Medicare Glossary

A written notice that providers must give you before providing services that Medicare may not cover. The ABN explains why Medicare may deny payment and estimates the cost so you can decide whether to receive the service.

The period from October 15 to December 7 each year when you can make changes to your Medicare Advantage or Part D prescription drug coverage for the following year.

The process you can use if you disagree with a coverage or payment decision made by Medicare, your Medicare plan, or your Medicare prescription drug plan.

An agreement by a doctor or supplier to accept the Medicare-approved amount as full payment for covered services. When a provider accepts assignment, you only pay the coinsurance and deductible amounts.

A person who has health insurance coverage under the Medicare program. Also referred to as an enrollee.

The way Original Medicare measures your use of hospital and skilled nursing facility services. A benefit period begins the day you're admitted and ends when you haven't received inpatient hospital or skilled nursing care for 60 days in a row.

Medications derived from living organisms, such as vaccines, blood products, and gene therapies. These are typically covered under Medicare Part B when administered in a clinical setting.

The stage of Medicare Part D prescription drug coverage where you pay a reduced copayment or coinsurance after you've spent a certain amount out-of-pocket for covered drugs during the year.

The federal agency that administers the Medicare program and works with state governments to administer Medicaid and the Children's Health Insurance Program.

An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage, such as 20% of the Medicare-approved amount.

A fixed amount you pay for a covered health care service, usually when you receive the service. For example, you might pay $20 for a doctor visit or $10 for a generic prescription.

A temporary limit on what a Medicare Part D drug plan will cover. You enter the coverage gap after your total drug costs reach a certain amount. In the gap, you pay a percentage of costs for drugs until you reach catastrophic coverage.

Prescription drug coverage that's expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. If you have creditable coverage, you can generally join a Medicare drug plan later without paying a penalty.

The amount you must pay for health care or prescriptions before your health insurance begins to pay. For example, if your deductible is $1,000, you pay the first $1,000 of covered services yourself.

The process of ending your enrollment in a Medicare Advantage Plan or Medicare prescription drug plan.

A person who qualifies for both Medicare and Medicaid coverage. Dual eligibles may receive help paying Medicare premiums, deductibles, and copayments through Medicaid programs.

Medical equipment that can withstand repeated use, is primarily used for a medical purpose, and is appropriate for use in the home. Examples include wheelchairs, hospital beds, and oxygen equipment.

A medical condition with severe symptoms that a prudent layperson believes requires immediate medical attention to prevent serious jeopardy to health, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

A statement from Medicare or your Medicare plan that explains what services were provided, the charges, what Medicare or your plan paid, and what you may owe the provider.

A Medicare program that helps people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance. Also called the Low Income Subsidy (LIS).

A list of prescription drugs covered by a Medicare prescription drug plan or Medicare Advantage Plan with prescription drug coverage. Formularies include both brand-name and generic drugs.

Your right under Original Medicare to choose any doctor, hospital, or other health care provider that accepts Medicare and is accepting new Medicare patients.

A prescription drug that has the same active ingredients as a brand-name drug and is typically less expensive. Generic drugs must meet the same quality standards as brand-name drugs.

A complaint you make about your Medicare plan or the care you received. For example, you might file a grievance if you had to wait too long for an appointment or if you were treated poorly by a provider.

Rights you have in certain situations when insurance companies are required to sell or offer you a Medigap policy. In these situations, an insurance company cannot deny you coverage or charge you more due to past or present health problems.

A type of Medicare Advantage Plan where you generally must get your care from doctors, hospitals, and other providers in the plan's network, except in emergencies. You usually need a referral to see a specialist.

Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment, and medical supplies provided in your home.

A special way of caring for people who are terminally ill and their families. Hospice provides medical, psychological, and spiritual care with the goal of helping people who are dying have peace, comfort, and dignity.

The period when you begin to pay copayments or coinsurance for your prescriptions after meeting your deductible until your total drug costs reach the coverage gap threshold.

The 7-month period when you first become eligible for Medicare, which includes the 3 months before you turn 65, the month you turn 65, and the 3 months after you turn 65.

Health care you receive when you're formally admitted to a hospital or skilled nursing facility for a medically necessary stay.

An amount added to your monthly premium if you don't enroll in certain parts of Medicare when you're first eligible. The penalty continues for as long as you have Medicare coverage.

Extra days that Medicare will pay for when you're in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. After these are used, you pay all costs.

The maximum amount a doctor who doesn't accept assignment can charge you. The limiting charge is 15% over Medicare's approved amount.

See Extra Help. A program that helps people with limited income and resources pay for prescription drug costs.

The most you pay during a policy period (usually a year) before your health insurance begins to pay 100% of the allowed amount for covered services. Medicare Advantage Plans have an annual out-of-pocket maximum.

A joint federal and state program that helps with medical costs for people with limited income and resources. Medicaid programs vary from state to state.

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

A type of Medicare health plan offered by private companies that contract with Medicare. Medicare Advantage Plans provide all Part A and Part B benefits and may include additional coverage like vision, hearing, and dental.

Hospital insurance that helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.

Medical insurance that helps cover doctors' services, outpatient care, medical supplies, and preventive services.

Prescription drug coverage offered through private insurance companies approved by Medicare. Part D helps cover the cost of prescription medications.

State programs that help people with limited income and resources pay for Medicare premiums and, in some cases, deductibles, coinsurance, and copayments.

A type of Medigap policy that requires you to use specific hospitals and, in some cases, specific doctors to get full insurance benefits (except in emergencies).

A notice you get after the doctor, provider, or supplier files a claim for Part A or Part B services. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you may owe.

A Medicare Supplement Insurance policy sold by private insurance companies to help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.

The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. In most Medicare Advantage Plans, you generally pay less if you use providers in the plan's network.

A provider who doesn't have an agreement with your Medicare Advantage Plan or other Medicare health plan. You may pay more to see a non-contracted provider.

A prescription drug that isn't on your plan's formulary (list of covered drugs). You may need to pay full price for non-formulary drugs unless you get an exception from your plan.

Hospital outpatient services given to help a doctor decide if you need to be admitted as an inpatient or can be discharged. Observation services may be given in the emergency department or another area of the hospital.

See Annual Enrollment Period. The time period from October 15 through December 7 when you can change your Medicare Advantage or Part D coverage.

Original Medicare is fee-for-service coverage. The federal government provides this coverage directly. Part A (Hospital Insurance) and Part B (Medical Insurance) make up Original Medicare.

Providers or health care facilities that don't have a contract with your health plan. Depending on your plan, services from out-of-network providers may cost you more or may not be covered.

Health care costs you pay yourself, like deductibles, copayments, and coinsurance. This doesn't usually include your insurance premium.

Health care you receive without being admitted to a hospital, such as in a doctor's office, clinic, or same-day surgery center.

A type of Medicare Advantage Plan that requires you to get a referral from your primary care doctor to see a specialist, but allows you to go out-of-network for an additional cost.

A type of Medicare Advantage Plan where you pay less if you use doctors, hospitals, and other providers that belong to the plan's network. You can use providers outside the network for an additional cost without a referral.

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best. Examples include flu shots, cancer screenings, and annual wellness visits.

A doctor who provides or coordinates your routine health care. Some Medicare Advantage Plans require you to choose a primary care physician.

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital, or provider that accepts the plan's payment terms and agrees to treat you.

A Medicare Savings Program that helps pay Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments for people with limited income and resources.

A group of practicing doctors and other health care experts who are paid by the federal government to review the care given to Medicare patients to ensure it meets quality standards.

A management tool designed to limit the use of selected drugs for quality, safety, or utilization reasons. Quantity limits restrict the amount of a medication you can receive in a given time period.

A written order from your primary care doctor for you to see a specialist or get certain medical services. Some Medicare Advantage Plans require referrals.

Health care services that help you keep, restore, or improve skills and functioning for daily living that have been lost or impaired because of illness, injury, or disability.

Services from licensed nurses in your home or in a nursing facility. Skilled care is medically necessary care that can only be safely and effectively performed by licensed or skilled technical personnel.

A facility that provides skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services.

A time outside the Annual Enrollment Period when you can sign up for or change your Medicare coverage based on certain life events, such as moving or losing other coverage.

A type of Medicare Advantage Plan that limits membership to people with specific diseases or characteristics and tailors benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

A Medicare Savings Program that helps pay Part B premiums for people with limited income and resources.

A type of prior authorization that requires you to try one drug to treat your medical condition before the plan will cover another drug for that condition. Also called "fail first."

A document that provides a summary of what a Medicare health or prescription drug plan covers and what you pay. It includes information about premiums, deductibles, and covered services.

A grouping of prescription drugs that determines how much you pay. Generally, a drug in a lower tier costs less than a drug in a higher tier.

A one-time temporary supply of a drug that's not on your plan's formulary that you can get when you first join a Medicare drug plan or when your plan's formulary changes.

Costs that count toward the out-of-pocket threshold in the Medicare Part D prescription drug program. Once you reach this amount, you enter catastrophic coverage.

Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

The collection of activities designed to ensure that services are medically necessary and that they're provided in the right setting and in a cost-effective manner. This includes prior authorization, step therapy, and quantity limits.

Health care benefits available to veterans through the Department of Veterans Affairs. Having VA benefits doesn't affect your Medicare eligibility, and you can have both.

A one-time review of your health during the first 12 months you have Part B. During this visit, your doctor will review your medical and social history, provide health advice, and give you referrals for other services.

A yearly appointment with your primary care doctor to develop or update a personalized prevention plan. This visit is different from a physical exam and focuses on prevention and screenings.