List of commonly used terms by those who service Medicare beneficiaries. If you have original Medicare and Medigap, or if you have an Advantage plan, you will encounter these words from time to time.
Any willing provider – Any doctor, hospital or medical practitioner that accepts Medicare assignment of benefits and agrees to the terms and conditions set forth by CMS.
Approved amount – Medicare set’s prices it considers adequate payment for medical services. This is the approved amount.
Assignment – Medical providers who accept the Medicare approved amount for services as payment in full. Seniors will save money by choosing doctors that accept assignment.
Beneficiary – One who is covered by original Medicare
Benefit period – Your benefit period begins the day you are admitted to a hospital or skilled nursing facility (SNF) and ends when you have not received any care for that illness or injury for 60 consecutive days. If you are admitted to a hospital or SNF after your benefit period ends you must satisfy a new deductible. There is no limit to the number of benefit periods you may have during a calendar year.
Carrier – A private insurance company that is approved to write coverage in your state. Carriers providing Medicare Advantage plans (Part C) and Prescription Drug Plans (Part D) must also be approved by CMS. Medicare supplement carriers are approved by your state but are not approved by CMS.
CMS – Center for Medicare Services.
Coinsurance – An amount you may be required to pay after you have satisfied your deductible. With original Medicare the amount is typically 20% of the approved amount billed after the deductible.
Copay, copayment, co-pay, co-payment – With some Advantage plans and Drug plans you are required to pay a fixed dollar amount every time you receive a service or purchase a prescription drug. Copay’s are also used for some outpatient hospital services covered by original Medicare.
Creditable coverage – Prior health coverage that affords you rights to supplement plans without restriction for pre-existing medical conditions. Examples of creditable coverage include an employer group health plan, COBRA, individual major medical coverage and Medicaid. Prior creditable coverage, without a break in coverage, allows you to bypass any waiting periods that might be imposed by a Medigap carrier.
Custodial care – Assistance provided by non-skilled personnel such as in an assisted living facility. Custodial care is not covered by original Medicare.
Deductible – An amount you must pay before original Medicare, your supplement plan, drug coverage or other insurance will pay. Original Medicare has deductibles that must be met before your Part A (hospital coverage) or Part B (doctor coverage) will pay. The deductible changes every year.
Drug list – Also called a drug formulary. This is a list of approved medications that are covered by your plan.
DME, Durable Medical Equipment – Medicare approved equipment for use outside the hospital. These can include wheelchairs, walkers, braces, hospital beds just to name a few.
Donut hole, doughnut hole – The coverage gap which you must pay under your Part D, prescription drug plan.
Dual eligible – One who is eligible for Medicare and public assistance through Medicaid.
Election period – The time during which you may enroll in original Medicare or an Advantage plan.
Enrollment period – A time when you may enroll or switch Medicare plans.
End of Life Counseling – A provision in Obamacare that would have paid your doctor extra to initiate end of life counseling and planning. This provision was repealed by HHS in January, 2011. You may still wish to discuss how much, or how little care you receive if you have a terminal illness, but your doctor will not receive a cash incentive to initiate these discussions.
ESRD, End Stage Renal Disease – Permanent kidney failure requiring dialisys or a kidney transplant.
Excess charges – The difference between what original Medicare allows and your doctor’s charge for services. If your doctor accepts assignment, they are limited in how much they can charge over and above the amount allowed by CMS.
Grievance – The process by which you may file a formal complaint with CMS about the way your plan or staff person has treated you.
Guaranteed issue rights, GI – Your rights under which a private insurance plan may not refuse to offer you coverage. In these situations, a carrier cannot refuse to offer you a policy or set restrictions on your coverage. If you apply during your guaranteed issue period, the carrier cannot charge you extra for pre-existing medical conditions or place exlusions on those conditions.
Guaranteed renewable – Medigap plans are guaranteed renewable (unless stated otherwise in the policy) and cannot be cancelled unless you have made false statements about your health on the application or have failed to pay the premium on a timely basis.