Words to Know

Appeal

An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services, or payment for services you already received.  You may also make a complaint if you disagree with a decision to stop services you are receiving.  For example, you may ask for an appeal if Medicare doesn't pay for an item or service you think you should be able to get.  There is a specific process that your Medicare+Choice Plan or the Original Medicare plan must use when you ask for an appeal.

Coinsurance

The percent of the Medicare-approved amount that you have to pay after you pay the deductible for Part A and/or Part B.  In the Original Medicare Plan, the coinsurance payment is a percentage of the approved amount for the service (like 20%).

Copayment

In some Medicare health plans, the amount that you pay for each medical service, like a doctor's visit.  A copayment is usually a set amount you pay for a service.  For example, this could be $10 or $20 for a doctor's visit.  Copayments are also used for some hospital outpatient services in the Original Medicare Plan.

End-Stage Renal Disease

(ESRD)

Kidney failure that is sever enough to need lifetime dialysis or a kidney transplant.

Grievance

A complaint about the way your Medicare health plan is giving care.  For example, you may file a grievance if you have problems with the cleanliness of the healthcare facility, calling the plan, staff behavior, or operating hours.  A grievance isn't the same as an appeal, which is the way to deal with a complaint about a treatment decision or a service that isn't covered (see Appeal.)

Guaranteed Issue Rights

(also called "Medigap Protections")

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy.  IN these situations, an insurance company can't deny you insurance coverage or place conditions on a policy, must cover you for all pre-existing conditions and can't charge you more for a policy because of past or present health problems.

Home Health Care

Skilled nursing care and certain other health care you get in your home for the treatment of an illness or injury.

Medicare+Choice Plan

A Medicare program that gives you more choices among health plans.  Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage-Renal Disease unless certain exceptions apply.

Medicare Managed Care Plan

A Medicare+Choice Plan option that is available in some areas of the country.  In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan's list.  Plans must cover all Medicare Part A and Part B health care.  Some managed care plans cover extras, like prescription drugs.  Your costs may be lower than in the Original Medicare Plan.

Medicare Preferred Provider Organization (PPO) Plan

A Medicare+Choice Plan in which you use doctors, hospitals, and providers that belong to the network.  You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Private Fee-for-Service Plan

A Medicare+Choice Plan option in which you may go to any Medicare-approved doctor or hospital that accepts the plans payment.  The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get.  You may pay more for Medicare-covered benefits.  You may have extra benefits the Original Medicare Plan doesn't cover.

Medicare Specialty Plan

A Medicare+Choice Plan that provides more focused health care for some people.  These plans give you all your Medicare health care as well as more focused care to manage a disease or condition such as congestive heart failure, diabetes, or End-Stage Renal Disease.

Medicare Summary Notice (MSN)

A notice you get after the doctor files a claim for Part A and Part B services in the Original Medicare Plan.  It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.  You might also get a notice called a Notice of Utilization.

Medigap Policy

A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage.  Except in Massachusetts, Minnesota, and Wisconsin, there are ten standardized plans labeled Plan A through Plan J.  Medigap policies only work with the Original Medicare Plan.

Open Enrollment Period (Medigap)

A one-time only, six month period when you can buy any Medigap policy you want that is sold in your state.  It starts when you sign up for Medicare Part B and you are age 65 or older.  During this period, you can't be denied coverage or charged more due to past or present health problems.

Original Medicare Plan

A pay-per-visit health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients.  You must pay the deductible.  Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance).  The Original Medicare Plan has two parts:  Part A (Hospital Insurance) and Part B (Medical Insurance).

Quality Improvement Organization (QIO)

Groups of practicing doctors and other health care experts paid by the Federal Government to check and improve the care given to Medicare patients.  They must review complaints you have about your Medicare-covered services and questions about your rights as a hospital patient.

Regional Home Health Intermediary (RHHI)

A private company that contracts with Medicare to pay home health bills and check on the quality of of home health care.

Skilled Nursing Facility (SNF)

A facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitative services and other related health services.

Skilled Nursing Facility Care

A level of care that requires daily involvement of skilled nursing or rehabilitation staff.  Examples of skilled nursing facility care include intravenous injections and physical therapy.  Needing custodial care, such as help with bathing and dressing, can't, in itself, qualify you for Medicare coverage in a skilled nursing facility.  However, if you qualify for skilled nursing or rehabilitation care, Medicare covers all of your care needs in the facility.

State Health Insurance Assistance Program

A State program that gets money from the Federal Government to give free local health insurance counseling to people with Medicare.