Glossary of Medicare and Health Insurance Terms

By: Source: AARP.org Date Posted: 2003-05-06 10:45:55

Accept Assignment
When doctors agree to accept the amount Medicare approves as payment in full for their services
Advocate/surrogate
A person you choose to make your wishes known to your doctor when you are unable to speak for yourself
Benefits
Health care services your health plan pays for, such visits to your doctor, approved hospital stays, and prescription drugs
Benefit Period (also called "Spell of Illness")
Under the Original Medicare Plan, a benefit period begins the day you go in the hospital or skilled nursing home. The benefit period ends when you have been out of the hospital or skilled nursing home for 60 days in a row. If you go into the hospital or skilled nursing again after 60 days have passed, you begin a new benefit period
Chronic illness
An illness that can go on for an extended period of time. Cancer, heart disease, diabetes, and arthritis are examples of chronic illnesses
COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law that gives certain workers and their families the right to keep their group health insurance longer if they lose it due to changes in their work or family life
Coinsurance
The amount you pay (usually a percentage) for your health care, after you pay the deductible
Copayment or "Copay"
The set amount you pay for each medical service you get. For example, a managed care plan might charge $15 - 20 for a doctor visit or for each prescription drug
Deductible
The amount you pay for your health care before your health plan begins to pay
Emergency Care
Care for severe pain, injury, sudden illness, or suddenly worsening illness that you believe can cause serious danger to your health if you do not get immediate medical care
Enroll
To join or sign up for a health insurance plan
Fee-for-Service
Traditional method of paying for medical care. You and/or your insurance company pay for each medical service you receive
Formulary
A list of medications preferred or recommended by your health plan. Doctors are encouraged to prescribe medicines on this list
Health Insurance Policy
The document that describes the health benefits an insurance company will and will not pay for
HIPAA (Health Insurance Portability and Accountability Act)
A federal law that gives you and your family certain protections when you are changing from one group plan to another or from a group plan to an individual insurance plan
Home Health Care
Health care that you get in your home for an illness or injury. Home health care services include skilled nursing care and physical, occupational, and speech therapy
Hospice Care
An organization or program that provides care and comfort for people who are dying and for their family members. Its focus is to help make people as comfortable as possible at the end of their life, rather than trying to cure their illness or injury. Hospice care includes physical care, pain control, and counseling
Health Maintenance Organization (HMO)
A managed care plan that provides health care to plan members on a pre-paid basis. In most HMOs, you must get all your care from the doctors and hospitals that are part of the plan's network. Usually a primary care doctor coordinates all of your care and refers you to specialists
Inpatient Care
Care you get in the hospital that requires an overnight stay
Insurable
You do not have certain medical problems that your insurance company does not want to pay for. You prove you are insurable by getting medical exams and tests that rule out certain medical problems
Medicaid
Medicaid is a federal and state insurance program that helps pay the health care costs of some people with low incomes
Medical Social Services
Counseling to help you cope with the social and emotional aspects of your illness
Medicare
Federal health insurance for people who are 65 and older, for some younger people with disabilities, and for people with end stage renal disease (kidney failure)
Medicare Approved Amount
The amount Medicare decides is a reasonable payment for a medical service. Medicare generally pays 80 percent of the approved amount and you pay 20 percent
Medicare + Choice Plans
A health plan, such as a Medicare Managed Care Plan or Medicare Private-Fee-for-Service Plan offered by a private insurance company and approved by Medicare. A Medicare + Choice plan is an alternative to the Original Medicare Plan that covers the same benefits and may offer extra benefits
Medicare Managed Care Plan
A health plan (like an HMO or PPO) that is offered by a private insurance company and available in some parts of the country. In most plans, you can only go to doctors, specialists or hospitals in the plan's network. The plan covers the same benefits as the Original Medicare Plan and may cover extras, like prescription drugs
Medicare Private Fee-for-Service (PFFS) Plan
A health plan offered by a private insurance company plan that accepts people with Medicare. You may go to any Medicare approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare program, decides how much you pay for the services you get. You may pay more for Medicare benefits. You also may have extra benefits not covered by the Original Medicare Plan
Medigap (Medicare Supplemental) Insurance Policies
Insurance policies sold by private insurance companies to fill some of the "gaps" or costs of the Original Medicare Plan. Except in Massachusetts, Minnesota and Wisconsin, you can choose from one of 10 standard policies, labeled A-J. Medigap policies only work with the Original Medicare Plan
Member Services
The department in your managed care plan that provides help and information to members of the plan and answers your questions about plan rules, costs, and health care services
Network
A group of doctors, hospitals, and pharmacies who contract with a health plan to provide health care to plan members. To get the most benefits for the lowest cost, you generally have to use the plan's network
Nursing Home (See Skilled Nursing Home)
Also called a skilled nursing facility
Original Medicare Plan
The traditional fee-for-service health plan that lets you go to any doctor or hospital that accepts Medicare. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). The Original Medicare Plan has two parts: Part A, which covers hospital services and Part B, which covers doctor services
Out-of-Pocket Costs
The part you pay for your health care. This may include premiums, deductibles, coinsurance, and/or copayments
Outpatient Care
Medical or surgical care that does not include an overnight stay in a hospital
Practice Protocols
Treatment guidelines set by medical specialty groups or other groups of health experts. These guidelines are based on high standards of medical care. You are more likely to get good quality care if your doctor follows the guidelines
Preferred Provider Organization (PPO)
A managed care plan that provides health care to its members on a prepaid basis. In a PPO, you can get care from the doctors and hospitals in the plan's network or pay more to go to doctors and hospitals outside the network. Many PPOs don't require you to choose a primary care doctor or get a referral to see a specialist
Premium
A payment for your health insurance. You might pay a premium to Medicare, an insurance company, or a health care plan. You usually pay premiums on a regular basis, such as monthly or quarterly
Preventive Care
Care that keeps you healthy or prevents illness, such as colorectal cancer screening, mammograms, and flu shots
Pre-existing Condition
A health care problem that was found and/or under treatment before the start date of a new insurance policy
Primary Care
Basic health care, such as a regular medical check-up. Primary care usually is given by a family practitioner, general practitioner, internist, obstetrician/gynecologist, nurse practitioner, or physician assistant
Provider
A person or facility, such as a doctor or hospital, that provides health care services
Quality Improvement Organization (QIO)
Groups of practicing doctors paid by Medicare to check and improve the care given to people with Medicare. A QIO reviews your appeals and complaints about the quality of care you have received
Rehabilitative Services
Health care ordered by your doctor to help you recover from an illness or injury. These services are given by skilled nurses and physical, occupational, and speech therapists. Examples of rehabilitative services are working with a physical therapist to help you walk and with an occupational therapist to help you take a shower or get dressed
Skilled Nursing Care
Care ordered by your doctor that must be given or supervised by a licensed registered nurse. Examples of skilled nursing care are giving shots, providing oxygen to help you breathe, and changing the dressing on a wound. Help from family members or care you give yourself is not considered skilled nursing care
Skilled Nursing Home (or Skilled Nursing Facility)
A place with the staff and equipment to give skilled nursing and/or rehabilitative care
Specialist
Doctors who focus on certain parts of the body or diseases. These doctors have many years of training in their specialty areas. Cardiologists (heart), oncologists (cancer), and rheumatologists (arthritis) are all specialists
State Health Insurance Assistance Program (SHIP)
A state program that is paid by Medicare to give free health insurance counseling and assistance to people with Medicare
Treatment Guidelines
(See Practice protocols.)
Urgently Needed Care
Care you get for sudden illness or injury that needs medical care right away, but is not life-threatening

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