Glossary of Medicare Terms


The following definitions will be helpful to you in understanding the vocabulary in your new plans.  Some of these have been taken from the publication “Medicare and You”:

Assignment—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.r

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 skilled nursing facility.  The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days inn a row.  If you go into a hospital or a SNF after one benefit period as 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.

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

Copayment—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 copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.

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.

Custodial care—Nonskilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

Deductible—The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

Excess Charges — Providers who will bill Medicare but don’t accept assignment can charge up to 15% more than the Medicare Allowed amount. This is covered by Supplements F & G.  There is no out of pocket maximum on the amounts charged.

Extra Help—A Medicare program to help people with limited income and resources pay Medicare prescription drug plan 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.  Useful to predict the amount of required copayments, determine if pre-authorization is needed to obtain a particular drug, etc.

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

IRMAA — Income Related Monthly Adjustment Amount.  These are higher premiums charged for Parts B & D by the government for those with Modified Adjusted Gross Incomes in excess of $85,000 (single) or $170,000 (couple).

Lifetime reserve days—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. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

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.

Medically necessary—Health care 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-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 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 plan—Refers to 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.

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

Preventive services—Health care 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 physician —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 health care 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 health care provider.

Primary care practitioner—A doctor who has a primary specialty in family medicine, internal medicine, geriatric medicine, or pediatric medicine; or a nurse practitioner, clinical nurse specialist, or physician assistant.

Quality Improvement Organization (QIO)—A group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to people with Medicare.

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.

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 facility (SNF) care—Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Tier The classification of a medication within the drug formulary, generally assigned based on preferred or non-preferred status, generic or brand name medication.  The lower the Tier number, the smaller your copayment will be.

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