who is either temporarily or permanently unable to function or someone who can function but not optimally. Most caregivers are unpaid, and are often a family member, friend or neighbor. Formal caregivers are paid care providers or volunteers associated with a service system.
Care Manager: A nurse or specially trained educator or doctor who will assess your needs and advise you on how to best manage your health conditions.
Carrier: A private company that has a contract with Medicare to process Part B claims.
Catastrophic Coverage: Insurance designed to protect you from having to pay very high out-of-pocket costs. Catastrophic coverage usually begins after you have spent a pre-determined amount on your health care. Original Medicare Part A and Part B do not offer catastrophic coverage. They always pay the same amount regardless of how much you have spent. TheMedicare prescription drug benefit (Part D) does offer catastrophic coverage. After you have spent a certain amount out-of-pocket, you will only pay five percent of the cost of each prescription drug (in addition to your monthly plan premium). Medicare private plans, like regional PPOs (Prefered Provider Organizations), may also have catastrophic coverage or caps on out-of-pocket costs, but these caps may exclude certain high cost services. Also, Medicare Medical Savings Accounts (MSAs) must pay all or most of your Medicare Part A and B costs after you have met your deductible.
Catastrophic Limit: The highest amount of money you have to pay out-of-pocket during a given period of time for certain services. After you have reached the catastrophic limit of your insurance plan, a higher level of coverage begins.
Center for Health Dispute Resolution (CHDR): See Maximus.
Centers for Medicare & Medicaid Services (CMS): Formerly known as the “Health Care Financing Administration (HCFA).” The United States government agency responsible for administering Medicare, Medicaid, SCHIP (State Children's Health Insurance), HIPPA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs.
Certificate of Medical Necessity (CMN): Documentation from a doctor which Medicarerequires before it will cover certain durable medical equipment (DME). The CMN states the patient’s diagnosis, prognosis, reason for the equipment, and estimated duration of need.
Chronic Illness: A disease or condition, such as diabetes or asthma, that lasts for a long period of time or is marked by frequent recurrence.
Claim: A bill that asks for payment for services or benefits you received. Medicare Part Aclaims are processed by fiscal intermediaries and Part B claims are processed by Medicarecarriers. Medicare private health plan (Part C) and Medicare private drug plan (Part D) claims are processed by the plans. See also, Medicare Administrative Contractors (MACs)and DME MAC (Durable Medical Equipment Medicare Administrative Contractor).
COBRA (Consolidated Omnibus Budget Reconciliation Act): A federal law guaranteeing employees and their families at risk of losing health insurance—due to termination of employment, death, divorce, or other circumstances—the right to purchase continued coverage under the employer’s group health plan for limited periods of time.
Coinsurance: The portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of an approved amount. In Original Medicare, the coinsurance is usually 20 percent of Medicare’s assignment.
Comprehensive Outpatient Rehabilitation Facility (CORF): A medical facility that providesoutpatient diagnostic, therapeutic and restorative services for the rehabilitation of an injury,disability or sickness.
Continuous Open Enrollment: A consumer's right to buy private insurance at any time, regardless of age or health status.
Conversion Policy: An employer-sponsored group health plan that can be converted to anindividual policy with the same insurance company. These policies are usually very expensive.
Coordination of Benefits: The sharing of costs by two or more health plans, based on their respective financial responsibilities for medical claims. Your primary insurance andsecondary insurance must coordinate benefits in order to pay claims.
Copayment: Also known as a “copay.” A set amount you are required to pay for each medical service you receive (like $5 or $35).
Coordination Period, 30-Month: For people with End-Stage Renal Disease (ESRD), the period of time during which a group health plan pays first and Medicare pays second. Medicare may pay the remaining costs if your group health plan does not pay 100 percent of your health care bills during the coordination period.
Cost Plan: A private health plan sponsored by a Health Maintenance Organization (HMO), through which you can get your Medicare benefits. A cost plan is not a “Medicare Advantage” (Part C) plan. It allows you to go out of network to get care. If you get out-of-network care from a provider that accepts Medicare as payment, your costs will be covered by Original Medicare.
Cost Sharing: If you have health coverage, the portion of medical care that you pay yourself, such as a copayment, coinsurance or deductible. See also, Out-Of-Pocket Costs.
Cost Tiers: A system that Medicare private drug plans use to price prescription drugs.Generic drugs are generally on the first, least expensive tier (Tier 1), followed by brand-namedrugs (Tier 2), and then specialty drugs (Tiers 3 and above), with each subsequent tier requiring higher out-of-pocket costs.
Coverage Gap: Also called a “Doughnut Hole.” A gap in Medicare prescription drugcoverage (Part D) during which you must pay all drug costs in full; followed by catastrophic coverage from the insurance plan.
Coverage Restrictions: Also called “Utilization Management Tools.” Restrictions that a health or drug plan may place on certain covered services to restrict their usage. Coverage restrictions include prior authorization, quantity limits and step therapy.
Creditable Coverage:
- Any health insurance coverage you had within 63 days of securing a new insurance policy that can be used to shorten the waiting period for pre-existing conditions.
- Prescription drug coverage that is considered to be as good as or better than theMedicare prescription drug benefit (Part D) in monetary value.
Curative Care: The treatment of patients with the intent of curing their disease or condition; for example, chemotherapy treatments to cure breast cancer.hyper
Currently Working: You are considered to be “currently working” as long as you have employment rights at your company even if you do not work on a regular basis, are on sick leave, are a seasonal worker, or have been temporarily laid-off. You are not considered to be “currently working” if you receive Social Security Disability Insurance (SSDI), have receiveddisability benefits from your employer for more than six months, or if you receive your employer insurance through COBRA.
Custodial Care: Non-medical care, such as cooking, cleaning, and shopping. Medicaregenerally does not cover custodial care.
