Glossary Terms

Confused by the lingo? Check out these definitions.

Benefit Period
Measurement of your hospital use. The period begins the day the patient is admitted in a hospital or skilled nursing facility (SNF) and ends when the patient no longer receives inpatient hospital care for 60 days.
The percentage a patient may be required to pay as a share of the cost for services after deductibles.
The fixed amount a patient maybe be required to pay as share of the cost for medical services or supplies (i.e. doctors visits or prescriptions).
Creditable Prescription Drug Coverage
Drug coverage received through insurance prior to your eligibility for Medicare that covers as much as Medicare would cover. When you become eligible for Medicare, you may generally keep this coverage.
Critical Access Hospital
A small facility that provides inpatient and outpatient services on a limited basis for people in rural areas.
Custodial Care
Non-skilled personal care that Medicare does not cover (i.e. bathing, dressing, eating, using the bathroom etc.).
The amount the patient must pay for health care and prescriptions before Original Medicare.
Special projects that usually operate for a limited time in order to test improvements in Medicare coverage, payment, and quality of care.
Extra Help
A Medicare program that helps people with limited income and resources pay premiums, deductibles, and coinsurance.
Formulary (Drug List)
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
Inpatient Rehabilitation Facility
A hospital that provides an intensive rehabilitation program.
Lifetime Reserve Days
Additional days that Medicare will pay for when the patient is in the hospital for over 90 days. Patients have a total of 60 reserve days that can be used within a lifetime. Medicare covers all costs except for daily coinsurance.
Long-term Care Hospital
Critical care hospitals that provide treatment for patients staying more than 25 days. Most patients are transferred from the intensive care unit (ICU). Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
Medically Necessary
The health care needed to diagnose or treat an illness, injury, condition, or disease that meet accepted standards of medicine.
Medicare-Approved Amount
In Original Medicare, this is the amount a doctor or supplier can be paid. Medicare pays part of this amount and the patient is responsible for the difference.
The periodic payment to Medicare, an insurance company, or a health care plan.
Preventive Services
Health care to prevent illness or detect illness at an early stage (i.e. mammograms, flu shots, pap tests).
Primary Care Doctor
The doctor patients see first for most health problems. In many Medicare Advantage Plans, the patient must see the primary care doctor before seeing any other health care provider.
A written order from a primary care doctor to see a specialist or get specific medical services. In many Health Maintenance Organizations (HMOs), if the patient does not get a referral first, the plan may not pay for the services.
Service Area
A geographic area where a health insurance plan accepts members if it limits membership based on location.
Skilled Nursing Facility (SNF) Care
Skilled nursing care and rehabilitation services provided on a daily basis is a SNF (i.e. physical therapy or injections that can only be given by a registered nurse (RN) or doctor).
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