The Insurance Store / Medicare Glossary / Helpful Medicare Definitions

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Medicare Glossary

A | B | C | D | E | F | H | I | L | M | N | O | P | R | S | U

Ambulatory Care—All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are hospitalized.

Appeal—As a Medicare Advantage plan member, you have the right to appeal any decision about your plan's failure to approve, furnish, arrange for or continue what you believe are covered services or to pay for services that you believe your plan is required to pay (including non-Original Medicare-covered benefits).

Benefits—Services provided to a member of a Medicare Advantage plan, like doctor visits or prescription coverage. Covered services are defined by the contract or policy.

Beneficiary—An individual participating in the federal Medicare program.

Centers for Medicare & Medicaid Services (CMS)—The federal agency that oversees all aspects of financing and regulation for the Medicare program.

Coinsurance—The portion of the bill or contracted charge for which you (the member) are responsible. For example, a 25% coinsurance for drugs means you pay 25% of the costs for that prescription and your health care plan pays 75% of the cost.

Copayment—The fee you pay at the time of medical services. For example, a $10 copayment (or copay) to see your regular doctor means you pay $10 at the time of your visit. Your plan pays the rest.

Coverage—The services or benefits provided.

Deductible—A specified amount of money a member must pay before insurance benefits begin. Usually expressed in terms of an "annual" amount.

Effective Date of Enrollment—The date that is shown on your Medicare Advantage plan identification card as the date that your membership begins.

Emergency Medical Condition—A medical condition brought on by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that not getting immediate medical attention could result in 1) serious jeopardy to the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child); 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part.

Emergency Services—Covered services that are 1) furnished by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.

Exclusion—A health care service not reimbursable through an insurance plan or HMO (e.g., elective cosmetic surgery, etc.).

Fee-for-Service (FFS)—A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as it is rendered and identified by a claim for payment.

Formulary—A list of selected prescription drugs and their appropriate dosages. Often health plans refer to this as a list of approved prescription medications (or preferred drug list) that are covered by the plan.

Health Education—Educational process or program designed for the improvement and maintenance of health.

Health Insurance—Term used to describe all types of insurance indemnifying or reimbursing costs for health care services.

Health Maintenance Organization (HMO) plan—A type of Medicare Advantage plan that contracts with medical groups to provide a full range of health services for their enrollees for a fixed, prepaid, per-member fee.

Hospice—A Medicare-certified organization or agency that is primarily engaged in providing pain relief, symptom management and support services to terminally ill people and their families.

Inpatient Services—Treatment obtained while hospitalized.

Insurance Store Advisor—A representative who assists members with enrolling in a plan offered by The Insurance Store.

Lock-in Period—The time period during which Medicare beneficiaries may not switch plans. The duration and dates of the "lock-in" period may vary according to special needs and eligibility.

Medicaid—A joint federal and state program that provides health insurance to people who have incomes and resources below certain limits.

Medicare—The federal government's health insurance program established by Title XVIII of the Social Security Act.

Medicare Advantage—A Medicare program that gives you more choices among Medicare health plans. Everyone who has Medicare Parts A and B is eligible, except those who have end-stage renal disease.

Medicare Advantage Part D (MAPD) Plan—A Medicare Advantage plan like some of the plans offered by The Insurance Store, that includes Medicare's Part D Prescription Drug Coverage benefit. That means you get ALL the parts of Medicare plus prescription coverage and much more. Everyone who has Medicare Parts A and B is eligible, except those who have end-stage renal disease.

Medicare Advantage Plan—A Medicare health plan, such as a Medicare managed care plan, or Private Fee-for-Service plan, like some of the plans offered by The Insurance Store, offered by a private company and approved by Medicare. An alternative to the Original Medicare plan.

Medicare Options—The beneficiaries' option to choose from several alternatives to Original Medicare.

Medicare Supplement Insurance (or Medigap)—Private health insurance that pays certain costs not covered by fee-for-service Medicare, such as Medicare co-insurance and deductibles.

Multi-Specialty Group—Physicians representing various medical specialties working together in a group setting.

Network—A group of health care providers under a contract.

Outpatient Services—Non-hospitalized treatment at a hospital, clinic or dispensary.

Preferred Provider Organization (PPO) plan—A type of Medicare Advantage plan 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.

Private Fee-for-Service (PFFS) plan—A type of Medicare Advantage plan that lets you choose your own doctors, hospitals and other providers, provided that they accept the plan's terms and conditions.

Plan Premium—The monthly/quarterly payment to a health care organization that entitles you to the covered services. However, a Medicare Advantage plan is not required to charge you a plan premium. To qualify for services, the beneficiary must continue to pay the monthly Medicare Part B premium and, if applicable, Medicare Part A premiums.

Prescription Drug Coverage Gap—Sometimes called the "donut hole" or the "gap," the prescription coverage gap is a standard guideline set by Medicare. After your total yearly drug costs—paid by you and your plan—have reached $2,700, you are responsible for paying 100% of your prescription costs until you have paid $4,350 in yearly out-of-pocket costs.

You can protect yourself from having to pay these expenses by selecting a plan that offers coverage through the "gap."

Preventive Care—An approach to health care that emphasizes taking care of small conditions before they become big conditions that can become very costly. Preventive care measures include routine physical exams, diagnostic tests (e.g., Pap tests), immunizations and more.

Primary Care Physician (PCP)—These physicians provide a full range of basic health services to their patients. General practitioners, pediatricians, family practice physicians and internists are recognized by health plans as primary care physicians.

Prospective Member—An individual who is qualified to join a Medicare Advantage plan.

Referral—Written permission from your primary care physician, or his/her contracting medical group or IPA, allowing you to see a certain specialist or to receive certain covered services. The Insurance Store has plans that let you visit a specialist with no referral.

Specialist—A doctor who provides health care services for a specific disease or part of the body. Examples include oncologists (care for cancer patients), cardiologists (care for the heart) and orthopedists (care for bones).

Urgent Care—Urgent care is needed when your medical condition does not place you in serious jeopardy but could get worse and care is immediately needed.

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