Medicare Glossary

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Helps cover: 

• Inpatient care in hospitals 
• Skilled nursing facility care  
• Hospice care 
• Home health care

Helps cover: 

• Services from doctors and other health care providers 
• Outpatient care 
• Home health care 
• Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment) 
• Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)

A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits, with a few exclusions, for example, certain aspects of clinical trials which are covered by Original Medicare even though you’re still in the plan. Medicare Advantage Plans include: 

• Health Maintenance Organizations 
• Preferred Provider Organizations 
• Private Fee-for-Service Plans 
• Special Needs Plans 
• Most Medicare services are covered through the plan 
• Most Medicare Advantage Plans offer prescription drug coverage

Helps cover the cost of prescription drugs (including many recommended shots or vaccines). Plans that offer Medicare drug coverage (Part D) are run by private insurance companies that follow rules set by Medicare.

An agreement by your doctor, other health care provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service as payment in full, and not to bill you for any more than the Medicare deductible and coinsurance.

The way that Original Medicare measures your use of hospital and skilled nursing facility services. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a skilled nursing facility) for 60 days in a row. If you go into a hospital or a skilled nursing facility 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.

An amount you may be required to pay as your share of the cost for benefits after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

An amount you may be required to pay as your share of the cost for benefits after you pay any deductibles. A copayment is a fixed amount, like $30.

Prescription drug coverage that’s expected to pay, on average, at least as much as Medicare drug coverage. This could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, VA, or individual health insurance coverage.

The amount you must pay for health care or prescriptions before Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your other insurance begins to pay.

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

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.

Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit.

A joint federal and state program that helps with medical costs for some people with limited income and (in some cases) resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

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.

The payment amount that Original Medicare sets for a covered service or item. Medicare pays its share and you pay your share of that amount.

The payment amount that Original Medicare sets for a covered service or item. Medicare pays its share and you pay your share of that amount.

Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

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).

The doctor you go to first for most health problems. They may talk with other doctors and health care providers about your care and refer you to them.

A written order from your primary care doctor for you to visit a specialist or get certain medical services. Without a referral, your plan may not pay for services from a specialist.

An area you must live in for the plan to accept you as a member. 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. Plans can, and in some cases must, disenroll you if you move outside their service area.

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 care and therapy services provided on a daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a physical therapist or a registered nurse.