AM Best rating
AM Best is a global credit rating agency that specializes in evaluating the financial strength and creditworthiness of insurance companies and other related entities within the insurance industry. The AM Best rating is a prominent measure used to assess the financial stability and performance of insurance companies, providing valuable insights to policyholders, regulators, and other stakeholders.
Acute Illness
An acute illness refers to a health condition that develops rapidly and has a relatively short duration. These illnesses typically come on suddenly and may cause severe symptoms, but they generally resolve within a short period, ranging from a few days to a few weeks. Acute illnesses can be caused by various factors, including infections (e.g., influenza, common cold), injuries, sudden onset of medical conditions (e.g., appendicitis), or exacerbation of chronic conditions (e.g., asthma attack). Prompt and appropriate medical attention is often required to manage acute illnesses effectively and prevent complications. It is essential to differentiate acute illnesses from chronic conditions, which are characterized by long-lasting and persistent health issues.
Ambulance Services
Ambulance services refer to the specialized transportation of individuals in need of medical attention or urgent care from one location to another, usually from the scene of an emergency or from one medical facility to another. Ambulances are equipped with medical equipment and staffed by trained healthcare professionals, such as Emergency Medical Technicians (EMTs) or Paramedics, who can provide immediate medical care during transportation.
Annual Election Period (AEP)
The Annual Election Period (AEP) is a time frame from October 15th to December 7th each year when Medicare beneficiaries can make changes to their Medicare coverage. During this period, individuals can switch between Original Medicare and Medicare Advantage plans, change from one Medicare Advantage plan to another, enroll in or change Medicare Part D prescription drug plans, and make adjustments to their Medicare Supplement Insurance (Medigap) plans. Any changes made during the AEP take effect on January 1st of the following year, providing beneficiaries the opportunity to review and modify their health and drug coverage to better suit their needs for the upcoming year.
Annual In-Network Deductible
An annual in-network deductible is the specific amount of money that an individual must pay out of their own pocket for covered medical services received from healthcare providers within the insurance plan’s network before the insurance coverage starts to contribute to the costs. This deductible applies to services obtained from healthcare providers who have a contract or agreement with the insurance company, offering discounted rates for their services. Once the policyholder meets the in-network deductible, the insurance plan will begin to cover a portion or all of the eligible medical expenses as per the terms of the policy, subject to any copayments or coinsurance. The deductible typically resets at the beginning of each policy year.
Annual Notice of Change (ANOC)
The Annual Notice of Change (ANOC) is a document that health insurance companies and Medicare Advantage plans are required to send to their members each year. It is a detailed notice that outlines the changes in coverage, costs, or benefits that will take effect in the upcoming plan year. The ANOC provides important information to policyholders, such as changes in premiums, copayments, deductibles, covered services, and pharmacy networks. It allows plan members to review and understand how their health insurance coverage will be affected and gives them an opportunity to make informed decisions about their healthcare options for the coming year. The ANOC is typically sent out before the Annual Election Period (AEP), allowing beneficiaries to consider these changes when making decisions about their healthcare coverage during the AEP.
Annual Wellness Visit (AWV)
The Annual Wellness Visit (AWV) is a preventive healthcare service provided by Medicare to beneficiaries. It involves an annual comprehensive evaluation of a person’s health and risk factors, focusing on preventive care and health promotion. During the visit, a healthcare provider reviews medical history, conducts assessments and screenings, and offers personalized health advice. The AWV also includes the creation of a personalized prevention plan. This service is covered by Medicare, and beneficiaries can receive it without additional cost, helping them proactively manage their health and make informed decisions to prevent potential health problems.
Annual deductible
An annual deductible is the amount of money an individual must pay out of pocket for covered expenses before their insurance coverage begins. It is a common feature in health insurance plans. Once the deductible is met, the insurance coverage starts, and the insurer pays a portion or all of the eligible medical expenses. The deductible typically resets at the beginning of each policy year, and the policyholder must meet it again before insurance coverage applies to new expenses. The amount of the deductible can vary depending on the insurance policy chosen.
An appeal refers to the formal process through which patients or their representatives challenge or request a review of a decision made by a health insurance company, healthcare provider, or a government healthcare program (e.g., Medicare or Medicaid). The purpose of a healthcare appeal is to seek a reconsideration or reversal of a denied claim, coverage determination, or any adverse decision related to medical treatment, services, or benefits. Patients may appeal when they believe that the initial decision was incorrect, and they wish to provide additional information or evidence to support their case. The appeal process allows individuals to have their case reviewed by an independent and impartial entity, aiming to resolve disputes and ensure fair and appropriate healthcare coverage and treatment options.
An assignment refers to an arrangement where a healthcare provider (such as a doctor, hospital, or medical facility) agrees to accept the payment directly from the patient’s health insurance plan or government program (e.g., Medicare or Medicaid) as the full payment for the covered services rendered.
Assisted Living Facility
An assisted living facility (ALF) is a residential housing option designed to provide personalized support and care for individuals who require assistance with daily activities, such as bathing, dressing, medication management, and meal preparation, but do not need the intensive medical care provided in nursing homes. Assisted living facilities offer a home-like environment with private or shared living spaces and communal areas for socialization and recreation. Trained staff members are available 24/7 to help residents with their needs while promoting independence and autonomy. ALFs often provide various services and amenities to cater to the unique needs of their residents, ensuring a comfortable and safe living environment for older adults or individuals with disabilities.
Balance Billing
Balance billing refers to the practice where a healthcare provider bills a patient for the difference between the provider’s actual charges for a service and the amount paid by the patient’s health insurance company or other third-party payer. This situation typically arises when the provider is considered “out-of-network” by the patient’s insurance plan, and the insurer pays only a portion of the billed amount.
A beneficiary refers to an individual who is eligible to receive health benefits, medical services, or coverage under a health insurance plan or government healthcare program. The beneficiary is the person for whom the healthcare services are provided and who is entitled to receive the benefits outlined in the insurance policy or program. This can include medical treatment, prescription medications, hospitalization, preventive services, and other healthcare-related expenses covered by the insurance plan or program. The beneficiary may be the primary insured person, a spouse, dependent children, or any other eligible individual as specified in the terms and conditions of the healthcare coverage.
Benefit period
A benefit period refers to a specific period during which health insurance or government healthcare programs provide coverage for certain medical services. It begins when the insured individual receives covered services and ends after a predetermined time, as specified in the policy or program guidelines. During this period, the individual’s cost-sharing responsibilities, such as deductibles and coinsurance, apply. Once the benefit period ends, any applicable cost-sharing arrangements typically reset, and subsequent services may be subject to different terms. Understanding the benefit period is crucial for determining insurance coverage and the individual’s financial responsibilities for healthcare services within that timeframe.
CMS star rating
The CMS star rating is a rating system used by the Centers for Medicare & Medicaid Services (CMS) to assess and compare the quality of Medicare Advantage (Part C) and Prescription Drug Plans (Part D). The star rating ranges from 1 to 5 stars, with 5 stars representing the highest quality and 1 star indicating the lowest. CMS evaluates various aspects of the plans, including health outcomes, customer service, patient experience, preventive care, and medication management, to determine the star ratings. The CMS star rating provides valuable information to Medicare beneficiaries, allowing them to compare and choose Medicare plans based on their performance and quality of care. Higher-rated plans may receive bonus payments or have other incentives to encourage continuous improvement in the quality of care they offer
COBRA (Consolidated Omnibus Budget Reconciliation Act)
COBRA, the Consolidated Omnibus Budget Reconciliation Act, is a federal law in the United States that permits certain employees and their dependents to continue their employer-provided health insurance coverage after experiencing qualifying events that would otherwise lead to coverage loss. Qualifying events include job loss, reduced work hours, retirement, or other life changes affecting eligibility. Under COBRA, eligible individuals can opt for continued coverage for a limited time, paying the full premium themselves. This law provides a safety net during transitional periods, allowing individuals and families to maintain health insurance temporarily until they secure alternative coverage.
A caregiver is an individual who provides support, assistance, and care to another person who may have physical, emotional, cognitive, or medical needs. Caregivers are often family members, friends, or trained professionals who take on the responsibility of looking after individuals who cannot fully care for themselves due to age, illness, disability, or other circumstances. Caregiving tasks can vary widely and may include helping with daily activities such as bathing, dressing, feeding, medication management, transportation, and emotional support. Caregivers play a crucial role in enhancing the quality of life and well-being of those they care for, often dedicating their time, energy, and compassion to ensure the comfort and safety of their loved ones or clients.
Catastrophic Coverage
Catastrophic coverage is a type of health insurance plan designed to protect individuals from extreme financial burdens in the event of a serious illness or medical emergency. These plans have lower monthly premiums but higher deductibles, meaning the policyholder must pay a significant amount out of pocket before coverage begins. Once the deductible is met, catastrophic coverage plans provide substantial coverage for medical expenses, up to a maximum limit. They are often available to young adults and individuals under 30 or those who qualify for a hardship exemption, offering essential protection against major medical costs while keeping premiums more affordable for generally healthy individuals.
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services (HHS). CMS is responsible for administering and overseeing Medicare, a health insurance program for individuals aged 65 and older and certain disabled individuals, and Medicaid, a joint federal and state program providing health coverage to low-income individuals, pregnant women, children, and individuals with disabilities. CMS ensures the proper implementation of these vital healthcare programs, regulating and working in collaboration with states to provide access to healthcare services for millions of Americans.
Certificate of Medical Necessity (CMN)
A Certificate of Medical Necessity (CMN) is an official document used in the healthcare industry to support the need for certain medical equipment, supplies, or services prescribed to a patient. It serves as a formal justification or authorization for specific medical items or treatments that may be covered by insurance companies, government healthcare programs, or other third-party payers. The CMN is typically completed and signed by a licensed healthcare provider, such as a physician or therapist, and includes relevant medical information and clinical documentation that demonstrates the medical necessity of the prescribed items or services. The document helps ensure that patients receive appropriate and reimbursable medical care while providing a basis for insurance claims processing and reimbursement.
A claim is a formal request submitted by a healthcare provider to an insurance company or government healthcare program seeking reimbursement for medical services provided to a patient. The claim includes detailed information about the services rendered, associated medical codes, charges, and relevant documentation. After processing the claim, the payer determines the amount of reimbursement owed to the provider for the services delivered. The claim submission and reimbursement process play a crucial role in ensuring healthcare providers receive appropriate compensation for the care they offer to patients.
Coinsurance refers to the portion of medical expenses that an individual is required to pay out of pocket after meeting their health insurance deductible. It is a cost-sharing arrangement between the insured individual and the insurance company. Typically expressed as a percentage (e.g., 20% or 30%), coinsurance means that the insurance company will cover a certain percentage of the allowed cost for covered services, while the individual is responsible for paying the remaining percentage. For example, if a medical service costs $100 and the coinsurance is 20%, the insurance company would cover $80, and the individual would pay $20 as their coinsurance for that service. Coinsurance continues until the individual reaches their out-of-pocket maximum for the policy year.
Coordination of Benefits
Coordination of Benefits (COB) in the Medicare context refers to the process of determining how Medicare benefits will be coordinated with other health insurance coverage that a Medicare beneficiary may have. When a person has multiple sources of health insurance, such as employer-sponsored insurance, retiree coverage, or spousal coverage, COB ensures that the different insurance plans work together to avoid overpayment or duplication of benefits. Medicare follows specific rules for coordinating benefits with other primary and secondary insurers, ensuring that the total amount paid by all insurance sources does not exceed the actual cost of the medical services provided to the beneficiary. This process helps optimize the use of available insurance resources while reducing potential financial burdens on the beneficiary.
In the Medicare context, a copayment is a fixed amount that a Medicare beneficiary is required to pay out of pocket for certain medical services or prescriptions covered under their Medicare plan. The copayment is typically a set dollar amount and is paid at the time the service is rendered or when the prescription is filled. The specific copayment amounts can vary depending on the type of Medicare plan the individual has, such as Original Medicare (Part A and Part B), a Medicare Advantage (Part C) plan, or a Medicare Part D prescription drug plan. Copayments are a form of cost-sharing, where the beneficiary shares the cost of healthcare services with Medicare to help cover the overall expenses.
Cost Plan
A Cost Plan is a unique type of Medicare health plan available in specific areas of the United States. It combines features of Medicare Advantage and Original Medicare. Beneficiaries have the option to receive services from providers within the plan’s network or outside the network. When using in-network providers, the plan’s rules and cost-sharing apply. If services are received outside the network, the plan functions like Original Medicare. A significant advantage of Cost Plans is the option for “deemed enrollment,” allowing beneficiaries to retain Original Medicare benefits while keeping their Cost Plan coverage. Eligibility and availability of Cost Plans vary by location, making it essential for beneficiaries to review the plan’s terms and benefits to determine if it aligns with their healthcare preferences and needs.
Cost Tiers
Cost tiers refer to the categorization of prescription drugs or healthcare services into different levels or levels of coverage based on their costs. In the context of health insurance plans, including Medicare Part D prescription drug plans, cost tiers are used to determine the amount of copayment or coinsurance that the beneficiary must pay for a particular drug. Typically, prescription drugs are grouped into several tiers, with each tier having a different cost associated with it. For instance, generic drugs may be placed in a lower-cost tier, while brand-name drugs or specialty medications may fall into higher-cost tiers, resulting in varying out-of-pocket expenses for the beneficiary depending on the drug’s tier. Understanding the cost tiers helps individuals plan for their medication expenses and make informed decisions about their healthcare coverage options.
Cost-sharing refers to the arrangement in which individuals who have health insurance or participate in a healthcare program share the costs of their medical services with the insurance provider or program. This sharing of expenses can take various forms, such as copayments (fixed dollar amounts for specific services), coinsurance (a percentage of the total cost for services), or deductibles (a specified amount that individuals must pay before the insurance coverage begins). Cost-sharing is a way to distribute healthcare expenses between the insured individual and the insurance company or program, encouraging responsible use of medical services while ensuring access to affordable care.
Coverage Gap
The coverage gap, also known as the “donut hole,” is a period within Medicare Part D prescription drug coverage where beneficiaries are responsible for a higher percentage of the cost of their medications. This gap occurs after the initial coverage limit is reached but before catastrophic coverage begins. During this phase, beneficiaries pay a greater share of the drug costs until they reach a certain out-of-pocket threshold, at which point catastrophic coverage takes effect, and their cost-sharing decreases significantly. The coverage gap was designed to be gradually closed under the Affordable Care Act, reducing the burden of high drug costs for Medicare Part D beneficiaries.
Coverage Restrictions
Coverage restrictions are limitations set by health insurance plans or pharmacy benefit managers on the coverage of specific medications or healthcare services. These restrictions can include prior authorization, step therapy, quantity limits, or formulary restrictions. Prior authorization requires approval before coverage is granted, while step therapy mandates trying less expensive treatments first. Quantity limits cap the amount of medication covered, and formulary restrictions pertain to the list of covered medications. These measures aim to control costs and ensure appropriate healthcare utilization but may require additional steps or appeals for patients to access certain treatments or services.
Creditable Coverage
Creditable coverage refers to health insurance or prescription drug coverage that meets or exceeds the minimum standards set by the Centers for Medicare & Medicaid Services (CMS). It includes coverage provided by employer-sponsored health plans, group health plans, individual health plans, Medicare, Medicaid, and certain other government programs. When individuals have creditable coverage and later decide to enroll in Medicare, they can avoid paying late enrollment penalties for Part B (medical insurance) or Part D (prescription drug coverage). Having creditable coverage demonstrates that the individual had continuous healthcare coverage before joining Medicare, ensuring a smooth transition and protecting them from potential financial penalties.
Custodial Care
Custodial care refers to non-medical assistance or support provided to individuals who need help with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). These activities include tasks such as bathing, dressing, eating, mobility, using the toilet, managing medications, meal preparation, housekeeping, and transportation. Custodial care is primarily focused on helping individuals with their personal care and maintaining a safe and comfortable living environment. Unlike skilled nursing care, custodial care does not involve medical treatment or procedures. It is often provided by caregivers, home health aides, or assisted living facilities to help individuals with physical or cognitive limitations, such as seniors or individuals with disabilities, to maintain their independence and quality of life.
A deductible is a specific amount of money that an individual must pay out of their own pocket for covered medical services or expenses before their health insurance coverage starts to contribute. It is an annual cost-sharing requirement imposed by insurance plans to share the financial responsibility with the insured individual. Once the deductible is met, the insurance company typically begins to cover a portion or all of the eligible medical expenses, subject to any copayments or coinsurance as defined by the insurance policy. The deductible usually resets at the start of each policy year, and the amount can vary depending on the insurance plan and the type of coverage. Higher deductible plans often have lower monthly premiums, while lower deductible plans may have higher premiums.
Denial of Coverage
Denial of coverage refers to a decision made by an insurance company or healthcare payer to refuse coverage for certain medical services, treatments, or medications that a policyholder or patient has requested or requires. The denial may occur for various reasons, such as the service or treatment not being deemed medically necessary, not being covered under the insurance plan’s terms, or not meeting specific criteria for approval. When coverage is denied, the individual may be responsible for paying the full cost of the service or treatment out of pocket, unless they successfully appeal the decision or find an alternative method of obtaining coverage. Denials of coverage can be appealed if the patient believes the denial is in error or unjustified.
Department of Veterans Affairs (VA)
The Department of Veterans Affairs (VA) is a U.S. government agency responsible for providing a wide range of benefits, services, and support to veterans of the U.S. military and their eligible dependents. The VA offers comprehensive healthcare services through VA medical centers and clinics, including medical, surgical, mental health, and long-term care services. Additionally, the VA provides disability compensation, educational assistance, vocational rehabilitation, home loan programs, life insurance, and burial benefits, among other services, to honor and assist veterans in recognition of their service to the nation. The VA’s mission is to care for and support veterans, ensuring they receive the benefits and services they earned through their military service.
Detailed Explanation of Non-Coverage (DENC)
A Detailed Explanation of Non-Coverage (DENC) is a formal notice provided to Medicare beneficiaries when their hospital stay is ending, but the hospital believes that continued care is not necessary or covered by Medicare. The DENC is given to the patient at least two days before the planned discharge date and provides detailed information about the reasons for the proposed discharge, the services that will no longer be covered, and the patient’s right to appeal the decision. This notice aims to inform the patient of their discharge rights and options, allowing them to consider their next steps and potentially appeal the decision if they believe they still need medically necessary care that should be covered by Medicare.
Detailed Notice of Discharge
A Detailed Notice of Discharge (DNOD) is a formal notice provided to Medicare beneficiaries when they are being discharged from a skilled nursing facility (SNF) or other healthcare facility. The DNOD includes important information about the reasons for the discharge, the date of the discharge, any services that will no longer be covered, and the patient’s right to appeal the discharge decision. This notice is intended to inform the patient of their discharge rights and options, ensuring they have the opportunity to understand the reasons behind the decision and to take appropriate actions if needed, such as arranging for alternative care or appealing the discharge if they believe it is not appropriate.
Disability refers to a physical or mental impairment that substantially limits one or more major life activities of an individual. A person with a disability may experience challenges in areas such as walking, seeing, hearing, speaking, or performing essential tasks independently. Disabilities can be temporary, permanent, or progressive, and they vary in their impact on an individual’s ability to participate fully in daily life. People with disabilities may qualify for various support services, accommodations, and benefits to enhance their quality of life and facilitate their inclusion in society.
Disenrollment is the voluntary process of withdrawing or canceling membership in a health insurance plan or healthcare program. Individuals may choose to disenroll for various reasons, such as changing plans, becoming eligible for different coverage, or no longer needing the current insurance. To disenroll, individuals usually provide notice to the insurance company or program administrator. Disenrollment allows individuals to end their participation in a particular plan and seek alternative coverage, ensuring continued access to healthcare services that meet their changing needs and circumstances.
Donut Hole
The Donut Hole, also known as the Coverage Gap, is a phase within Medicare Part D prescription drug coverage where beneficiaries pay a higher portion of the cost for their medications. This occurs after reaching the initial coverage limit but before entering catastrophic coverage. During this gap, beneficiaries are responsible for a greater share of their drug costs until they reach a certain out-of-pocket spending threshold. Once the threshold is reached, they move into the catastrophic coverage phase, where their cost-sharing significantly reduces. The Donut Hole was designed to be gradually closed under the Affordable Care Act, providing relief for Medicare Part D beneficiaries by reducing their out-of-pocket expenses for prescription drugs.
Drug Tiers
Drug tiers refer to the categorization of prescription medications into different levels or tiers based on their cost and coverage by a health insurance plan, especially in Medicare Part D prescription drug plans or other drug coverage plans. Each tier represents a specific level of cost-sharing for the beneficiary, typically in the form of copayments or coinsurance, depending on the drug’s tier. Generally, generic drugs are placed in lower-cost tiers, while brand-name drugs or specialty medications are placed in higher-cost tiers. The specific tier assignments for drugs can vary between different insurance plans, and beneficiaries should review their plan’s formulary to understand how drugs are classified and what their out-of-pocket costs may be for each tier.
Dual-eligible individuals are those who qualify for both Medicare and Medicaid benefits. They are typically low-income and meet the eligibility criteria for both government healthcare programs. By being dual-eligible, they receive comprehensive healthcare coverage, including medical services, prescription drugs, long-term care, and other essential healthcare services. The coordination of benefits between Medicare and Medicaid ensures that these individuals have access to a wide range of healthcare services and support to meet their healthcare needs effectively.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) refers to medical devices, equipment, and supplies that are used to aid in the treatment, management, or recovery of a medical condition or disability. These items are intended for repeated use and must be prescribed by a healthcare provider. Examples of DME include wheelchairs, walkers, crutches, hospital beds, oxygen equipment, diabetic supplies, and certain prosthetics. Durable Medical Equipment plays a critical role in supporting patients with mobility issues, chronic conditions, or post-surgery recovery, enhancing their quality of life and enabling them to carry out daily activities more independently.
End-Stage Renal Disease (ESRD)
End-Stage Renal Disease (ESRD) refers to the advanced and irreversible stage of kidney disease where the kidneys have lost their ability to function effectively. In ESRD, the kidneys are no longer able to filter waste products and excess fluids from the blood, leading to a buildup of toxins and fluid imbalances in the body. Individuals with ESRD require ongoing dialysis treatments or a kidney transplant to sustain life since the kidneys cannot perform their vital functions adequately. ESRD is a serious condition that requires comprehensive medical management to manage its symptoms and complications effectively.
Enrollment Periods
Enrollment periods refer to specific timeframes during which individuals can sign up for or make changes to their health insurance plans, such as Medicare, Medicaid, or private health insurance coverage. These periods are typically designated by government agencies or insurance companies and occur annually or under certain qualifying circumstances. During enrollment periods, individuals can choose a new plan, switch plans, or make adjustments to their existing coverage, ensuring access to healthcare services and benefits that align with their needs and circumstances. It is essential for individuals to be aware of and take advantage of these enrollment periods to secure appropriate health insurance coverage and avoid potential penalties for late enrollment.
Evidence of Coverage (EOC)
The Evidence of Coverage (EOC) is a document provided by health insurance plans, like Medicare Advantage or Medicare Part D plans, containing crucial details about the plan’s benefits, costs, coverage rules, and limitations. It serves as a comprehensive guide for beneficiaries, explaining how the plan operates, what medical services and drugs are covered, associated costs (such as premiums and copayments), and procedures for accessing healthcare services. Reviewing the EOC is vital for understanding one’s rights and responsibilities under the plan and making informed decisions about healthcare coverage options.
Exception Request
An exception request is a formal appeal submitted by a patient or their healthcare provider to seek coverage or special consideration for a specific medical service, treatment, or medication that may not be typically covered by the insurance plan. It is made when the standard coverage criteria do not fully meet the patient’s unique medical needs. The request asks the insurance company to make an exception and consider covering the service or medication due to medical necessity or other valid reasons. The insurance company reviews the request and makes a decision based on relevant medical information and coverage guidelines.
Excess Charge
Excess charge in Medicare refers to the additional amount that a healthcare provider can bill beyond the Medicare-approved amount for a service when they do not accept assignment. This charge is limited to 15% above the Medicare-approved amount, and beneficiaries are responsible for paying it out of pocket. However, some states restrict excess charges, and some providers may not charge excess amounts even if they don’t accept assignment. Beneficiaries should verify providers’ acceptance of assignment to avoid unexpected costs.
Expedited Appeal
An expedited appeal is a rapid process used to appeal a denial of coverage or service by a health insurance plan or healthcare program. It is requested when the patient’s medical condition or treatment urgency requires immediate attention. The insurance company or program must respond promptly and make a swift decision to provide coverage or service if the denial would seriously jeopardize the patient’s health or life. The expedited appeal process ensures timely access to crucial healthcare services when urgent action is needed.
Explanation of Benefits (EOB)
Explanation of Benefits (EOB) is a statement or document that health insurance companies send to policyholders after a healthcare service or medical treatment has been provided and processed by the insurance company. The EOB provides detailed information about the medical services or treatments received, the amount billed by the healthcare provider, the portion covered by the insurance company, any remaining balance, and the patient’s financial responsibility, such as copayments, deductibles, or coinsurance. The EOB helps policyholders understand how their insurance benefits were applied to the specific medical services and provides transparency into the financial aspects of their healthcare coverage.
Extra Benefits
Extra benefits in healthcare or health insurance are additional services or perks offered by some insurance plans beyond the standard coverage. These benefits can include dental and vision care, wellness programs, fitness memberships, transportation assistance, and OTC allowances. They enhance the well-being of beneficiaries and may be offered by Medicare Advantage plans and other insurance options. Extra benefits can vary among plans and are important factors for individuals when choosing their healthcare coverage.
Extra Help
Extra Help, also known as the Low-Income Subsidy (LIS) program, is a federal assistance program in the U.S. that helps low-income Medicare beneficiaries afford their prescription drug costs. It provides financial support by reducing or eliminating copayments, coinsurance, and deductibles associated with Medicare Part D plans. Eligibility is based on income and resources, and qualified individuals receive significant assistance to manage medication expenses, ensuring access to prescription drugs at an affordable cost.
Federal Employees Health Benefits (FEHB)
The Federal Employees Health Benefits (FEHB) program is a comprehensive health insurance program offered by the U.S. Office of Personnel Management (OPM) for federal employees, retirees, and their eligible dependents. It provides a variety of health insurance plans from private companies, giving participants the flexibility to choose the coverage that best suits their needs. The FEHB program ensures that federal employees and their families have access to quality healthcare services and options to tailor their healthcare coverage.
Fee-for-Service (FFS) is a healthcare payment model where providers are reimbursed for each service or procedure they perform based on predetermined fees. Payment is not tied to the outcome or quality of care but solely on the quantity and type of services provided. FFS is a traditional payment system commonly used in healthcare, in contrast to alternative models that promote cost-efficiency and care coordination.
Fitness Benefits
Fitness benefits are health insurance or wellness program offerings that incentivize individuals to engage in fitness-related activities and programs for better physical health. These benefits may include gym access, fitness class discounts, reimbursement for fitness expenses, or rewards for achieving fitness goals. They aim to promote preventive care and overall wellness, encouraging individuals to adopt healthy lifestyle habits. Many employers and health insurance plans provide fitness benefits to support their members or employees in leading active and healthy lives.
Foreign travel emergency
A foreign travel emergency is a medical situation that occurs while traveling abroad and requires urgent medical attention. Health insurance plans offering travel benefits may cover expenses for medical evacuation, hospitalization, and emergency medical care while abroad. It is vital for travelers to review their health insurance policy to understand the coverage for foreign travel emergencies and consider additional travel insurance for comprehensive protection.
A formulary is a list of prescription drugs covered by a health insurance plan. It helps policyholders and healthcare providers understand which medications are approved and available for coverage. Formularies are categorized into tiers, each with different cost-sharing levels. The drugs listed are selected based on safety, effectiveness, and cost-effectiveness. The formulary may be updated periodically. Patients can choose medications from the formulary that align with their medical needs and budget.
Formulary Restrictions
Formulary restrictions are limitations imposed by health insurance plans on certain prescription medications listed in the formulary. These restrictions may include prior authorization, step therapy, quantity limits, or specific conditions for coverage. The aim is to control costs, promote cost-effective drug use, and ensure appropriate medication selection. However, these restrictions may require additional steps for patients and providers, potentially affecting treatment plans and out-of-pocket costs.
Gaps in Coverage
Gaps in coverage refer to periods when an individual does not have health insurance or when their insurance does not provide coverage for specific medical services or medications. These gaps can occur for various reasons, such as losing or changing jobs, aging out of parental coverage, or reaching the limit of coverage for certain benefits. During these gaps, individuals may face challenges in accessing healthcare services, and they may be responsible for paying out-of-pocket for medical expenses. It is essential for individuals to be aware of any potential gaps in their coverage and explore options to maintain continuous health insurance or find alternative sources of coverage to ensure access to necessary medical care.
General Enrollment Period (GEP)
The General Enrollment Period (GEP) is an annual time window from January 1st to March 31st, during which eligible individuals can enroll in Medicare Part B or make changes to their existing Medicare coverage. It allows those who missed their initial enrollment period or have only Part A coverage to sign up for Part B. Being aware of the GEP is crucial to avoid late enrollment penalties and ensure timely access to Medicare benefits.
A grievance in healthcare is a formal complaint made by a patient or their representative regarding the quality of care or services received. It involves expressing dissatisfaction with aspects such as medical errors, billing issues, delays in care, or improper treatment. Healthcare organizations and insurance plans have grievance processes to address and resolve these complaints, ensuring patients’ concerns are taken seriously and appropriately addressed to enhance the overall quality of care and patient experience.
Guaranteed Issue Right
Guaranteed Issue Right is a legal protection that allows individuals to obtain health insurance coverage without facing medical underwriting or denial based on health conditions or pre-existing conditions. Insurance companies must offer coverage to eligible individuals regardless of their health history. This protection ensures access to insurance for those who might otherwise face challenges or high costs due to their health status. Guaranteed Issue Rights are granted during specific circumstances, such as certain enrollment periods or when someone loses existing coverage.
Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) is a managed care health insurance plan that provides comprehensive healthcare services through a network of designated providers. Members select a primary care physician (PCP) who coordinates their medical care and referrals to specialists within the network. HMOs prioritize preventive care, cost containment, and care coordination, with lower out-of-pocket costs for members who stay within the network. Referrals from the PCP are usually required to see specialists. HMOs are popular for predictable healthcare costs and coordinated services.
Home Health Agency (HHA)
A Home Health Agency (HHA) is a healthcare organization that provides skilled medical services and support to individuals in their homes. It allows patients who are ill, disabled, or recovering from an injury to receive medical care and assistance while staying at home. The HHA’s team of healthcare professionals develops personalized care plans, including services like wound care, therapy, and medical monitoring, to improve patient health and function, promoting independence and a better quality of life.
Home Health Aide
A Home Health Aide (HHA) is a trained and certified healthcare professional who provides essential assistance and support to individuals in their homes. HHAs assist patients who are ill, disabled, or recovering from injuries with various activities of daily living, such as bathing, dressing, eating, and mobility. They may also help with medication reminders, light housekeeping, and monitoring the patient’s health under the direction of a nurse or therapist. Home Health Aides play a crucial role in enabling patients to receive necessary care and support while staying in the comfort of their own homes.
Hospice is a specialized form of palliative care provided to terminally ill patients who have a life expectancy of six months or less. It focuses on improving the quality of life for patients and their families during the final stages of a serious illness. Hospice care emphasizes pain and symptom management, emotional and spiritual support, and addressing the patient’s holistic needs. It is typically provided in the patient’s home, but it can also be offered in hospice centers or nursing homes. Hospice care aims to provide comfort, dignity, and compassionate support to patients and their loved ones as they navigate the end-of-life journey.
In-network, in the context of healthcare, refers to healthcare providers, hospitals, or facilities that have a contract or agreement with a specific health insurance plan or network. When a provider or facility is in-network, it means they have agreed to accept the insurance plan’s negotiated rates for services. As a result, patients who are members of that insurance plan typically pay lower out-of-pocket costs when they receive care from in-network providers. Choosing in-network providers and facilities helps patients maximize their insurance benefits and avoid higher expenses associated with out-of-network care.
Income-Related Monthly Adjustment Amount (IRMAA)
The Income-Related Monthly Adjustment Amount (IRMAA) is an additional premium that high-income Medicare beneficiaries may be required to pay for their Medicare Part B and Part D coverage. IRMAA is determined based on the individual’s modified adjusted gross income (MAGI) from two years prior. If a beneficiary’s MAGI exceeds certain income thresholds, they will be subject to IRMAA, resulting in higher monthly premiums for their Medicare coverage. The purpose of IRMAA is to adjust premiums for higher-income beneficiaries and help fund the Medicare program. It is essential for individuals with higher incomes to be aware of IRMAA and its potential impact on their Medicare costs.
Initial Coverage Election Period (ICEP)
The Initial Coverage Election Period (ICEP) is the first opportunity for individuals to enroll in a Medicare Part D prescription drug plan. It typically occurs when they are first eligible for Medicare. The ICEP lasts for a total of seven months, beginning three months before the individual’s Medicare Part B coverage starts and ending three months after it begins. During this period, individuals can choose a Part D plan that best meets their prescription drug needs. It is essential for individuals approaching Medicare eligibility to consider enrolling in a Part D plan during their ICEP to avoid potential late enrollment penalties and ensure they have prescription drug coverage when needed.
Initial Enrollment Period (IEP)
The Initial Enrollment Period (IEP) is the first opportunity for individuals to enroll in Medicare. It is a seven-month period that typically begins three months before their 65th birthday, includes their birth month, and extends for three months after their birth month. During the IEP, individuals can sign up for Original Medicare (Part A and Part B) as well as choose additional coverage options, such as Medicare Advantage (Part C) or Medicare Part D prescription drug plans. It is crucial for individuals approaching age 65 to be aware of their IEP and enroll in Medicare during this period to avoid potential late enrollment penalties and ensure timely access to healthcare coverage.
Inpatient Hospital Coverage
Inpatient hospital coverage is a type of health insurance benefit that covers medical services and treatment received by a patient who has been formally admitted to a hospital for a specific medical condition or procedure. Inpatient care involves staying overnight or for an extended period in the hospital for intensive medical care, surgeries, treatments, or other medically necessary interventions that require continuous monitoring and supervision. Health insurance plans typically provide coverage for inpatient hospital services, which can include room and board, nursing care, medical procedures, medications, and other necessary treatments. Patients often have cost-sharing responsibilities such as deductibles, coinsurance, or copayments associated with inpatient hospital stays, depending on their specific health insurance plan.
Late Enrollment Penalty
Additional cost imposed on individuals who sign up for insurance or benefit programs after the designated enrollment period has passed, commonly seen in health insurance plans like Medicare, to encourage timely enrollment and discourage adverse selection.
Lifetime Reserve Days
Lifetime Reserve Days refer to a specific provision in Medicare coverage that provides beneficiaries with a limited number of extra hospitalization days beyond their standard Medicare benefits. These reserve days can be used for extended hospital stays but are subject to an additional coinsurance payment. Once these days are exhausted, the beneficiary is responsible for all further hospitalization costs until the start of a new benefit period.
Low-Income Subsidy (LIS)
Low-Income Subsidy (LIS) is a government assistance program in the United States that helps individuals with limited income and resources afford their prescription drug costs under Medicare Part D. Also known as “Extra Help,” this subsidy provides financial assistance to pay for premiums, deductibles, and co-payments, making prescription medications more affordable for eligible beneficiaries. The program is designed to ensure that low-income individuals have access to necessary medications without facing significant financial burdens.
Maximum Out-of-Pocket (MOOP)
Maximum Out-of-Pocket (MOOP) refers to the highest limit on the amount of money an individual or family must pay for covered healthcare services within a specific period, usually a year, under their health insurance plan. Once the MOOP is reached, the insurance company will generally cover 100% of the remaining eligible medical expenses for the rest of that period. This provision offers financial protection to policyholders, limiting their healthcare expenses to a predictable and manageable amount during the designated time frame.
Meals After Hospital Stay
Meals after a hospital stay refer to the provision of food services and nourishment provided to patients during their recovery period after being discharged from the hospital. These meals are intended to support the patient’s healing process and may be offered through various means, such as home-cooked meals, meal delivery services, or assistance from family and caregivers. Adequate nutrition during the post-hospitalization period is essential for the patient’s overall well-being and to aid in their recovery from illness or medical treatment.
Medicaid is a government-funded health insurance program in the United States that provides medical coverage to low-income individuals and families. It is jointly administered by the federal government and individual states, with each state having the flexibility to set its own eligibility criteria and benefits within federal guidelines. Medicaid aims to ensure that vulnerable populations have access to essential healthcare services, including doctor visits, hospital stays, prescription drugs, and more, without facing financial hardship.
Medicaid Buy-In
Medicaid Buy-In refers to a program that allows individuals with disabilities to “buy in” to Medicaid coverage by paying a premium, even if their income would typically exceed the eligibility threshold for regular Medicaid. This initiative enables people with disabilities to access vital healthcare services and support while still maintaining the ability to work and earn income. The Medicaid Buy-In program varies by state, with specific eligibility requirements and cost structures determined by each state’s Medicaid program.
Medicaid Spend-Down
Medicaid Spend-Down, also known as “Medicaid excess income” or “Medically Needy Medicaid,” is a program that allows individuals with income that exceeds the standard Medicaid eligibility limits to “spend down” their excess income on medical expenses. Once they have incurred enough medical expenses to reach the state’s designated “spend-down” amount, they become eligible for Medicaid coverage for the remainder of the designated period. This program helps individuals with high medical costs gain access to Medicaid benefits, even though their income would otherwise be above the regular Medicaid threshold.
Medical Supplies
Medical supplies encompass a wide variety of equipment and consumables used by medical professionals to diagnose, treat, and care for patients. These essential items are vital for delivering effective healthcare services and supporting various medical procedures and treatments.
Medically Necessary
Medically necessary refers to healthcare services, treatments, procedures, or supplies that are deemed essential and appropriate for the diagnosis, management, or prevention of a patient’s medical condition. These services are determined based on established medical standards and are considered essential for maintaining or improving the patient’s health and well-being.
Medicare is a federal health insurance program in the United States primarily targeted at individuals aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions. It provides coverage for essential healthcare services, including hospital care, medical services, and prescription drugs, to eligible beneficiaries.
Medicare Advantage
Medicare Advantage, also known as Medicare Part C, is an alternative way for Medicare beneficiaries in the United States to receive their Medicare benefits. Offered by private insurance companies approved by Medicare, Medicare Advantage plans combine Part A (hospital insurance) and Part B (medical insurance) coverage, often including additional benefits like prescription drug coverage and wellness programs. These plans may also have different cost structures and provider networks than traditional Medicare, providing beneficiaries with more choices in their healthcare coverage.
Medicare Advantage Drug Plan (MAPD)
A Medicare Advantage Drug Plan (MAPD) is a type of Medicare Advantage plan that includes prescription drug coverage in addition to the standard Medicare Part A and Part B benefits. Offered by private insurance companies approved by Medicare, MAPD plans provide beneficiaries with a comprehensive package that combines medical services and prescription drug coverage, often with added benefits like vision, dental, and wellness programs.
Medicare Advantage Open Enrollment Period (MA OEP)
The Medicare Advantage Open Enrollment Period (MA OEP) is a period that occurs annually, typically from January 1st to March 31st, during which individuals who are already enrolled in a Medicare Advantage plan have the opportunity to make changes to their coverage. During this period, beneficiaries can switch to a different Medicare Advantage plan or return to Original Medicare (Part A and Part B) and, if desired, add a standalone Medicare Part D prescription drug plan.
Medicare Advantage Plan (Part C)
A Medicare Advantage Plan, also known as Medicare Part C, is an alternative way for Medicare beneficiaries in the United States to receive their Medicare benefits. Offered by private insurance companies approved by Medicare, Medicare Advantage plans combine Part A (hospital insurance) and Part B (medical insurance) coverage, often including additional benefits like prescription drug coverage and wellness programs. These plans may also have different cost structures and provider networks than traditional Medicare, providing beneficiaries with more choices in their healthcare coverage.
Medicare Card
A Medicare card is an important identification card issued by the U.S. federal government to individuals who are eligible for Medicare benefits. It contains the beneficiary’s name, Medicare number, and the type of coverage they have, whether it’s Original Medicare (Part A and Part B) or a Medicare Advantage plan (Part C).
Medicare Fraud
Medicare fraud refers to the intentional and deceptive act of individuals or organizations, such as healthcare providers or suppliers, submitting false information or misleading claims to the Medicare program for financial gain. This fraudulent activity can involve billing for services not provided, overcharging for services, or misrepresenting the nature and necessity of medical treatments, ultimately defrauding the government and undermining the integrity of the Medicare system.
Medicare Medical Savings Account (MSA)
A Medicare Medical Savings Account (MSA) is a type of high-deductible Medicare Advantage plan that combines a high-deductible health insurance policy with a medical savings account. The plan deposits funds into the savings account, and beneficiaries can use these funds to pay for qualified medical expenses before reaching their plan’s deductible. Once the deductible is met, the plan covers all further Medicare-approved expenses.
Medicare Prescription Drug Benefit
The Medicare Prescription Drug Benefit, also known as Medicare Part D, is a federal program in the United States that provides prescription drug coverage to Medicare beneficiaries. Offered through private insurance companies approved by Medicare, Part D helps beneficiaries afford their prescription medications, reducing out-of-pocket costs and ensuring access to essential drugs.
Medicare Private Drug Plan
A Medicare Private Drug Plan, also known as a Medicare Part D plan, is a type of private insurance plan offered by Medicare-approved private insurance companies. It provides prescription drug coverage to Medicare beneficiaries, helping them to afford necessary medications and reducing their out-of-pocket costs for prescription drugs.
Medicare SELECT
Medicare SELECT is a type of Medicare Supplement Insurance (Medigap) policy that operates in certain states in the United States. Unlike standard Medigap plans, Medicare SELECT requires beneficiaries to use a specific network of hospitals and healthcare providers to receive full coverage benefits. However, in emergency situations, beneficiaries are still covered regardless of the provider’s network.
Medicare Savings Program (MSP)
The Medicare Savings Program (MSP) is a state-run program in the United States that assists low-income Medicare beneficiaries with their Medicare costs. The MSP helps eligible individuals pay for premiums, deductibles, coinsurance, and co-payments associated with Medicare Part A and Part B, ensuring that beneficiaries with limited financial resources can access necessary healthcare services
Medicare Summary Notice (MSN)
A Medicare Summary Notice (MSN) is a document that provides a summary of healthcare services and supplies that Medicare beneficiaries have received. It is sent by Medicare to beneficiaries every three months and includes information about the medical services billed on their behalf, the amount approved by Medicare, and any out-of-pocket costs they may owe. The MSN is essential for beneficiaries to review and verify that the services listed were received and accurately billed, ensuring the correct billing and proper use of Medicare benefits.
Medicare Supplement
Medicare Supplement, also known as Medigap, is private health insurance designed to complement Original Medicare (Medicare Part A and Part B) by helping to cover some of the out-of-pocket costs that beneficiaries would otherwise pay. These out-of-pocket costs can include deductibles, co-payments, and coinsurance, and Medicare Supplement plans vary in coverage levels to provide additional financial protection and access to healthcare services.
Medicare Supplement Open Enrollment Period
The Medicare Supplement Open Enrollment Period is a six-month period that begins when an individual is both 65 years old and enrolled in Medicare Part B. During this period, individuals have a one-time opportunity to purchase any Medicare Supplement plan offered in their state without being subject to medical underwriting. This means that insurance companies cannot deny coverage or charge higher premiums based on pre-existing health conditions during this enrollment period.
Medicare-Certified refers to healthcare facilities, services, and suppliers that meet the standards and requirements set by the Centers for Medicare & Medicaid Services (CMS) to participate in the Medicare program. These facilities and providers have undergone a rigorous evaluation process to ensure they meet specific quality and safety standards, allowing them to offer services covered by Medicare to eligible beneficiaries.
Medicare-approved amount
The Medicare-approved amount refers to the maximum fee that Medicare recognizes and agrees to pay for a particular healthcare service or medical supply. This approved amount is typically determined based on a pre-established fee schedule or a negotiated rate with healthcare providers. Medicare beneficiaries are generally responsible for paying their share of the approved amount, which may include deductibles, coinsurance, and any additional charges above the Medicare-approved rate.
Medigap, also known as Medicare Supplement Insurance, is private health insurance that helps fill the gaps in coverage left by Original Medicare (Medicare Part A and Part B). Medigap plans are offered by private insurance companies and can help pay for certain out-of-pocket costs, such as deductibles, co-payments, and coinsurance, providing additional financial protection and access to healthcare services for Medicare beneficiaries.
Medigap Open Enrollment Period
The Medigap Open Enrollment Period is a six-month window that starts when an individual turns 65 and enrolls in Medicare Part B. During this time, they have the chance to purchase any Medigap plan available in their state without facing medical underwriting, ensuring they can access supplemental coverage without being denied or charged higher premiums based on their health condition. After this period, they can still apply for Medigap, but they might be subject to medical underwriting and potential limitations on coverage options.
In healthcare, a network is a collection of healthcare providers and facilities that have an agreement with an insurance company or healthcare organization to offer services to their members or patients. Patients who use in-network providers generally enjoy lower out-of-pocket costs, while using out-of-network providers may result in higher expenses and reduced coverage.
Non-Participating Provider
A non-participating provider, also known as an out-of-network provider, is a healthcare professional or facility that does not have a contract or agreement with a specific insurance company or healthcare organization. When patients receive services from non-participating providers, they may have to pay higher out-of-pocket costs compared to using in-network providers, and the insurance company may cover a smaller portion of the expenses or none at all, depending on the policy terms.
Notice of Medicare Non-Coverage (NOMNC)
The Notice of Medicare Non-Coverage (NOMNC) is a standardized form issued by Medicare to beneficiaries in skilled nursing facilities or home health settings. It serves as a notification to inform beneficiaries of the end of their Medicare-covered services and their right to appeal the decision. The NOMNC allows beneficiaries to understand when their Medicare-covered services will no longer be provided and gives them an opportunity to request a review if they believe the decision is incorrect or if they wish to explore alternative options for care.
Nursing Home
A nursing home is a residential facility that provides around-the-clock care and medical supervision to individuals who require long-term or specialized medical care and assistance with daily living activities. Nursing homes are designed to accommodate elderly individuals, disabled individuals, or those with chronic medical conditions who are unable to live independently or require a higher level of care than can be provided at home.
Observation Stay
An observation stay refers to a short-term period when a patient is admitted to a hospital for evaluation and monitoring, usually for less than 24 hours. During this time, healthcare providers assess the patient’s condition to determine if they need further medical treatment or if they can be discharged home safely. Observation stays are often used to make a more accurate diagnosis or determine the appropriate level of care for the patient.
Original Medicare
Original Medicare is the traditional fee-for-service health insurance program provided by the U.S. government, encompassing Medicare Part A (hospital insurance) and Part B (medical insurance) coverage for eligible individuals. It allows beneficiaries to visit any Medicare-approved healthcare provider but may involve out-of-pocket costs and does not include prescription drug coverage, which may require a separate enrollment in a Medicare Part D plan.
Out-of-network refers to healthcare providers, hospitals, or medical facilities that do not have a contract or agreement with a particular insurance company or healthcare organization. When patients seek services from out-of-network providers, they may face higher out-of-pocket costs, and the insurance company may cover a smaller portion of the expenses or none at all, depending on the terms of the insurance policy.
Out-of-Pocket Costs
Out-of-pocket costs refer to the expenses that individuals have to pay for their healthcare services or medical supplies, which are not covered by their health insurance. These costs include deductibles, co-payments, and coinsurance, as well as any fees for services or treatments not covered by the insurance plan. Out-of-pocket costs are the responsibility of the patient and can vary depending on the type of insurance coverage they have and the specific healthcare services they receive.
Outpatient Care
Outpatient care refers to medical services and treatments that are provided to patients who do not require an overnight stay in a hospital or healthcare facility. It includes a wide range of healthcare services, such as doctor’s visits, diagnostic tests, surgeries, therapies, and treatments, which are delivered in a clinic, medical office, or outpatient department within a hospital. Patients receiving outpatient care typically do not need to be admitted to the hospital and can return home on the same day after receiving their medical services.
Outpatient Mental Health Care
Outpatient mental health care refers to the provision of mental health services and treatments that do not require hospitalization or a residential stay. These services are delivered in an outpatient setting, such as a mental health clinic, counseling center, therapist’s office, or a psychiatric department within a hospital. Outpatient mental health care may include individual or group therapy, counseling sessions, medication management, and other forms of treatment for mental health conditions, allowing patients to receive care while still living in their community and maintaining their daily routines.
Outpatient Rehabilitation Services
Outpatient rehabilitation services are a range of therapeutic treatments and interventions provided to patients who do not require an overnight stay in a hospital or inpatient facility. These services are offered on an outpatient basis, usually at a rehabilitation center or clinic, and are designed to help individuals recover from injuries, surgeries, or medical conditions that affect their physical or cognitive abilities. Outpatient rehabilitation services may include physical therapy, occupational therapy, speech therapy, and other specialized therapies, allowing patients to receive care while residing at home and participating in their normal activities.
Over-the-Counter Allowance
An Over-the-Counter (OTC) Allowance is a benefit offered by certain health insurance plans or Medicare Advantage plans that provides a specified amount of money or credit to beneficiaries for purchasing over-the-counter medications and healthcare products. This allowance allows beneficiaries to buy certain non-prescription items, such as pain relievers, vitamins, first aid supplies, and other health-related products, without the need for a doctor’s prescription. The items covered under the OTC allowance are typically listed in a specific catalog or online portal provided by the insurance plan, and beneficiaries can use the allowance to purchase eligible items directly from participating retailers.
Over-the-Counter Drug
An over-the-counter (OTC) drug refers to a medication or healthcare product that can be purchased without a prescription from a healthcare professional. These drugs are readily available in pharmacies, grocery stores, and other retail outlets, and they are labeled with clear instructions for safe and appropriate use. OTC drugs are generally used to treat common ailments and symptoms, such as pain, cold and flu, allergies, and digestive issues, and they provide individuals with convenient access to self-medication for minor health conditions.
Palliative Care
Palliative care is a specialized medical approach focused on providing relief from the symptoms, pain, and stress of serious illnesses. Its goal is to improve the quality of life for patients and their families by addressing physical, emotional, and spiritual needs, and it can be offered at any stage of the illness alongside curative treatments.
Part A
Part A refers to one of the components of Original Medicare, the U.S. federal health insurance program for eligible individuals. Medicare Part A is known as hospital insurance and provides coverage for inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Beneficiaries typically do not pay a premium for Part A if they or their spouse have worked and paid Medicare taxes for a certain period. However, there are deductibles and co-insurance associated with Part A services.
Part A Deductible
The Part A Deductible refers to the specific amount that Medicare beneficiaries are required to pay out of pocket before their Medicare Part A coverage begins to pay for certain services. As of my last knowledge update in September 2021, this deductible applies to each benefit period and may change annually. Once the deductible is met, Part A coverage helps cover hospital inpatient stays, skilled nursing facility care, and some home health and hospice services for the remainder of that benefit period. It’s important to note that the Part A Deductible is separate from the Part B Deductible, which applies to other Medicare services like outpatient care and doctor visits.
Part B
Part B is another component of Original Medicare, the U.S. federal health insurance program for eligible individuals. Medicare Part B is known as medical insurance and provides coverage for a wide range of outpatient medical services, including doctor visits, preventive care, laboratory tests, medical equipment, and certain outpatient treatments. Beneficiaries are typically required to pay a monthly premium for Part B coverage, and they may also have to meet an annual deductible before Medicare starts paying its share of the costs. After the deductible is met, Part B usually covers 80% of the Medicare-approved amount for covered services, while the beneficiary is responsible for the remaining 20% as coinsurance.
Part B Copays/Coinsurance
Part B Copays/Coinsurance refers to the out-of-pocket costs that Medicare beneficiaries are responsible for paying when they receive certain medical services covered under Medicare Part B. After the Part B Deductible is met, beneficiaries are typically required to pay a percentage of the Medicare-approved amount as coinsurance (usually 20%) for most covered services. Additionally, for some services, beneficiaries may be required to pay a fixed copayment amount instead of coinsurance. These copayments and coinsurance amounts can vary depending on the specific service or treatment received, and they are the beneficiary’s responsibility to pay directly to the healthcare provider.
Part B Deductible
The Part B Deductible is the specific amount that Medicare beneficiaries are required to pay out of pocket for covered medical services before Medicare Part B coverage begins. As of my last knowledge update in September 2021, this deductible amount may change annually. Once the deductible is met, Medicare Part B typically covers 80% of the Medicare-approved amount for covered services, while the beneficiary is responsible for the remaining 20% as coinsurance. It’s important to note that the Part B Deductible is separate from the Part A Deductible, which applies to hospital and skilled nursing facility services.
Part B Excess Charges
Part B Excess Charges are additional fees that healthcare providers may charge Medicare beneficiaries if they do not accept Medicare’s approved amount as full payment. These charges can result in higher out-of-pocket costs for beneficiaries, and it’s important to verify if a provider accepts Medicare assignment to avoid unexpected expenses.
Part B Premium Reduction
A Part B Premium Reduction refers to a subsidy or assistance program that helps eligible individuals with low income and limited resources to pay for their Medicare Part B premiums. The reduction is designed to ease the financial burden of healthcare costs for those who may struggle to afford the standard Part B premium. This assistance is typically provided through state or federal programs and can vary in amount depending on the individual’s income level and other factors. Beneficiaries who qualify for a Part B premium reduction receive a lower premium amount or have their Part B premium fully covered by the subsidy.
Part C
Part C, also known as Medicare Advantage, is an alternative way for Medicare beneficiaries in the United States to receive their Medicare benefits. Medicare Advantage plans are offered by private insurance companies approved by Medicare and combine the coverage provided by Medicare Part A (hospital insurance) and Part B (medical insurance). These plans often include additional benefits like prescription drug coverage, dental, vision, hearing, and wellness programs, providing beneficiaries with more comprehensive and tailored healthcare coverage options. Medicare Advantage plans may have different cost structures and provider networks than Original Medicare, giving beneficiaries more choices in their healthcare coverage.
Part D
Part D refers to the Medicare prescription drug coverage program in the United States. It is a separate part of Medicare that helps beneficiaries afford prescription medications. Part D plans are offered by private insurance companies approved by Medicare and provide coverage for a wide range of prescription drugs, including brand-name and generic medications. Medicare beneficiaries can choose to enroll in a standalone Part D plan to complement their Original Medicare coverage (Part A and Part B) or select a Medicare Advantage plan that includes prescription drug coverage (Medicare Advantage Prescription Drug plan, also known as MAPD). Part D plans have their own premiums, deductibles, and copayments, and the specific drugs covered may vary depending on the plan’s formulary.
Participating Provider
A participating provider is a healthcare professional, hospital, or medical facility that has a contractual agreement with a specific insurance company or healthcare organization. When patients receive services from participating providers, they typically benefit from reduced out-of-pocket costs and the insurance company’s negotiated rates for covered services, making it advantageous for patients to use providers within their insurance plan’s network.
Patient Assistance Program (PAP)
A Patient Assistance Program (PAP) is a program offered by pharmaceutical companies or nonprofit organizations to help patients with limited financial resources access certain medications at reduced or no cost. PAPs are designed to assist patients who are unable to afford their prescription medications and may not have adequate insurance coverage. Eligible individuals can apply for assistance through these programs, and if approved, they may receive free or discounted medications directly from the pharmaceutical company or through a pharmacy participating in the program. PAPs can be valuable resources for patients facing financial challenges in obtaining essential medications for their health conditions.
Point-of-Service (POS) Option
A Point-of-Service (POS) Option is a type of health insurance plan that combines features of both Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. With a POS plan, beneficiaries can choose to receive medical services from a network of healthcare providers at lower out-of-pocket costs, similar to an HMO. However, they also have the flexibility to go out-of-network for medical care, but at higher costs, as is the case with a PPO. This hybrid approach allows individuals to balance cost savings with the ability to access a broader range of healthcare providers.
Pre-Existing Condition
A pre-existing condition refers to a medical condition or health issue that an individual has before applying for or enrolling in a health insurance plan. These conditions can include chronic illnesses, injuries, or any health-related problem for which the individual has received medical advice, diagnosis, or treatment in the past. In some insurance markets, individuals with pre-existing conditions may face higher premiums or be denied coverage altogether, although under certain laws (e.g., Affordable Care Act in the U.S.), insurers are prohibited from denying coverage or charging higher rates based on pre-existing conditions.
Pre-existing Condition Waiting Period
A pre-existing condition waiting period is a specified period of time during which an insurance company may delay coverage for certain health conditions that an individual had before enrolling in a health insurance plan. During this waiting period, the insurance plan may not cover any medical expenses related to the pre-existing condition. After the waiting period ends, the insurance coverage typically becomes effective, and the plan may start covering medical expenses related to the pre-existing condition. However, under certain laws, such as the Affordable Care Act in the U.S., waiting periods for pre-existing conditions are generally not allowed in certain health insurance plans.
Preferred Pharmacy
A preferred pharmacy is a pharmacy that has a special arrangement with a health insurance plan or pharmacy benefit manager, offering beneficiaries lower prescription drug costs or additional benefits. Patients can enjoy reduced copayments or coinsurance when they use preferred pharmacies, making it a cost-saving option for maximizing the benefits of their insurance plan.
Preferred Provider Organization (PPO)
A Preferred Provider Organization (PPO) is a type of health insurance plan that offers a network of healthcare providers, hospitals, and medical facilities with negotiated rates for services. PPO plans allow beneficiaries to receive care from both in-network and out-of-network providers, but using in-network providers generally results in lower out-of-pocket costs. Beneficiaries in PPO plans are not required to choose a primary care physician and do not need referrals to see specialists, offering more flexibility and autonomy in managing their healthcare.
A premium is a regular payment made by an individual to an insurance company in exchange for insurance coverage. It ensures that the policyholder maintains access to the benefits outlined in the insurance policy and can vary based on the type of insurance, coverage level, and other factors.
Prescription Drug Plan (PDP)
A Prescription Drug Plan (PDP) is a type of insurance plan that provides coverage for prescription medications. PDPs are offered by private insurance companies approved by Medicare and are available to Medicare beneficiaries who wish to add prescription drug coverage to their Original Medicare (Part A and Part B) or Medicare Advantage (Part C) plans. PDPs have their own formulary, which is a list of covered medications, and beneficiaries pay a monthly premium, copayments, and/or coinsurance for their prescription drugs, depending on the specific plan they choose. These plans help beneficiaries afford necessary medications and reduce out-of-pocket costs for prescription drugs.
Preventive Care
Preventive care refers to healthcare services and interventions aimed at preventing illness, detecting health conditions at an early stage, and promoting overall health and well-being. These services are designed to keep individuals healthy and may include routine check-ups, vaccinations, screenings, counseling, and other preventive measures. Preventive care is an essential aspect of healthcare that can help reduce the risk of developing certain diseases and improve overall health outcomes, particularly when individuals take an active role in maintaining their well-being through healthy lifestyle choices and regular medical check-ups.
Primary Care Provider (PCP)
A Primary Care Provider (PCP) is a healthcare professional who serves as the main point of contact for an individual’s medical care. PCPs play a crucial role in managing a patient’s overall health and coordinating their healthcare needs. They provide routine medical services, such as preventive care, health screenings, and vaccinations, and they also diagnose and treat common medical conditions. Additionally, PCPs may refer patients to specialists or coordinate care with other healthcare providers when necessary. Having a PCP is essential for establishing a strong and continuous relationship with a healthcare provider, ensuring that patients receive comprehensive and personalized medical attention.
Prior Authorization
Prior authorization is a pre-approval process used by insurance companies to determine if they will cover the cost of a specific medical service or treatment. It ensures medical necessity and cost-effectiveness before providing coverage.
Private Fee-for-Service (PFFS) plan
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan offered by private insurance companies that determines how much it will pay healthcare providers and how much the beneficiary will be responsible for paying for covered services. Unlike other Medicare Advantage plans, PFFS plans do not require the use of a network, allowing beneficiaries to see any healthcare provider who accepts the plan’s payment terms and conditions.
Program of All-Inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) is a comprehensive and integrated healthcare program in the United States designed to meet the needs of elderly individuals who qualify for nursing home care but prefer to receive care and services in their homes or community settings. PACE provides a wide range of medical, social, and supportive services, including medical care, therapy, prescription drugs, social activities, and transportation, with the goal of allowing seniors to maintain their independence and avoid nursing home placement. The program is funded by Medicare and Medicaid and is available to individuals who meet specific eligibility criteria, including age requirements and need for nursing home-level care.
Qualified Disabled Working Individual (QDWI)
The Qualified Disabled Working Individual (QDWI) program is a part of the Medicare Savings Programs in the US, helping disabled individuals who return to work and lose their premium-free Medicare Part A coverage. It assists by paying for their Medicare Part A premium, enabling continued access to Medicare benefits while working.
Qualified Medicare Beneficiary (QMB)
The Qualified Medicare Beneficiary (QMB) program is one of the Medicare Savings Programs in the United States that helps low-income individuals with their Medicare costs. QMB provides assistance by covering Medicare Part A and Part B premiums, as well as cost-sharing expenses such as deductibles, coinsurance, and copayments, allowing eligible beneficiaries to reduce their out-of-pocket healthcare expenses.
Qualifying Individual (QI)
The Qualifying Individual (QI) program is one of the Medicare Savings Programs in the United States that assists low-income individuals with their Medicare Part B premiums. QI helps pay for the Part B premium, thereby reducing the financial burden for eligible beneficiaries and ensuring continued access to Medicare benefits. It is available to individuals who meet specific income and asset criteria set by their state of residence.
Quantity Limit
A quantity limit is a restriction set by insurance companies or pharmacy benefit managers on the maximum amount or dosage of a medication that a patient can receive within a specific period. It is used to control costs and promote safe and appropriate use of medications, ensuring patients have access to necessary drugs while preventing overuse or misuse.
Redetermination, in the context of healthcare and insurance, refers to the process of requesting a review or appeal of a decision made by the insurance company regarding coverage, benefits, or payment for medical services, treatments, or medications. When a claim or coverage request is denied or not fully approved, the individual or their healthcare provider has the right to request a redetermination to challenge the decision and provide additional information to support the claim or request. The insurance company will reevaluate the case and issue a new decision based on the provided information and relevant policies.
Respite Care
Respite care is a temporary care service provided to individuals with disabilities, chronic illnesses, or elderly individuals, giving their primary caregivers a short break from their caregiving responsibilities. The aim is to provide caregivers with time to rest and attend to other personal tasks while ensuring the well-being of the care recipients.
S&P Company Credit Rating
In the healthcare context, the S&P Company Credit Rating refers to the evaluation of a healthcare organization’s financial strength and credit risk, helping stakeholders assess its ability to meet its financial obligations and manage potential investment or lending risks.
SHIP (State Health Insurance Assistance Program)
The State Health Insurance Assistance Program (SHIP) is a government-funded program in the United States that provides free, unbiased counseling and assistance to Medicare beneficiaries and their families. SHIP offers personalized guidance on various aspects of Medicare, including coverage options, enrollment, claims, and appeals, helping individuals make informed decisions about their healthcare coverage based on their unique needs and circumstances.
Service Area
In the healthcare context, a service area refers to the geographic region or area where a healthcare provider, hospital, or health plan offers its medical services and serves its patient population. It defines the boundaries within which the healthcare entity operates and provides healthcare services to the community.
Skilled nursing facility (SNF)
A Skilled Nursing Facility (SNF) is a healthcare institution that provides specialized and intensive nursing care to individuals who require a higher level of medical attention and assistance than what can be provided at home or in a regular nursing home. SNFs offer round-the-clock skilled nursing services, rehabilitation therapies, and medical care to patients recovering from an illness, injury, or surgery, or those with chronic medical conditions that require ongoing monitoring and treatment. These facilities are often utilized by individuals transitioning from a hospital stay to a more extended recovery period before returning home or moving to a long-term care facility, depending on their needs.
Social Security Disability Insurance (SSDI)
Social Security Disability Insurance (SSDI) is a federal program in the United States that provides financial assistance to individuals who are unable to work due to a severe disability. To be eligible for SSDI, applicants must have worked and paid Social Security taxes for a certain number of years and have a medical condition that meets the Social Security Administration’s definition of disability. If approved, beneficiaries receive monthly cash benefits to help support themselves and their families while they are unable to work due to their disabling condition. SSDI also offers access to Medicare after a waiting period of 24 months from the date of disability onset.
Special Enrollment Period (SEP)
A Special Enrollment Period (SEP) is a specific timeframe outside the regular open enrollment period during which individuals can enroll in or modify their health insurance coverage due to qualifying life events. These events may include marriage, having a baby, losing other health coverage, moving to a new area, or changes in income. SEPs provide flexibility for individuals to adjust their healthcare coverage based on significant life changes.
Special Needs Plan (SNP)
A Special Needs Plan (SNP) is a specialized type of Medicare Advantage plan tailored to meet the specific healthcare needs of certain groups, such as those eligible for both Medicare and Medicaid, individuals with chronic conditions, or those residing in long-term care facilities. SNPs offer personalized care management and targeted services to ensure comprehensive healthcare coverage for their unique populations.
A specialist is a medical professional who has undergone additional training and education in a specific area of medicine beyond their primary medical degree. These healthcare providers focus on diagnosing, treating, and managing particular medical conditions or diseases within their specialized field. Some common examples of medical specialists include cardiologists, neurologists, oncologists, and dermatologists. Patients are often referred to specialists by their primary care physicians when more specialized care is required for a specific health issue.
Specified Low-Income Medicare Beneficiary (SLMB)
The Specified Low-Income Medicare Beneficiary (SLMB) program is a part of the Medicare Savings Programs in the US. It assists individuals with limited income by helping to pay for their Medicare Part B premiums, ensuring continued access to Medicare benefits. SLMB is designed to support low-income beneficiaries in affording their healthcare expenses while enrolled in Medicare.
State Pharmaceutical Assistance Program (SPAP)
The State Pharmaceutical Assistance Program (SPAP) is a state-level program in the US that provides financial assistance to individuals for their prescription drug costs. It is separate from federal Medicare or Medicaid programs and varies by state in terms of eligibility criteria and covered medications, offering assistance to those who need help affording their medications.
Step Therapy
Step therapy, also known as “fail first” therapy, is a cost-control strategy used by health insurance companies that requires patients to try less expensive or preferred medications before providing coverage for more expensive alternatives. The goal is to ensure cost-effectiveness but can result in delays in accessing potentially more suitable treatments if the initial steps are ineffective.
Supplemental Security Income (SSI)
Supplemental Security Income (SSI) is a federal assistance program in the US that provides financial support to low-income individuals who are aged, blind, or disabled. It aims to help meet basic needs for those who qualify based on income and resource limitations. Unlike Social Security Disability Insurance (SSDI), SSI is a needs-based program and does not require a work history for eligibility.
TRICARE for Life (TFL)
TRICARE for Life (TFL) is a healthcare program in the United States that provides comprehensive health coverage for military retirees and their eligible dependents. It serves as a supplement to Medicare, covering additional medical expenses not fully paid by Medicare, such as deductibles, copayments, and certain services not covered by Medicare alone. TFL ensures that eligible beneficiaries have access to a wide range of medical services and prescription drugs to support their healthcare needs.
Tiering Exception
A tiering exception is a process that allows patients to request coverage for a prescription medication at a lower cost-sharing level than the one assigned by their health insurance plan. The request is typically based on medical necessity, and the insurance company evaluates it to determine if the medication should be covered with reduced copayments or coinsurance.
Transportation Services
Transportation services in the context of healthcare refer to the provision of transportation assistance to patients who may have difficulty traveling to medical appointments or accessing healthcare facilities on their own. These services are designed to help individuals who may not have access to private transportation or face mobility challenges, ensuring they can reach their healthcare providers and receive necessary medical care. Transportation services can be offered by healthcare organizations, community-based programs, or specialized transportation providers, and they play a crucial role in improving healthcare access and outcomes for patients with transportation barriers.
Urgent Care
Urgent care refers to a category of medical services that provide immediate medical attention and treatment for non-life-threatening illnesses and injuries. It is designed to offer a middle ground between emergency room care (for severe or life-threatening conditions) and routine primary care (for non-urgent and scheduled visits). Urgent care centers are typically equipped to handle a variety of medical issues that require prompt attention but are not severe enough to warrant a visit to the emergency room. They are convenient options for patients who need medical care outside of regular office hours or when their primary care provider is unavailable.
Urgently Needed Services
Urgently Needed Services refers to essential medical care and treatment that must be provided immediately to prevent serious harm to an individual’s health. These services are required when a patient’s condition is urgent, requiring prompt attention, but may not necessarily be life-threatening or severe enough to warrant emergency room care. Urgently needed services are critical in addressing time-sensitive health issues and ensuring that patients receive timely medical attention to prevent further complications. Examples include urgent medical procedures, treatments for acute illnesses, and interventions for conditions that require immediate attention to avoid deterioration.
Veterans Affairs (VA) Benefits
Veterans Affairs (VA) Benefits are a range of services and support programs provided by the United States Department of Veterans Affairs to eligible veterans, their dependents, and survivors. These benefits are designed to assist veterans in various aspects of their lives, including healthcare, disability compensation, education and training, home loans, vocational rehabilitation, employment assistance, and burial benefits. The VA benefits aim to honor and recognize the service and sacrifices of veterans by providing them with essential resources and assistance for their well-being, transition to civilian life, and long-term care needs.