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Medicare Glossary A - D from Humana
Medicare Terms and Definitions Explained
A | B | C | D
A
ACTUAL CHARGE
The amount of money a doctor or supplier charges for a specific medical service or supply. Because Medicare and insurance companies usually negotiate lower rates for members, this amount is often more than the "approved amount" you and Medicare actually pay.
ADMISSION
Entry into a facility as a registered inpatient according to the rules and regulations of the facility. An admission ends when you are discharged or released from the facility.
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ADMITTING PHYSICIAN
The doctor responsible for admitting a patient to a hospital or other inpatient health facility.
ADVANCE COVERAGE DECISION
A decision a Private Fee-for-Service Plan makes on whether a certain service is covered under the plan.
ADVANCED IMAGING
Radiology tests that use complex, highly developed, non-invasive technology to view the interior of the body. Examples include CT scans, ultrasound, MRA, and MRI tests.
AMBULATORY CARE
All types of health services that do not require an overnight hospital stay.
AMBULATORY SURGICAL CENTER
A place other than a hospital that does outpatient surgery – also known as an “in and out” center. At an ambulatory surgery center, you may stay for only a few hours or for one night.
ANNUAL DEDUCTIBLE
The amount of covered expenses you must pay before your insurance plan pays benefits. In Medicare, the annual deductible is the amount you must pay for healthcare before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. See the definitions for benefit period, Medicare Part A, and Medicare Part B.
ANNUAL ELECTION PERIOD
November 15 through December 31 of each year. Usually, this is the only time when Medicare Advantage health plans and prescription drug plans are open and accepting new members, other than those who are newly eligible. Medicare Supplement plans are open for enrollment year-round if you meet certain requirements. See the definition for Medicare Supplement insurance.
ANNUAL PLAN PREMIUM
The total amount you pay for a Humana Medicare plan during the calendar year.
APPEAL
A special kind of complaint you make if you disagree with a decision to deny a request for healthcare services or payment for services you already received. You can also make a complaint if you disagree with a decision to stop services you are receiving. For example, you may ask for an appeal if Medicare doesn’t pay for an item or service you think you should be able to get. Medicare Advantage and Medicare prescription drug plan carriers, as well as Original Medicare, must follow a specific process when you ask for an appeal.
APPROVED AMOUNT
The fee Medicare sets as reasonable for a covered medical service. This amount is what you and Medicare pay for a service or supply. The amount may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the “Approved Charge.”
ASSIGNMENT
In the Original Medicare plan, this term means a doctor agrees to accept Medicare’s approved amount as full payment. If you are in the Original Medicare plan, you can save money by going to a doctor who accepts assignment – but you may still have some costs, such as coinsurance. See the definitions for actual charge, approved amount, and coinsurance.
ASSISTED LIVING
A type of living arrangement where personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, assisted living residents pay a regular monthly rent plus additional fees for services they get.
AT-HOME RECOVERY
Under certain Medicare Supplement plans, this covers home care certified by your doctor for personal care, when recovering from a Medicare-covered injury or sickness. At-home recovery service must be received within eight weeks of the last Medicare-approved visit.
ATTENDING PHYSICIAN
The licensed doctor who has primary responsibility for the patient’s medical care and treatment.
AUTHORIZATION
A verbal or written approval from the health plan. To receive coverage for some services, members must get authorization before they receive care.
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B
BALANCE BILLING
A situation under Private Fee-for-Service Plans where some physicians can charge and bill you 15 percent more than the plan’s payment amount for services.
BENEFICIARY
A person who has health insurance through the Medicare or Medicaid program.
BENEFITS
The Medicare-approved services provided by an insurance policy. In a health plan, benefits are the coverage amounts for healthcare services you receive, such as doctor’s office visits, etc.
BENEFIT MAXIMUM
The largest dollar amount your health plan will pay toward your medical costs over the course of a plan year.
BENEFIT PERIOD
An interval of time during which you are admitted to a hospital or skilled nursing facility. The benefit period begins the day you go to the facility and ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins.
BENEFIT SUMMARY
A brief description or outline of your plan’s coverage, including the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.
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C
CALENDAR YEAR
The 12-month period that begins on January 1 and ends on December 31. When you first become covered under a policy, the first calendar year begins for you on the effective date of your policy and ends on the following December 31.
CATASTROPHIC ILLNESS
A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services for this type of condition could cause you financial hardship if you are not properly insured.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high-quality healthcare.
CERTAIN REQUIREMENTS
To be eligible for a Medicare Supplement plan, you must have Medicare Part A and Part B. You are guaranteed the right to buy a Medicare Supplement (Medigap) policy if you are in your Medigap Open Enrollment Period or covered under a protection. Your Medigap Open Enrollment Period, for Medicare Supplement plans, lasts six months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. Once your Medigap Open Enrollment Period starts it cannot be changed. Federal law doesn’t require insurance companies to sell Medigap policies to those under age 65, however, some states may require Medigap insurance companies to sell you a Medigap policy, even if you are under age 65. To find out more, check with your state insurance department.
CLAIM
A request for payment for services and benefits you received. Claims are also called bills for all Part A and Part B services billed through private insurance companies. The word claim is also used for Part B physician/supplier services billed through the private insurance companies. See definitions for Medicare Part A and Medicare Part B.
COINSURANCE
The percentage of billed charges you may have to pay after you pay any plan deductibles. The coinsurance payment is a percentage of the cost of the service. For instance, your health plan might pay 70 percent of billed charges, and your coinsurance payment is the remaining 30 percent.
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF)
A facility that provides a full range of rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
COORDINATION OF BENEFITS
A process for determining which plan or insurance policy pays first if a person has more than one health plan or insurance policy that covers the same benefits. If one of the plans is a Medicare health plan, federal law may decide who pays first. Also called cross-over.
COPAYMENT
The flat amount you pay to a healthcare provider or pharmacy at the time of service. Copayments vary depending on your plan and the services you receive. Copayments do not reduce your annual deductible or out-of-pocket maximums.
COST SHARING
The amounts you pay for medical care yourself – for example, a copayment, coinsurance, or deductible.
COVERED BENEFIT
A health service or item your health plan pays for either partially or fully.
COVERED SERVICES
Services a health plan pays for in part or in full, as defined and limited by statute. For instance, Medicare Supplement plans covered services include most doctor’s services, care in outpatient departments of hospitals, diagnostic tests, durable medical equipment, ambulance services, and other health services that are not covered by Medicare Part A.
CREDITABLE COVERAGE (Medicare Supplement Plans)
Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.
CREDITABLE COVERAGE (Prescription Drug Plans)
Prescription drug coverage (like from an employer or union), that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.
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D
DAYS SUPPLY
The amount of days the prescribed medication is to last – for example, a 30-day supply or 90-day supply.
DEDUCTIBLE
The total amount you must pay for healthcare before your health plan begins to pay.
DIAGNOSTIC SERVICES
An examination, test, study, or procedure performed to identify the condition that is causing symptoms or to determine the status of a condition. Most diagnostic services take place in an outpatient setting, although some may require a hospital admission or overnight stay in a hospital or diagnostic facility.
DISABLED ENROLLEE
An individual under age 65 who has been entitled to disability benefits for at least two years and who is enrolled in Medicare Part B.
DISCLOSURE
Release or divulgence of information by an entity to persons or organizations outside of that entity.
DISENROLL
To end your coverage with a health plan.
DOSE
Measured portion of medicine – for instance, 30 milligrams or 100 milligrams.
DRUG DISCOUNT PROGRAM
A program that allows members to receive a discount on medications not covered by their pharmacy benefit plan.
DRUG LIST
A list of medications your plan covers – also known as a formulary. Humana’s Medicare Drug List shows which drugs are covered and which drug tier they’re in – preferred generic, preferred brand, non-preferred brand, or specialty. See the definition for drug tiers.
DRUG TIERS
Some plans place prescription drugs together in a group, or tier. For example, Humana’s Drug List specifies whether a medication is a Preferred Generic, Preferred Brand, Non-Preferred Brand, or Specialty drug. With some plans, the amount you pay at the pharmacy depends on the tier for the drug.
DUAL ELIGIBLES
People who are entitled to Medicare and also eligible for Medicaid.
DURABLE MEDICAL EQUIPMENT (DME)
Certain purchased or rented items prescribed by a healthcare provider to be used in a patient’s home. Examples of durable medical equipment Medicare covers when medically necessary: hospital beds, iron lungs, oxygen equipment, seat lift equipment, and wheelchairs.
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