Medicare Glossary of Terms: Important Definitions & Terminology

The decisions you make about your Medicare coverage as you approach age 65 will have lasting implications for the quality and ease of your retirement years. Yet, the vast amount of unfamiliar Medicare terminology makes it difficult to capture Medicare's real opportunities.

We present this Medicare glossary to help you understand the language of Medicare.

Agreement from a doctor to accept Medicare's approved amount as full payment for a service. Under Original Medicare, if a doctor accepts assignment, the patient's payment is limited to the 20% coinsurance of the approved amount.

Groups of doctors, hospitals, and other health care professionals who join together to improve the quality of patient care while lowering the cost of Medicare by avoiding duplication of services and preventing medical errors.

The fundamental tasks required to care for oneself independently, including grooming, dressing, toileting, mobility, feeding, and bathing.

A notice that a health care provider or supplier must give an Original Medicare beneficiary before providing care when they believe Medicare will not cover their services or items, also known as a waiver of liability.

A notice from a Medicare Advantage plan to a beneficiary advising in advance whether a specific service will be covered.

A legal document a person signs outlining how medical and financial decisions will be made if that person is no longer capable of communicating their preferences. When focused on health, it can include a health care power of attorney, health care proxy, and living will.

The period — also known as the Fall Open Enrollment — between October 15 and December 7 every year when beneficiaries can switch between Original Medicare and Medicare Advantage, enroll in a new Medicare Advantage plan, or sign up for Part D if they didn't do so during their Initial Enrollment Period. Changes take effect the following January 1.

A notice beneficiaries receive from their private Medicare Advantage and Part D plans at least two weeks before the October 15 start of the AEP, announcing any changes in their coverage, costs, or service areas for the coming year.

A formal review process a Medicare beneficiary can call upon in the case of disagreement with Medicare-related coverage or payment decisions. The process must follow federal regulations specified for deadlines, processes, required information, and steps in the appeals sequence.

Acceptance by a doctor, service provider, or supplier to consider the Medicare-approved amount as full payment for a service or good, with no recourse to bill the patient further.

The difference between Medicare's approved amount for a service and the amount charged by a health care provider who does not accept Medicare assignment — also known as excess charges.

A period wherein Medicare Part A pays for hospital and skilled nursing facility services, starting the day the patient is admitted formally as an inpatient and ending once the patient has not received any further services for 60 consecutive days. A new hospitalization will trigger a new benefit period and require payment of the Part A deductible again.

The last of four payment phases of a Part D prescription drug plan, during which the beneficiary pays a small coinsurance or copayment for covered drugs for the rest of the calendar year.

A request for payment submitted by health care providers for goods and services a beneficiary has received. Medicare processes those for Part A and Part B, and private insurers process those for Medicare Advantage and Part D plans.

COBRA is a law that stands for the “Consolidated Omnibus Budget Reconciliation Act,” which protects employees and their families when employer-sponsored health benefits are lost. They can continue in the employer's group health plan for a set period but will have to pay the total cost of the coverage, not the discounted employee rate.

In reference to Medicare only, coinsurance is the percentage a beneficiary pays of the Medicare-approved cost of a covered service after paying any deductibles. For example, the beneficiary pays the remaining 20% after Medicare Part B pays its 80% share.

A type of health care plan, also known as Medicare Advantage or managed care plans, that provides all the same services as Original Medicare but through a network of approved providers with whom the insurer has negotiated pricing, resulting in cost-effective care. Beneficiaries may be restricted to the plan's network of doctors and hospitals — or pay all or part of the bill.

A predetermined amount a Medicare Advantage beneficiary may have to pay before receiving each medical service or supply, such as $20 for a doctor visit or $15 for a prescription drug — also known as a copay.

The out-of-pocket cost a beneficiary pays for health care services and prescriptions through copayments, coinsurance, and deductibles as their contribution toward the total Medicare-defined cost.

The third payment phase of a Part D prescription drug plan, during which the beneficiary pays 25% of the cost of covered prescription drugs, also known as the donut hole.

Prescription drug coverage from a source such as an employer that is equal to — or better than — Medicare Part D coverage, which allows a beneficiary to delay enrolling in Medicare's Part D without incurring late enrollment penalties.

A small rural hospital that meets specific guidelines, such as having 25 beds or less, average hospital stays of 96 hours or less, and providing 24/7 emergency care through an on-call physician or registered nurse with emergency care training.

Non-medical care provided by non-skilled caregivers, particularly related to activities of daily living (ADLs) such as eating, bathing, toileting, and dressing. With the exception of some innovative programs available through Medicare Advantage, Medicare doesn't pay for custodial care.

The amount beneficiaries pay each year out of pocket for medical services or prescription drugs before their health plan begins to pay for benefits.

The third payment phase of a Part D prescription drug plan, during which the beneficiary pays its highest share of covered prescription drug costs. Also known as the coverage gap.

An individual who qualifies for both Medicare and Medicaid coverage.

Medical equipment such as wheelchairs, walkers, oxygen equipment, and hospital beds that can be used repeatedly within the home. Medicare only covers the cost of DMEs if ordered by a doctor.

A legal document that authorizes an individual to make decisions that can extend to all pertinent areas of the signatory’s life and remains in effect if that person becomes incapacitated through accident, illness, or mental decline. The authorization ends if revoked or when the signatory dies.

Kidney disease that requires a kidney transplant or ongoing dialysis. ESRD patients can qualify for Medicare, regardless of age.

The required marketing document that lists all of the Medicare Advantage and Part D plan benefits of a particular plan and how to access care. This document can be found on the Plan’s website on October 15th every year and lists the benefits for the next year.

A prescription drug coverage determination involving Part D or Medicare Advantage plans. Tiering exceptions hope to get better cost-sharing terms, and formulary exceptions aim to add a drug to a medication list or waive restrictions to access a drug.

The difference between Medicare's approved amount for a service and the amount charged by a health care provider who does not accept Medicare assignment, also known as balance billing.

A Medicare program — also known as Part D Low-Income Subsidy (LIS) — designed to help individuals with limited income and resources pay for Part D premiums, deductibles, and other out-of-pocket costs.

The list of prescription drugs covered by a specific standalone Part D or Medicare Advantage plan. Lists vary from plan to plan and can be changed by insurers each year.

A period from January 1 through March 31 each year when qualified individuals can first enroll in Medicare Part B if they missed their Initial Enrollment Period (IEP) and don't qualify for a Special Enrollment Period (SEP). A late enrollment penalty may result. Coverage starts the first of the month after enrollment.

A lower-cost alternative to a brand-name drug that uses the same active ingredients, works the same way, and is approved by the Food and Drug Administration (FDA).

A formal complaint a beneficiary files with their Medicare Advantage or Part D plan within 60 days of a disappointing administrative or customer service event. Issues related to denied coverage or supply require an appeal, not a grievance.

Health insurance offered to employees and their families by an employer or employee organization. The company's size determines if the insurance is a primary or secondary payer to Medicare.

Consumer protection for individuals aged 65 or older that ensures their right to purchase Medicare Supplement (Medigap) insurance within 63 days of losing certain kinds of health coverage. Conditions are identical to those when individuals first qualify for Medicare.

Legal assurance that the insurer cannot terminate an insurance plan at the end of a term unless the beneficiary fails to pay premiums, commits fraud, or makes a material misrepresentation when applying for the plan.

An individual or facility qualified and licensed to provide health care, such as doctors, nurses, and hospitals.

A type of Medicare Advantage plan in which beneficiaries must go to doctors and hospitals within the plan's network of contracted providers, except in emergencies. Coverage often also requires a referral from a primary care provider (PCP).

A type of Medicare Advantage plan with a significant deductible to be met before the insurance company starts paying its share. Monthly premiums are often lower, and some plans include health savings accounts (HSAs) from which certain medical expenses can be paid with tax-free funds.

A Medicare-certified organization that provides homebound beneficiaries with home care services that their doctors order, including skilled nursing services and therapeutic services such as physical and occupational therapy, but not custodial care.

An end-of-life program of pain management and comfort tailored to the needs of someone who is terminally ill, their family, and their caregivers. Care is provided in the home or at a hospice facility.

An outside organization contracted by Medicare to review a beneficiary's case regarding an appealed payment, coverage decision, or where the health plan fails to make a timely appeals decision.

A seven-month period during which an individual eligible for Medicare can first sign up for Medicare Advantage because they are enrolled in both Part A and Part B. The period — which runs simultaneously with their Initial Election Period — includes the three months before the 65th birthday, the birthday month, and the three months that follow.

The second payment phase of a Part D prescription drug plan, during which the beneficiary and the insurer share the covered prescription drug costs. It follows the deductible phase.

A seven-month period during which an individual is first eligible to sign up for Medicare Part B. It typically starts three months before the individual meets all of Medicare's eligibility requirements at age 65 and lasts for seven months. In cases of disability, the seven-month period starts three months before the 25th month of disability benefits.

The care received under Medicare Part A when a beneficiary is formally admitted to a hospital or skilled nursing facility. It does not include time in a hospital for observation or outpatient services.

A group health plan sponsored by an employer or employee organization with 100 or more employees.

An amount added to monthly Medicare Part B or Part D premiums (also Part A if not premium-free) when an individual enrolls after failing to do so during their Initial Enrollment Period unless they have other creditable coverage. Penalties may last as long as coverage exists.

With Medicare Part A, a total of 60 additional days of coverage to be used when a beneficiary is in the hospital for more than 90 days during any benefit period. Once used, they are exhausted and not replenished.

A Medicare program administered by Humana that provides temporary Part D prescription drug coverage for low-income beneficiaries who qualify for Extra Help but have no current drug coverage.

In Original Medicare, the maximum amount a health care provider who does not accept assignment can charge as full payment for healthcare services. It is equal to 15% above Medicare's approved amount and does not apply to equipment or supplies.

The period between April 1 and October 14, when Medicare Advantage and Part D beneficiaries cannot change their plans unless they qualify for a Special Enrollment Period.

Non-medical care provided by non-skilled caregivers, particularly related to activities of daily living (ADLs) such as eating, bathing, toileting, and dressing. Medicare doesn't pay for long-term care, also known as custodial care.

A medical assistance program designed for individuals with limited incomes and resources. Programs are funded jointly by state and federal dollars, and benefits can vary from state to state. However, beneficiaries qualifying for both Medicare and Medicaid have most health care costs covered.

A screening process used by insurance companies to decide whether to accept an applicant, add a waiting period for pre-existing conditions, or increase premiums based on the applicant's medical history.

Services, procedures, or equipment that meet accepted standards of medicine and are required to diagnose and treat a medical condition.

A federal government health program available to U.S. citizens or legal residents who are at least age 65, under age 65 with a qualifying disability, or have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

A period from January 1 through March 31 each year when Medicare Advantage beneficiaries can switch to a different Medicare Advantage plan or switch back to Original Medicare. Only one plan change is allowed per year.

A type of Medicare health plan offered by Medicare-approved private insurers that provides all of Original Medicare's Part A and Part B benefits, plus prescription drug coverage and often other benefits such as dental, hearing, or vision.

A Medicare Advantage plan that includes Part D coverage for prescription medications.

A health care provider that Medicare approves or certifies after passing a state government agency inspection. Medicare only pays for services received from certified health care providers, including hospitals, home health agencies, nursing homes, or dialysis facilities.

A type of Medicare plan only available in specific areas of the country that’s sold by Medicare-approved private insurers and is a hybrid between Medicare Advantage and Original Medicare. The plan pays for in-network services, but Original Medicare pays non-emergency out-of-network services, with the beneficiary paying related deductibles and coinsurance.

Optional insurance for prescription drugs sold through Medicare-approved private insurers either as a standalone plan with Original Medicare or as part of Medicare Advantage plans.

A plan offered by a Medicare-approved private insurer that provides coverage of Original Medicare's Part A and Part B benefits. Plans include Medicare Advantage, Medicare Cost, and Demonstration or Pilot Programs.

A plan that joins a bank account to a high-deductible Medicare Advantage plan. Money deposited into the account by Medicare is used to help pay for health care expenses. It is usually less than the deductible, leaving the beneficiary to pay out-of-pocket before the plan begins to contribute.

One component of Original Medicare that helps cover most medically necessary inpatient hospital, skilled nursing facility, home health, and hospice care, but not custodial or long-term care.

One component of Original Medicare that helps cover medically necessary doctors' and preventive services, hospital outpatient care, medical supplies, and some home health and ambulance services.

Any of four programs run by states to help eligible people with limited income and resources pay for some or all of their Medicare costs, including Part A, Part B, and Part D premiums, deductibles, and coinsurance. Programs vary in eligibility requirements and benefits.

A type of Medigap policy that negotiates rates with a network of providers, much like a Medicare Advantage plan would. Beneficiaries would require a referral from their primary care provider (PCP) before using a service to receive the full benefit of gap coverage of that service except in emergencies.

A type of Medicare Advantage plan designed to care for specific groups of people who would benefit from more focused and special health care. Groups include Medicare and Medicaid dual-eligibles, those with certain chronic conditions, and those living in nursing homes.

A notice — and not a bill — received each quarter by Original Medicare beneficiaries after a doctor, supplier, or other health care provider files a claim for Part A or Part B services. It explains the Medicare-approved amount, what Medicare paid, and what the beneficiary must pay.

Also known as Medigap. See Medigap.

Optional insurance — also known as Medicare Supplement Insurance — sold by private insurers to help Original Medicare beneficiaries cover the Part A and Part B out-of-pocket costs or gaps their insurance does not pay, including the 20% coinsurance and deductibles.

A one-time opportunity provided by federal law to buy any Medigap policy sold in an individual's state with no medical underwriting, possible denials, or upcharges for pre-existing conditions. The period lasts six months, starting the first month an individual is at least 65 years old and is covered by Part B.

A group health plan that a small employer (with 20 or fewer employees) sponsors along with one or more other employers. Such plans can affect how the Medicare secondary payer rules are applied.

A group of healthcare professionals and facilities — including doctors, hospitals, and pharmacies — that contract with a Medicare Advantage plan to provide healthcare services to plan members. Members will have the lowest costs when staying within the network when selecting providers.

A fee-for-service health plan offered directly by the federal government that includes Part A (Hospital Insurance) and Part B (Medical Insurance), also known as traditional Medicare. After a beneficiary meets a deductible, Medicare pays its portion (typically 80%) of Medicare-approved amounts for services provided by most U.S. doctors and hospitals.

The portion of health care costs paid by beneficiaries for health care services and prescriptions in the form of deductibles, copayments, and coinsurance. With Original Medicare, the exposure can be open-ended; with Medicare Advantage, there are maximum limits.

Medical or surgical care provided in a hospital where the patient has not been officially admitted as an inpatient, including overnight stays for observation. The services are covered by Part B — not Part A — and may result in higher out-of-pocket costs.

An amount a beneficiary must pay to Medicare above the regular monthly premiums for Part B or Part D if they fail to join when first eligible. Although there are exceptions, the higher payment amount lasts as long as their coverage exists.

An option available to a type of Medicare Advantage HMO plan that lets members visit doctors and hospitals outside of the plan's network for certain services at a higher cost.

A legal document that authorizes an individual to make decisions that can extend to all pertinent areas of the signatory’s life. The authorization ends if revoked, if the signatory becomes incapacitated through accident, illness, or mental decline, or when the signatory dies.

A medical condition or illness that exists before a new health plan takes effect and that can affect coverage. It’s important to note that if you join a Medicare Advantage Plan, you do not have to worry about pre-existing conditions.

A type of Medicare Advantage plan in which beneficiaries pay a copayment or coinsurance for using a plan's in-network doctors and hospitals, but can use out-of-network providers usually at an extra cost.

An individual's monthly payment of a fixed amount to Medicare or another insurer to participate in a specific health care or prescription drug plan.

Health care intended to avoid illness or detect it early on while treatment is likely to be most effective, such as flu shots and mammogram screenings.

The insurance policy that pays first when an individual is covered by more than one insurance plan.

A tool Medicare Advantage and Part D plans use to control costs by requiring plan members to obtain plan permission through their physician for a given medical service or medication to be covered, also known as pre-authorization or pre-approval.

A type of Medicare Advantage plan in which beneficiaries can use any doctor or hospital available under Original Medicare if the provider agrees to the set amount the plan pays providers. Plan rules must be followed carefully, and services may cost more or less than under Original Medicare.

A program funded by Medicare and Medicaid that provides coordinated care through a team of health care professionals so people can meet their health needs in the community instead of a nursing home or other care facility.

An individual or facility, including a doctor, hospital, pharmacy, or outpatient clinic, that furnishes a beneficiary with health care services or items.

A written authorization that Medicare Advantage plans usually require from a beneficiary's primary care provider (PCP) for certain medical services and specialist visits to be covered.

One of the regional facilities of the Centers for Medicare & Medicaid Services (CMS) that ensure guidance and consistent application of Medicare policy in their territory.

Health care services that nurses and physical, occupational, and speech therapists provide in inpatient or outpatient settings to promote recovery from an illness or injury, including improving functions for daily living.

A brief period of inpatient care for a patient in a nursing home, hospital, or hospice inpatient facility to allow the patient's caregiver some time off to rest.

An insurance plan, policy, or program that pays some or all of the costs of a medical or hospital claim after a primary insurer pays its part. Depending on the situation, the secondary payer could be Medicare, Medicaid, or another insurer.

A geographic area where a Medicare Advantage or Part D plan may limit its acceptance of members and, in general, its network of service providers. Beneficiaries may be disenrolled for moving out of the plan's service area.

Medically necessary health care that must be provided by or under the supervision of a skilled professional.

A licensed facility with the staff and equipment needed to provide skilled nursing care and rehabilitation. Facilities must be certified by Medicare for their services to be covered.

Specific periods during which Medicare Advantage and Part D plan beneficiaries can change health and drug coverage outside of the designated Annual Election Period without incurring late enrollment penalties. Qualifying life events can include a change of residence, loss of current coverage, and new eligibility into programs such as Extra Help or Medicaid.

A type of Medicare Advantage plan designed to care for specific groups of people who would benefit from more focused and special health care. Groups include Medicare and Medicaid dual-eligibles, those with certain chronic conditions, and those living in nursing homes.

One of three Medicare Savings Programs (MSPs) administered by a state's Medicaid program that helps individuals with limited income and assets pay for Medicare, in this case covering the cost of the Part B premium.

A process used by individuals seeking Medicaid eligibility to get below the medically needy monthly income limits. It entails subtracting their incurred expenses for medical and remedial care for which they have no insurance.

A federally funded state program that provides free local health insurance counseling and assistance to Medicare-eligible individuals, their families, and their caregivers.

The agency in each state that’s responsible for that state's Medicaid program — also known as the state's Medicaid office — is tasked to help its residents with limited income and resources get assistance in paying medical expenses.

A state-subsidized program that helps residents pay for prescription drugs depending on their age, financial need, or medical condition. Programs often help pay the Part D premium and any cost-sharing.

A tool Part D plans use — also known as fail first — to control costs by requiring doctors to prescribe one or more less-costly drugs to treat a condition. Only if those drugs fail will the plan pay for the more expensive prescribed drug.

A federal benefits program administered by the Social Security Administration that provides a monthly benefit to individuals with limited income and resources and who are over age 65, disabled, or blind. Applicants will have insufficient work credits to collect Social Security retirement or disability benefits.

Agreement by a provider to consider the Medicare-approved amount for a medical service or supply as full payment.

Remote medical care provided to a patient by a practitioner in a different location using two-way communication such as a computer or cell phone.

A request as part of the Part D appeals process in which a beneficiary can show that formulary drugs available on lower tiers to treat their condition are ineffective or dangerous. The goal is to obtain the lower cost-sharing level for a higher-tiered (but not specialty tier) drug.

A system used by many Part D plans that puts drugs in various groups with different cost-sharing requirements. As a result, lower-tier generic drugs will have lower copayments than higher-tier brand-name or specialty drugs.

Under Part D, the total dollars spent during the year on formulary drugs by the plan's member or on the member's behalf and applied toward the coverage gap's upper threshold amount. Once that amount is reached, the member enters the minimal-cost final phase: catastrophic coverage.

Usually, a one-time, 30-day supply of a drug a Part D plan member has been taking but is not on a new plan's formulary, or has additional coverage restrictions, including prior authorization or step therapy requirements.

Assistance with activities of daily living (ADLs) that can be provided by home health aides and do not require medically trained providers.

Medically necessary care or services for an illness or injury that requires medical attention within 24 hours, but won't result in disability or death if it doesn't get immediate attention.

Restrictions that a health care or drug plan may place on specific covered services or products to limit their use. For example, in the case of Part D, insurers can control costs by requiring prior authorizations, quantity limits, and step therapy.

A notice — also known as an advanced beneficiary notice of noncoverage (ABN) — that a healthcare provider or supplier must give an Original Medicare beneficiary before providing care when they believe Medicare will not cover their services or items.

If you’re still unclear about some Medicare definitions and need assistance through the process, you can visit our website or call (844) 910-2061 to be connected to a licensed insurance agent who can walk you through your Medicare options. OpenMedicare is here to help!