Medicare Glossary

Medicare is a federal health insurance program primarily for individuals aged 65 and older, as well as for certain younger people with disabilities. Understanding the various terms associated with Medicare can help individuals make informed decisions about their healthcare. The Medicare Glossary* covers a comprehensive range of terms related to Medicare plans and benefits.

* See the Medicare Glossary Terms of Use at the bottom of this page.

A

Accountable Care Organization (ACO): A group of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal is to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

Advance Beneficiary Notice of Noncoverage (ABN): A notice given to Medicare beneficiaries by a healthcare provider or supplier that Medicare may not cover the services or items provided.

Advance Directive: A legal document that outlines a person's wishes for medical treatment in the event they become unable to communicate their preferences. 

Ambulance Services: Emergency transportation services to or from a hospital or other medical facility, covered by Medicare under specific conditions. 

Ambulatory Surgical Center (ASC): A facility that provides surgical services on an outpatient basis, where patients do not need to stay overnight. Medicare Part B covers services provided in ASCs. 

Annual Enrollment Period (AEP): A designated period each year (October 15 to December 7) when Medicare beneficiaries can enroll in or change their Medicare Advantage, Medicare Supplement, or Prescription Drug Plan.  

Annual Notice of Change (ANOC): A yearly notice received from a Medicare Advantage or Part D plan in late September. 

Appeal: A formal request to Medicare to reconsider a decision regarding coverage or payment for services or items.

Appeals Process: The procedure through which beneficiaries can challenge a denial of coverage or services by Medicare or Medicaid, often involving multiple levels of review. 

Appeal Rights: The formal process by which a beneficiary can challenge and seek a review of decisions made by Medicare regarding coverage or payment. 

Assignment: An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Assisted Living Facility (ALF): A residential setting providing personal care, such as help with daily activities, for individuals who do not need the intensive medical care provided in nursing homes but need more support than can be provided at home. 

Authorized Representative: An individual appointed by a Medicare or Medicaid beneficiary to make decisions or handle matters on their behalf, such as filing claims or appeals. 

B

Balance Billing: When a provider bills you for the difference between their charge and the amount Medicare will pay.

Behavioral Health Services: Mental health and substance use disorder services covered by Medicare and Medicaid, including counseling and therapy. 

Beneficiary: A person who receives benefits from Medicare.

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO): An organization that helps Medicare beneficiaries with complaints and quality of care concerns, ensuring that care is effective, safe, and respectful. 

Beneficiary Identification Number (BIN): A unique number assigned to each Medicare beneficiary for identification purposes when accessing healthcare services. 

Beneficiary Protection Center (BPC): A resource provided by some states or organizations that offers assistance and information to Medicare and Medicaid beneficiaries regarding their rights and protections. 

Benefit Period: For Medicare, the period during which Medicare pays for covered services, which starts with an inpatient hospital stay and ends when the beneficiary has not been an inpatient for 60 consecutive days.

Benefits Period: The time frame used by Medicare to measure your hospital and skilled nursing facility stays, which affects how Medicare pays for services. 

Budget Neutrality: A principle ensuring that changes in payment systems do not increase overall program costs. 

Bundled Payments: A method of reimbursement in which payments to healthcare providers are based on the expected costs of a predefined set of services. This approach encourages providers to deliver more efficient and coordinated care.

C

Care Coordination: The deliberate organization of patient care activities and sharing of information among all participants concerned with a patient’s care to achieve safer and more effective care. The organization of patient care activities between two or more participants involved in a patient’s care to ensure that services are not duplicated and gaps in care are addressed.

Caregiver Support Services: Programs and resources designed to assist individuals who provide unpaid care to family members or friends with health conditions, including respite care and counseling. 

Catastrophic Coverage: The stage in Medicare Part D coverage where after you have spent a certain amount of out-of-pocket costs, you only pay a small coinsurance or copayment for covered drugs for the rest of the year.

Certified Application Counselor (CAC): A trained individual who provides free assistance to individuals seeking to enroll in health insurance coverage through the Health Insurance Marketplace. 

Certified Nurse Practitioner (CNP): A registered nurse with advanced education and training who is certified to provide some services that may also be provided by a doctor, often covered by Medicare Part B. 

Chronic Care Improvement Program (CCIP): A Medicare program aimed at improving the quality of care for individuals with chronic conditions. 

Chronic Care Management (CCM): A program designed by Medicare to provide care coordination services to patients with multiple chronic conditions. It includes creating a comprehensive care plan, managing medications, and coordinating with various healthcare providers.

Chronic Care Model: A framework for organizing care that is focused on managing chronic diseases and conditions, improving patient outcomes, and enhancing the quality of care. 

Chronic Condition: A medical condition that is ongoing, such as diabetes or heart disease, which requires continuous management.

Coinsurance: The percentage of costs you pay after you've paid your deductible. For example, if Medicare pays 80%, you pay 20%.

Comparative Billing Report (CBR): A document provided by Medicare to providers that shows a summary of their billing patterns compared to their peers. It helps providers understand how their billing practices align with or differ from others.

Comprehensive Outpatient Rehabilitation Facility (CORF): A facility that provides outpatient diagnostic, therapeutic, and restorative services for the rehabilitation of injury, disability, or illness. CORF services include physician services, physical therapy, and social or psychological services.

Consumer Assistance Program (CAP): A program providing help with understanding and navigating health insurance options and benefits, often funded by state or federal sources. 

Consumer Operated and Oriented Plan Programs (CO-OPs): Nonprofit health insurance plans established to offer affordable and consumer-driven options in the health insurance marketplace. 

Coordination of Benefits (COB): The process used to determine the order in which multiple insurance plans pay for services when a beneficiary is covered by more than one plan. 

Copayment (Copay): A fixed amount you pay for a healthcare service or prescription drug, usually at the time you receive the service.

Cost-Sharing: The portion of healthcare costs that beneficiaries are required to pay out-of-pocket, including deductibles, copayments, and coinsurance. 

Coverage Gap (Donut Hole): A gap in prescription drug coverage under Medicare Part D where you might have to pay higher out-of-pocket costs for your medications after you and your plan have spent a certain amount, but before you reach the catastrophic coverage phase.

Critical Access Hospital (CAH): A designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS) to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities.

D

Deductible: The amount you must pay out-of-pocket for healthcare or prescriptions before Medicare begins to pay.

Deductible Limitation: The maximum amount you have to pay out-of-pocket for covered services before your health plan starts to pay. 

Donut Hole (Coverage Gap): See Coverage Gap.

Dual Eligible: Someone who is eligible for both Medicare and Medicaid.

Dual-Eligible Special Needs Plan (D-SNP): A type of Medicare Advantage plan specifically for individuals who are eligible for both Medicare and Medicaid, offering coordinated care across both programs. 

Durable Medical Equipment (DME): Medical equipment like wheelchairs, walkers, oxygen equipment, or hospital beds that are ordered by a healthcare provider for use in the home. DMEs are typically covered under Part B of Medicare.

Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS): Items covered by Medicare that include durable medical equipment, prosthetics, orthotics, and supplies needed for medical purposes. 

Drug Coverage Gap: See Coverage Gap. 

Drug Formulary: A list of prescription medications covered by a Medicare Part D plan, which can vary between plans. 

Drug List (Formulary): A list of prescription medications covered by a Medicare Part D or Medicare Advantage Plan, which can affect out-of-pocket costs for prescriptions. 

Drug Utilization Review (DUR): A program that ensures prescribed medications are appropriate, safe, and effective, and checks for drug interactions and overuse. 

E

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT): Medicaid's comprehensive and preventative child health program, which covers screening, diagnosis, and treatment for individuals under 21. 

Early Retirement: Retiring before reaching full retirement age, which can affect eligibility for certain Medicare benefits and premiums. 

Eligibility Verification: The process of confirming a person’s eligibility for Medicare or Medicaid benefits, often done through official documents or online verification systems. 

Emergency Medical Condition: A medical situation where immediate attention is needed to prevent serious harm or death, and which must be covered by Medicaid in emergencies.

Emergency Medical Transportation (EMT): Services provided to transport patients to emergency medical facilities, covered by Medicare under specific conditions. 

End-Stage Renal Disease (ESRD): Permanent kidney failure requiring dialysis or a kidney transplant.

Excess Charges: If you have Original Medicare and your doctor doesn't accept assignment, you may be billed for more than the Medicare-approved amount. These additional costs are called excess charges.

Explanation of Benefits (EOB): A statement sent by Medicare or your Medicare plan after you receive healthcare services, detailing what was billed, what Medicare paid, and what you may owe.

Extended Coverage: Additional benefits or services provided beyond the standard coverage, which may be available through supplemental insurance or specific health plans. 

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

F

Family Caregiver: An individual who provides unpaid care to a family member with health issues, potentially supported through various Medicare programs. 

Family Caregiver Support Program: A program that provides assistance and support to family members who are caring for individuals with chronic illnesses or disabilities, potentially including financial aid or respite services.

Federal Employees Dental and Vision Insurance Program (FEDVIP): Provides dental and vision insurance to federal employees, retirees, and their families, which is separate from Medicare coverage. 

Federal Employee Health Benefits (FEHB) Program: Health insurance coverage for federal employees and retirees, which can sometimes coordinate with Medicare benefits. 

Federal Poverty Level (FPL): A measure of income issued annually by the Department of Health and Human Services (HHS) used to determine eligibility for various programs, including Medicare Savings Programs.

Federally Qualified Health Center (FQHC): A health center receiving federal funding to provide primary care services in underserved areas, often providing care to Medicare and Medicaid beneficiaries. 

Formulary: A list of prescription drugs covered by a Prescription Drug Plan (PDP). The formulary may change annually.

Frailty: A condition often seen in older adults, characterized by decreased strength, endurance, and physiological function that increases an individual's vulnerability to dependency and death. Frailty is considered in Medicare programs to tailor healthcare services for the elderly.

FSA (Flexible Spending Account): A special account you put money into that you use to pay for certain out-of-pocket healthcare costs.

Full Benefit Dual Eligible (FBDE): Refers to individuals who qualify for both Medicare and Medicaid, receiving comprehensive health coverage through both programs, which often includes financial assistance for out-of-pocket costs. 

Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs): A Medicare Advantage plan specifically designed to provide comprehensive and integrated care for individuals who qualify for both Medicare and Medicaid benefits. They aim to streamline services and improve coordination of care for dual eligible beneficiaries.

G

Gap Coverage: See Coverage Gap.

Generic Drug: A prescription drug that has the same active ingredients as a brand-name drug and is approved by the FDA. Generic drugs usually cost less.

Good Faith Estimate (GFE): An estimate provided by healthcare providers of the expected costs of services, which is required under certain conditions to assist patients in understanding potential financial responsibilities.

Grandfathered Plan: A health plan that was in place before certain changes in law or regulations, which may still follow older rules or coverage guidelines. 

Grievance: A formal complaint about any aspect of your Medicare care, other than a decision regarding coverage or payment.

Group Health Plan: An employer-sponsored health insurance plan that may provide additional benefits to Medicare beneficiaries, often used in conjunction with Medicare coverage. 

Gross Income: Total income before any deductions or taxes, used to determine eligibility for various assistance programs, including some Medicare Savings Programs.

Guardianship: Legal authority granted to an individual to make decisions on behalf of someone who is unable to make their own decisions, which can impact Medicaid eligibility and benefits. 

H

Health Insurance Portability and Accountability Act (HIPAA): A federal law that protects the privacy of your health information and gives you rights over that information.

Health Maintenance Organization (HMO): A type of Medicare Advantage Plan that requires you to use doctors, hospitals, and other healthcare providers in the plan's network, except in emergencies.

Health Savings Account (HSA): A tax-advantaged savings account that can be used for qualified medical expenses, which may be relevant for some Medicare beneficiaries depending on their insurance setup.  An account used to pay for qualified medical expenses, often used in conjunction with high-deductible health plans. 

High-Deductible Health Plan (HDHP): A health insurance plan with lower premiums but higher deductibles, which may be paired with Health Savings Accounts (HSAs) for some Medicare beneficiaries. 

Highly Integrated Dual Special Needs Plan (HIDE-SNP): An integrated care plan that combines the benefits of Medicare and  Medicaid from a managed care organization (MCO) into a more unified care  plan. 

Home and Community-Based Services (HCBS): Services that support individuals in receiving care in their home or community rather than in an institutional setting, often covered by Medicaid. 

Home Health Care: Services provided in your home for the treatment of an illness or injury. Medicare covers certain home health care services under Part A and/or Part B.

Hospital Readmissions Reduction Program (HRRP): A Medicare program that reduces payments to hospitals with excess readmissions, encouraging hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and reduce avoidable readmissions.

I

Income-Based Assistance Programs: Programs that provide financial help based on a person's income level to cover costs like Medicare premiums, deductibles, and co-payments. 

Income-Based Premiums: Premiums for health insurance that are adjusted based on the beneficiary’s income level, potentially lowering costs for those with lower incomes. 

Income-Based Repayment: A plan that adjusts monthly payments for certain types of debts based on the borrower’s income, sometimes used in financial planning for healthcare costs. 

Income-Related Monthly Adjustment Amount (IRMAA): An additional amount some people might pay with their Medicare Part B and Part D premiums, based on their income.

In-Network: Refers to healthcare providers or facilities that are part of a health plan's network of providers with which it has negotiated a discount.

Initial Enrollment Period (IEP): A seven-month period when you can first sign up for Medicare (three months before the month you turn 65, the month you turn 65, and three months after).

Inpatient Rehabilitation Facility (IRF): A facility that provides intensive rehabilitation services to patients who need a high level of care and supervision.

Inpatient Care: Medical treatment that requires admission to a hospital.

Integrated Care: An approach to healthcare that coordinates primary, behavioral, and social services to treat the whole person more effectively. This approach is often used in managing patients with complex, chronic conditions.

Integrated Care Program: A program that combines various aspects of healthcare, including physical, mental, and social services, to provide comprehensive care for individuals with complex needs. 

J

J-Codes: Billing codes used for drugs administered in a clinical setting, such as injections or infusions, used by Medicare to process claims. 

J-Code (Healthcare Common Procedure Coding System - HCPCS): A specific type of billing code used to identify drugs administered in a clinical setting. 

Joint Commission: An independent, non-profit organization that accredits and certifies healthcare organizations in the United States, including those providing Medicare and Medicaid services. 

Joint Operating Agreements: Agreements between different healthcare organizations to collaborate on providing services, which can impact Medicare and Medicaid beneficiaries by offering integrated care options. 

K

Kaiser Family Foundation (KFF): A non-profit organization that provides information on health issues, including Medicare and Medicaid, often used as a resource for beneficiaries. 

L

Life Expectancy: The average number of years a person is expected to live based on various factors, which can affect healthcare planning and insurance coverage needs. 

Lifetime Reserve Days: Additional days that Medicare Part A 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.

Limited Benefit Plan: An insurance plan that provides only a specific set of benefits or a cap on the coverage amount, which can affect out-of-pocket costs and service availability. 

Long-Term Care: Services and support for personal care needs. Most long-term care isn’t medical care, but rather help with basic personal tasks of everyday life.

Long-Term Care Insurance: Private insurance designed to cover the costs of long-term care services, which Medicare generally does not cover comprehensively. 

Long-Term Services and Supports (LTSS): Services that help individuals with chronic illnesses or disabilities with daily activities, often covered partially by Medicaid. 

Low-Income Subsidy (LIS): Also known as "Extra Help," it is a program to help people with limited income and resources pay for Medicare prescription drug plan costs.

M

Maximum Out-of-Pocket (MOOP): Also known as Total Maximum Out-of-Pocket (MOOP), is the total amount you could pay for covered services in a plan year, after which the insurance plan pays 100% of the covered costs.

Medicaid Expansion: The expansion of Medicaid eligibility under the Affordable Care Act to include more low-income individuals, which varies by state. 

Medicaid Managed Care: A system in which state Medicaid programs contract with private managed care organizations to provide Medicaid services to beneficiaries. 

Medical Home: A model of care where a primary care provider coordinates all aspects of a patient’s care to ensure comprehensive and continuous care. 

Medically Necessary: Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.

Medicare Administrative Contractor (MAC): A private company that contracts with Medicare to process claims and perform other functions related to Medicare Part A and Part B.

Medicare Advantage (Part C): A type of Medicare health plan offered by private companies that contract with Medicare. These plans provide all Part A and Part B benefits, often including prescription drug coverage, and may offer additional benefits such as dental and vision care.

Medicare Advantage Organizations (MAO): Are private companies approved to offer Medicare benefits through Medicare Advantage plans, providing an alternative to traditional Medicare (Parts A and B) with additional coverage options like prescription drugs, dental, and vision. 

Medicare Benefits Manual: A comprehensive guide issued by the Centers for Medicare & Medicaid Services (CMS) outlining coverage, rules, and procedures for Medicare beneficiaries. 

Medicare Cost Plan (MCP): A health plan offered by private insurance companies, combining Medicare Part A and Part B coverage and often additional benefits. You can see any doctor that accepts Medicare, with Original Medicare covering out-of-network services. These plans offer flexibility with providers and can include extra benefits like vision or dental. Enrollment is possible anytime the plan is accepting new members, and you can leave the plan and return to Original Medicare anytime. 

Medicare Fraud: The intentional deception or misrepresentation made with the knowledge that the deception could result in an unauthorized benefit, often involving false billing or claims. 

Medicare-Medicaid Coordination Office: A federal office that works to improve the quality of care for individuals who are eligible for both Medicare and Medicaid by promoting better coordination of services. 

Medicare-Medicaid Plan (MMP): A type of health plan that provides coordinated services and integrated benefits for individuals who are eligible for both Medicare and Medicaid. These plans are designed to streamline care and improve outcomes for individuals who have complex health needs and are enrolled in both federal healthcare programs. 

Medicare Part A: Hospital insurance that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part A Deductible: The amount you must pay for hospital stays under Medicare Part A before Medicare begins to cover costs. 

Medicare Part B: Medical insurance that covers certain doctors' services, outpatient care, medical supplies, and preventive services.

Medicare Part B Deductible: The amount you must pay for outpatient care under Medicare Part B before Medicare starts paying. 

Medicare Part C (Medicare Advantage): A type of Medicare health plan offered by private insurance companies that includes all benefits from Part A and Part B and often additional benefits. 

Medicare Part D: Prescription drug coverage that helps pay for the cost of prescription drugs.

Medicare Part D Plan: A plan that offers prescription drug coverage and is offered by private insurance companies approved by Medicare. 

Medicare Savings Programs (MSP): State-run programs that help pay premiums, deductibles, coinsurance, and copayments for people with limited income and resources.

Medicare Summary Notice (MSN): A notice sent to Medicare beneficiaries every three months detailing all the services or supplies that were billed to Medicare, what Medicare paid, and what the beneficiary may owe.

Medicare Supplement (Medigap): Private insurance policies that help pay for some of the healthcare costs that Original Medicare doesn’t cover, such as copayments, coinsurance, and deductibles. Medigap plans are standardized and labeled A through N.

N

National Coverage Determination (NCD): A decision by the Centers for Medicare & Medicaid Services (CMS) on whether a particular service or item is covered under Medicare nationwide. 

Network: The facilities, providers, and suppliers your health insurer has contracted with to provide healthcare services.

Network Adequacy: Standards ensuring that a health plan has enough healthcare providers to deliver timely and appropriate care to its members. 

Network Pharmacy: A pharmacy that has a contract with a Medicare drug plan to provide prescription drugs to plan members at negotiated prices.

Non-Participating Provider: A healthcare provider who does not accept assignment for Medicare claims and may bill you for amounts above the Medicare-approved amount. 

Nursing Facility (NF) Care: Care provided in a facility, such as a nursing home, for individuals who require assistance with daily living activities and/or skilled medical care. 

Nursing Facility Quality Improvement Program: A Medicare initiative aimed at enhancing the quality of care in nursing facilities through improved standards and practices.

Nursing Home Care: Extended care provided in a facility for individuals who need help with daily activities or have significant medical needs. 

O

Observation Services: Hospital outpatient services given to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged.

Observation Status: A hospital classification for patients who are not admitted but are under observation, which affects coverage and billing.

Open Enrollment Period (OEP): The six-month period that begins when you first enroll in Medicare Part B, during which you can buy any Medigap policy sold in your state regardless of health status.

Original Medicare: The traditional Medicare program provided directly through the federal government, consisting of Part A (hospital insurance) and Part B (medical insurance).

Out-of-Network: Refers to healthcare providers or facilities that are not part of a health plan's network of providers.

Out-of-Pocket Costs: The expenses for medical care that aren’t reimbursed by insurance, including deductibles, copayments, and coinsurance.

Out-of-Pocket Maximum: The maximum amount a beneficiary will pay out-of-pocket for covered services in a plan year, after which the plan covers 100% of the costs. 

Outpatient Behavioral Health Services: Mental health and substance use disorder services provided on an outpatient basis, covered by Medicare Part B and Medicaid. 

Outpatient Care: Medical or surgical care that does not require an overnight stay in a hospital or medical facility.

Outpatient Services: Medical services or procedures performed that do not require an overnight stay in a hospital or medical facility. 

Outpatient Therapy Services: Services provided outside of a hospital setting to treat a variety of conditions, covered by Medicare Part B under certain conditions. 

Other Health Insurance: Insurance coverage other than Medicare, such as employer health plans, which may work in conjunction with Medicare to cover healthcare costs. 

P

PACE (Program of All-Inclusive Care for the Elderly): A Medicare and Medicaid program that helps people meet their healthcare needs in the community instead of going to a nursing home or other care facility.

Part B Drug: A drug that is usually not self-administered and that is provided as part of a doctor’s service.

Part D Drug: A drug available only by prescription, used and sold in the U.S., and used for a medically accepted indication.

Participating Provider: A healthcare provider who has agreed to accept Medicare's approved amount as full payment for covered services. 

Patient Protection and Affordable Care Act (ACA): A federal law aimed at expanding access to health insurance, reducing healthcare costs, and improving healthcare quality. 

Personal Care Services: Assistance with activities of daily living (ADLs) such as bathing, dressing, and eating, often provided in the home and covered by Medicaid in some states. 

Premium: The amount you pay for your Medicare or other health insurance monthly.

Preauthorization: The process by which a healthcare provider must obtain approval from Medicare or a Medicare Advantage Plan before providing certain services to ensure coverage. 

Preexisting Condition: A health condition that existed before enrolling in a new health insurance plan, which may affect coverage and costs depending on the plan and regulations. 

Preferred Provider Organization (PPO): A type of Medicare Advantage Plan that offers more flexibility in choosing doctors and hospitals. You pay less if you use providers in the plan's network, but you can use out-of-network providers for a higher cost.

Prescription Assistance Program: Programs that help individuals obtain prescription medications at reduced costs or through subsidies, which may complement Medicare Part D coverage. 

Prescription Drug Plan (PDP): A stand-alone plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

Preventive Services: Healthcare and medical services to prevent illness or detect illness at an early stage, such as flu shots and mammograms.

Primary Care Doctor: A doctor who provides general healthcare and coordinates other healthcare you may need.

Prior Authorization: Approval that you must get from a Medicare health plan before you receive a specific service or item to ensure that the service or item is covered.

Program Integrity: Efforts and practices aimed at preventing and detecting fraud, waste, and abuse in Medicare and Medicaid programs.

Q

Qualified Disabled and Working Individuals (QDWI) Program: A program that assists eligible individuals by covering their Medicare Part A premiums, specifically designed for disabled individuals who are employed.

Qualified Individual (QI) Program: A program that offers financial assistance to eligible individuals by covering their Medicare Part B premiums, aimed at reducing the cost burden for those with limited income.

Qualified Medicare Beneficiary (QMB) Program: A Medicare Savings Program that helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments for individuals with limited income and resources.

Quality Improvement Organization (QIO): An organization contracted by Medicare to review and improve the quality of care provided to beneficiaries. 

R

Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services.

Rehabilitation Services: Medical services aimed at restoring a person’s abilities or functional status, including physical therapy and occupational therapy. 

Respite Care: Temporary relief for a primary caregiver by providing substitute care for a patient.

Risk Adjustment Factor (RAF): A measure used in Medicare Advantage plans to adjust payments based on the health status and expected healthcare needs of beneficiaries.

Risk Adjustment Model: A method used to adjust payments to Medicare Advantage plans based on the health status and risk profile of their enrollees.

Rural Health Clinics (RHCs): Clinics located in rural areas that provide primary care services and are eligible for specific Medicare and Medicaid reimbursement programs. 

S

Secondary Insurance: An additional health insurance plan that pays for costs not covered by the primary insurance, often used in conjunction with Medicare to help cover additional expenses. 

SHIP (State Health Insurance Assistance Program): A state program that gets funding from the federal government to provide free local health coverage counseling to people with Medicare.  A program which also provides  free, unbiased counseling and assistance to Medicare beneficiaries, helping them understand their options and make informed decisions.

Skilled Nursing Facility (SNF) Care: A level of care that requires the daily involvement of skilled nursing or rehabilitation staff, which is covered by Medicare Part A under certain conditions.

Special Enrollment Period (SEP): A time outside the usual enrollment periods when you can sign up for Medicare or make changes to your coverage, triggered by certain events like moving or losing other insurance coverage.

Special Needs Plan (SNP): A type of Medicare Advantage Plan specifically designed to provide focused care and services to people with special health care needs, such as those living with chronic conditions or disabilities.

Specified Low-Income Medicare Beneficiary (SLMB) Program: A program that assists eligible individuals by paying for their Medicare Part B premiums, aimed at helping those with limited income to afford their Medicare coverage.

Supplemental Security Income (SSI): A federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind, and disabled people, who have little or no income.

State Children's Health Insurance Program (SCHIP): A program that provides health coverage to children in low-income families, often working in conjunction with Medicaid. 

State Medicaid Director: The official responsible for overseeing the administration of Medicaid programs in a state, including program management and policy implementation. 

State Medicaid Program: Each state's program that provides health coverage to eligible low-income individuals, including children, pregnant women, elderly, and disabled individuals. 

Supplemental Benefits: Additional benefits offered by Medicare Advantage plans beyond what is covered by Original Medicare, such as vision, dental, or fitness programs. 

T

Tax Credit for Health Insurance: A subsidy provided under the Affordable Care Act to help individuals and families pay for health insurance, which can be relevant for those with Medicare and Medicaid.

Telehealth: The use of electronic information and telecommunications technologies to provide care and services from a distance.

Telemedicine: The use of electronic communication and information technology to provide healthcare services remotely, often covered by Medicare under certain conditions. 

Tiered Formulary: A system used by Prescription Drug Plans to categorize covered drugs into different tiers. Drugs in lower tiers usually cost less than drugs in higher tiers.

Total Maximum Out-of-Pocket (MOOP): The total amount you could pay for covered services in a plan year, after which the insurance plan pays 100% of the covered costs. 

Transitional Care: Services provided to support a patient’s transition from a hospital or other care setting back to the community, including follow-up care and support. 

Transitional Care Management (TCM): A Medicare service designed to ensure that patients discharged from a hospital or other healthcare facility receive appropriate follow-up care. TCM services include a face-to-face visit with a healthcare provider and care coordination services.

Trial Right: A provision that allows Medicare beneficiaries to test a new Medicare Advantage plan for up to 12 months, during which they can return to their original Medicare coverage (Part A, Part B) and plan without penalty if they are not satisfied.

U

Universal Health Coverage: A health insurance system in which all citizens receive healthcare services, including preventive, curative, and emergency services, often discussed in comparison to U.S. healthcare programs. 

Urgent Care: Care for an illness or injury that needs immediate attention but isn’t severe enough for an emergency room visit.

Urgently Needed Care: Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away but isn't life-threatening.

Usual, Customary, and Reasonable (UCR): A standard used by insurance companies to determine the amount they will pay for services, based on what is usual, customary, and reasonable for the same service in a particular geographic area.

Utilization Management: The process of assessing the necessity, appropriateness, and efficiency of healthcare services and treatments to ensure quality and cost-effectiveness. 

Utilization Review: The process of evaluating the necessity, appropriateness, and efficiency of healthcare services and procedures, often used to manage costs and ensure quality. 

 V

Vaccines: Medicare Part B covers some preventive vaccines such as flu, pneumococcal, and Hepatitis B for certain individuals, while Part D covers other vaccines not covered by Part B.

Value-Based Care: A healthcare delivery model in which providers are paid based on patient health outcomes rather than the volume of services provided, aiming to improve quality and reduce costs. 

Value-Based Purchasing: A healthcare model where providers are rewarded for delivering high-quality care and achieving better patient outcomes, potentially affecting Medicare and Medicaid reimbursements.

Veterans Affairs (VA) Benefits: Health care benefits provided by the Department of Veterans Affairs to eligible veterans.

Veterans Health Administration (VHA): The part of the U.S. Department of Veterans Affairs that provides healthcare services to eligible military veterans.  Provides healthcare services to U.S. veterans, which may coordinate with Medicare and Medicaid benefits for eligible individuals. 

Visitor/Traveler (V/T) Beneficiary: A Visitor/Traveler (V/T) beneficiary refers to a U.S. citizen enrolled in Medicare who temporarily travels outside their Medicare Advantage (MA), Medicare Advantage with Prescription Drug (MA-PD), or Prescription Drug Plan (PDP) service area. Medicare typically covers emergency or urgently needed care during such travel, but plan restrictions and more may apply.

W

Waiver of Liability: A process that allows you to ask a healthcare provider to waive charges for services that Medicare doesn't cover.

Welfare-to-Work Program: Programs that assist individuals receiving public assistance in finding employment, which can impact Medicaid eligibility and benefits for low-income workers.

Wellness Incentive Programs: Programs offered by some Medicare Advantage plans that provide rewards or incentives for participating in health and wellness activities. 

Wellness Visit: A preventive visit to your primary care provider that includes a review of your health, risk assessment, and a personalized plan to maintain or improve your health. Many Wellness Visits are conducted yearly.

Wellness Visit: A yearly appointment with your primary care provider to create or update a personalized prevention plan and perform preventive services.

Work-Related Injury or Illness: An injury or illness that occurs as a result of employment, which may be covered by worker's compensation and could affect Medicare or Medicaid coverage. 

X

Xerox Imaging: A term sometimes used in healthcare for medical imaging technology, although not a standard term in Medicare or Medicaid contexts. 

X-Ray Technician: A healthcare professional trained to perform X-ray imaging procedures, which are covered by Medicare Part B when deemed medically necessary. 

X-rays: Imaging tests that use a small amount of radiation to create pictures of the inside of the body. Medicare Part B covers medically necessary diagnostic X-rays.

Y

Yearly Deductible: The amount you must pay for healthcare or prescriptions before Medicare or your plan begins to pay its share each year.

Yearly Maximum Benefit: The maximum amount a health plan will pay for covered services within a plan year, beyond which beneficiaries may be responsible for additional costs. 

Yearly Maximum Out-of-Pocket (MOOP): The total amount of money you would spend for covered services in a year before your plan pays 100% for the rest of the covered services.

Z

Zero-Cost Sharing Plan: A health plan where beneficiaries do not pay for covered services, which might be available in certain Medicare Advantage or Medicaid plans.

Zero-Dollar Copayment Plan: A health plan where beneficiaries do not pay any copayments for certain covered services, which may be part of a Medicare Advantage or Part D plan. 

Zero-Dollar Premium Plan: A Medicare Advantage plan that does not charge an additional premium beyond what you pay for Medicare Part B.

The Medicare Glossary is intended for informational purposes only and should not be considered medical, financial, or legal advice. Individuals should consult with a qualified healthcare professional, financial advisor, or legal expert before making any decisions regarding Medicare coverage. The terms included in this glossary may be updated periodically to reflect the latest changes and additions. For the most current and personalized advice, always seek professional guidance.

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