Advance Beneficiary Notice of Noncoverage — A notice given to a person with Original Medicare before an item or service is provided if it is believed that Medicare may deny payment. If you aren’t given this notice before you get the item or service and Medicare denies payment, then you may not have to pay for it.
Advance directive — A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a living will and a durable power of attorney for health care.
Appeal — The action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan or your Medicare Prescription Drug Plan. You have the right to appeal if Medicare, your Medicare health plan or your Medicare drug plan denies one of these:
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need.
Assignment — An agreement by your doctor, provider or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service and not to bill you for any more than the Medicare deductible and coinsurance.
Beneficiary and Family Centered Care Quality Improvement Organization — A type of quality improvement organization (a group of doctors and other health care experts under contract with Medicare) that reviews complaints and quality of care for people with Medicare. The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) makes sure there is consistency in the case review process while taking into consideration local factors and needs, including general quality of care and medical necessity.
Benefit period — A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.
Catastrophic coverage — After you reach your total out-of-pocket maximum for the year, you automatically get catastrophic coverage.
Coinsurance — The 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.
Coordination of benefits — A way to figure out who pays first when two or more health insurance plans are responsible for paying the same medical claim.
Copayment — An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
Cost sharing — An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit or prescription drug. This amount can include copayments, coinsurance and/or deductibles.
Coverage gap (Medicare prescription drug coverage) — The coverage gap, or donut hole, begins after the total cost of your medication (what you paid and what the plan paid combined) reaches a specified dollar amount for that year. Once you are in the coverage gap, you will receive a 75% discount on your medication. During the coverage gap, your costs may be higher than they were during the initial coverage phase, where you may have been paying less than 25% of the cost for your medications.
Creditable prescription drug coverage — Prescription drug coverage (for example, from an employer or union) that is as good as or better than Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.
Deductible — The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan or your other insurance begins to pay.
Donut hole — See Coverage Gap above.
Durable medical equipment — Certain medical equipment, like a wheelchair or hospital bed, that’s ordered by your doctor for use in the home.
Employer or union retiree plans — Plans that give health and/or drug coverage to employees, former employees and their families. These plans are offered to people through their (or a spouse’s) current or former employer or employee organization.
End-Stage Renal Disease — Also known as ESRD, this disease causes permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
Extra Help — A Medicare program, also known as Low-Income Subsidy (LIS), to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles and coinsurance.
Formulary — A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
Generic drug — A prescription drug that has the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand name drugs.
Grievance — A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you.
Group health plan — A health plan offered by an employer or employee organization that provides health coverage to employees and their families.
The size of the employer determines if Medicare is the primary or secondary insurance. In general, Medicare is the primary payer when you have a small group health plan. The definition of a small (or large) employer depends on the reason for Medicare eligibility.
Small Group Health Plan
There are exceptions to these rules. If you are uncertain of how your group health plan is classified, contact your employer.
Guaranteed issue rights — Rights you have in certain situations when insurance companies are required by law to sell or offer you certain Medigap policies. In these situations, an insurance company can’t deny you certain Medigap policies or place conditions on them, like exclusions for pre-existing conditions and can’t charge you more for certain Medigap policies because of a past or present health problem.
Guaranteed renewable policy — Insurance policies that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.
Health care provider — A person or organization that’s licensed to give health care. Doctors, nurses and hospitals are examples of health care providers.
Health Insurance Portability and Accountability Act of 1996 — Also known as HIPAA. The Standard for Privacy of Individually Identifiable Health Information (also called the Privacy Rule) of HIPAA assures your health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well-being.
Homebound — To be homebound means you have trouble leaving your home without help (like using a cane, wheelchair, walker, crutches, special transportation or help from another person) because of an illness or injury, or leaving your home isn’t recommended because of your condition and you’re normally unable to leave your home because it’s a major effort. You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.
Home health care — Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.
Hospice — A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver.
Hospital outpatient setting — A part of a hospital where you get outpatient services, like an emergency department, observation unit, surgery center or pain clinic.
Income-Related Monthly Adjustment Amount (IRMAA) — If you have higher income, the law requires an adjustment to your monthly Medicare Part B and Medicare Part D premiums. This adjustment is called IRMAA. Higher-income people pay higher premiums. This affects less than 5% of people with Medicare.
Initial coverage limit — Once you’ve met your yearly deductible, you’ll pay a copayment or coinsurance for each covered drug until you reach the year's out-of-pocket maximum.
In-network — Doctors, hospitals, pharmacies and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network doctors, hospitals, pharmacies and other health care providers.
Inpatient care — Health care that you get when you’re admitted to a health care facility, like a hospital or skilled nursing facility.
Lifetime reserve days — In Original Medicare, these are additional 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. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Limiting charge — In Original Medicare, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to durable medical equipment in Minnesota. All other Minnesota medical providers are required to accept assignment.
Living will — A written legal document, also called a medical directive or advance directive. It shows what type of treatments you want, or don’t want, in case you can’t speak for yourself. Usually, this document only comes into effect if you’re unconscious.
Long-term care — Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, like dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. People may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.
Long-Term Care Ombudsman — Long-Term Care Ombudsman are advocates for residents of nursing homes, board and care homes, assisted living facilities and similar adult care facilities. They work to resolve problems of individual residents and to bring about changes at the local, state and national levels that will improve residents’ care and quality of life. They may be able to provide information about home health agencies in your area.
Medicaid — A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
Medical Assistance — Also known as MA, this is Minnesota’s Medicaid program. It provides health care coverage to over 700,000 low-income Minnesotan’s each month. Most enrollees get their health care through health plans. The rest receive care on a fee-for-service basis, with providers billing the state directly for services provided.
Medically necessary — 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.
Medicare — Medicare is a federal health insurance program for people 65 and older, certain younger people with disabilities and people with End-Stage Renal Disease (ESRD).
Medicare medical savings account — A type of Medicare Advantage Plan that combines a high-deductible health plan and a medical savings account. Plans do not include coverage for Medicare Part D, but you may add a stand-alone Part D plan.
Medicare Administrative Contractor — Also known as MAC, this is a company that processes claims for Medicare.
Medicare Advantage Plan (Part C) — A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare Advantage prescription drug plan — A Medicare Advantage Plan that offers Medicare prescription drug coverage (Part D), Part A and Part B benefits in one plan.
Medicare-approved amount — In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.
Medicare-approved supplier — A company, person or agency that’s been certified by Medicare to give you a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.
Medicare-certified provider — A health care provider (like a home health agency, hospital, nursing home or dialysis facility) that’s been approved by Medicare. Providers are approved or certified by Medicare if they’ve passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified.
Medicare Cost Plan — A type of Medicare health plan available in Minnesota. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare.
Medicare Health Maintenance Organization Plan — A type of Medicare Advantage Plan also known as an HMO. In most HMOs, you can only go to doctors, specialists or hospitals on the plan’s list except in an emergency. Most HMOs also require you to get a referral from your primary care physician.
Medicare health plan — Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans and Demonstration/Pilot Programs.
Medicare Part A — Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
Medicare Part B — Part B covers certain doctors’ services, outpatient care, medical supplies and preventive services.
Medicare Part B-ID — Part B-ID covers immunosuppressive drugs for people with End-Stage Renal Disease who have lost Part B coverage because of a successful kidney transplant while on Medicare (after 36 months).
Medicare Preferred Provider Organization Plan — A type of Medicare Advantage Plan, also known as a PPO, in which you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. You can use doctors, hospitals and providers outside of the network for an additional cost.
Medicare Prescription Drug Coverage — Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.
Medicare Part D — Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
Medicare Private Fee-For-Service Plan — A type of Medicare Advantage Plan (Part C). also known as PFFS, in which you can generally go to any doctor or hospital you could go to if you had Original Medicare if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals and how much you must pay when you receive care. A PFFS Plan is very different than Original Medicare and you must follow the plan rules carefully when you go for health care services. When you’re in a PFFS Plan, you may pay more or less for Medicare-covered benefits than in Original Medicare.
Medicare Savings Program — A Medicaid program that helps people with limited income and resources pay some or all their Medicare Part A and B premiums, deductibles and coinsurance.
Medicare SELECT — A type of Medigap policy that may require you to use hospitals, and in some cases, doctors within its network to be eligible for full benefits.
Medicare Special Needs Plan — A special type of Medicare Advantage Plan (Part C), also known as SNP, that provides more focused and specialized health care for specific groups of people, like those who have both Medicare and Medical Assistance, who live in a nursing home or have certain chronic medical conditions. Minnesota has a SNP for people aged 65 and older who are eligible for Medical Assistance and enrolled in Medicare Parts A and B called Minnesota Senior Health Options (MSHO).
Medicare Summary Notice — A notice you get after the doctor, other health care provider or supplier files a claim for Part A or Part B services in Original Medicare. It explains what the doctor, other health care provider or supplier billed for, the Medicare-approved amount, how much Medicare paid and what you must pay.
Medigap basic benefits — Benefits that all Medigap policies must cover, including Part A and Part B coinsurance amounts, blood and additional hospital benefits not covered by Original Medicare.
Medigap open enrollment period — A one-time-only for most people, six-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. In the state of Minnesota, this period starts the first month that you’re covered under Part B. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems.
Medigap policy — Medicare Supplement Insurance sold by private insurance companies to fill gaps in Original Medicare coverage.
Minnesota insulin safety net program — Created to help Minnesotans who face difficulty affording their insulin. The program has two parts. The urgent need program and the continuing need program. In the urgent need program people who are eligible can receive a 30-day supply of insulin immediately at their pharmacy for no more than $35.00. In the continuing need program people who are eligible can receive up to a year supply of insulin for no more than $50.00 per 90-day refill. For more information go to mninsulin.org.
Modified adjusted gross income — Your adjusted gross income plus any tax-exempt Social Security, interest or foreign income you have.
Network — The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Original Medicare — Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A and/or Part B benefits.
Out-of-network — A benefit that may be provided by your Medicare Advantage Plan. Generally, this benefit gives you the choice to get plan services from outside of the plan’s network of health care providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.
Out-of-pocket costs — Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.
Outpatient hospital care — Medical or surgical care you get from a hospital when your doctor hasn’t written an order to admit you to the hospital as an inpatient. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests or x-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.
Penalty — An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don’t join when you’re first eligible. You pay this higher amount if you have Medicare. There are some exceptions.
Physical therapy — Treatment of an injury or a disease by mechanical means, like exercise, massage, heat and light treatment.
Point-of-service option — In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.
Preferred pharmacy — A pharmacy that’s part of a Medicare drug plan’s network. You pay lower out-of-pocket costs if you get your prescription drugs from a preferred pharmacy instead of a non-preferred pharmacy.
Premium — The periodic payment to Medicare, an insurance company or a health care plan for health or prescription drug coverage.
Preventive services — Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include pap tests, flu shots and screening mammograms).
Primary care doctor — The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.
Prior authorization — Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs.
Referral — A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Respite care — Temporary care provided in a nursing home, hospice inpatient facility or hospital so that a family member or friend who is the patient’s caregiver can rest or take some time off.
Secondary payer — The insurance policy, plan or program that pays second on a claim for medical care. This could be Medicare, Medical Assistance or other insurance depending on the situation.
Service area — A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.
Skilled nursing care — Care, such as certain intravenous injections, that can only be given by a registered nurse or doctor.
Skilled nursing facility — Also known as SNF. This is a nursing facility with the staff and equipment to give skilled nursing care, and in most cases, skilled rehabilitative services and other related health services.
Skilled nursing facility care — Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a SNF.
Social Security credits — You qualify for Social Security benefits by earning Social Security credits when you work in a job and pay Social Security taxes. Social Security credits are based on the amount of your earnings. You can earn up to the maximum of four credits per year.
Speech-Language Therapy — Also known as Speech-Language Pathology Services. Treatment that helps you strengthen or regain speech, language and swallowing skills.
State Health Insurance Assistance Program — A state program, also known as SHIP, that gets money from the federal government to give free local health insurance counseling to people with Medicare.
Step therapy — A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.
Supplemental Security Income — A monthly benefit paid by Social Security, also known as SSI, to people with limited income and resources who are disabled, blind or age 65 and older. SSI benefits aren’t the same as Social Security retirement or disability benefits.
Telemedicine — Medical or other health services given to a patient using a communications system (like a computer, phone or television) by a practitioner in a location different than the patient’s.
Tiers — Most Medicare Part D plans offer tier-based pricing. This means that drugs are grouped into categories called tiers. The cost of the drugs varies by tier. In general, a drug in a lowered number tier will cost you less than a drug in a higher numbered tier.
TRICARE — A health care program for active-duty and retired uniformed services members and their families.
TRICARE FOR LIFE — Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 and older, their eligible family members and survivors and certain former spouses.
