Senior Health Care Glossary
As you research and evaluate your Senior Health Insurance options, there may be several terms or concepts that are new to you. In order to help with this process, we have put together the following glossary to guide you.
Appeal
A complaint filed with Medicare or your healthplan when you disagree with a decision they have made. Medicare plans have a specific process they must follow when you ask for an appeal. There are 3 reasons you may want to file an appeal:
- They deny paying for a service, supply, or prescription that you think you should be able to get.
- They deny reimbursement for care you've already recieved.
- They stop paying for care you are already getting.
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Benefit Period
Medicare uses benefit periods to measure your usage of hospital and skilled nursing facility services (SNF). A benefit period starts when you go to a hospital or SNF and ends after you have not recieved care for 60 consecutive days. If you go to a hospital or skilled nursing facility after that 60 days, a new benefit period starts. As a member, you are responsible for any applicable inpatient deductibles, and there is no limit to the number of benefit periods you can have.
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Coinsurance
The amount you will have to pay for services once you have satisfied your deductible. This is often a set percentage (ex. 20%) of the total service cost, but in the case of prescription drug plans, it may vary depending on how much you've spent.
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Copayment
In some plans, you pay a small set amount (ex. $10, $15, $20) for prescriptions, doctor's visits, or other services, regardless of the service's total cost.
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Creditable Prescription Drug Coverage
Prescription drug coverage that is considered 'at least as good' as standard Medicare coverage.
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Deductible
The amount you must pay in medical expenses before your health plan starts to pay. This amount is often dependent on the specific plan you choose or the time period your policy has determined.
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Formulary
A list of prescription drugs and types of drugs covered by your prescription plan.
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Health Maintenance Organization Plan (HMO)
A type of health coverage where you can usually only go to doctors, specialists or hospitals that are part of your plan's network except in an emergency. This limited provider network typically allows for a lower monthly premium.
For more information on HMO Plans, click here >>
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Long-term Care
Services to help people in their daily activities over a long period of time as well as provide for health and personal assistance. Examples include: nursing homes, assisted living facilities, and types of custodial care
For more information on Long-Term Care, click here >>
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Medicaid
A government program designed to provide healthcare to low-income individuals. Benefits vary based on your location, but if you qualify, most health care costs are covered if you also qualify for Medicare.
For more information on Medicaid, click here >>
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Medically Necessary
Services or supplies that are deemed 'necessary' for your diagnosis and treatment, meet standards of good medical practice, and are not primarily for convenience.
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Medicare Advantage Plan
A private healthcare plan that has partnered with Medicare to provide you Medicare benefits. It can be an HMO, PPO, or Fee-for-Service Plan.
For more information on Medicare Advantage Plans, click here >>
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Medicare-approved Amount
The maximum amount that a doctor or supplier can be paid by Medicare, including any amount that you pay.
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Medicare Cost Plan
A type of HMO where if you get Medicare-covered services outside your plan's network without a referral, Medicare will pay for the services. Emergency services, however, must be covered by your plan.
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Medicare Health Plan
A Medicare Advantage Plan or other Medicare plan, such as a Medicare Cost Plan.
For more information on Medicare Advantage Plans, click here >>
For more information on other Medicare plans, click here >>
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Medicare Prescription Drug Plan
A private, supplementary plan that adds prescription drug coverage to an existing Medicare plan without prescription coverage.
For more information on Medicare Prescription Plans, click here >>
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Medigap Policy
Supplemental insurance policies that "fill in the gaps" of Medicare coverage. There are 12 standard plans (Plan A - Plan L) except in Massachusetts, Minnesota, and Wisconsin, which differ.
For more information on Medigap Policies, click here >>
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Original Medicare Plan
A traditional fee-for-service insurance policy which provides members with the freedom to choose any doctor or hospital for treatment. Medicare will pay its share of the approved amount, and the member contributes the agreed-upon coinsurance. This plan has two elements, Part A and Part B.
For more information on the Original Medicare Plan, click here >>
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Penalty
A tariff added to your monthly Medicare premium if you do not join by a set deadline (when you first become eligible). There are some exceptions; follow up with your local Medicare information for details.
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Point-of-Service Plan (POS)
This HMO option lets members receive treatment from doctors and hospitals outside of the HMO network for a set fee.
For more information on POS Plans, click here >>
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Preferred Provider Organization Plan (PPO)
This Medicare Advantage product offers members the choice of in or out-of-network care, offering a discount for in-netowrk treatment.
For more information on PPO Plans, click here >>
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Premium
The amount a member must pay to an insurance company or health care plan, including Medicare, as a fee for coverage. The frequency of this payment is unique to each plan.
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Private Fee-for-Service Plan
A Medicare Advantage Plan which gives members the freedom to see any Medicare-approved doctor or hospital that accepts the specific plan. Rather than Medicare setting the pay-out level, with this product the payment is determined by the carrier.
For more information on Medicare Advantage Plans, click here >>
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Referral
A written approval from your primary care physician allowing you to see a specialist or receive additional care. Referrals are a primary requirement of many HMOs in order to ensure coverage and reimbursement.
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Skilled Nursing Facility Care
A level of care which includes the daily involvement of a skilled nursing or rehabilitation professional. Depending on your demonstrated need, Medicare may cover all your care expenses while in a Skilled Nursing Facility.
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Special Needs Plan
This type of plan offers more directed care for specified groups of people, including nursing home residents or individuals who qualify for both Medicare and Medicaid.
For more information on Medicare Advantage Plans, click here >>
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