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Medicare Glossary of Terms

Health care terminology doesn’t have to be confusing. Here are simple definitions of the terms you’re likely to find on this website and out in the health care world

 

A

ACTIVITIES OF DAILY LIVING (ADLS) - activities performed as part of a person's daily routine of self-care, such as bathing, dressing, toileting, transferring to and from bed and eating.

ACTUARY - someone who estimates insurance risks and premiums.

ADMISSION - a registered patient, usually admitted for at least 24 hours, to a hospital, skilled nursing facility or other health care facility.

AFTERCARE - services following hospitalization or rehabilitation.

ALTERNATE CARE - non-inpatient care received in a less intensive setting than a hospital or other inpatient facility (such as day-surgery center).

APPEAL - a formal request to review an action when you are not satisfied with a decision made by your health plan.

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B

BEHAVIORAL HEALTH CARE - assessment and treatment of mental or substance abuse disorders.

BENEFICIARY - a person who receives insurance benefits.

BENEFIT LEVEL - the limit or amount of services a person is entitled to based on the contract with a health plan.

BOARD CERTIFIED - a doctor who has completed an approved residency and passed an examination given by a medical specialty board.

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C

CARRIER - a company that manages or sells health benefit programs.

CASE MANAGEMENT - the process of identifying patients with specific health care needs and working with them and their physician(s) to provide the best treatments possible.

CASE MANAGER - a nurse, doctor or social worker who works with patients, health care providers, physicians and insurers to determine and coordinate a health care plan. Also called a care coordinator.

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) - the federal agency responsible for administering Medicare and supervising states’ administration of Medicaid.

CERTIFICATE OF COVERAGE (COC) - a description of the benefits included in a health plan.

CLAIM -information submitted by a provider or a covered person that establishes the specific health services provided to a patient and requests payment.

COGNITIVE IMPAIRMENT - reduced memory or reasoning.

COINSURANCE - a percentage of the cost of a service that you must pay to the provider for that service.

COPAYMENT (COPAYS) - a dollar amount that you pay to the doctor at your visit.

COVERAGE GAP - the name for the step in a Medicare Part D prescription plan in which you pay all of your expenses for eligible drugs.

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D

DATE OF SERVICE - the date health care services were provided to the covered person.

DEDUCTIBLE - the amount of eligible expense a covered person must pay each year out of pocket before the plan will pay.

DEPENDENT - an individual who relies on a member for financial support and/or obtains health coverage through a spouse, parent or grandparent who is the member.

DISABILITY - any condition resulting in functional limitations that interfere with someone’s ability to perform his/her customary work and that results in substantial limitation of one or more major life activities.

DISCHARGE PLANNING - the evaluation of patients' medical needs in order to arrange for appropriate care after discharge from an inpatient setting.

DRUG FORMULARY - a list of prescription medications preferred for use by the health plan and dispensed through contracted pharmacies to covered persons.

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E

EFFECTIVE DATE - the date a contract becomes active.

ELIGIBILITY DATE - the defined date a member becomes eligible for benefits under an existing contract.

EMPLOYEE ASSISTANCE PROGRAM (EAP) - services designed to assist employees, their family members, and employers in finding solutions for workplace and personal problems.

EMPLOYER CONTRIBUTION - the amount an employer contributes toward the premium costs of the health plan.

ENROLLEE - someone who is enrolled for coverage under a health plan contract.

EXCLUSIONS - specific conditions or circumstances the policy or plan will not cover or reimburse.

EXPLANATION OF BENEFITS (EOB) - the coverage statement that list services provided, amount billed and payment made.

EXTENDED CARE FACILITY - a nursing home or nursing center that is licensed and provides 24-hour nursing care. It may offer skilled, intermediate or custodial care, or any combination of these levels of care.

EXTENSION OF BENEFITS - a provision that allows medical coverage to continue past the end date of the policy for employees not actively at work and for dependents hospitalized on that date.

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F

FACILITY - a physical location where health care or services are provided, such as a hospital, clinic, emergency room or ambulatory care center.

FORMULARY - see drug formulary.

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G

GENERIC DRUG - A generic drug is less expensive than a brand name drug and sold under a common or "generic" name for that drug. It’s otherwise exactly the same. Also called generic equivalent.

GRIEVANCE - Your statement of dissatisfaction with any part of your care. A grievance can be filed over the phone or in writing, and must be filed directly with your plan.

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H

HEALTH BENEFITS PACKAGE - the services and coverage a health plan offers a group or individual.

HEALTH COVERAGE - the payment of benefits for covered sickness or injury. This may include dental, medical and vision care, as well as other benefits.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) - a federal law intended to improve the availability and stability of health insurance coverage.

HEALTH MAINTENANCE ORGANIZATION (HMO) - a company that provides or arranges for health services for its plan members.

HEALTH PLAN - health maintenance organization, preferred provider organization, insured plan, self-funded plan or other group that covers health care services.

HOME HEALTH AGENCY (HHA) - a facility or program licensed, certified or otherwise authorized according to state and federal laws to provide health care services in the home.

HOSPICE - a facility or program that provides care for the terminally ill.

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I

IMPAIRMENT - any loss or abnormality of psychological, physiological or anatomical structure or function (e.g., hearing loss).

IN-AREA SERVICES - health care received within the authorized service area from a contracted provider that is contracted with the health plan. Also called in-network services.

INPATIENT - an individual who has been admitted to a hospital as a registered bed patient for at least 24 hours and is receiving services under the direction of a physician.

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J

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K

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L

LONG-TERM CARE - assistance and care for people with chronic disabilities. Long-term care's goal is to help people with disabilities live as independently as possible. It is focused more on caring than on curing.

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M

MAXIMUM OUT-OF-POCKET COSTS - the limit on total member copayments, deductibles and coinsurance under a benefit contract.

MEDICAID - a federal program administered and operated by state governments that provides medical benefits to eligible low-income people needing health care. The program's costs are shared by the federal and state governments.

MEDICARE - a nationwide, federally-administered health insurance program that covers the costs of hospitalization, medical care, and some related services for eligible people, usually individuals age 65 and older and disabled individuals under age 65.

MEDICARE BENEFICIARY - a person designated by Social Security as entitled to receive Medicare benefits.

MEDICARE SUPPLEMENT POLICY - a policy offered by an insurer that generally pays a policyholder's Medicare coinsurance, deductible and copayments for Medicare Parts A and B and may provide additional supplemental benefits, depending on the policy.

MEMBER - a person who enrolled in a health plan during the reporting period. Members include all people directly enrolled (enrollees/subscribers) and their eligible dependents. Also known as covered person and plan participant.

MENTAL HEALTH PROVIDER - a psychiatrist, licensed consulting psychologist, social worker, hospital or other facility duly licensed and qualified to provide mental health services under the law of the jurisdiction in which treatment is received.

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N

NETWORK - a system of contracted physicians, hospitals and ancillary providers that provides health care to members.

NETWORK PROVIDER - a provider who has contracted with the health plan to deliver medical services to covered persons. The provider may be a physician, hospital, pharmacy, other facility or other health care provider. Also known as network or participating provider.

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O

OUT-OF-AREA (OOA) - coverage for treatment obtained by a covered person temporarily outside the network service area.

OUT-OF-NETWORK (OON) - coverage for treatment by a non-contracted provider. Typically, it requires payment of a deductible and higher copayments and coinsurance than for treatment from a contracted provider. Some health plans do not offer benefits for out-of-network treatment, except in emergencies.

OUT-OF-POCKET COSTS/EXPENSES (OOPS) - the portion of payments for covered health services required to be paid by the enrollee, including copayments, coinsurance and deductibles.

OUTPATIENT - a person who receives health care services at a hospital or free-standing surgical center without being admitted to a hospital.

OVER-THE-COUNTER (OTC) DRUG - a drug product that does not require a prescription under federal or state law.

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P

PARTICIPATING PROVIDER - a provider who has contracted with the health plan to deliver medical services to covered persons. The provider may be a physician, hospital, pharmacy, other facility or other health care provider. Also known as network or in-network provider.

PAYER - an organization that pays for health care expense coverage.

PHYSICIAN - any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is licensed and qualified under the law.

PRE-EXISTING CONDITION - any medical condition that has been diagnosed or treated within a specified period. Pre-existing conditions may not be covered for some specified amount of time (usually six to 12 months).

PREFERRED PROVIDER ORGANIZATION (PPO) - a program that establishes contracts with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides better benefits and lower member cost for services received from preferred providers.

PREFERRED PROVIDERS - physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan.

PREMIUM - the amount paid by member to a carrier for providing coverage under a contract.

PRESCRIPTION MEDICATION - a drug that has been approved by the Food and Drug Administration and which can, under federal or state law, be given only from a licensed physician or other practitioner with authority.

PREVENTIVE CARE - health care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization and well-person care.

PRIMARY CARE - basic or general health care, traditionally provided by family practice, pediatrics and internal medicine practitioners.

PROVIDER - a physician, hospital, group practice, nursing home, pharmacy or any individual or group of individuals that provides a health care service.

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Q

QUALIFIED MEDICARE BENEFICIARY (QMB) - a person whose income falls below 100% of federal poverty guidelines, for whom the state must pay the Medicare Part B premiums, deductibles and copayments.

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R

RATE - the amount of money per enrollment classification paid to a carrier for medical coverage. Rates usually are charged on a monthly basis.

REFERRAL - the recommendation by a physician and/or health plan for a covered person to receive care from a different physician or facility. Sometimes required for treatment by specialists and for out-of-network treatment.

RETIREE BENEFITS - provided by employers to their retirees. Usually designed to supplement Medicare for Medicare-eligible retirees.

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S

SECOND OPINION - the medical opinion of another health care professional – to be compared against a medical diagnosis.

SECONDARY CARE - services provided by medical specialists, such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients.

SERVICE AREA - the geographic area serviced by the health plan.

SKILLED NURSING FACILITY (SNF) - a facility that accepts patients in need of rehabilitation and medical care.

SPECIAL NEEDS PLANS (SNP) - health plans tailored to meet the needs of people living with one or more chronic illnesses who are also eligible for Medicare.

SUBSCRIBER - see enrollee.

SUMMARY PLAN DESCRIPTION - a description of the entire benefits package available to an employee as required.

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T

TREATMENT FACILITY - a residential or non-residential facility that provides treatment of substance abuse or mental illness.

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U

URGENT CARE - an alternative to hospital emergency department care for use in non-emergencies. Used when health conditions are urgent, but are not health- or life-threatening.

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V

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W

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X

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Y

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Z

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