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Friday, December 3, 2021

Glossary of Medicare Terms

Medicare Terms
• Co-payment
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.
• Cost Plans
A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan's network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).
• Deductible
The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
• HMO - Health Maintenance Organization
Local HMOs are plans with defined networks of providers, which beneficiaries must use in order to receive coverage, serving specific geographic areas consisting of aggregations of counties.
• HMO SNP - Special Needs Plan
Medicare Special Needs Plans are a type of Medicare Advantage Plan (Part C) for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions). Medicare SNPs provide their members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D). Medicare SNPs were created to give certain groups of people better access to Medicare with plans designed to meet their unique needs.
• HMO with POS Option
An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.
• LPPO - Local Preferred Provider Organization
Local PPOs are network based plans that serve specific geographic areas consisting of aggregations of counties, like HMOs, but with more flexibility in provider choice within the network. Beneficiaries may use providers outside the network but will pay more out of pocket cost.
• Medicaid
A joint Federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
• Medicare
The Federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
• Medicare Advantage
The Medicare Advantage program was created as part of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. The Medicare Advantage program replaced the Medicare+Choice program. It gives beneficiaries the option to receive their healthcare through a variety of private health plans (CMS, 2004).
• Medicare Part A (Hospital Insurance)
Coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
• Medicare Part B (Medical Insurance)
Coverage for certain doctors' services, outpatient care, medical supplies, and preventive services.
• Medicare Part C (Medicare Advantage Plan)
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
• Medicare Part D (Prescription Drugs)
A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
• MSA - Medicare Savings Account
MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.
• Original Medicare
Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A and/or Part B benefits.
• Out-of-Network
A benefit that may be provided by your Medicare Advantage plan. Generally, this benefit gives you the choice to get plan services from outside of the plan's network of health care providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.
• PACE - Programs of All-Inclusive Care for the Elderly
A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically-necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.
• PFFS - Private Fee-For-Service
These plans are private health plans that pay providers directly for the services they provide to Medicare beneficiaries using the same payment rates that apply in the traditional Medicare program (MedPAC, 2004). PFFS plans do not coordinate care, however they are part of the Medicare Advantage program and receive capitated payments from CMS for each enrollee.
• POS - Point-of-Service
In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.
• Prescription Drug Plans
Sometimes referred to as stand-alone prescription drug plans or PDPs, these are private plans that contract with Medicare to provide coverage for prescription drugs only. Beneficiaries who join a PDP continue to get all other Medicare benefits through the original, fee-for-service program.
• Primary Care Doctor
The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you 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.
• SNP - Special Needs Plans
Special Needs Plans are Medicare Advantage coordinated care plans that specialize in serving individuals with special needs such as those who are institutionalized, dual eligibles, or those suffering from chronic or disabling conditions.
• Star Rating
CMS rates Medicare Advantage plans on a scale of one to five stars, with five stars representing the highest quality. The CMS defines the star ratings in the following manner: 5 Stars Excellent performance; 4 Stars Above average performance; 3 Stars Average performance; 2 Stars Below average performance; 1 Star Poor performance.

Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or prescription drug coverage costs. For more information, visit, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.

If you have questions about Medicare, visit or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.