Interactive Glossary - Section D-F
A-C D-F G-I J-L M-O P-R S-U V-W X-Z
D
Deductible: In long-term care, also known as the “elimination period.” The amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year.
Demand Bill: When you receive an Advance Beneficiary Notice (ABN), a Home Health Advance Beneficiary Notice (HHABN), or Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) from a health care provider, a demand that the provider continue to bill Medicarefor the given services even though the provider does not think that Medicare will cover them. In order to demand bill, you must sign the ABN and agree to pay for the services in full if Medicare denies coverage.
Denial of Coverage: A refusal by Original Medicare, a Medicare private health plan (Part C), or Medicare private drug plan (Part D) to pay for medical services.
Department of Veterans Affairs (VA): A government agency that provides federal benefits to veterans and their families. These benefits include (but are not limited to) pensions, educational stipends and health care services. See also, VA Benefits.
Detailed Explanation of Non-Coverage (DENC): A notice that is given to you by a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice agency when you appeal its decision to end your care to theQuality Improvement Organization (QIO). The DENC explains why the services will no longer be provided and any applicable Medicare coverage rules.
Detailed Notice of Discharge: A notice given to you by a hospital after you have requested aQuality Improvement Organization (QIO) review of the hospital’s decision that you bedischarged. (You would have been notified that the hospital wanted to discharge you in the “Important Message from Medicare” Notice). The Detailed Notice of Discharge explains why services will no longer be covered, provides a description of Medicare coverage restrictions, and explains how those rules apply to your case. Once you request QIO review of a discharge decision, the hospital must provide you this notice in all cases (whether you in are in Original Medicare or in a Medicare private health plan).
Dialysis: The technique used to artificially cleanse your blood of toxins when your kidneys no longer work either temporarily or permanently.
Disability: A restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being. The Social Security Administration (SSA) judges “disability”—and whether you qualify for financial assistance—based on whether you can work. (Definition of the World Health Organization)
Discharge: The end to your stay as an inpatient in a medical institution such as a hospital orskilled nursing facility (SNF).
Discharge Plan: A plan for post-hospitalization care intended to identify an individual’s need for medical and social services and resources available to help prevent re-hospitalization. A discharge plan must involve
DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies): See Durable Medical Equipment (DME).
Doughnut Hole: See Coverage Gap.
Drug Class: A group of drugs that treat the same symptoms or have similar effects on the body. For example, people with Medicare often use statin class drugs, which are used for reducing cholesterol. Drugs in this class include (but are not limited to) Lipitor, Zocor, Pravachol, Zetia, and Vytorin.
Drug Tiers: See Cost Tiers.
Dual Eligible: A person who has both Medicare and Medicaid.
Durable Medical Equipment (DME): Equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment and hospital beds. To be covered by Medicare, durable medical equipment must be prescribed by a doctor. Many types of adaptive equipment are not covered.
Durable Medical Equipment Medicare Admininstrative Contractor (DME MAC): A private insurance company that has a contract with Medicare to process durable medical equipment (DME) claims. DME MACs follow Medicare national guidelines to decide on a local level what types of equipment should be covered on a case-by-case basis and how much Medicare will pay for the equipment. See also, Medicare Administrative Contractors (MACs).
Durable Medical Equipment Regional Carrier (DMERC): The former name of DME MACs (Durable Medical Equipment Medicare Administrative Contractors), until September 2007.
Durable Power of Attorney: Legal document that lets you (“the principal”) appoint another person(s) (your “agent” or “attorney in fact”) to make decisions about your personal affairs (property, financial matters including health insurance, and other legal decisions) on your behalf. Making the document “durable” allows the agent(s) to act if you become ill or cannot otherwise act or your own behalf.
E
Earned Income: Money you get because you work, such as wages from work and earnings from self-employment.
Elimination Period: See Deductible.
Employer Group Health Plan: See Group Health Plan.
End-Stage Renal Disease (ESRD): Kidney failure that requires you to be on dialysis or have a kidney transplant.
Enrollment: Joining Original Medicare or becoming a member of a Medicare private health plan (Part C) or Medicare private drug plan (Part D).
Enrollment Periods: Certain periods of time when you can join the Original Medicareprogram, or elect a Medicare private health plan (Part C), Medicare private drug plan (Part D) or supplemental insurance plan (Medigap). (See also, Annual Coordinated Election Period, Continuous Open Enrollment Period, General Enrollment Period, Initial Coverage Election Period, Initial Enrollment Period, Initial Open Enrollment Period, Open Enrollment Period, Special Election Period, and Special Enrollment Period.)
Explanation of Medicare Benefits (EOMB): If you are enrolled in a Medicare private health plan (Part C), the notice you get from Medicare after receiving medical services from a doctor, hospital or other health care provider. It tells you what the provider billed Medicare, Medicare's approved amount, the amount Medicare paid, and what you have to pay. It is not a bill. See also, Medicare Summary Notice (MSN).
Exception Request: A formal, written request to your Medicare private drug plan (Part D) asking that it pay for a drug you need that is not on its list of covered drugs (formulary) or asking it to lower the price of a drug you need that is on its formulary but it costs too much.
Excess Charges: The difference between a doctor's or other health care provider's actual charge and Medicare’s approved amount for payment.
Extra Help: A federal program administered by Social Security that helps people withMedicare who have low incomes and assets pay for their Medicare prescription drugcoverage (Part D), including coinsurance, deductibles, and premiums. There are different levels of Extra Help. You may get “full” Extra Help or “partial” Extra Help, depending on your income.
Extra Help Premium Amount: Also known as a “benchmark.” The amount of money that "full"Extra Help will pay for the monthly premium of a Medicare private drug plan (Part D) that offers basic benefits.
Expedited Appeal: A fast appeal of a Medicare private health plan’s or Medicare private drug plan’s denial of coverage when a person's "life, health, or ability to regain maximum function" is in jeopardy. These appeals may take up to 72 hours.
F
Federal District Court:
Federal Poverty Level (FPL): The federally set level of income that an individual or family can earn below which it is recognized that they can not afford necessary services. The FPL is used in eligibility criteria of many programs, including Extra Help and Medicaid. The FPL changes every year and varies depending on the number of people in your household. It is higher in Alaska and Hawaii.
Federally Qualified Health Center (FQHC): Health centers located in “medically underserved areas” which provide low-cost health care. Medicare will pay for some health services in FQHCs that it generally does not cover, such as routine check-ups. FQHCs include community health centers, migrant health centers, and health centers for the homeless.
Fee-for-Service: Payment to providers for each service they provide, as in Original Medicare.
Fiscal Intermediary: Also known as an “Intermediary.” A private company that has a contract with Medicare to process Medicare Part A claims.
Formulary: The list of prescription drugs for which a Medicare private health plan (Part C) that offers drug coverage—Medicare Advantage Prescription Drug Plan (MA-PD)—or aMedicare private drug plan (Part D) will help pay. Drugs not on the formulary are generally not covered by private plans.
Formulary Restrictions: See Coverage Restrictions.
Free Look: A period of time when you can try out a Medicare supplemental insurance(Medigap) policy. During this time (usually 30 days), you can cancel the policy and get a full refund.
Deductible: In long-term care, also known as the “elimination period.” The amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year.
Demand Bill: When you receive an Advance Beneficiary Notice (ABN), a Home Health Advance Beneficiary Notice (HHABN), or Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) from a health care provider, a demand that the provider continue to bill Medicarefor the given services even though the provider does not think that Medicare will cover them. In order to demand bill, you must sign the ABN and agree to pay for the services in full if Medicare denies coverage.
Denial of Coverage: A refusal by Original Medicare, a Medicare private health plan (Part C), or Medicare private drug plan (Part D) to pay for medical services.
Department of Veterans Affairs (VA): A government agency that provides federal benefits to veterans and their families. These benefits include (but are not limited to) pensions, educational stipends and health care services. See also, VA Benefits.
Detailed Explanation of Non-Coverage (DENC): A notice that is given to you by a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice agency when you appeal its decision to end your care to theQuality Improvement Organization (QIO). The DENC explains why the services will no longer be provided and any applicable Medicare coverage rules.
Detailed Notice of Discharge: A notice given to you by a hospital after you have requested aQuality Improvement Organization (QIO) review of the hospital’s decision that you bedischarged. (You would have been notified that the hospital wanted to discharge you in the “Important Message from Medicare” Notice). The Detailed Notice of Discharge explains why services will no longer be covered, provides a description of Medicare coverage restrictions, and explains how those rules apply to your case. Once you request QIO review of a discharge decision, the hospital must provide you this notice in all cases (whether you in are in Original Medicare or in a Medicare private health plan).
Dialysis: The technique used to artificially cleanse your blood of toxins when your kidneys no longer work either temporarily or permanently.
Disability: A restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being. The Social Security Administration (SSA) judges “disability”—and whether you qualify for financial assistance—based on whether you can work. (Definition of the World Health Organization)
Discharge: The end to your stay as an inpatient in a medical institution such as a hospital orskilled nursing facility (SNF).
Discharge Plan: A plan for post-hospitalization care intended to identify an individual’s need for medical and social services and resources available to help prevent re-hospitalization. A discharge plan must involve
- input from you and your representatives about your preferences and care needs after hospitalization;
- information and instructions to you and your caregivers about post-hospitalization care you need; and
- arrangement of necessary post-hospital services, transfers and referrals to appropriate services and facilities.
DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies): See Durable Medical Equipment (DME).
Doughnut Hole: See Coverage Gap.
Drug Class: A group of drugs that treat the same symptoms or have similar effects on the body. For example, people with Medicare often use statin class drugs, which are used for reducing cholesterol. Drugs in this class include (but are not limited to) Lipitor, Zocor, Pravachol, Zetia, and Vytorin.
Drug Tiers: See Cost Tiers.
Dual Eligible: A person who has both Medicare and Medicaid.
Durable Medical Equipment (DME): Equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home; for example, wheelchairs, oxygen equipment and hospital beds. To be covered by Medicare, durable medical equipment must be prescribed by a doctor. Many types of adaptive equipment are not covered.
Durable Medical Equipment Medicare Admininstrative Contractor (DME MAC): A private insurance company that has a contract with Medicare to process durable medical equipment (DME) claims. DME MACs follow Medicare national guidelines to decide on a local level what types of equipment should be covered on a case-by-case basis and how much Medicare will pay for the equipment. See also, Medicare Administrative Contractors (MACs).
Durable Medical Equipment Regional Carrier (DMERC): The former name of DME MACs (Durable Medical Equipment Medicare Administrative Contractors), until September 2007.
Durable Power of Attorney: Legal document that lets you (“the principal”) appoint another person(s) (your “agent” or “attorney in fact”) to make decisions about your personal affairs (property, financial matters including health insurance, and other legal decisions) on your behalf. Making the document “durable” allows the agent(s) to act if you become ill or cannot otherwise act or your own behalf.
E
Earned Income: Money you get because you work, such as wages from work and earnings from self-employment.
Elimination Period: See Deductible.
Employer Group Health Plan: See Group Health Plan.
End-Stage Renal Disease (ESRD): Kidney failure that requires you to be on dialysis or have a kidney transplant.
Enrollment: Joining Original Medicare or becoming a member of a Medicare private health plan (Part C) or Medicare private drug plan (Part D).
Enrollment Periods: Certain periods of time when you can join the Original Medicareprogram, or elect a Medicare private health plan (Part C), Medicare private drug plan (Part D) or supplemental insurance plan (Medigap). (See also, Annual Coordinated Election Period, Continuous Open Enrollment Period, General Enrollment Period, Initial Coverage Election Period, Initial Enrollment Period, Initial Open Enrollment Period, Open Enrollment Period, Special Election Period, and Special Enrollment Period.)
Explanation of Medicare Benefits (EOMB): If you are enrolled in a Medicare private health plan (Part C), the notice you get from Medicare after receiving medical services from a doctor, hospital or other health care provider. It tells you what the provider billed Medicare, Medicare's approved amount, the amount Medicare paid, and what you have to pay. It is not a bill. See also, Medicare Summary Notice (MSN).
Exception Request: A formal, written request to your Medicare private drug plan (Part D) asking that it pay for a drug you need that is not on its list of covered drugs (formulary) or asking it to lower the price of a drug you need that is on its formulary but it costs too much.
Excess Charges: The difference between a doctor's or other health care provider's actual charge and Medicare’s approved amount for payment.
Extra Help: A federal program administered by Social Security that helps people withMedicare who have low incomes and assets pay for their Medicare prescription drugcoverage (Part D), including coinsurance, deductibles, and premiums. There are different levels of Extra Help. You may get “full” Extra Help or “partial” Extra Help, depending on your income.
Extra Help Premium Amount: Also known as a “benchmark.” The amount of money that "full"Extra Help will pay for the monthly premium of a Medicare private drug plan (Part D) that offers basic benefits.
Expedited Appeal: A fast appeal of a Medicare private health plan’s or Medicare private drug plan’s denial of coverage when a person's "life, health, or ability to regain maximum function" is in jeopardy. These appeals may take up to 72 hours.
F
Federal District Court:
- General trial court of the United States court system. Each federal judicial district has at least one courthouse, and most districts have more than one. Each state has at least one judicial district.
- The level in the Medicare process of appeals that comes after the Medicare Appeals Council (MAC) level. This is the final level of the Medicare appeals process.
Federal Poverty Level (FPL): The federally set level of income that an individual or family can earn below which it is recognized that they can not afford necessary services. The FPL is used in eligibility criteria of many programs, including Extra Help and Medicaid. The FPL changes every year and varies depending on the number of people in your household. It is higher in Alaska and Hawaii.
Federally Qualified Health Center (FQHC): Health centers located in “medically underserved areas” which provide low-cost health care. Medicare will pay for some health services in FQHCs that it generally does not cover, such as routine check-ups. FQHCs include community health centers, migrant health centers, and health centers for the homeless.
Fee-for-Service: Payment to providers for each service they provide, as in Original Medicare.
Fiscal Intermediary: Also known as an “Intermediary.” A private company that has a contract with Medicare to process Medicare Part A claims.
Formulary: The list of prescription drugs for which a Medicare private health plan (Part C) that offers drug coverage—Medicare Advantage Prescription Drug Plan (MA-PD)—or aMedicare private drug plan (Part D) will help pay. Drugs not on the formulary are generally not covered by private plans.
Formulary Restrictions: See Coverage Restrictions.
Free Look: A period of time when you can try out a Medicare supplemental insurance(Medigap) policy. During this time (usually 30 days), you can cancel the policy and get a full refund.
