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Medicare Glossary M - P from Humana
Common Medicare Language Fully Explained
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MANAGED CARE ORGANIZATION
Entities that serve Medicare or Medicaid beneficiaries by having a network of employed or affiliated providers. The term generally includes Health Maintenance Organization, Preferred Provider Organization, and Private Fee-for-Service plans.
MAXIMUM ANNUAL BENEFIT (MAB)
The maximum dollar amount a health plan will pay during a plan period. The plan period is usually your effective date through the end of the calendar year.
MAXIMUM MEDICAL OUT-OF-POCKET
The most money you will be required to pay a year for deductibles and coinsurance, in addition to regular premiums.
MAXIMUM PLAN BENEFIT COVERAGE
The maximum dollar amount a health plan will pay during a benefit period. Medicare plans have a Maximum Plan Benefit Coverage limit only for service categories where the plan offers enhanced benefits.
MEDICAID
A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.
MEDICAL INSURANCE (Medicare Part B)
Insurance to cover medical expenses such as doctors’ services, outpatient hospital services, and a number of other non-hospital medical services and supplies.
MEDICALLY NECESSARY
Healthcare services or supplies that are appropriate for a particular sickness or injury. To be considered medically necessary, a healthcare service or item must be consistent with the symptoms and treatment of the injury or sickness. It also needs to be within the standards of good medical practice in the area and the most appropriate level of care that can be provided to you safely. Also, medically necessary services cannot be solely for your convenience or the convenience of a doctor or hospital.
MEDICARE
The federal health insurance program available to people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD) – permanent kidney failure with dialysis or a transplant.
MEDICARE ADVANTAGE HEALTH MAINTENANCE ORGANIZATION (HMO) PLAN
See the definition for Health Maintenance Organization (HMO).
MEDICARE ADVANTAGE ORGANIZATION
A state-licensed public or private entity that meets Centers for Medicare & Medicaid Services (CMS) requirements to hold a Medicare Advantage contract.
MEDICARE ADVANTAGE PLAN
A health plan offered by a private insurer as an alternative to Original Medicare. Medicare Advantage plans feature fixed costs, limits on out-of-pocket expenses with most plans, and worldwide coverage for emergency and urgent care. Plans can come with or without prescription drug coverage. Plan types include:
- Health Maintenance Organization plans (HMO)
- Preferred Provider Organization plans (PPO)
- Private Fee-for-Service plans (PFFS)
MEDICARE ADVANTAGE HEALTH MAINTENANCE ORGANIZATION (HMO) PLAN
See definition for Health Maintenance Organization (HMO)
MEDICARE ADVANTAGE PREFERRED PROVIDER ORGANIZATION (PPO) PLAN
See the definition for Preferred Provider Organization (PPO).
MEDICARE ADVANTAGE PRIVATE-FEE-FOR-SERVICE (PFFS) PLAN
See the definition for Private Fee-for-Service (PFFS).
MEDICARE-APPROVED AMOUNT
This is the amount Medicare and you pay to a doctor or supplier for a service or supply. It may be less than the actual amount charged by a doctor or supplier.
MEDICARE BENEFITS
Health insurance available under Medicare Part A and Part B – also known as Original Medicare.
MEDICARE COVERAGE
Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). See the definitions for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
MEDICARE ELIGIBLE EXPENSES
Expenses that are:
- Considered as covered by Medicare
- Recognized by Medicare as being reasonable and necessary
- Paid by Medicare NOT solely due to deductible or copayment provisions of the Medicare Act or because a maximum allowed under Medicare coverage has been exhausted
In determining if an expense is reasonable and necessary, Medicare considers the usual charge in the area where you live as well as the medical need for the treatment provided.
MEDICARE HANDBOOK
A booklet with information on such things as how to file a claim and what type of care is covered under the Medicare program. All Medicare beneficiaries receive this handbook when they first enroll in the program.
MEDICARE PART A (Hospital Insurance)
Federal insurance to cover hospital expenses such as room and board and other inpatient hospital services.
MEDICARE PART B (Medical Insurance)
Federal insurance to cover medical expenses such as doctors’ services, outpatient hospital services, and a number of other non-hospital medical services and supplies.
MEDICARE PART C (Medicare Advantage Plans)
Health benefits coverage offered by a Medicare Advantage Organization. You receive a specific set of health benefits at a uniform premium and uniform level of cost-sharing. Part C is available to all Medicare beneficiaries residing in a plan’s service area.
MEDICARE PART D (Prescription Drug Coverage)
Optional Medicare prescription drug coverage offered through private companies and organizations. You can get Part D coverage through a Medicare-approved stand-alone drug plan or a Medicare Advantage HMO, PPO, or PFFS plans that includes drug coverage.
MEDICARE PREMIUMS
The monthly premium you pay for your Medicare Part A or Medicare Part B coverage.
MEDICARE REQUIRED DRUGS AND SUPPLIES
Certain prescription drug products Medicare requires private insurers to cover.
MEDICARE SAVINGS PROGRAMS
Programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay your Medicare deductibles and coinsurance.
MEDICARE SELECT PLAN
Select plans are sold in some states (such as Louisiana). Medicare SELECT is one of the standardized Medigap plans A through L. However, you must use specific hospitals and, in some cases, specific doctors to get your full insurance benefits. Contact your state insurance department for more information.
MEDICARE SUPPLEMENT INSURANCE
A policy sold by a private insurance company that helps cover the “gaps” in coverage that are left unpaid after Original Medicare pays its portion of your healthcare expenses. For this reason, these plans are often called “Medigap” plans. Medicare Supplement policies pay only for services Medicare considers medically necessary. Payments are generally based on the Medicare-approved charge. The policy might not fully cover all of your medical costs.
Except in Minnesota, Massachusetts, and Wisconsin, there are 12 standardized policies labeled Plan A through Plan L. While the costs of these policies may vary, individual insurance companies must provide the same standardized benefits as outlined by law.
Get more information on Humana's Medicare Supplement Plans.
MEDICARE + CHOICE
Appears on: Enrollment – Enrollee Information The previous name for Medicare health plans offered by private insurers; now called Medicare Advantage.
MEDIGAP OPEN ENROLLMENT PERIOD
A one-time only, six month period when Federal law allows you to buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can't be denied a Medigap policy or charged more due to past or present health problems. Some state may have additional open enrollment rights under state law.
MONTHLY PREMIUM
The monthly payment to an insurance company or a healthcare plan for healthcare coverage in addition to your Medicare Part A or Part B premium.
MY DRUG LIST
Prescriptions you select in the Rx Calculator so you can estimate your costs. If you take a drug now or expect to take the drug, you can put the medication on “My Drug List” by clicking on the “Add a Drug” button.
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N
NETWORK
A group of healthcare providers who have agreed to charge a set rate for members of a health benefits plan. Providers on the list of network members are also called participating providers. Your network choices may vary, depending on your plan and where you live.
NON-COVERED SERVICE
The service:
- Does not meet the requirements of a Medicare benefit category
- Is not reasonable and necessary, as defined by statute 1862 (a)(1)
- Is excluded from coverage for other statutory reasons
NON-FORMULARY DRUGS
Drugs that are not included on a plan-approved list.
NON-NETWORK (Medicare Advantage Plans)
Doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health plan’s provider network. See the definition for network.
NON-PARTICIPATING PHARMACY (Medicare Advantage Plans and Medicare Prescription Drug Plans)
See definition for out-of-network pharmacy.
NON-PARTICIPATING PHYSICIAN (Medicare Advantage Plans)
See definition for out-of-network doctor.
NON-PREFERRED BRAND DRUG
Higher-cost brands that include drugs with preferred generic or therapeutic alternatives. Also includes some self-administered injectable medications.
NURSING FACILITY
A facility that primarily provides skilled nursing care and related services to residents, other than those with mental disabilities. Services provided may be either rehabilitation for people who are injured, disabled, or sick, or regular, health-related care services above the level of custodial care.
NURSING HOME
A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.
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O
OCCUPATIONAL THERAPY
Services to help you return to usual activities – such as bathing, preparing meals, housekeeping – after an illness. These services can be either inpatient or outpatient.
OPEN ENROLLMENT PERIODS (OEP)
A certain period of time when you can make one Medicare Advantage selection during January 1 thru March 31 of each year. See the definition for election period.
ORIGINAL MEDICARE PLAN
A pay-per-visit health plan that lets you go to any doctor, hospital, or other healthcare supplier who accepts Medicare and is accepting new Medicare patients. Medicare pays its share of the Medicare-approved amount, and you pay your share – coinsurance plus the deductible. See the definitions for coinsurance and deductible.
OUT-OF-AREA
Services provided to members of a Medicare Advantage plan by providers who have no contractual or other relationship with the plan.
OUT-OF-NETWORK
Doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health plan’s provider network. See the definition for network.
OUT-OF-NETWORK
Appears on: My Physicians page
The healthcare provider is not on the list of preferred providers for the health benefits plan. With PPO plans, you pay less when you use in-network providers – also known as participating providers. With HMO plans, you have coverage only with in-network providers. PFFS plans don’t have a network. Your network choices may vary, depending on your plan and where you live.
OUT-OF-NETWORK BENEFIT
Generally, an out-of-network benefit gives you the option to use a doctor, specialist, or hospital that is not a part of the plan’s contracted network. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.
OUT-OF-NETWORK DOCTOR
A primary care physician or specialist who does not belong to a health plan’s provider network. In some cases, your out-of-pocket costs may be higher for an out-of-network doctor. See the definition for network.
OUT-OF-NETWORK PHARMACY
A pharmacy that is not under contract with Humana. If you use an out-of-network pharmacy:
- You may pay a much larger share of the total cost of your care through deductible and coinsurance.
- You pay toward a separate deductible. Even if you have met your deductible for use of in-network providers, it does not count toward the separate deductible you pay if you got to an out-of-network pharmacy.
- In addition to paying coinsurance, you may be billed by an out-of-network provider for the amount not covered by your insurance plan.
OUT-OF-POCKET COSTS
Healthcare costs that you pay on your own because they are not covered by your Medicare plan or other insurance.
OUTPATIENT
Someone who received medical services or supplies while not confined in a hospital.
OUTPATIENT CARE
Medical or surgical care that does not include an overnight hospital stay.
OUTPATIENT HOSPITAL SERVICES
Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:
- Blood transfusions
- Certain drugs
- Hospital-billed laboratory tests
- Mental healthcare
- Medical supplies such as splints and casts
- Emergency room or outpatient clinic, including same-day surgery
- X-rays and other radiation services
OUTPATIENT SERVICES
A service you get in one day – 24 hours – at a hospital outpatient department or community mental health center.
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P
PART A (Original Medicare)
See the definition for Medicare Part A (Hospital Insurance)
PART B (Original Medicare)
See the definition for Medicare Part B (Medical Insurance)
PART C (Medicare Advantage Plans)
See the definition for Medicare Part C (Medicare Advantage Plans)
PART D (Medicare prescription drug coverage)
See the definition for Medicare Part D (prescription drug coverage)
PARTICIPATING HOSPITALS
For people with Original Medicare, these are hospitals that participate in the Medicare program.
PARTICIPATING PHYSICIAN OR SUPPLIER
For people with Original Medicare, this is a doctor or other provider who agrees to accept all Medicare claims. These providers accept “Medicare assignment.” They may bill you only for the Original Medicare deductible and your coinsurance or copayment amounts.
PATIENT ADVOCATE
A person whose job is to speak on a patient’s behalf and help patients get any information or services they need.
PCP
See the definition for Primary Care Physician.
PDP
See the definition for precription drug plan.
PERMANENT MAILING ADDRESS
The address where you currently reside. This is considered to be your primary residence.
PFFS PLAN
See the definition for Private Fee-for-Service (PFFS).
PHARMACY COINSURANCE
The set percentage you pay of the total cost of your prescription drug. When you go to an in-network pharmacy, your coinsurance is based on the Humana-approved charge, which may be less than the original charge.
PHARMACY COPAYMENT
The set amount you pay when you receive a prescription drug. A copayment can range from a few dollars to a few hundred dollars; depending on the type of drug you receive.
PHYSICAL THERAPY
Treatment of injury and disease by mechanical means such as heat, light, exercise, and massage.
PHYSICIAN
A licensed medical practitioner who is practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given.
PLAN PREMIUM
Your monthly payment to Humana for healthcare coverage or prescription drug coverage, in addition to your Medicare Part A or Part B premiums.
POWER OF ATTORNEY
A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a healthcare proxy, appointment of healthcare agent or a durable power of attorney for healthcare.
PPO PLAN
See the definition for Preferred Provider Organization (PPO).
PRE-EXISTING CONDITION
A condition for which a doctor gave you medical advice, recommended treatment, or provided treatment within six months before the effective date of your insurance plan.
PREFERRED BRAND DRUG
Medications manufactured by one manufacturer that are typically lower-cost among all brand-name drugs.
PREFERRED GENERIC DRUG
Drugs that are chemically the same as brand-name drugs with regard to their active ingredients, dosage, safety, strength, how they are taken, and what they are used to treat. Since generics work the same way in your body, they have the same risks and benefits as the brand-name medications. A generic drug is called by its “chemical” name instead of a “brand” name and is typically sold at a lower price. Talk to your doctor about your medication options. In most cases, your doctor can prescribe a generic drug instead of the "brand-name", saving you money when you fill the prescription.
PREFERRED PROVIDER ORGANIZATION (PPO)
A Medicare Advantage plan that gives you two ways to receive medical services. You can use doctors, hospitals, and other healthcare providers in the plan’s network and pay less for your care. Or you have the option of going outside the network, but you will pay more for your healthcare services. Get more information on HumanaChoicePPO plans.
PREMIUM
The payment to Medicare, an insurance company, or a healthcare plan for healthcare coverage. Most people pay their premium monthly.
PRESCRIPTION DRUG GUIDE
A list of the medications covered by Humana’s prescription drug benefits. See the definition for Drug List.
PRESCRIPTION DRUG PLAN
Optional Medicare drug coverage offered through private insurance companies – also known as a “PDP” or Medicare Part D. PDPs have a monthly plan premium in addition to the Medicare premium you already pay. PDP plan benefits vary, but companies offering these plans are required to offer benefits as good as or better than Medicare’s standard requirement.
PREVENTIVE CARE/ PREVENTIVE SERVICES
Care to keep you healthy or to prevent illness – for example, colorectal cancer screenings, yearly mammograms, and flu shots.
PRIMARY CARE
A basic level of care usually given by doctors who work with general and family medicine, internal medicine, pregnant women, and children. A nurse practitioner, a state-licensed registered nurse with special training, can also provide this basic level of healthcare.
PRIMARY CARE PHYSICIAN (PCP)
The doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she also may talk with other doctors and healthcare providers about your care and refer you to them. In many Health Maintenance Organization (HMO) plans, you must see your primary care physician before you see any other healthcare provider.
PRIOR AUTHORIZATION
Your doctor must obtain approval from Humana before the service or prescription will be covered.
PRIVATE FEE-FOR-SERVICE (PFFS) PLAN
With a private fee-for-service (PFFS) plan, you can visit any Medicare doctor, specialist, or hospital that accepts Medicare payment and accepts the terms, conditions and payment rate of the Humana Gold Choice PFFS plan. Get more information on Humana Gold Choice PFFS plans.
An Insurance Company with a Medicare Advantage contract to offer a Private Fee-for-Service plan available to anyone enrolled in both Part A and Part B of Medicare through age or disability. Enrollment period restrictions apply, call Humana for details. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan's terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Website at www.humana-medicare.com/humana-gold-choice-terms-conditions.asp.
PROCEDURE
Something done to fix a health problem or to learn more about it – for example, surgery, tests, or putting in an intravenous line.
PROVIDER
A person or facility that offers healthcare services – for example, a doctor, hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, non-physician provider, laboratory, supplier, etc. Generally, a provider is licensed or certified and practices within the scope of his or her license or certification.
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