Glossary | Colorado Medicare Insurance Plans

Assignment: An acceptance by a doctor, provider or supplier to be paid directly by Medicare. This is acceptance to the payments Medicare specifically approves. The doctor, provider or supplier agrees to not bill you for any more than the Medicare deductible and coinsurance.
Beneficiary: An individual that receives their health care through Medicaid or Medicare Insurance.
Benefit period: A benefit period BEGINS the day a beneficiaries is admitted into a hospital or skilled nursing facility. A benefit period ENDS 60 days in a row after a beneficiary leaves the hospital or snf. Once a beneficiaries benefit period ends they are now subject to a new Medicare Part A deductible if they return for inpatient care.
Centers for Medicare & Medicaid Services (CMS): Medicare, Medicaid, and Children's Health Insurance Programs are administered by this federal agency.
Coinsurance: Typically a percentage of your medical costs that you owe. Medicare Part B coinsurance is 20%.
Coordination of benefits: Two or more health insurance plans work together to determine who pays a the same medical bill first.
Copayment: A flat fee that you owe as a portion of your medical costs. A doctor visit may have a copayment of $20 for example.
Coverage determination (Part D): Medicare drug plan decision about your drug benefits. Your prescription drug plan determines whether the drug is covered, and you have met requirements for obtaining the medication.
Coverage gap (Medicare prescription drug coverage): An individual pays higher amounts for their prescription drugs until they reach a certain dollar amount. Once they reach a specific threshold the individual then qualifies for catastrophic coverage, which lowers their medication costs.
Creditable coverage (Medigap): A Medigap policy may require a waiting period for pre-existing conditions unless the individual had creditable health coverage previously.
Creditable prescription drug coverage: This is prescription drug coverage, usually from an employer or union that is expected to pay at least as much as Medicare's standard prescription drug coverage. Anyone who has this type of coverage when they become eligible for Medicare can usually keep the coverage without paying a penalty if they decide to enroll in the Medicare prescription drug coverage at a later date.
Custodial care: Personal care with activities like eating, dressing, bathing and mobility. In general, custodial care is not covered by Medicare
Deductible: A deductible must paid first before Medicare or other insurance pays for an individuals medical costs.
Department of Health and Human Services (HHS): Center for Medicare and Medicaid services (CMS) is overseen by HHS. CMS oversees Medicaid, Medicare, CHIP - Childrens Health Insurance Program and the Marketplace.
Durable medical equipment: Medical equipment ordered by a doctor for use in a beneficiaries home (ie. Walker, wheelchair and hospital beds)
End-Stage Renal Disease (ESRD): Dialysis or kidney transplant needed due to chronic kidney failure
Extra Help: A program designed to help individuals with low income to fund Medicare prescription drug costs. This includes help with premiums, deductibles and coinsurance.
Formulary: A list of covered drug by a specific prescription drug plan or health insurer.
Generic drug: Generic drugs are typically less expensive than brand name drugs even though they have same active ingredients.
Home health care: Doctor ordered health care supplies and services in your home. Home health care is provided through Medicare on a limited basis as ordered by a doctor.
Homebound: Unable to leave home without some type of help including crutches, walker, wheelchair or special transportation. This is due to an injury or illness.
Hospice: A broad spectrum of care including physical, medical and emotional support for people terminally ill. This support is also provided for the terminally ills family and loved ones.
Inpatient care: Professional medicare care received in a hospital or skilled nursing facility to receive health care.
Lifetime reserve days: Original Medicare provides 60 reserve days that maybe used during a Medicare beneficiaries lifetime. These reserve days will be needed for hospital stays longer than 90 days. All costs are paid during the hospital stays except daily coinsurance.
Long-term care: Care for individuals who need assistance with the Acitivities of Daily Living (ADLs) which includes dressing, bathing, mobility assistance, etc. Most health insurance products do not cover long-term care except long term care insurance. Medicare does not cover Long Term Care.
Medicaid: Help for people with limited resources and income. Medicaid is a federal and state program that helps with health care costs.
Medicare: For people who are 65 or older, individuals under 65 with disabilities and those with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare is defined as a federal medical insurance program.
Medicare Advantage Plan (Part C): A Medicare health insurance provided by private insurance companies that contract with Medicare. Part C programs provide Part A and Part B coverage, and sometimes Part D coverage. Similar to most employer plans, Advantage plans offer HMO's, PPO's and other plan options
Medicare Health Maintenance Organization (HMO) Plan: HMOs are a type of Medicare Advantage health plan that typically requires a referral from a primary physician for medical treatment. Members of an HMO must adhere to a network when selecting a specialist, doctor, hospital or other medical provider
Medicare Part A: Referred to as Hosptial Insurance which includes admittance in hospitals, (SNFs) skilled nursing facilities, home health care and hospice care.
Medicare Part B: While Part A covers inpatient care (hospitals), Part B covers outpatient care. In addition to outpatient care, Part B also includes doctor's services, medical supplies and preventative services.
Medicare Preferred Provider Organization (PPO) Plan: PPOs are similar to HMOs in that they encompass a network of providers, including doctors, hospitals and other medical services. The main difference between HMOs and PPOs is that you may utilize a doctor outside the established network at an additional cost with a PPO plan. A plan that may be offered in a Medicare Advantage plan.
Medicare prescription drug coverage (Part D): Private insurance companies contract with CMS (Centers for Medicare and Medicaid services) to offer prescription drug programs for an additional cost through Part D.
Medicare Private Fee-For-Service (PFFS) Plan: In general, individuals enrolled in a PFFS plan can go to any doctor that accepts Medicare. The PFFS plan determines how much it will pay doctors or hospitals, so its very important to know and follow plan rules. You costs maybe more or less than if you had just original Medicare. Maybe offered via Medicare Advantage
Medicare Special Needs Plan (SNP): A plan for individuals in specific groups. These groups include individuals who have Medicare and Medicaid, who have certain chonics health conditions or live in a nursing home. Similar to HMOs and PPOs, Special Needs Plan are a type of Medicare Advantage.
Medicare Supplement policy (Medigap): A health insurance policy sold by private insurers to help fill "gaps" in a Medicare coverage.
Medicare-certified provider: Providers that have passed state inspection. Providers include home health agencies, hospitals, skilled nursing facilities. Coverage by Medicare is only offered through certified providers.
Network: A list of healthcare providers contracted with an insurer to provide healthcare for their members. Providers include doctors, supplies and healthcare facilities.
Occupational therapy: Therapy to help people recover from injury, illness or disabled. Recovery help includes help with daily activities like bathing, preparing meal and housekeeping.
Original Medicare: Health care plan consisting of Parts A and B. Part A is general for inpatient care like hospital stays and skilled nursing facilities and Part B is for medical services like doctors or medical supplies.
Out-of-pocket costs: Costs that are not covered by your health insurance or prescription drug plan or Medicare. Deductibles, Copayments and Coinsurance maybe part of your out of pocket costs.
Point-of-service option: An option that allows an individual to use hospitals and doctors outside the plan network in an HMO - Health Maintenance Organization. This option is for an additional cost.
Pre-existing condition: Health issue that exists before the beginning of the health insurance coverage.
Premium: Amount due to a private health insurer, Medicare or prescription drug plan for coverage.
Preventive services: Health services intended to avert or identify illnesses at a early stage. Many individuals will obtain flu shots, Pap tests and screening procedures to help prevent illness.
Primary care doctor: This is usually the first doctor you see for preventative care or other medical issues. Your primary care doctor may talk with your other medical providers to coordinate and evaluate your health.
Referral: Primary care physicians directive to obtain more extensive medical services or see a specialist. Most Health Maintenance Organizations (HMOs) require a referral to see a medical specialist.
Rehabilitation services: Medical services to help recover lost or impaired functioning due to sickness or disabledment. Physical, occumpational and sometime psychiatric therapy is involved with rehabilitation services.
Respite care: For individuals that have a friend or family caregiver may be temporarilty admitted to a nursing home, hospice care or hospital so that caregiver can rest or take a break.
Service area: Medicare Advantage plans generally have a specific geographic area that its plan accepts members. Often, this area is based on an individuals zip code. You maybe disenrolled if you move out of the plan's specified service area.
Skilled nursing care: Health care that may include occupational therapy, physcial therapy and the need for intravenous injections given by a registered nurse.
Skilled nursing facility (SNF): A facility that provides skilled nursing care which includes rehabilitation, speech therapy and other medical related services.
Step therapy: A criteria that precription drug plans require individuals to do with specific medications. A patient would be required to utilize lower cost medications first before proceeding to higher cost medications in order to receive coverage.
TRICARE: Active-duty and retired military service members as well as their families qualify for the Tricare health insurance program
Urgent Care: Medical services that are needed immediately and cannot wait to get medical attention from a provider within the plan network. Urgent care is provided outside the plan network.