General Medicare Definitions
Terms that will help You Navigate the Medicare Maze
The following are terms meant to help you better understand Medicare. If you have any questions about Medicare or what Medicare Supplement Insurance can do for you, contact MedicareMall now.
Benefit Period
Coinsurance
Co-payment
Creditable Prescription Drug Coverage
Critical Access Hospital
Custodial Care
Deductible
Extra Help
Inpatient Rehabilitation Facility
Institution
Lifetime Reserve Days
Long-Term Care Hospitals
Medically Necessary
Medicare-Approved Amount
Medicare Health Plan
Premium
Primary Care Doctor
Quality Improvement Organization (QIO)
Referral
Service Area
Skilled Nursing Facility (SNF) Care
TTY
Benefit Period
A benefit period begins the day you enter a hospital or skilled nursing facility (SNF), and ends 60 days after your last treatment. If you return to a hospital or SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods.
Coinsurance
This is your share of the cost for services. Included after you pay any deductibles, this may be applicable to you. Coinsurance is usually a percentage (for example, 20%).
Co-payment
A co-payment is the amount you may be required to pay as your share of the cost for a medical service or supply. A co-payment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
Creditable Prescription Drug Coverage
This coverage (often provided by an employer or union) is expected to pay, on average, at least as much as Medicare prescription drug plans. People who have this kind of coverage when they become eligible for Medicare can usually keep the coverage without paying a penalty if they decide later to enroll in Medicare prescription drug plans.
Critical Access Hospital
This is a small facility that provides outpatient services and limited inpatient services to people in rural areas.
Custodial Care
Custodial care provides non-skilled personal care such as help with such daily activities as bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include simple health-related care such as applying ointment or eye drops. In most cases, Medicare doesn’t pay for custodial care.
Deductible
This is the amount you must pay for health care or prescriptions before Original Medicare or any other health plan begins to pay.
Extra Help
This Medicare program helps people with limited income and resources pay Medicare prescription drug plan costs, including premiums, deductibles, and coinsurance.
Inpatient Rehabilitation Facility
This is a hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.
Institution
An institution is a facility that provides short-term or long-term care. Examples of institutions are nursing homes, skilled nursing facilities (SNFs), and rehabilitation hospitals. Private residences, such as assisted living facilities or group homes, are not considered institutions.
Lifetime Reserve Days
Original Medicare continues payments for a limited time when you are 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 a daily coinsurance.
Long-Term Care Hospitals
These acute-care hospitals provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
Medically Necessary
This refers to services or supplies that are needed for the diagnosis or treatment of a medical condition and meet accepted standards of medical practice.
Medicare-Approved Amount
In Original Medicare, this is the amount a doctor or supplier can be paid. It includes the amount Medicare pays along with any deductible, coinsurance, or co-payment that you pay. It may be less than the actual amount a doctor or supplier charges.
Medicare Health Plan
A Medicare health plan is offered by a private company that contracts with Medicare to provide Medicare Part A and Medicare Part B benefits to people on Medicare who enroll in the plan. Medicare health plans include Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-Inclusive Care for the Elderly (PACE).
Premium
A premium is a periodic payment to Medicare, an insurance company, or a health care plan provider for health or prescription drug coverage.
Primary Care Doctor
Your primary care doctor is the doctor you see first for most health problems. He or she makes sure you get the care you need to stay healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage plans, you must see your primary care doctor before you see any other health care provider.
Quality Improvement Organization (QIO)
This is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to people on Medicare.
Referral
A referral is a written order from your primary care doctor for you to see a specialist or to get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can receive medical care from anyone other than your primary care doctor. If you don’t get a referral, the plan may not pay for the services.
Service Area
Some health plans limit membership to residents of specific geographic areas. Members of a plan may be disenrolled if they move out of the plan’s service area.
Skilled Nursing Facility (SNF) Care
This refers to skilled nursing care and rehabilitation services provided on a daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy and intravenous injections that can only be given by a registered nurse or doctor.
TTY
A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or severely speech-impaired. TTY users can communicate with non-users through a message relay center (MRC), which has TTY operators available to send and interpret TTY messages.
That’s a lot to know.
That’s why MedicareMall is in your corner, ready to help you choose the Medicare supplement plan that’s best for you. With so many Medigap plan choices out there, MedicareMall will walk you through the Medicare maze and help you find the best Medicare supplement insurance possible. Contact MedicareMall now and we’ll work with you to ensure you get the coverage you need.
Return to the Learning Center
MedicareMall Learning Center Index