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Medicare Terms


This glossary explains terms in the Medicare program, but it is not a legal document. The official Medicare program provisions are found in the relevant laws, regulations, and rulings.

Term

Definition


 A "TIER"
is a specific list of drugs. Your plan may have several tiers, and your co-payment amount depends on which tier your drug is listed. Plans can choose their own tiers, so members should refer to their benefit booklet or contact the plan for more information.
ABUSE (PERSONAL) When another person does something on purpose that causes you mental or physical harm or pain.
ACCESS Your ability to get needed medical care and services.
ACCESSIBILITY OF SERVICES Your ability to get medical care and services when you need them.
ACCESSORY DWELLING UNIT (ADU) A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.
ACCREDITED (ACCREDITATION) Means having a seal of approval. Being accredited means that a facility or health care organization has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities and organizations. Organizations that accredit Medicare Managed Care Plans include the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and the American Accreditation HealthCare Commission/URAC.
ACT/LAW/STATUTE Term for legislation that passed through Congress and was signed by the President or passed over his veto.
ACTIVITIES OF DAILY LIVING (ADL)* Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.
ACTUAL CHARGE The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves. (See Approved Amount; Assignment.)
ADDITIONAL BENEFITS Health care services not covered by Medicare and reductions in premiums or cost sharing for Medicare-covered services. Additional benefits are specified by the MA Organization and are offered to Medicare beneficiaries at no additional premium. Those benefits must be at least equal in value to the adjusted excess amount calculated in the ACR. An excess amount is created when the average payment rate exceeds the adjusted community rate (as reduced by the actuarial value of coinsurance, co-payments, and deductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the adjusted excess, which will be used to pay for services not covered by Medicare and/or will be used to reduce charges otherwise allowed for Medicare-covered services. Additional benefits can be subject to cost sharing by plan enrollees. Additional benefits can also be different for each MA plan offered to Medicare beneficiaries.
ADJUSTED AVERAGE PER CAPITA COST (AAPCC) An estimate of how much Medicare will spend in a year for an average beneficiary. (See Risk Adjustment.)
ADJUSTED COMMUNITY RATING (ACR) How premium rates are decided based on members' use of benefits and not their individual use of benefits.
ADMINISTRATIVE LAW JUDGE (ALJ) A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors.
ADMITTING PHYSICIAN The doctor responsible for admitting a patient to a hospital or other inpatient health facility.
ADVANCE BENEFICIARY NOTICE (ABN) A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it. If the doctor or supplier does give you an ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor or supplier for it. ABN?s only apply if you are in the Original Medicare Plan. They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan.
ADVANCE COVERAGE DECISION A decision that your Private Fee-for-Service Plan makes on whether or not it will pay for a certain service.
ADVANCE DIRECTIVE (HEALTH CARE) Written ahead of time, a health care advance directive is a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.
ADVANCE DIRECTIVES A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.
ADVOCATE A person who gives you support or protects your rights.
AFFILIATED PROVIDER A health care provider or facility that is paid by a health plan to give service to plan members.
AMBULATORY CARE All types of health services that do not require an overnight hospital stay.
AMBULATORY SURGICAL CENTER A place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, you may stay for only a few hours or for one night.
ANCILLARY SERVICES Professional services by a hospital or other inpatient health program. These may include x-ray, drug, laboratory, or other services.
ANESTHESIA Drugs that a person is given before surgery so he or she will not feel pain. Anesthesia should always be given by a doctor or a specially trained nurse.
ANNUAL ELECTION PERIOD The Annual Election Period for Medicare beneficiaries is the month of November each year. Enrollment will begin the following January. Starting in 2002, this is the only time in which all Medicare + Choice health plans will be open and accepting new members. (See Election Periods.)
APPEAL An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if Medicare doesn't pay for an item or service you think you should be able to get. There is a specific process that your Medicare Advantage Plan or the Original Medicare Plan must use when you ask for an appeal.
APPEAL PROCESS The process you use if you disagree with any decision about your health care services. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can have the initial Medicare decision reviewed again. If you are in the Original Medicare Plan, your appeal rights are on the back of the Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) that is mailed to you from a company that handles bills for Medicare. If you are in a Medicare managed care plan, you can file an appeal if your plan will not pay for, or does not allow or stops a service that you think should be covered or provided. The Medicare managed care plan must tell you in writing how to appeal. See your plan's membership materials or contact your plan for details about your Medicare appeal rights. (See also Organization Determination.)
APPROVED AMOUNT The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the a true amount charged by a doctor or supplier. The approved amount is sometimes called the "Approved Charge." (See Actual Charge; Assignment.)
AREA AGENCY ON AGING (AAA) State and local programs that help older people plan and care for their life-long needs. These needs include adult day care, skilled nursing care/therapy, transportation, personal care, respite care, and meals.
ASSESSMENT The gathering of information to rate or evaluate your health and needs, such as in a nursing home.
ASSIGNED CLAIM A claim submitted for a service or supply by a provider who accepts Medicare assignment.
ASSIGNMENT In the Original Medicare Plan, this means a doctor agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.
ASSISTED LIVING A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the "assisted living" residents pay a regular monthly rent. Then, they typically pay additional fees for the services they get.
AUTHORIZATION



 		 MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)

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BALANCE BILLING A situation in which Private Fee-for-Service Plan providers (doctors or hospitals) can charge and bill you 15% more than the plan's payment amount for services.
BASIC BENEFITS Basic Benefits includes both Medicare-covered benefits (except hospice services) and additional benefits.
BASIC BENEFITS (MEDIGAP POLICY) Benefits provided in Medigap Plan A. They are also included in all other standardized Medigap policies. (See Medigap Policy.)
BENEFICIARY The name for a person who has health care insurance through the Medicare or Medicaid program.
BENEFIT PERIOD The way that Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into the hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins if you are in the Original Medicare Plan. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.
BENEFITS The money or services provided by an insurance policy. In a health plan, benefits are the health care you get.
BENEFITS DESCRIPTION (PLAN) The scope, terms and/or condition (s) of coverage including any limitation (s) associated with the plan provision of the service.
BIOLOGICALS Usually a drug or vaccine made from a live product and used medically to diagnose, prevent, or treat a medical condition. For example, a flu or pneumonia shot.
BOARD AND CARE HOME A type of group living arrangement designed to meet the needs of people who cannot live on their own. These homes offer help with some personal care services.
BOARD-CERTIFIED

 		 This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.


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CAPITATION A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.
CAPPED RENTAL ITEM Durable medical equipment (like nebulizers or manual wheelchairs) that costs more than $150, and the supplier rents it to people with Medicare more than 25 percent of the time.
CARE PLAN A written plan for your care. It tells what services you will get to reach and keep your best physical, mental, and social well being.
CAREGIVER A person who helps care for someone who is ill, disabled, or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide care-giving services for a cost.
CARRIER A private company that has a contract with Medicare to pay your Medicare Part B bills. (See Medicare Part B.)
CASE MANAGEMENT A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.
CASE MANAGER A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.
CATASTROPHIC ILLNESS A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause you financial hardship.
CATASTROPHIC LIMIT The highest amount of money you have to pay out of your pocket during a certain period of time for certain covered charges. Setting a maximum amount you will have to pay protects you.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.
CERTIFICATE OF MEDICAL NECESSITY A form required by Medicare that allows you to use certain durable medical equipment prescribed by your doctor or one of the doctor's office staff.
CERTIFIED (CERTIFICATION) This means a hospital has passed a survey done by a State government agency. Being certified is not the same as being accredited. Medicare only covers care in hospitals that are certified or accredited.
CERTIFIED NURSING ASSISTANT (CNA) CNAs are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom.
CERTIFIED REGISTERED NURSE ANESTHETIST A nurse who is trained and licensed to give anesthesia. Anesthesia is given before and during surgery so that a person does not feel pain. (See Anesthesia.)
CIVILIAN HEALTH AND MEDICAL PROGRAM (CHAMPUS) Run by the Department of Defense, in the past CHAMPUS gave medical care to active duty members of the military, military retirees, and their eligible dependents. (This program is now called "TRICARE")
CLAIM A claim is a request for payment for services and benefits you received. Claims are also called bills for all Part A and Part B services billed through Fiscal Intermediaries. "Claim" is the word used for Part B physician/supplier services billed through the Carrier. (See Carrier; Fiscal Intermediaries; Medicare Part A; Medicare Part B.)
CLINICAL BREAST EXAM An exam by your doctor/health care provider to check for breast cancer by feeling and looking at your breasts. This exam is not the same as a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.
CLINICAL PRACTICE GUIDELINES Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.
CLINICAL TRIALS Clinical trials are one of the final stages of a long and careful research process to help patients live longer, healthier lives. They help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care, like how well a new cancer drug works. The trials help doctors and researchers see if the new care works and if it is safe. They may also be used to compare different treatments for the same condition to see which treatment is better, or to test new uses for treatments already in use.
COGNITIVE IMPAIRMENT A breakdown in a person's mental state that may affect a person's moods, fears, anxieties, and ability to think clearly.
COINSURANCE (MEDICARE PRIVATE FEE-FOR-SERVICE PLAN) The percentage of the Private Fee-for-Service Plan charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).
COINSURANCE (OUTPATIENT PROSPECTIVE PAYMENT SYSTEM) The percentage of the Medicare payment rate or a hospital's billed charge that you have to pay after you pay the deductible for Medicare Part B services.
COMMUNITY MENTAL HEALTH CENTER A place where Medicare patients can go to receive partial hospitalization services.
COMPLAINT (See Grievance.)
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF) A facility that provides a variety of services including physicians' services, physical therapy, social or psychological services, and outpatient rehabilitation.
CONDITIONAL PAYMENT A payment made by Medicare for services for which another payer is responsible.
CONFIDENTIALITY Your right to talk with your health care provider without anyone else finding out what you have said.
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)* A law that lets some people keep their employer group health plan coverage for a period of time after: the death of your spouse, losing your job, having your working hours reduced, leaving your job voluntarily, or getting a divorce. You may have to pay both your share and the employer's share of the premium. Generally, you also have to pay an administrative fee.
CONSUMER ASSESSMENT OF HEALTH PLANS STUDY (CAHPS) An annual nationwide survey that is used to report information on Medicare beneficiaries' experiences with managed care plans. The results are shared with Medicare beneficiaries and the public.
CONTINUATION OF ENROLLMENT Allows MCOs to offer enrollees the option of continued enrollment in the M+C plan when enrollees leave the plan's service area to reside elsewhere. CMS has interpreted this to be on a permanent basis. M+C Organizations that choose the continuation of enrollment option must explain it in marketing materials and make it available to all enrollees in the service area. Enrollees may choose to exercise this option when they move or they may choose to terminate enrollment.
CONTINUING CARE RETIREMENT COMMUNITY (CCRC) A housing community that provides different levels of care based on what each resident needs over time. This is sometimes called "life care" and can range from independent living in an apartment to assisted living to full-time care in a nursing home. Residents move from one setting to another based on their needs but continue to live as part of the community. Care in CCRCs is usually expensive. Generally, CCRCs require a large payment before you move in and charge monthly fees.
COORDINATION OF BENEFITS Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.
COORDINATION PERIOD A period of time when your employer group health plan will pay first on your health care bills and Medicare will pay second. If your employer group health plan doesn't pay 100% of your health care bills during the coordination period, Medicare may pay the remaining costs.
COST SHARING The cost for medical care that you pay yourself like a co-payment, coinsurance, or deductible. (See Coinsurance; Co-payment; Deductible.)
COVERAGE BASIS The M+C Plan charge schedule used to base the maximum dollar coverage or coinsurance level for a service category (e.g., a $500 annual coverage limit for a prescription drug benefit may be based on a Published Retailed Price schedule, or 20% coinsurance for DME benefit may be based on a Medicare FFS fee schedule).
COVERED BENEFIT A health service or item that is included in your health plan, and that is paid for either partially or fully.
COVERED CHARGES Services or benefits for which a health plan makes either partial or full payment.
CREDITABLE COVERAGE Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. (See Pre-existing Conditions.)
CRITICAL ACCESS HOSPITAL A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
CUSTODIAL CARE

  		 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 round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn't pay for custodial care.

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DEDUCTIBLE (MEDICARE) The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. (See Benefit Period; Medicare Part A; Medicare Part B.)
DEEMED Providers are ?deemed? when they know, before providing services, that you are in a Private Fee-for-Service Plan, and they agree to give you care. Providers that are ?deemed? agree to follow your plan's terms and conditions of payment for the services you get.
DEFICIENCY (NURSING HOME) A finding that a nursing home failed to meet one or more federal or state requirements.
DEHYDRATION A serious condition where your body's loss of fluid is more than your body's intake of fluid.
DIABETIC DURABLE MEDICAL EQUIPMENT Purchased or rented ambulatory items, such a glucose meters and insulin infusion pumps, prescribed by a health care provider for use in managing a patient's diabetes, as covered by Medicare.
DIAGNOSIS The name for the health problem that you have.
DIAGNOSIS-RELATED GROUPS A way to pay hospitals for health care based on diagnosis, age, gender, and complications.
DIALYSIS Dialysis is a treatment that cleans your blood when your kidneys don't work. It gets rid of harmful wastes and extra salt and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they are not a cure for permanent kidney failure (See hemodialysis and peritoneal dialysis.).
DIETHYLSTILBESTROL (DES) A drug given to pregnant women from the early 1940s until 1971 to help with common problems during pregnancy. The drug has been linked to cancer of the cervix or vagina in women whose mother took the drug while pregnant.
DISCHARGE PLANNING A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient's home care.
DISCOUNT DRUG LIST A list of certain drugs and their proper dosages. The discount drug list includes the drugs the company will discount.
DISENROLL Ending your health care coverage with a health plan.
DRUG TIERS Drug tiers are definable by the plan. The option “tier” was introduced in the PBP to allow plans the ability to group different drug types together (i.e., Generic, Brand, Preferred Brand). In this regard, tiers could be used to describe drug groups that are based on classes of drugs. If the “tier” option is utilized, plans should provide further clarification on the drug type (s) covered under the tier in the PBP notes section (s). This option was designed to afford users additional flexibility in defining the prescription drug benefit.
DUAL ELIGIBLES Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.
DURABLE MEDICAL EQUIPMENT Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.
DURABLE MEDICAL EQUIPMENT (DME) Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant or clinical nurse specialist) for use in the home. A hospital or nursing home that mostly provides skilled care can't qualify as a ?home? in this situation. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.
DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC) A private company that contracts with Medicare to pay bills for durable medical equipment.
DURABLE POWER OF ATTORNEY

 		 A legal document that enables you to designate another person, called the attorney-in-fact, to act on your behalf, in the event you become disabled or incapacitated.


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ELDERCARE Public, private, formal, and informal programs and support systems, government laws, and finding ways to meet the needs of the elderly, including: housing, home care, pensions, Social Security, long-term care, health insurance, and elder law.
ELECTION Your decision to join or leave the Original Medicare Plan or a Medicare + Choice plan.
ELECTION PERIODS Time when an eligible person may choose to join or leave the Original Medicare Plan or a Medicare + Choice plan. There are four types of election periods in which you may join and leave Medicare health plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.
  • Annual Election Period: The Annual Election Period is the month of November each year. Medicare health plans enroll eligible beneficiaries into available health plans during the month of November each year. Starting in 2002, this is the only time in which all Medicare + Choice health plans will be open and accepting new members.
  • Initial Coverage Election Period: The three months immediately before you are entitled to Medicare Part A and enrolled in Part B. If you choose to join a Medicare health plan during your Initial Coverage Election Period, the plan must accept you. The only time a plan can deny your enrollment during this period is when it has reached its member limit. This limit is approved by the Centers for Medicare & Medicaid Services. The Initial Coverage Election Period is different from the Initial Enrollment Period (IEP).
  • Special Election Period: You are given a Special Election Period to change Medicare +C hoice plans or to return to Original Medicare in certain situations, which include: You make a permanent move outside the service area, the Medicare + Choice organization breaks its contract with you or does not renew its contract with CMS; or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).
  • Open Enrollment Period: If the Medicare health plan is open and accepting new members, you may join or enroll in it. If a health plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.
ELIGIBILITY/MEDICARE PART A You are eligible for premium-free (no cost) Medicare Part A (Hospital Insurance) if:
  • You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retirement Board, or
  • You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or
  • You or your spouse had Medicare-covered government employment, or
  • You are under 65 and have End-Stage Renal Disease (ESRD).

If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if:

  • You are age 65 or older, and
  • You are enrolled in Part B, and
  • You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the 5 years immediately before the month in which you apply.
ELIGIBILITY/MEDICARE PART B You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the 5 years immediately before the month during which you enroll in Part B.
EMERGENCY CARE Care given for a medical emergency when you believe that your health is in serious danger when every second counts.
EMPLOYER GROUP HEALTH PLAN (GHP) A GHP is a health plan that:
  • Gives health coverage to employees, former employees, and their families, and
  • Is from an employer or employee organization.
END-STAGE RENAL DISEASE (ESRD) Permanent kidney failure requiring dialysis or a kidney transplant.
END-STAGE RENAL DISEASE NETWORK A group of private organizations that make sure you are getting the best possible care. ESRD networks also keep your facility aware of important issues about kidney dialysis and transplants.
ENHANCED BENEFITS Defined as Additional, Mandatory and Optional Supplemental benefits.
ENROLL To join a health plan.
ENROLLMENT FEE The amount you must pay every year to get a Medicare-approved drug discount card.
ENROLLMENT PERIOD A certain period of time when you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.
ENROLLMENT/PART A There are four periods during which you can enroll in premium Part A: Initial Enrollment Period (IEP), General Enrollment Period (GEP), Special Enrollment Period (SEP), and Transfer Enrollment Period (TEP).
  • Initial Enrollment Period: The IEP is the first chance you have to enroll in premium Part A. Your IEP starts 3 months before you first meet all the eligibility requirements for Medicare and continues for 7 months.
  • General Enrollment Period: January 1 through March 31 of each year. Your premium Part A coverage is effective July 1 after the GEP in which you enroll.
  • Special Enrollment Period: The SEP is for people who did not take premium Part A during their IEP because you or your spouse currently work and have group health plan coverage through your current employer or union. You can sign up for premium Part A at any time you are covered under the Group Health Plan based on current employment. If the employment or group health coverage ends, you have 8 months to sign up. The 8 months start the month after the employment ends or the group health coverage ends, whichever comes first.
  • Transfer Enrollment Period: The TEP is for people age 65 or older who have Part B only and are enrolled in a Medicare managed care plan. You can sign up for premium Part A during any month in which you are enrolled in a Medicare managed care plan. If you leave the plan or if the plan coverage ends, you have 8 months to sign up. The 8 months start the month after the month you leave the plan or the plan coverage ends. If you enroll in Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, your coverage starts on July 1. (See Enrollment.)
EPISODE OF CARE The health care services given during a certain period of time, usually during a hospital stay.
EVIDENCE Signs that something is true or not true. Doctors can use published studies as evidence that a treatment works or does not work.
EXCESS CHARGES If you are in the Original Medicare Plan, this is the difference between a doctor's or other health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.
EXCLUSIONS (MEDICARE) Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home.
EXPEDITED APPEAL A Medicare + Choice organization's second look at whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.
EXPEDITED ORGANIZATION DETERMINATION
 		 A fast decision from the Medicare + Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.


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FACILITY CHARGE Some plans may vary cost shares for services based on place of treatment; in effect, charging a cost for the facility in which the service is received.
FEDERALLY QUALIFIED HEALTH CENTER (FQHC) Health centers that have been approved by the government for a program to give low cost health care. Medicare pays for some health services in FQHCs that are not usually covered, like preventive care. FQHCs include community health centers, tribal health clinics, migrant health services, and health centers for the homeless.
FEE SCHEDULE A complete listing of fees used by health plans to pay doctors or other providers.
FISCAL INTERMEDIARY A private company that has a contract with Medicare to pay Part A and some Part B bills. (Also called "Intermediary.")
FISCAL YEAR For Medicare, a year-long period that runs from October 1st through September 30th of the next year. The government and some insurance companies follow a budget that is planned for a fiscal year.
FORMULARY A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary.
FORMULARY DRUGS Listing of prescription medications which are approved for use and/or coverage by the plan and which will be dispensed through participating pharmacies to covered enrollees.
FRAUD AND ABUSE Fraud: To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse: Payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare. This is not the same as fraud.
FREE LOOK (MEDIGAP POLICY)* A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.
FREEDOM OF INFORMATION ACT (FOIA)

 		 A law that requires the U.S. Government to give out certain information to the public when it receives a written request. FOIA applies only to records of the Executive Branch of the Federal Government, not to those of the Congress or Federal courts, and does not apply to state governments, local governments, or private groups.

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GAPS The costs or services that are not covered under the Original Medicare Plan.
GATEKEEPER In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.
GENERAL ENROLLMENT PERIOD (GEP) The General Enrollment Period is January 1 through March 31 of each year. If you enroll in Premium Part A or Part B during the General Enrollment Period, your coverage starts on July 1.
GENERIC DRUG A prescription drug that has the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
GRIEVANCE A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered (see Appeal).
GROUP HEALTH PLAN A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.
GROUP OR NETWORK HMO A health plan that contracts with group practices of doctors to give services in one or more places.
GUARANTEED ISSUE RIGHTS (ALSO CALLED "MEDIGAP PROTECTIONS") 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 insurance coverage or place conditions on a policy, must cover you for all pre-existing conditions, and can't charge you more for a policy because of past or present health problems.
GUARANTEED RENEWABLE


 		 A right you have that requires your insurance company to automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud or don't pay your premiums.


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HEALTH CARE PROVIDER A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.
HEALTH EMPLOYER DATA AND INFORMATION SET (HEDIS) A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare & Medicaid Services (CMS) collects HEDIS data for Medicare plans. (See Centers for Medicare & Medicaid Services.)
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) A law passed in 1996 which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also:
  • limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage;
  • usually gives you credit for health coverage you have had in the past;
  • may give you special help with group health coverage when you lose coverage or have a new dependent; and
  • generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance.
HEALTH MAINTENANCE ORGANIZATIONS (HMO) A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.
HEALTH MAINTENANCE ORGANIZATIONS (HMO) A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.
HEMODIALYSIS (HD) This treatment is usually done in a dialysis facility but can be done at home with the proper training and supplies. HD uses a special filter (called a dialyze or artificial kidney) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body (See dialysis and peritoneal dialysis.).
HOME AND COMMUNITY-BASED SERVICE WAIVER PROGRAMS (HCBS) The HCBS programs offer different choices to some people with Medicaid. If you qualify, you will get care in your home and community so you can stay independent and close to your family and friends. HCBS programs help the elderly and disabled, mentally retarded, developmentally disabled, and certain other disabled adults. These programs give quality and low-cost services.
HOME HEALTH AGENCY An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.
HOME HEALTH CARE Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
HOMEBOUND Normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn't keep you from getting home health care.