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Medicare Glossary

Understanding Medicare means knowing the meaning of many familiar and
unfamiliar terms. We define many of these terms below.

Acute Illness:
A disease or condition that comes on rapidly and severely, but that
can-with proper treatment-be cured, such as pneumonia or a broken bone.

Administrative Law Judge (ALJ):
A hearing officer who presides over appeals to Medicare by people with
Medicare or their providers. The ALJ level follows the CHDR appeals
level (for private plan appeals), the reconsideration level (for Part A
appeals) and the fair hearing level (for Part B appeals).

Advance Beneficiary Notice (ABN):
A notice health care providers and suppliers are required to give a
person with Original Medicare when they believe that Medicare will not
cover their services or items and the person has no reason to know that
Medicare will not cover the items or services. If your provider does
not give you an ABN to sign and you have no reason to know the
procedure is not covered, then you do not have to pay. If you sign an
ABN before you get the service or item, and Medicare does not pay for
it, you generally pay for it, although there are a few exceptions.
Providers are not required to give you an ABN for services or items
Medicare never covers.

Advance Coverage Decision:
A Private Fee-For-Service plan�s determination about whether or not it
will pay for a certain service. Note: this is completely unrelated to
an advance beneficiary notice (ABN), which only applies to people with
Original Medicare.

Advance Directive:
A legal document that outlines how you want medical decisions made if
you lose the ability to make decisions for yourself. A health care
advance directive may include a living will and a power of attorney for
health care decisions.

Advanced Illness:
A serious disease or condition that has progressed too far to be cured,
such as cancer that has spread throughout the body.

ALS/Lou Gehrig�s Disease:
A disease that affects the motor nerve cells of the spinal cord and
causes their degeneration. Patients with this disease can qualify for
Medicare coverage regardless of age.

Annual Coordinated Election Period (ACEP):
The period of time between November 15 and December 31 of every year
when you can change your Medicare private drug plan and/or your
Medicare health plan choice for the following year. This is also the
time you can enroll in the Medicare prescription drug benefit (Part D)
if you do not enroll during your Initial Enrollment Period (you may
have to pay a premium penalty if you enroll during this time unless you
had drug coverage from another source that was at least as good as
Medicare�s and you were not without that coverage for more than 63
days). Your new coverage will begin January 1.

Appeal:
A special kind of complaint that you make to your private Medicare plan
or Original Medicare when you disagree with a decision it has made
about your health care. For example, you might appeal if your health
plan doesn't pay for care you need.

Approved Amount:
The fee that Medicare sets as its rate for a medical service. Medicare
will cover 80 percent of this amount (or 50 percent for mental health
services) and you (or your supplemental insurance) are responsible for
the remainder. All doctors and other providers who take assignment must
accept this approved amount as full payment, even if they normally
charge more for the service.

Assets:
Resources such as savings and checking accounts, stocks, bonds, mutual
funds, retirement accounts, and real estate.

Assignment:
A Medicare term used to describe an agreement by a doctor to accept
Medicare's approved amount as payment in full. Any doctor who is a
"participating provider" in the Medicare program always takes
assignment. Participating providers may not charge you more than
Medicare's approved amount. If you have Original Medicare, it can save
you money to see a doctor who takes assignment.

Assistive Technology:
Any item, piece of equipment or system that is used to increase,
maintain or improve the functional capabilities of individuals with
disabilities. For example, Closed Circuit Television is an assistive
technology, which Medicare will cover if medically necessary. Simple
items like "grabbers" and "reachers" are not covered by Medicare.

Balance Bill:
When doctors and hospitals charge you for the balance on a bill after
your health plan or Original Medicare has paid its approved amount.

Beneficiary:
A person over 65 or under 65 with Social Security Disability Insurance
who receives health insurance through the Medicare program.

Benefit Period:
The amount of time during which Medicare pays for hospital and skilled
nursing facility (SNF) services. A benefit period begins the first day
you enter the hospital or SNF and ends when you no longer receive
hospital or skilled care in a SNF for 60 days in a row. With each new
benefit period, you pay a new deductible. Your coinsurance is
determined by the number of days you have been in the facility during
each benefit period.

Capped Rental Item:
Durable medical equipment (such as a wheelchair) that Medicare covers
initially for rental, rather than for purchase, often because of its
high cost. Medicare pays the rental fees for these items in monthly
installments. You can keep a capped rental item as long as it is
medically necessary and elect to buy it after renting it for ten
months. If you continue to rent it, you are not responsible for the
cost of its repairs or replacement parts.

Carrier:
Also called "Medicare Carrier." A private company that has a contract
with Medicare to process Part B claims.

Catastrophic Coverage:
Insurance designed to protect you from having to pay very high
out-of-pocket costs. Catastrophic coverage usually begins after you
have spent a pre-determined amount. Medicare Parts A and B do not offer
catastrophic coverage. They always pay the same amount regardless of
how much you have spent. The new Medicare prescription drug benefit
(Part D) does offer catastrophic coverage. After you have spent a
certain amount out-of-pocket ($3,600 in 2006), you will only pay five
percent of the cost of each prescription (in addition to your monthly
plan premium).

Catastrophic Limit:
The highest amount of money you have to pay out-of-pocket during a
given period of time for certain services. After you have reached the
catastrophic limit, a higher level of coverage begins.

Center for Health Dispute Resolution (CHDR):
An independent agency that contracts with the Centers for Medicare and
Medicaid Services to review Medicare private plan appeals.

Centers for Medicare & Medicaid Services (CMS):
Formerly known as the Health Care Financing Administration (HCFA), CMS
is the United States government agency responsible for administering
Medicare and Medicaid. It is made up of three agencies: the Center for
Beneficiary Choices, the Center for Medicare Management, and the Center
for Medicaid and State Operations.

Certificate of Medical Necessity (CMN):
Documentation from a doctor which Medicare requires before it will
cover certain durable medical equipment. The CMN states the patient�s
diagnosis, prognosis, reason for the equipment, and estimated duration
of need.

Chronic Illness:
A disease or condition that lasts for a long period of time or is marked
by frequent recurrence, such as diabetes or asthma.

Claim:
A bill that asks for payment for services or benefits you received.
Medicare Part A claims are processed by Fiscal Intermediaries and Part
B claims are processed by Medicare Carriers.

COBRA:
A federal law guaranteeing employees and their families at risk of
losing health coverage-due to termination of employment, death,
divorce, or other circumstances-the right to purchase continued
coverage under the employer�s group health plan for limited periods of
time.

Coinsurance:
The portion of the cost of care you are required to pay after your
health plan pays. Usually, it is a percentage of an approved amount. In
Original Medicare the coinsurance is usually 20% of the
Medicare-approved amount.

Comprehensive Outpatient Rehabilitation Facility (CORF):
A medical facility that provides outpatient diagnostic, therapeutic and
restorative services for the rehabilitation of an injury, disability or
sickness.

Continuous Open Enrollment:
A consumer's right to buy private insurance at any time, regardless of
age or health status.

Conversion Policy:
An employer-sponsored group policy that can be converted to an
individual policy with the same insurance company. These policies are
usually very expensive.

Coordination of Benefits:
The sharing of costs by two or more health plans, based on their
respective financial responsibilities for medical claims. Your primary
insurance and secondary insurance must coordinate benefits in order to
pay claims.

Copayment:
A set amount you are required to pay for each medical service you
receive, such as a visit you make to a health care provider. It usually
ranges from $5 to $25.

Coordination Period:
For people with end-stage renal disease, the period of time during
which an employer group health plan pays first and Medicare pays
second. Medicare may pay the remaining costs if your group health plan
doesn�t pay 100 percent of your health care bills during the
coordination period.

Cost Sharing:
The portion of medical care that you pay yourself, such as a copayment,
coinsurance or deductible.

Cost Tiers:
A system that drug plans use to price medications. Generic drugs are
generally on the first, and least expensive tier, followed by
brand-name drugs, and then specialty drugs, with each subsequent tier
requiring higher out-of-pocket costs.

Creditable Coverage:

1. Any health insurance coverage you had within 63 days of securing a
   new insurance policy that can be used to shorten the waiting period for
   pre-existing conditions.
2. Prescription drug coverage that is
   considered to be as good as or better than the Medicare prescription drug
   benefit in monetary value.

Curative Care:
The treatment of patients with the intent of curing their disease or
condition; for example, chemotherapy treatments to cure breast cancer.

Custodial Care:
Non-medical care, such as cooking, cleaning, and shopping. Medicare generally
does not cover custodial care.

Deductible:
The amount of health care expenses you must pay before your health plan
or Medicare begins to pay. These amounts can change every year.

Denial of Coverage:
A refusal by Medicare or a private plan to pay for medical services that
are not covered under its policy.

Department of Veterans Affairs (VA):
A government agency that provides federal benefits to veterans and
their families. These benefits include pensions, educational stipends
and health care services, among others. See also VA Benefits.

Disenrollment:
Leaving a health plan like an HMO.

DME: Durable Medical Equipment.
Equipment that is primarily serving a medical purpose, is able to
withstand repeated use, and is appropriate for use in the home; for
example, wheelchairs, oxygen equipment and hospital beds. To be covered
by Medicare, durable medical equipment must be prescribed by a doctor.
Many types of adaptive equipment are not covered.

Doughnut Hole:
Also called a "Coverage Gap."
A gap in insurance coverage during which you must pay all drug costs in
full; often followed by "catastrophic coverage" from the insurance plan.

Drug Class:
A group of drugs that treat the same symptoms or have similar effects
on the body. For example, people with Medicare often use statin class
drugs, which are used for reducing cholesterol. Drugs in this class
include (but are not limited to) Lipitor, Zocor, Pravachol, Zetia, and
Vytorin.

Dual Eligible:
A person who has both Medicare and Medicaid.

Earned Income:
Money you get because you work, such as wages from work and earnings
from self-employment.

Election Periods:
The times when a Medicare-eligible person can choose to join or leave
Original Medicare or a Medicare Advantage plan. There are four types of
election periods: the annual election period, the initial election
period, the special election period, and the open enrollment period.

Enrollment:
Joining Original Medicare or becoming a member of a private health plan,
like a Medicare HMO.

EOMB:
Explanation of Medicare Benefits.
Also known as a "Medicare Summary Notice (MSN)."
The notice you get from Medicare after receiving medical services from
a doctor, hospital or other health care provider. It tells you what the
provider billed Medicare, Medicare's approved amount, the amount
Medicare paid, and what you have to pay. It is not a bill.

ESRD: End-Stage Renal Disease. Kidney failure that
requires you to be on dialysis or have a kidney transplant.

Excess Charges:
The difference between a doctor's or other health care
provider's actual charge and the Medicare-approved payment amount.

Extra Help:
A Federal program that is administered by Social Security that helps
people with Medicare who have low incomes and assets pay for their
Medicare drug coverage (including coinsurance, deductibles, and
premiums). If you have Medicaid, receive Supplemental Security Income
(SSI), or are enrolled in a Medicare Savings Program (MSP), then you
are automatically eligible for Extra Help.

Expedited Appeal:
A fast appeal of a denial of health care services made by a Medicare
private plan (HMO, PPO, PFFS) when a person's "life, health, or ability
to regain maximum function" is in jeopardy. These appeals generally
take 72 hours.

Federal Poverty Level (FPL):
The federally set level of income that an individual or family can earn
below which it is recognized that they can not afford necessary
services. The FPL is used in eligibility criteria of many programs,
including Extra Help and Medicaid. The FPL changes every year and
varies depending on the number of people in your household. It is
higher in Alaska and Hawaii.

Federally Qualified Health Center (FQHC):
Health centers located in "medically underserved areas" that provide
low-cost health care. Medicare will pay for some health services in
FQHCs that it generally does not cover, such as a routine check-up.
FQHCs include community health centers, migrant health services, and
health centers for the homeless.

Fee-for-Service:
Payment to providers for each service they provide, as in Original Medicare.

Fiscal Intermediary:
Also called "Intermediary." A private company that has a contract with
Medicare to process Medicare Part A claims (bills from hospitals and skilled
nursing facilities).

Formulary:
The list of prescription drugs that your private health plan, like a
Medicare HMO, will pay for either in part or in full. Drugs not on the
formulary are generally not covered by private health plans.

Free Look:
A period of time when you can try out a Medicare supplemental insurance
(Medigap) policy. During this time (usually 30 days), you can cancel
the policy and get a full refund.

Gaps in Coverage:
Services or costs that are not covered under the Original Medicare
plan, such as prescription drugs, deductibles, and coinsurance.

Gatekeeper:
In a managed care plan, like an HMO, your primary care doctor (PCP)
oversees your care and decides when to refer you to specialty care.

General Enrollment Period:
The time period between January 1 and March 31 of every year when you
can enroll in Medicare Part B. If you enroll during this period, your
coverage will begin on July 1.

Grievance:
A complaint filed with your Medicare health plan about the care you are
receiving. For example, you may file a grievance if you are
dissatisfied with the condition of a health care facility or if you
have a complaint about staff behavior or the facility�s operating
hours. An appeal, not a grievance, is the appropriate way to complain
about a denial of care or coverage.

Guaranteed Issue:
A consumer protection that gives people the right to buy Medicare
supplemental insurance (Medigap). Because of this right, which is in
effect during certain times, an insurance company cannot deny you
insurance coverage or place conditions on a policy, must cover your
pre-existing conditions, and cannot charge you more for a policy
because of your health status.

HCFA: Health Care Financing Administration.
The former name of the Centers for Medicare and Medicaid Services (CMS).

Health Care Provider:
Also called "Provider." An individual or facility, such as a
doctor or hospital, which provides health care services.

Hill-Burton Program/Facilities:
Hospitals and clinics that offer free or reduced-cost care to patients
who meet qualifying income limits. These vary in what types of services
they offer and do not provide services that are covered by a patient's
insurance.

HINN: Hospital-Issued Notice of Non-Coverage.
A written notice that explains why a patient is not being admitted to
or is being discharged from a hospital. It also explains a person's
rights to appeal that decision.

HIPAA:
The Health Insurance Portability and Accountability Act amended the
Employee Retirement Income Security Act (ERISA), to provide new rights
and protections for members of group health plans. HIPAA contains
protections both for health coverage offered in connection with
employment (group health plans) and for individual insurance policies
sold by insurance companies (individual policies).

HMO:
Health Maintenance Organization.
A type of managed care plan that generally covers only the care you get
from doctors, hospitals, and other health care providers that are in
the HMO network. The government pays HMOs a set amount to provide
health care to people with Medicare. HMO members must choose a primary
care doctor who coordinates their care and decides when they can go to
a specialist.

Home Health Agency:
An organization that provides home care services, such as skilled
nursing care, physical therapy, occupational therapy, speech therapy,
and personal care.

Homebound:
A person whose condition is such that there exists a normal inability
to leave home, and leaving home requires "a considerable and taxing
effort. A person does not have to be confined to the bed to be
considered homebound by Medicare. Leaving home for short
periods of time for special non-medical events, such as a family
reunion, funeral or graduation, would not exclude someone from being
considered homebound. A doctor must certify this condition.

Home Health Aide:
A worker who helps a patient at home with activities of daily living,
such as getting in and out of bed, dressing, bathing, eating and using
the bathroom. Medicare does not pay separately for aides to perform
house-keeping services, such as cooking and cleaning, but they may do
light housekeeping related to personal care during the visit. Medicare
will not pay for home health aide services unless they are accompanied
by a skilled need.

Home Health Care:
Care provided at home to treat an illness or injury. Medicare will only
cover care in the home if the person has a skilled care need (see Skilled Care).

Hospice:
Comprehensive care for people who are terminally ill that includes pain
management, counseling, respite care, prescription drugs, inpatient and
outpatient services, and services for the terminally ill person's
family.

Housekeeping Services:
See Custodial Care.

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 this period, the plan must accept you, unless it has reached its
member limit.

Initial Enrollment Period:
The first chance you have to enroll in Part A, Part B or Part D if you
don�t get it automatically. If you enroll during this time, which
begins three months before you first meet the eligibility requirements
for Medicare and continues for seven months, you do not pay a premium
penalty.

Inpatient Care:
Care that you get when you are in the hospital overnight.

Intermediary: Also known as "Fiscal Intermediary."
A private company that has a contract with Medicare to process Part A claims.

Lifetime Reserve Days: Also called "Reserve Days."
When you are in the hospital for more than 90 days, Medicare pays for 60
additional reserve days that you can only use once in your lifetime.
They are not renewable once you use them.

Limiting Charge:
An upper limit on how much doctors who do not accept Medicare's
approved amount as payment in full can charge to people with Medicare.
Federal law sets the limit at 15 percent more than the
Medicare-approved amount. Some states limit it even further. For
example, in New York it is 5 percent more. This charge is in addition
to 20 percent coinsurance (50 percent for mental health services).
Providers who "opt out" of Medicare are not subject to these limiting
charges and can charge as much as they want, if the patient signs an
agreement with them prior to receiving care.

Low-Income Subsidy (LIS): See Extra Help.

Long-Term Care:
Custodial care given at home or in a nursing home. Medicare does not cover
long-term care.

Long-term care ombudsman:
An independent advocate for nursing home and assisted living facility
residents who provides information about how to find a facility and how
to get quality care. Every state is required to have an Ombudsman
Program that addresses complaints and advocates for improvements in the
long-term care system.

Maintenance Care:
Care given to people with chronic diseases or conditions to keep them
from getting worse. For example, exercise and physical therapy can
minimize abnormal or painful positioning of the joints and may prevent
or delay curvature of the spine in a person with Muscular Dystrophy.

Managed Care Plan:
A health plan (like an HMO) run by a private company or entity that
receives a set amount of money from the government to provide
Medicare-covered benefits.

Medicaid: A state-run program that covers medical expenses
for people with low or limited incomes.

Medicaid Spend-Down:
A state-run Medicaid program for people whose income is higher than
would normally qualify them for Medicaid, but who have high medical
expenses that reduce their incomes to the Medicaid eligibility level.
Not all states have Medicaid spend-down.

Medical Social Services:
A service generally intended to help the patient and family cope with
the logistics of daily life with an advanced illness. Medical social
services include assessing social and emotional factors related to the
patient�s illness and care; evaluating the patient�s home situation,
financial resources, and availability of community resources; and
helping the patient access community resources to assist in recovery.
The social worker may also provide counseling to the patient and family
to address emotions and issues related to the illness.

Medical Supplies:
Items covered by Medicare if they are used by home health agency staff to
fulfill the plan of care, such as wound dressings.

Medically Necessary:
Procedures, services, or equipment that meet good medical standards and
are necessary for the diagnosis and treatment of a medical condition.

Medicare-Approved Amount:
Also called "Medicare-approved charge."
This is the amount Medicare will pay for certain medical services or
equipment. Generally you are responsible for paying 20% of the
Medicare-approved amount.

Medicare Advantage Drug Plan (MAPD):
A Medicare drug plan offered through a Medicare Advantage plan (such as
an HMO, PPO or PFFS) that offers Medicare prescription drug coverage
(Medicare Part D).

Medicare Advantage Plans (formerly Medicare+Choice):
Private plans a person with Medicare can
join. Many of these private Medicare plans are not yet available in
most parts of the country.

Medicare Carrier:
Also called "Carrier." A private company that has a contract with
Medicare to process Part B claims.

Medicare+Choice:
See Medicare Advantage.

Medicare Prescription Drug Benefit:
See Part D.

Medicare Savings Programs (MSP):
Also known as Medicare Buy-In programs, they help pay your Medicare
premiums and sometimes also coinsurance and deductibles. There are
three Medicare Savings Programs, with different eligibility limits:
QMB, SLMB, and QI-1.

Medicare SELECT: A type of Medigap policy that will
generally give you full coverage as long as you see doctors and hospitals
in its network.

Medicare Social HMO:
A special type of health plan that provides the full range of Medicare
benefits offered by standard Medicare HMOs, plus other services that
can include: prescription drug and chronic care benefits, respite care
and short-term nursing home care; homemaker, personal care services,
and medical transportation; eyeglasses, hearing aids, and dental
benefits.

Medigap:
A Medicare supplemental insurance policy that is sold by private
insurance companies to fill "gaps" in Original Medicare. This insurance
policy is usually available in the form of ten different plans labeled
A through J and only works with
Original Medicare.

MSA: Medical Savings Account.
A type of private Medicare plan that may be offered as an option for
people with Medicare. With an MSA, you buy a high-deductible insurance
policy and open a savings account where Medicare will deposit money to
help you pay for medical bills. This plan is not yet available anywhere
in the country.

MSN:
Medicare Summary Notice. Also called "Explanation of Medicare
Benefits (EOMB)."
The notice you get in the mail from Medicare after getting medical
services from a doctor, hospital or other health care provider. It
tells you what the provider billed Medicare, Medicare's approved
amount, the amount Medicare paid, and what you have to pay. The MSN
is not a bill.

National coverage determination (NCD):
A decision about particular treatments that Medicare will or will not
cover for particular conditions. Medicare contractors are required to
follow NCDs.

Network:
A group of doctors and hospitals that contract with a managed care plan
to provide healthcare services to plan members. Generally, managed care
plan members may only receive covered services from doctors and
hospitals in the plan's network.

Open Enrollment Period:
A certain period of time when you can join a Medicare health plan.
During that time, the plan must allow all eligible individuals to join.

Opt Out:
Doctors can "opt out" of Medicare by notifying the Medicare carrier
that they will not accept Medicare payments and telling their
patients-in writing before treating them-that Medicare will not pay for
their services and that the patients must pay for the care themselves.
Doctors who have "opted out" can charge as much as they want, and their
patients have to pay the entire bill themselves. The only time a doctor
who has opted out can receive payment from Medicare is when the doctor
provides a patient emergency or urgent care services and the patient
does not have a contract with that doctor. If the doctor did not
provide a written contract before the patient received the services,
the patient is not liable for payment.

Original Medicare:
Also known as "Traditional Medicare."
The federal health insurance program, created in 1965, under which
the government pays providers directly for each service a person
receives (on a fee-for-service basis). About 89 percent of the Medicare
population is enrolled in Original Medicare, as opposed to a private
Medicare plan (HMO, PPO).

Outpatient Prospective Payment System (OPPS):
The system through which Medicare decides how much money a hospital or
community mental health center will get for each outpatient service
patients with Medicare receive. The rate of reimbursement varies with
the location of the hospital or clinic.

Out-of-Network Provider:
A doctor or hospital that is not part of a managed care plan's network.
If you get services from an out-of-network provider, it usually means
that you likely will have to pay out of your own pocket for the
services you received.

Out-of-Pocket Costs:
Health care costs that you must pay because Medicare or other insurance
does not cover them.

Outpatient Care:
Medical care that does not require you to stay in the hospital overnight.

Palliative Care:
The care of patients with a terminal illness, not with the intent of
trying to cure them, but to relieve their symptoms. Palliative care
consists of relief of pain and nausea, as well as psychological, social
and spiritual support services.

Part A:
The part of Medicare that covers most medically necessary hospital,
skilled nursing facility, home health, and hospice care.

Part B:
The part of Medicare that covers most medically necessary doctors'
services, preventive care, durable medical equipment, hospital
outpatient services, laboratory tests, x-rays, mental health, and some
home health and ambulance services.

Part C:
The part of Medicare concerning private health care plans that can offer
Medicare benefits. These plans, which are sometimes known as Medicare
Advantage plans, include Health Maintenance Organizations (HMOs),
Preferred Provider Organizations (PPOs), Private Fee for Service plans
(PFFSs) and Medical Savings Accounts (MSAs). You must have Medicare
Parts A and B to join a Part C plan.

Part D:
The part of Medicare that will provide prescription drug coverage starting
in January 2006. The benefit will be provided by private companies.
People who enroll in Part D will pay a monthly premium in addition to
their Part B premium.

Participating Provider:
A doctor or other health care provider who agrees to "take
assignment"-accept Medicare's approved amount as payment in full. Any
doctor who is a "participating provider" in the Medicare program always
takes assignment. Participating providers may not charge you more than
Medicare's approved amount. If you have Original Medicare, you can save
money if you see a doctor who takes assignment (you still pay your
coinsurance).

Personal Care:
Assistance with activities of daily living, such as bathing, feeding
and toileting. Providers of personal care (home health aides) are not
required to undergo medical training.

PCP (Primary Care Physician):
The doctor that manages your care and refers you to specialty care if
you need it. A managed care plan, like an HMO, requires you to have a
PCP. If you don't consult your PCP before seeing a specialist, your
managed care plan, will likely not cover your care.

PFFS (Private Fee-for-Service):
A plan that allows you to use any doctor or hospital anywhere in the
country as long as that provider accepts the plan's terms and
conditions. This plan must cover all Medicare benefits and may offer
additional benefits. But, you may pay more for Medicare benefits and
you cannot buy a Medigap plan to fill gaps in coverage.

Physical Therapy:
Exercise and physical activities used to condition muscles and improve
levels of activity. Physical therapy is helpful for those with physical
debilitating illness.

Plan of Care:
A doctor�s written plan describing the type and frequency of services
and care a particular patient needs.

POS Option (Point-of-Service Option):
The right of managed care plan members to partial coverage for certain
services they get outside the managed care plan network of providers.

PPO (Preferred Provider Organization):
A type of managed care plan that should partially cover the care from
out-of-network providers. To get full coverage, you must use network
providers.

Pre-Authorization:
Also called "pre-approval." An approval that a managed care plan member
must ask for from the plan or primary care doctor fin order to know that the
plan will pay for certain medical services, such as an inpatient hospital stay.
In some plans, of you do not get pre-authorization the plan will not cover the
care.

Pre-Existing Condition:
A condition or illness you were diagnosed with or got treatment for
before your new health care coverage began.

Premium:
The amount that an individual who wants health care coverage must pay
to an insurer, health plan or Medicare.

Premium Penalty:
The amount that you must pay to Medicare in addition to the regular
monthly premium for late enrollment. The Part B premium is an
additional 10 percent of the premium for each year you delay
enrollment. Part D will have a premium penalty of at least 1 percent
for every month you delay enrollment .

Prescription Drug Plan (PDP):
A "stand-alone" Medicare drug plan offered through a private insurance
company that only offers prescription drug benefits for people with
Medicare.

Preventive Care:
Care to keep you healthy or prevent illness, such as routine checkups
and flu shots and tests like prostate cancer screening and yearly
mammograms.

Primary Insurance: Health care coverage that pays first on a
claim for medical and hospital care. In most cases, Medicare is your primary
insurer.

Provider:
Also called "Health Care Provider." An individual or facility (such
as a doctor, hospital or durable medical equipment supplier), which provides
health care services.

PSO: Provider-Sponsored Organization.
A type of managed care plan that is very similar to an HMO, except that
it is operated by a group of doctors and hospitals. This plan is not
available in most parts of the country.

QI-1 Program: Qualifying Individual-1 Program.
Federal program administered by each state's Medicaid program that pays
the Part B premium for people with Medicare with low incomes.

QI-2 Program: Qualifying Individual-2 Program.
Until 2001, this federal program administered by each state's Medicaid
program paid the Part B premium for people with Medicare with low
incomes. This program is no longer offered.

Quality Improvement Organizations (QIOs):
Groups of practicing doctors and other health care experts paid by the
federal government to check and improve the care given to Medicare
patients. QIO's must review your complaints about the quality of care
you get in inpatient hospitals, hospital outpatient departments,
hospital emergency rooms, skilled nursing facilities, home health
agencies, Private Fee-for-Service plans, and ambulatory surgical
centers.

QMB Program:
Qualified Medicare Beneficiary Program.
Federal program administered by each state's Medicaid program that
helps people with Medicare with low incomes pay their coinsurance,
deductibles, and premiums.

Railroad Medicare Carrier:
A private company that provides Medicare coverage for railroad retirement
beneficiaries.

Referral:
Authorization that an HMO and other managed care plans usually require
for services not provided your primary care doctor. For instance, HMOs
generally require you to get a referral from your primary care doctor
in order to see a specialist or get an eye exam.

Regional Home Health Intermediary:
A private company that contracts with Medicare to pay home health bills
and monitor the quality of home health care. There are four Regional
Home Health Intermediaries in the U.S., each serving states in one of
four U.S. regions.

Rehabilitative Care:
The care of patients with the intent of curing, improving or preventing
a worsening of their condition. For example, physical therapy after hip
replacement surgery to resume walking, or occupational therapy to
prevent carpal tunnel syndrome.

Respite Care:
A hospice service that provides relief for caregivers of hospice
patients by arranging a brief period (up to five days) of inpatient
care for the patient.

Retiree Insurance:
Health insurance provided by employers to former employees who have
retired. Retiree insurance always pays secondary to (after) Medicare.

Retroactive Disenrollment:
A way to discontinue enrollment in a Medicare private plan that you
mistakenly joined, effective back to the date you joined, and enroll in
Original Medicare as of that date. Your providers will need to resubmit
any claims from the time you joined the Medicare private plan to
Original Medicare.

Secondary Insurance:
Health care coverage that pays after the primary insurer on a claim for
medical or hospital care. It usually pays for all or some of the costs
that the primary insurer did not cover, but may not cover services not
covered by the primary insurer.

Service Area:
The area within which a private Medicare plan provides medical services
to its members. In an HMO, it is the area where your network of doctors
and hospitals is located.

SHIP (State Health Insurance Assistance Program):
A federally-funded program in each state that answers questions about
Medicare free of charge.

Skilled Care:
Medically reasonable and necessary care performed by a skilled nurse or
therapist. If a home health aide (someone who provides help with daily
living activities, such as bathing and eating) or other person can
perform the service,
it is not considered "skilled care." Skilled nursing includes care from
Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). Skilled
therapy includes care from licensed physical, occupational and speech
therapists.

Skilled Nursing Facility (SNF):
A Medicare-approved facility which provides short-term post-hospital
extended care services, at a lower level of care than provided in a
hospital.

Skilled Nursing Services:
Services from a registered nurse, which include administration of
medications; tube feedings; catheter changes; wound care; teaching and
training activities; observation and assessment of a patient's
condition; and management and evaluation of a patient's care plan.

Skilled Therapy Services:
Services from licensed physical, speech/language, and occupational
therapists (if originally accompanied by physical or speech therapy
services). Physical therapy services which qualify people for home
health care include: assessment; therapeutic exercises; gait training;
range of motion tests; ultrasound, shortwave, and microwave diathermy
treatments; teaching services; and development, implementation,
management, and evaluation of a patient care plan. Maintenance therapy
is covered if a physical therapist's skills are necessary for the safe
and effective provision of repetitive services which use complex,
sophisticated procedures.

SLMB Program (Specified Low-Income Medicare Beneficiary Program):
Federal program administered by each state's Medicaid program that pays
the Part B premium for people with Medicare with low incomes.

Special Election Period:
A set time when you can switch to another Medicare private health plan,
if one is available. During this time, Medicare private plans must
enroll individuals who apply whose private plans are closing.

Special Enrollment Period (SEP):
A period of time, triggered by specific circumstances, during which you
can enroll in Medicare Part B or Part D without having to pay a premium
penalty. Under Part B, your SEP begins the month after employment or
group health coverage ends (whichever comes first). Under Part D, you
are eligible for an SEP if you lose-through no fault of your own-any
type of drug coverage that was considered "creditable."

Specialist:
A doctor who specializes in treating only a certain part of the body or a
certain condition. For instance, a cardiologist only treats people with
heart problems.

Speech Therapy: Therapeutic treatment of speech
impairments (such as lisping and stuttering) or speech difficulties that
result from illness.

SSDI (Social Security Disability Insurance):
Monthly benefits provided through the United States Social Security
Administration for people who lose their ability to work because of a
medical impairment. People who receive SSDI for 24 months are eligible
for Medicare.

SSI (Supplementary Security Income):
Monthly benefits for people with low incomes and assets who are older than 65,
blind, or have a disability.

State Pharmaceutical Assistance Program (SPAP):
State-subsidized programs that provide assistance in paying for prescription
drug costs. SPAPs vary by state.

Supplemental Insurance:
Also called secondary coverage, supplemental insurance fills gaps in
Medicare coverage by helping to pay for the portion of health care
expenses that Original Medicare does not pay for, such as deductibles
and coinsurance. Supplemental insurance includes Medigap plans and
retiree insurance from a former employer. Supplemental insurance may
offer additional benefits that Medicare does not cover.

Supplier:
Also known as "Provider." A person or business from whom you can
buy medical equipment, like a walker or wheelchair.

Take Assignment:
A term used to describe an agreement by a doctor to accept Medicare's
approved amount as payment in full. Any doctor who is a "participating
provider" in the Medicare program always takes assignment.
Participating providers may not charge you more than Medicare's
approved amount. If you have Original Medicare, it can save you money
to see a doctor who takes assignment. But, you still pay your
coinsurance (or share) of the cost of the doctor visit, usually 80
percent of the Medicare-approved amount.

TRICARE:
The Department of Defense�s health care program for active duty and retired
military personnel and their family members. TRICARE consists of
several different programs, including TRICARE for Life, a retiree
benefit that acts as supplemental coverage to Medicare. TRICARE also
offers coverage to reserve force members who are on active duty for 30
days or more.

TRICARE for Life:
The health care program for military retirees who have served honorably
for at least 20 years. They must be enrolled in Part B to receive the
benefits. It pays secondary to Medicare and covers out-of-pocket
expenses including deductibles and coinsurance. People who qualify can
receive free or low-cost medications from military treatment
facilities, TRICARE network and non-network pharmacies, and the
National Mail Order Pharmacy.

Unearned income:
Money you get from sources other than current employment. Includes
Social Security benefits, Veterans benefits, pensions, annuities and
other regular payments you receive, such as alimony and workers'
compensation.

Urgent Care:
A sudden illness or injury that needs immediate medical attention but
is not life threatening.

Veterans Administration (VA) Benefits:
Benefits given by the federal government to people who have been in
"active" service in the military, naval, or air service (veterans, not
career officials) and, under certain conditions, to their family
members. These benefits include pensions, educational stipends and
health care, among others. Veterans can receive VA health care services
only at VA facilities.

Waiting Period:
The time between when you sign up for a Medigap or private Medicare health
plan and the coverage begins.

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