Glossary

Defines terms you may encounter when dealing with Medicare or with health care-related issues. Click on a letter below to view the list of words that start with that letter, or scroll down to browse all the words in the glossary.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Abuse: Incidents or practices that are inconsistent with sound and accepted medical, business, or fiscal procedures.
Acute: A health condition that is short-term, following the onset of a disease or as a result of an injury that occurred over a brief time period.
Administrative Law Judge: An official who has responsibility for making a decision in matters of administrative law. Medicare administrative law judges are assigned to the federal Department of Health and Human Services and make decisions regarding Medicare Parts A, B, C, and D appeals that have passed the initial levels of consideration.
Advance Beneficiary Notice (ABN): A notice that a doctor or supplier should give a Medicare beneficiary to sign when the doctor or supplier believes that Medicare will not pay for a particular service. By signing the notice, the beneficiary agrees to pay for the service. If the doctor or supplier does not provide the beneficiary with a notice, and Medicare does not pay for the service, then the beneficiary does not have to pay for the service. The advance beneficiary notice applies only to Medicare fee-for-service, not in managed care plans.
Amyotrophic Lateral Sclerosis (ALS): Often referred to as Lou Gehrig's Disease, ALS is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. People diagnosed with ALS can receive Medicare the first month their Social Security Disability Insurance (SSDI) benefits begin.
Annual Election Period (Medicare Advantage Managed Care and Medicare Part D): The Annual Election Period (AEP) for Medicare beneficiaries runs from November 15 through December 31 each year. During this time beneficiaries may change prescription drug plans, change Medicare Advantage plans, return to original Medicare, or enroll in a Medicare Advantage plan for the first time. Enrollment changes take effect on January 1. This is the only period during which most people with Medicare can change prescription drug plans.
Appeal: An appeal is a complaint you may file if you disagree with any decision about your health care services. For example, if Medicare doesn't pay for a service you received, you may appeal. An appeal is sent in writing to your Medicare health plan or the Original Medicare plan. There is a formal process you must follow when filing an appeal. More info: Medicare appeals.
Approved Amount: The amount Medicare determines to be reasonable for a service that is covered under Medicare Part B. Medicare Part B will pay for 80% of these approved amounts and no more. If your doctor does not accept the approved amount, by law she or he can charge no more than 15% above this amount. The approved amount is sometimes called the "approved charge" or "allowable amount."
Assignment (for people in Original Medicare): If your doctor "accepts assignment," it means that the doctor will charge you the standard rates or "approved amount" that the federal government sets for medical services. Medicare Part B will pay for 80% of these standard charges and no more. If your doctor does not charge the standard rates, by law the doctor cannot charge more than 15% above these rates. You may want to choose doctors who accept assignment to keep your costs low. Doctors and other health care providers that "accept assignment" are referred to as "participating providers."
Attained Age Rating: This is the most common way that Medigap policies are priced in California. Attained age rated policies go up in price as a separate individual cost factor as one ages. In other words, the insurer charges each 75-year-old more than it charges each 70-year-old, instead of spreading that cost between all 70- and 75-year-olds. Typically, these plans appear less expensive at younger ages, but can cost considerably more in later years. In addition, the premium will likely go up each year due to rising health care costs, separately from the cost associated with age.
Authorized Representative: Someone who has the legal right to make health care decisions on your behalf (for example, through a power of attorney) or someone you designate to make decisions about enrolling or disenrolling from a Medicare prescription drug plan.

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Basic Benefits: Medigap policies A through J must include "basic benefits." Basic Medigap benefits include coverage of the hospital charges required under Medicare Part A for hospital days 61-90 and 91-150 in a benefit period, the blood deductibles under Part A, and the 20% coinsurance under Part B.
Benchmark Plan: A basic Medicare Part D plan that has a premium below the average in California ($24.86 in 2009). The full Low-Income Subsidy (LIS) covers the premium and deductible of benchmark plans; if you receive the full LIS, you will not pay a premium or deductible if you enroll in a benchmark plan. You are, however, still responsible for copayments of $1.10-$6 for each covered medication.

Benefit Period (for Original Medicare): A benefit period is the way Medicare measures the time you spend in a hospital or skilled nursing facility. The benefit period begins the day you enter the hospital or skilled nursing facility and ends when you have not received Medicare-covered hospital or skilled nursing care for 60 days in a row. If you enter the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you may have. (Note: benefits periods apply when you use Original fee-for-service Medicare. They do not apply if you are in a Medicare Advantage plan.)

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California Prescription Drug Discount Program for Medicare
Recipients: Provides people with Medicare who have no other coverage for prescription drugs a discounted price on their prescription drugs when they ask for the Medi-Cal price at a Medi-Cal pharmacy. This program cannot be used for drugs that are covered by someone's Medicare prescription drug plan and it is not a substitute for a Medicare prescription drug plan. More info: California Prescription Drug Discount.
California State Disability Insurance (SDI): California administers the State Disability Insurance (SDI) program. It is a public disability insurance program that pays a benefit every other week.
Carrier: A health insurance company under contract with the federal government to handle claims processing for Medicare Part B services.
Catastrophic Coverage: This refers to the Part D drug benefit. Once your Part D countable out-of-pocket costs reach $4,350 (in 2009), you pay a small coinsurance (such as 5%) or copayment for covered drug costs until the end of the calendar year. (Note: Expenses that count toward this catastrophic coverage are also referred to as your "true out-of-pocket" costs, or (TrOOP). Catastrophic coverage also refers to coverage for high-cost medical conditions or emergencies, usually after a large deductible is met.
Centers for Medicare and Medicaid Services (CMS): The agency of the federal government that administers the Medicare, Medicaid, and state Children's Health Insurance programs. Formerly known as the Health Care Financing Administration (HCFA).
CHAMPUS: The Civilian Health and Medical Program run by the Department of Defense. CHAMPUS gives medical care to the dependents of active duty military members and to retired military members. (Now called TRICARE.)
Claim: A written or electronic request that medical services be paid by Medicare or some other insurance company, such as a Medigap policy.
COBRA: Consolidated Omnibus Budget Reconciliation Act, or COBRA, legally requires an employer to continue coverage under the employer's group health plan for a period of time after: the death of your spouse, the loss of your job, the reduction of work hours, or getting a divorce. You may have to pay both your share and the employer's share of the premium. Cal-COBRA provides California protections which, in certain circumstances, broaden and extend the continuation of coverage of employees beyond the federal COBRA law.
Coinsurance: The percentage of the Medicare-approved amount that you pay after paying the deductible for Part A and/or Part B. In Original Medicare, the coinsurance payment is a percentage (20%) of the cost of the service.
Community Rating (Medigap pricing): In a Community Rating plan, sometimes referred to as a No Age Rating plan, the premium is the same for all people regardless of age. No matter how old you are, the plan costs the same, e.g., whether you are 60 or 85 years old. The premium can only increase if it is raised for all similar plans in the state.
Copayment: In some Medicare Advantage plans, this is the amount that you pay for each medical service, such as a visit to the doctor or the filling of a prescription. A copayment is usually a set amount. For example, it could be $10 or $20 for all doctor visits. Copayments also are used for some hospital outpatient services in Original Medicare. Copayments for prescription drugs may be a dollar amount or a percentage of the total cost.
Cost Sharing: Payments that include deductibles, coinsurance, and copayments.
Coverage Determination (Medicare Prescription Drug Coverage): You can request this from your Medicare Drug Plan if your pharmacist tells you that your drug plan will not cover a drug you think should be covered or wants to charge you a higher price than you think you should pay. More info: Coverage Determinations.
Creditable Coverage: 1) Any previous health coverage that can be used to shorten the pre-existing condition waiting period for a Medigap policy. 2) Any prescription drug coverage you may have that is considered at least as good as the standard Medicare prescription drug plan. If you have creditable coverage, you can choose not to get Medicare Prescription Drug Coverage when you are first eligible for it and you will not have to pay a penalty if you decide to enroll later.
Custodial Care: Non-skilled personal care services, such as assistance with bathing, cooking, walking, and dressing. Custodial care is usually referred to as "long-term care" and is not generally covered by Medicare.

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Deductible: An amount that you must pay for health care or prescription drugs before Medicare, a Medicare Advantage plan, or prescription drug plan begins to pay. In the case of Medicare Part A, there is a deductible for each benefit period. In the case of Medicare Part B, deductibles are charged annually. In the case of Medicare Part D (Medicare Prescription Drug Coverage), deductibles are charged annually. These amounts can change every year.
Donut Hole: The gap phase of Part D prescription drug coverage during which you are responsible for paying 100% of your drug costs ($3,454 in 2009). Drugs included on your plan's formulary that you purchase through your plan's pharmacy or network count toward your donut-hole costs. Once you've reached $3,454 in out-of-pocket expenses, you will be eligible for catastrophic coverage.
Drug Categories: Drugs in the same class that are used to treat a specific condition or illness such as high blood pressure, high cholesterol, heartburn or depression.
Durable Medical Equipment (DME): Medical equipment that is ordered by a doctor for use in the home. These items may be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under Medicare Part B, and you pay 20% coinsurance under Original Medicare.

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Election Periods: The time when you may choose to join or leave Original Medicare or a Medicare managed care plan. There are four periods during which you may join or leave Medicare managed care plans: Annual Election Period, Initial Coverage Election Period, Special Election Period, and Open Enrollment Period.
End-Stage Renal Disease (ESRD): Kidney failure that is severe enough to require lifetime dialysis or a kidney transplant. See our fact sheet Medicare and People with End Stage Renal Disease (ESRD) (PDF).
Enhanced Coverage (Medicare Prescription Drug Coverage): Drug plans that offer more benefits (often covering more drugs on their formularies) and often charge higher premiums (and lesser cost-sharing) than standard drug plans.
Exception (Medicare Prescription Drug Coverage): A request for a coverage determination that requires you to submit a supporting statement from your doctor explaining why you need the drug you are requesting. More info: Drug Coverage Appeals.
Excess Charge (for people in Original Medicare): The difference between the Medicare-approved amount and the actual charge for services or goods you receive. Non-participating doctors cannot charge more than 15% above the Medicare-approved amount. Some Medigap policies offer benefits that will pay the excess charges.
Expedited Appeal: An appeal of a health care decision (where a medical service is at issue) for Medicare Advantage, Original Medicare, or Medicare Prescription Drug Coverage enrollees that is expedited, or decided quickly. This type of appeal can be a verbal or written request. More info: Medicare appeals.

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Fast-Track Appeal: An appeal process available to Medicare HMO members if their coverage for care in a hospital, skilled nursing facility, home health care agency or a comprehensive rehabilitation facility is about to end. This appeal differs from an expedited appeal in that an outside organization, California's Quality Improvement Organization (QIO), Lumetra, reviews your appeal instead of the HMO. More info: Medicare appeals.
Fee Schedule: A complete list of fees used by health plans to pay doctors or other providers.
Fee-for-service: A payment system by which a doctor, hospital, or other health care provider is paid a specific amount for each service performed as it is provided and identified by a claim for payment.
Fiscal Intermediary: A private insurance company that has a contract with Medicare to pay Part A and some Part B bills. Also known as an "intermediary."
Formulary: A list of the drugs covered by a Medicare prescription drug plan (PDP) or Medicare Advantage Prescription Drug plan (MA-PD).
Fraud: An intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of some unauthorized benefit.

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General Enrollment Period

The General Enrollment Period (GEP) is January 1 through March 31 of each year. If you enroll in Medicare Part B or Part A (if you don't get it automatically without paying a premium) during the GEP, then your coverage starts on July 1.

Grievance

A complaint about the way your Medicare Advantage plan or Medicare prescription drug plan is providing care. For example, you may file a grievance if you have problems with:

The cleanliness of a health care facility
Telephone customer service
Staff behavior
Operating hours
You have to wait too long for your prescriptions

A grievance is not the same as an appeal. An appeal is the way to file a complaint about a treatment decision or a service that is not covered. A beneficiary may file a grievance at the same time an appeal is filed.

More info: Medicare appeals.

Guaranteed Issue Rights: A situation where an insurance company is required by law to issue you a Medigap policy.
Guaranteed Issue Protections: Medigap "guaranteed issue" protections are special rights you have in certain situations to buy a Medigap policy. During these certain situations, an insurance company cannot deny you insurance, place conditions on a policy, or charge you more for a policy because of past or current health problems. More info: Your rights to buy a Medigap policy.
Guaranteed Renewable: This applies to Medigap policies where the benefits cannot change. As long as you pay your premium, guaranteed renewable policies are automatically renewed each year. You still must pay your monthly Medicare Part B premium.

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Health Insurance Counseling and Advocacy Program (HICAP): A program that provides free health insurance counseling and assistance to people with Medicare and their families. Paid professional and community volunteers provide the counseling and assistance. HICAP is a California State Health Insurance and Assistance Program (SHIP) financed by the federal government and the California Department of Aging.
Health Maintenance Organization (HMO): A group of doctors, hospitals, and other health care providers that provide health care. In an HMO (also known as a Medicare Advantage plan, formerly known as a Medicare managed care plan or Medicare+Choice plan), you typically get all your care from the providers who are part of the plan. If you go outside the plan to see a doctor, you will be charged more for the care.
High-deductible Option (Medigap): A few insurance companies offer a Medigap high-deductible option for policies F and J. The high-deductible option offers the same benefits as the standardized Medigap policies F and J, plus a deductible of $1,900 in 2008. The deductible increases annually.
Home Health Agency: An organization that provides health care services in the home, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and care by home health aides.
Home Health Care: Skilled health care and custodial health aide services provided in the home on a part-time basis for the treatment of an illness or injury. Home health care is covered under Medicare Part A and Part B. Durable medical equipment is also covered when provided by a home health agency.
Hospice: A special program in which a Medicare-approved public or private organization provides pain relief, symptom management, and supportive services to people who are dying and to their families. Some home care is also covered under the Medicare Part A hospice benefit.

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Initial Coverage Election Period (ICEP): The ICEP is the period where individuals newly eligible for Medicare can join a Medicare Advantage plan. This period begins 3 months before the person is eligible for Medicare and ends the last day of the month one’s Medicare benefits begin.
Independent Review Entity (IRE): The entity that performs the second review in the Medicare prescription benefit appeals process and in the Medicare Advantage appeals process. The request for it must be in writing and sent directly to the IRE. More info: Medicare appeals.
Initial Enrollment Period (IEP): The IEP for individuals who are turning age 65 is a 7-month period, which begins on the first day of the 3rd month before the month in which they turn 65, includes the month of their 65th birthday, and ends on the last day of the 3rd month after their 65th birthday. During this 7-month period, Medicare beneficiaries can enroll in Medicare Part A, Part B, and a Medicare drug plan (Part D). See “Initial Coverage Election Period” for Medicare Advantage plans (Part C), above.
Inpatient: An individual who is admitted to a hospital or other health facility overnight for the purpose of receiving a diagnosis, treatment, or other health services.
Issue Age Rating: A Medigap policy premium that is based on the age of the person when the policy is purchased. The policy does not increase automatically as the person ages. The premium can only increase if it is raised for all similar policies in the state.

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Lifetime Reserve Days: In Original Medicare, you are given 60 extra days covered by Medicare when you are in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, you will not get any more during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except a daily coinsurance.
Limiting Charge (for people in Original Medicare): The highest dollar amount that can be charged by doctors and other providers who do not accept Medicare assignment. The limit is 15% over Medicare's approved amount. See "Non-participating Provider," or "Assignment," or "Excess Charge."
Long-term Care (LTC): Personal care services, previously called custodial care, given at home or in a skilled nursing facility for people with chronic disabilities and lengthy illnesses. Medicare does not generally cover long-term care.
Long-term Care Ombudsman: A long-term care ombudsman is an advocate who resolves disputes between residents of skilled nursing homes or residential care facilities (also known as board and care, or assisted living facilities) and the facility management. An ombudsman also works to inform residents and their family members of their rights and protections while residing in a facility.
Low-Income Subsidy (LIS): This benefit helps low-income people with Medicare to pay for Medicare Prescription Drug Coverage. More info: Extra Help.

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Mediation: A method of conflict resolution between beneficiaries and providers regarding quality of care concerns. A professional mediator facilitates a meeting between the two parties to promote reconciliation, settlement or compromise. Lumetra, California's Quality Improvement Organization (QIO), administers the mediation program.
Medicaid: A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Most health care costs are covered if you qualify for both Medicare and Medicaid. In California, Medicaid is known as Medi-Cal. More info: Medi-Cal.
Medi-Cal: In California, Medicaid is known as Medi-Cal. Medicaid is a joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Most health care costs are covered if you qualify for both Medicare and Medicaid. More info: Medi-Cal.
Medi-Cal Dual Eligibles: Medicare beneficiaries who are entitled to Medicare Part A and/or Part B and who are also eligible for full Medi-Cal benefits. More info: Medi-Cal.
Medically Necessary: Services or supplies required for the diagnosis or treatment of a beneficiary's medical condition, which meet the standards of good medical practice in the local area, and aren't just for the convenience of a beneficiary or his/her doctor.
Medicare: The federal health insurance program for people 65 years of age and older, some younger people with disabilities, people with amyotrophic lateral sclerosis (ALS) (also known as Lou Gehrig's disease), and people with end-stage renal disease (ESRD).
Medicare Advantage Plans: Formerly known as Medicare + Choice plans, Medicare Advantage plans include: health maintenance organizations (HMOs), preferred provider organizations (PPOs), special needs plans (SNPs), private fee-for-service (PFFS) plans, and Medical Savings Account (MSA) plans. Private insurance companies offer these plans. To join, you must continue to pay Part B premiums but receive all Medicare-covered benefits through the private plan chosen. More info: Medicare Advantage.
Medicare Advantage Managed Care Plan: One type of Medicare Advantage plan. Medicare Advantage Managed Care plans (formerly known as Medicare managed care or Medicare+Choice) are primarily health maintenance organizations (HMOs) but also include Preferred Provider Organizations (PPOs) or any other plan that requires you to use a certain group of doctors and hospitals, known as a network, to provide and coordinate the care you receive. If you are enrolled in a Medicare Advantage managed care plan, you generally must use only the plan's providers. If you want to see a doctor or get other services outside of the plan's network, you will be charged more, or possibly all, of the costs of your care. This is in contrast to Medigap policies that supplement Original Medicare and allow you to choose any doctor or other provider who accepts Medicare's payment.
Medicare Advantage Prescription Drug Plan (MA-PD): Medicare prescription drug plans offered by Medicare Advantage programs, usually a voluntary add-on to the Medicare Advantage plan that costs an additional premium.
Medicare Appeals Council (MAC): The entity that performs the fourth review in all the Medicare appeals processes. The request must be in writing and sent directly to the MAC. More info: Medicare appeals.
Medicare Managed Care Plan: See above, "Medicare Advantage Managed Care Plan."
Medicare Medical Savings Account (MSA) plan: A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Insurance Policy with a high deductible. The other part is a special savings account where Medicare deposits money to help you pay your medical bills.
Medicare Prescription Drug Coverage (Medicare Part D): Prescription drug benefit added to Medicare as part of the 2003 Medicare Modernization Act (MMA). Benefits began January 2006 and are offered by private companies through prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PDs). Drug coverage is limited to drugs on a plan's formulary. More info: Medicare Prescription Drug Coverage.
Medicare Savings Programs: Medicare Savings Programs help people with low income and asset levels pay for health care coverage: Qualified Medicare Beneficiary (QMB), Specified Low-income Medicare Beneficiary (SLMB), Qualified Individual (QI), and Qualified Disabled Working Individual (QDWI). You must meet certain income and asset limits to qualify for these programs. More info, see our section on Medicare Savings Programs.
Medicare Select: A type of Medigap plan that may require you to use doctors and hospitals within its network to be eligible for full benefits. Medicare Select plans also offer standard benefits offered under Medigap policies A through J, and may have lower premiums.
Medicare Summary Notice (MSN): A notice sent by the Medicare carrier to the Medicare beneficiary following a health care visit or hospital stay. The MSN provides information about how the doctor or other health care provider was paid. The MSN used to be called the Explanation of Medicare Benefits (EOMB). People enrolled in Medicare managed care plans do not receive a Medicare Summary Notice.
Medigap: Medigap is private insurance that supplements Original Medicare by paying the Medicare deductibles and coinsurance. There are 12 nationally standardized Medigap policies (plans A through L). Policies provide coverage for Medicare cost-sharing amounts and some services not covered by Medicare, such as care while traveling outside the United States.

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No Age Rating (for Medigap pricing of policies): In a No Age Rating plan, more commonly referred to as a Community Rating plan, the premium is the same for all people regardless of age. No matter how old you are, the plan costs the same, e.g., whether you are 60 or 85 years old. The premium can only increase if it is raised for all similar plans in the state.
Nonparticipating Provider (for people in Original Medicare): A doctor or supplier who does not accept assignment on all Medicare claims.

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Ombudsman: An advocate for nursing home and residential care facility residents. An ombudsman works to solve problems between residents and facility management. Also called a "Long-term Care Ombudsman."
Open Enrollment Period (Medicare AdvantageManaged Care): The Open Enrollment Period (OEP) provides you with one opportunity to enroll in, disenroll from, or change a Medicare Advantage plan between January 1st through March 31st. To make a change, you must have Medicare Parts A and B and live in the MA plan’s service area. You cannot drop Part D coverage or pick up Part D coverage during the OEP.
Open Enrollment (for Medigap policies): If you enroll in Medicare Part B and you are 65 years old or older, there is a one-time, 6-month period called Open Enrollment. During this period, you are guaranteed that an insurer will sell you any Medigap policy and not charge you extra because of your health history. If you are younger than 65, blind or disabled, and on Medicare, you have an Open Enrollment period for 6 months when you are first eligible for Medicare Part B, but you may buy only one of 5 Medigap policies. However, this Open Enrollment period does NOT apply to people who have kidney failure, also known as end-stage renal disease (ESRD). When you are 65, regardless of whether you have end-stage renal disease, you qualify for a new Open Enrollment period, and you will have the opportunity to buy 1 of the 12 Medigap policies.
Original Medicare: Medicare is the federal health insurance program. It covers most people age 65 or older, some people under age 65 who are disabled, and people with end-stage renal disease. Original Medicare is divided into two parts: Part A: Hospital Insurance, and Part B: Medical Insurance. (Note: Part C and Part D are both offered by private insurance companies. Original Medicare (Parts A and B) is provided by the government.
The term ‘Original Medicare’ also refers to having fee-for-service Medicare, meaning having just Medicare and possibly a supplement insurance such as a Medigap, and not being enrolled in a Medicare Advantage plan.
Out-of-area Care: Health care received while outside the geographic service area of a Medicare Advantage managed care plan. Typically, prior approval is needed from the primary care provider before the plan will pay for out-of-area care, except in emergencies.
Outpatient: An individual who receives treatment at a hospital or clinic but does not require an overnight stay.

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Part A: The hospital insurance part of Original Medicare that covers inpatient hospital stays, hospice care, home health care, and care provided in skilled nursing facilities.
Part B: The medical insurance part of Original Medicare that covers doctors' services and outpatient care. Some of the other services covered include X-rays, medical equipment, and limited ambulance service.
Part C: See Medicare Advantage.
Part D: See Medicare Prescription Drug Coverage.
Participating Provider (for people in Original Medicare): A doctor or supplier who agrees to accept assignment on all Medicare claims. These doctors and suppliers may bill you only for Medicare deductibles and/or coinsurance amounts.
Patient Assistance Programs: Discount programs offered by pharmaceutical companies to low-income people who take some of the drugs that they manufacture.
Peer Review Organization (PRO): Now known as Quality Improvement Organization (QIO). See "Quality Improvement Organization" for information.
Penalty (Medicare Prescription Drug Coverage): Amount added to the premium of a Medicare prescription drug plan if you wait to enroll in one after your initial enrollment period and you do not have prescription coverage that is considered at least as good as the standard Medicare drug coverage (creditable coverage). The penalty is 1% per month for every month you were eligible for coverage and did not sign up. The penalty will be added to your premium each year for as long as you have Medicare prescription drug coverage.
Pre-existing Condition: A health problem discovered and treated before health insurance is bought. Usually, treatment must have been received sometime during the last six months for the condition to be considered pre-existing.
Preferred Provider Organization (PPO) Plans: A type of Medicare Advantage managed care plan in which you use doctors, hospitals, and providers that belong to a network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
Premium: A periodic or monthly payment made to Medicare, an insurance company, or health care plan for health care coverage.
Prescription Drug Plans (PDPs): Plans offered by commercial companies for Medicare Prescription Drug Coverage (also known as Part D). Plans differ in monthly premiums, drugs covered, cost-sharing amounts and participating pharmacies.
Preventative Benefits: Preventive benefits help keep you healthy by providing early detection of certain health conditions. Medicare covers several preventive services, such as cancer screenings, bone mass measurements, flu shots, and a “Welcome to Medicare” physical exam.
Primary Care Physician (PCP) (for people in Medicare Advantage plans): The main doctor to whom you go for care. This doctor is the first to check on your health problems and will coordinate your health care with other doctors, specialists, and therapists. In many Medicare managed care plans, you must see your primary care physician before you may see any other health care providers or specialists. Also known as a "gatekeeper."
Private Fee for Service (PFFS) Plans: A type of Medicare Advantage plan. Unlike HMOs, you are not required to use a network of providers. You can see any provider who accepts Medicare and agrees to accept payment from the PFFS plan. In this type of plan your providers do not bill Medicare for services. Instead, they must bill the PFFS plan, which then pays the bills using the funds they receive from Medicare on a monthly basis. Services covered by the plan usually require a copayment, and in some cases, require you to pay a percentage of the Medicare-approved amount, at times up to 35 percent.
Provider: An individual or facility, such as a doctor or hospital, that is licensed and certified by the State of California to provide health care services.
Provider Sponsored Organization (PSO): This is a type of managed care plan in which a group of doctors, hospitals, and other health care providers agree to give health care to people with Medicare for a set amount of money from Medicare every month. These plans are run by the doctors and providers themselves, and not by an insurance company.

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Qualified Disabled Working Individual (QDWI): An assistance program available to people who had Social Security and Medicare because of disability, but who have lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the limit allowed. QDWI pays the Part A premium if an individual meets certain qualifying criteria.
Qualified Independent Contractor (QIC): The entity that performs the second review in the Medicare Part A and B appeals process. The request for it must be in writing and sent directly to the QIC. More info: Medicare Part A and B appeals.
Qualified Individual (QI): An assistance program that pays a portion of Medicare Part B premiums for individuals who have a low monthly income and have Medicare Part A.
Qualified Medicare Beneficiary (QMB): An assistance program for people who have low monthly incomes and who qualify for Medicare. QMB pays the Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services provided by Medicare providers.
Quality (Health Care): Measurements of how well the health plan and care providers are doing at keeping their members healthy or treating them when they are sick. High-quality health care means doing the right thing at the right time, in the right way, for the right person — and getting the best possible results.
Quality Assurance: The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and then checking results to see if the treatment or therapy was successful.
Quality Improvement Organization (QIO): Groups of practicing doctors and other health care experts who have a contract with the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, private fee-for-service plans, and ambulatory surgical centers. For California, Health Services Advisory Group (HSAG) is the Quality Improvement Organization.

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Railroad Retirement: A social insurance program administered by the Railroad Retirement Board (RRB) that provides retirement benefits to the country's railroad workers.
Respite Care: Short-term care intended to give the caregiver (usually a family member) of a beneficiary in hospice some needed rest. Respite care must be provided in a Medicare-approved facility, such as a hospice inpatient facility, hospital or nursing home.
Service Area: The geographic area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
Share of Cost (Medi-Cal): The amount of money a person must pay in a given month before receiving Medi-Cal benefits. A share of cost is like an insurance deductible. People on Medi-Cal with a share of cost meet the resource limits for Medi-Cal ($2,000 for an individual and $3,000 for a couple) but have incomes above the monthly income limits. More info: Medi-Cal with a Share of Cost.
Skilled Nursing Care: A level of care including services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
Skilled Nursing Facility (SNF): A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services, and other related health services.
Social Security Administration (SSA): This federal government agency determines whether an individual is eligible for Medicare Parts A and B and is responsible for the enrollment process in Parts A and B. SSA distributes Medicare cards to beneficiaries and is responsible for administering the Low Income Subsidy ("extra help") available to people with low incomes and assets to help pay for Medicare Prescription Drug Coverage. SSA website.
Social Security Credits: For each $1,050 in earnings you have (in 2008), Social Security awards you one credit, up to a maximum of four credits for each year. The amount of earnings needed to obtain one credit increases each year. Most people require 40 credits (which takes 10 years to accumulate) to be eligible for benefits, although disability or survivor benefits may require fewer credits.
Social Security Disability Insurance (SSDI): Social Security Disability Insurance (SSDI) benefits are cash payments issued by the Social Security Administration to individuals who are unable to do any kind of work for which they are suited and whose disability is expected to last 12 months or longer, or who are terminally ill. Therefore, a person may have a disabling condition, but not meet the Social Security definition of disabled because he or she is still able to work. Individuals under age 65 may qualify for Medicare if they have been eligible for SSDI benefits for at least 24 months. People with end-stage renal disease (ESRD) are eligible for Medicare generally within three months of beginning dialysis. People with amyotrophic lateral sclerosis (ALS) (also known as Lou Gehrig's disease) are eligible for Medicare beginning with the first month of their eligibility for Social Security benefits.
Special Election Period: A set time period triggered by certain events when a beneficiary can change health plans or return to Original Medicare. These events include when you move outside the service area, or your Medicare managed care plan violates its contract with you, or the plan does not renew its contract with the federal government, or other exceptional conditions. The Special Election Period is different from the Special Enrollment Period (SEP).

Note: There are also several SEPs for Medicare Part D, Contact your local HICAP for more information.
Special Enrollment Period (SEP): A set time when you can sign up for Medicare Part B if you did not take Part B during the Initial Enrollment Period because you or your spouse was currently working and had group health plan coverage through an employer or union. You can sign up for Medicare Part B at any time while you are covered under the group plan. If the employment or group health coverage ends, you have eight months to sign up. The eight-month SEP starts the month after the employment ends or the group health coverage ends, whichever comes first. The Special Enrollment Period is different from the Special Election Period.
Special Needs Plan (SNP): A type of Medicare Advantage (MA) plan designed for certain populations. For example, an SNP may limit its enrollment to people in certain long-term care facilities (like a nursing home), people who are eligible for both Medicare and Medi-Cal ("dual eligibles"), or people with certain chronic or disabling conditions. The goal of these plans is to provide health care and services to those who can benefit the most from the expertise of the plans' providers and focused care management. All SNPs must provide Medicare prescription drug coverage.

Specified Low-income Medicare Beneficiaries (SLMB): An assistance program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources. These individuals have higher incomes than Qualified Medicare Beneficiaries (QMBs).
Standard Coverage (Medicare Prescription Drug Coverage): The basic coverage offered by Medicare prescription drug plans, which includes a set deductible, formulary, and copayment structure. More info: Medicare Prescription Drug Overview.
Suppliers: Individuals or agencies (aside from doctors or hospitals) that provide medical equipment or services. Some examples are ambulance companies, medical equipment rental businesses, and laboratories.
Supplemental Security Income (SSI): Administered through Social Security, SSI provides monthly payments to people who are blind or disabled and have limited income and resources. A person can be eligible for SSI even if s/he has never worked or paid taxes. A person can also be eligible for SSI while receiving social security benefits. How much SSI a person receives depends on where s/he lives. Generally, to be eligible for SSI payments a person must be a U.S. citizen or meet certain requirements for non-citizens. A person with SSI automatically qualifies for full Medi-Cal.

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TRICARE: TRICARE is the health care program for members of the military, eligible dependents, and military retirees. TRICARE was formerly called the CHAMPUS program.
True Out of Pocket (TrOOP) Costs: Expenses that count toward your Part D out-out-pocket threshold ($4,350 in 2009) and trigger catastrophic coverage. More Info: TrOOP

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Voluntary Enrollee: Voluntary enrollees are individuals who do not qualify for Medicare under the main categories (being 65 or older and receiving Social Security or Railroad Retirement benefits or being under 65 and receiving disability benefits for more than 24 months). Voluntary enrollees must be 65 or older and U.S. citizens or immigrants who have been in this country for 5 years (you must be a legal immigrant when you apply). As a "voluntary enrollee," you can buy into Medicare Part A and Part B, but you will have to pay a high monthly premium, which increases annually.

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Waiting Period: A waiting period is the time during which an insurance company does not have to pay benefits for a pre-existing condition. It can be no longer than six months and begins on the effective date of your policy.

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Page updated Jan. 5, 2009

Glossary

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