A process where external organizations (or “accrediting bodies”) evaluate health care facilities’ policies, procedures, and performance to make sure they are meeting predetermined criteria.
In Original Medicare, a notice that a doctor, supplier, or provider gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payment. In this situation, if you aren’t given an ABN before you get the item or service, and Medicare denies payment, then you may not have to pay for it. If you are given an ABN, and you sign it, you will probably have to pay for the item or service if Medicare denies payment.
A facility where simpler surgeries are performed for patients who aren’t expected to need more than 24 hours of care.
A person who has health care insurance through the Medicare or Medicaid programs.
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 in a row.
The Federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs.
A way to figure out who pays first when two or more health insurance plans are responsible for paying a medical claim.
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 a 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.
If the drug plan doesn’t give you a prompt decision and you can show that the delay would affect your health, the plan’s failure to act is considered to be a coverage determination. If you disagree with the coverage determination, the next step is an appeal.
See Creditable Coverage (Medigap) or 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.
Non-skilled personal care, such as 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.
A Federal agency that administers programs for protecting the health of all Americans, including the Medicare, Medicaid, and Children’s Health Insurance Programs.
Certain medical equipment, such as a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.
A legal document that enables you to designate another person to act on your behalf in the event you become disabled or incapacitated.
A type of Medicare prescription drug coverage determination. You must request an exception, and your doctor or other prescriber must send a supporting statement explaining the medical reason for the exception.
Federally-funded nonprofit health centers or clinics that serve medically under-served areas and populations. Federally-qualified health centers provide primary care services even if you can’t afford them. Services are provided on a sliding scale fee based on your ability to pay.
In general, a health plan offered by an employer or employee organization that provides health coverage to employees, former employees, and their families.
Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre-existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.
Your condition keeps you from leaving home without help (like using a wheelchair or walker, needing special transportation, or getting help from another person).
A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver as well.
Once you have met your yearly deductible, you will pay a copayment or coinsurance for each covered drug until you reach your plan’s out-of-pocket maximum (or initial coverage limit). You will then enter your plan’s coverage gap (sometimes called the “donut hole”).
A variety of services that help people with their medical and non-medical needs over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care you need.
A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that has been approved by Medicaid. Providers are approved or “certified” if they have passed an inspection conducted by a state government agency.
The Federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.
A company, person, or agency that has been certified by Medicare to give you a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.
A health care provider that has been approved by Medicare. Providers are approved or “certified” by Medicare if they have passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified.
The company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have, and determines whether the coverage pays before or after Medicare.
A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).
MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible.
Coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Coverage for certain doctors’ services, outpatient care, medical supplies, and preventive services.
Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.
A stand-alone drug plan that 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 Prescription Drug Plans.
A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.
A notice you get after the doctor or provider files a claim for Part A or Part B services in Original Medicare. It explains what the doctor or provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.
A one-time-only, 6-month period when Federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems.
A pharmacy that’s part of a Medicare drug plan’s network but isn’t a Preferred Pharmacy. You may pay higher out-of-pocket costs if you get your prescription drugs from a Non-Preferred Pharmacy instead of a Preferred Pharmacy.
Treatment that helps you return to your usual activities (like bathing, preparing meals, and housekeeping) after an illness.
Services that Medicare doesn’t cover, but that a Medicare health plan may choose to offer.
Approval from a Medicare drug plan that may be required before you fill your prescription in order for the prescription to be covered by your plan.
A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically-necessary care and services based on your needs as determined by an interdisciplinary team.
A state program that helps pay Part A premiums for people who have Part A and limited income and resources.
A company that acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary.
Services that help you regain abilities, such as speech or walking, that have been impaired by an illness or injury. These services are given by nurses, and physical, occupational and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.
Care such as intravenous injections that can only be given by a registered nurse or doctor.
A state agency that’s in charge of the State’s Medicaid program and can give information about programs that help pay medical bills for people with limited income and resources.
Groups of drugs that have a different cost for each group. A drug in a lower tier will cost you less than a drug in a higher tier.