Medicare Terms Dictionary

Last updated: October 7, 2015

Definitions of Technical Terms

Assignment

An agreement by your doctor or other 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.

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 go to a hospital or SNF. The benefit period ends when you haven't received any inpatient hospital (or skilled care in SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods a beneficiary can have.

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. In a Medicare prescription drug plan (Part D) or Medicare health plan, the coinsurance will vary depending on how much you have spent.

Copayment

An amount you may be required to pay as your share of the cost for a medical service or supple, like a doctor's visit or prescription. A copayment is usually a set amount, rather than a percentage.

Cost Sharing

The amount you pay for health care and/or prescriptions. The amount can include copayments, coinsurance, and/or deductibles.

Creditable

Creditable coverage is any coverage that is offered through an employer or group sponsored health plan, or some other health plan, that is equal or better than coverage you would receive under Medicare. Providing proof to Medicare that you have creditable coverage at the time you enroll will keep you from having to pay a late penalty fee if you enroll in prescription drug coverage after your initial enrollment period.

Deductible

The amount you must pay for health care or prescriptions, before Original Medicare, you Medicare drug plan, your Medicare health plan, or your other insurance begins to pay. These amounts can change every year.

Extra Help

A Medicare program to help people with limited income and resources pay Medicare Part D prescription drug costs, such as premiums, deductibles, and coinsurance.

Guaranteed Issue Rights

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medicare supplement policy. In these situations, an insurance company can't deny you a Medigap policy, or place conditions on a Medicare supplement policy, such as exclusions for preexisting conditions, and can't charge you more for a policy because of past or present health problems.

Health Maintenance Organization (HMO)

A type of Medicare health plan that is available in most areas of the country. Plans must cover all Medicare Part A and Part B services. 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 emergency.

High Deductible Medicare Supplement Policy

A type of Medicare supplement policy that has a high deductible but a lower monthly premium. You must pay the deductible before the Medicare supplement policy pays anything. The deductible amount can change each year.

Medical Underwriting

Medical underwriting is the process an insurance company uses to determine whether or not to accept you as a beneficiary under a policy. The company also uses medical underwriting to determine how much of a monthly premium to charge you. Medical underwriting is based on information you give to the company about your past and present medical conditions

Medically Necessary

Services or supplies that are needed for the diagnosis or treatment of your medical condition and accepted standards of medical practice.

Medicare Advantage Plans

Medicare Advantage Plans (like an HMO or PPO), also called "Medicare Part C", are health plans run by Medicare-approved private insurance companies. Medicare Advantage Plans include Part A, Part B, and sometime other coverage like Medicare prescription drug coverage (Part D), sometimes for extra cost.

Medicare Medical Savings Account (MSA) Plan

A type of Medicare Advantage Plan. 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. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.

Medicare Special Needs Plan (SNP)

A special type of Medicare Advantage Plan 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.

Medicare-Approved Amount

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.

Medigap

A Medicare supplement insurance policy.

Open Enrollment Period (Medicare Supplement Insurance)

A one-time only 6-month period when federal law allows you to buy any Medicare supplement policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B. During this period, you can't be denied a Medicare supplement policy or be charged more due to a past or present health problem. Kansas regulations allow individuals under age 65 the same open enrollment whether they receive Medicare because of age or disability.

Out-of-Network

Generally, an out-of-network benefit provides you with the option to get plan services out of the plan’s contracted network of providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.

Out-of-Pocket Costs

Health or prescription drug costs that you must pay on your own because they are not covered by Medicare or other insurance.

Preexisting Condition

A health problem you had before the date that a new insurance policy starts.

Preferred Provider Organization (PPO)

A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Premium

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

Private Fee-for-Service Plan

A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that agrees to treat you under the plan and that accepts the plan’s payment terms. The plan decides how much you must pay for services.

Referral

A written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for your care.

Service Area

The area where a health plan accepts members. For plans that limit which doctors and hospitals you may use, it’s generally the area where you can get routine (non-emergency) services. The plan may dis-enroll you if you move out of the plan’s service area.

Skilled Nursing Facility (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitation services and other related health services.

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