DaleyCare Medicare Glossary
Learn more about Medicare. Start with these definitions.
Medicaid is the health care program for low-income individuals who cannot otherwise afford Medicare or other commercial health insurance plans. The program is funded in part by the government and by the state in which the enrollee lives.
Medical underwriting is a process used by insurance carrier to evaluate whether to accept an applicant for coverage or to determine the premium rate for the policy. Medical underwriting is used when people enroll in Medigap plans outside of their initial enrollment period or the limited special enrollment periods that are available.
Medically necessary refers to services or supplies that are necessary for diagnosis or treatment of a medical condition.
Medicare Advantage – or Medicare Part C – allows Medicare beneficiaries to receive Medicare-covered benefits through private health plans instead of through Original Medicare. Advantage plans often include additional benefits – beyond those included in Medicare Part A and Part B – such as prescription drug coverage. In exchange for the benefits, coverage may be limited to network of providers. An Advantage plan may be an HMO, PPO or private fee-for-service plan, but it must be approved by Medicare and follow its guidelines.
A Medicare Advantage prescription drug plan (MA-PD) is an option for Medicare beneficiaries who want to enroll in Medicare Part D prescription drug coverage, which subsidizes the costs of prescription drugs. A Medicare Advantage prescription drug plan would offer Medicare Part A and Medicare Part B benefits within the same plan.
A Medicare cost plan is similar to a Medicare HMO in that enrollees have access to a network of doctors and hospitals approved by Medicare. Unlike other Medicare HMO plans, however, a cost plan offers policy holders the option of receiving coverage outside of the network, in which case the Medicare-covered services are paid for through Original Medicare. Some cost plans may include prescription drug coverage. Enrollees can join a Medicare cost plan when it’s accepting new members, but may decide to return to Original Medicare at any time.
Medicare open enrollment – also known as the annual election period or annual coordinated election period – refers to the annual period during which Medicare plan enrollees can reevaluate their coverage – whether it’s Original Medicare, Medicare Advantage or a prescription drug plan through Medicare Part D. During Medicare open enrollment, a beneficiary can switch Medicare Advantage plans, switch from Medicare Advantage back to Original Medicare, join a Medicare prescription drug plan or drop Medicare Part D coverage entirely.
Medicare Part A or “hospital insurance” covers inpatient care, including inpatient hospital stays (of at least one night), skilled nursing facility stays (if they meet criteria), home health care and hospice care.
Medicare Part B or “medical insurance” covers medically necessary outpatient expenses, including physician and nursing fees, as well as a range of services (such as x-rays, diagnostic tests, some vaccinations and renal dialysis) and some equipment.
Medicare Part C – or Medicare Advantage – plans offer Medicare-covered benefits through private health plans instead of through Original Medicare. The plans often include benefits beyond those in Medicare Part A and Part B– such as prescription drug coverage . In exchange for the additional benefits, coverage may be limited to network of providers.
Medicare Part D is prescription drug coverage that subsidizes the costs of prescription drugs for Medicare beneficiaries. Medicare recipients select the coverage by enrolling in either a prescription drug plan (PDP) – which covers only prescription drugs – or a Medicare Advantage plan, which covers prescriptions and other medical expenses. Enrollees pay a co-pay for each prescription, a monthly premium and an annual deductible.
Medicare Select is a type of Medicare supplement (Medigap) plan sold in some states that can be any of the standardized Medigap plans (A-N) but which requires policy holder to receive services from within a defined network of hospitals and – in some cases – doctors in order to be eligible for full benefits.
As a Medicare beneficiary, you will receive a Medicare Summary Notice (MSN) if you receive a Medicare-covered service. The MSNs will be mailed to you every three months and will detail the services and supplies you received, how much Medicare will pay, and how much you need to pay the provider. The MSN is not a bill.
If you don’t believe your MSN is correct, or if payment is being denied, you should call your provider/physician first to be sure they submitted the right information. If you decide to appeal, you need to do it within 120 days of the day you receive the MSN. Appeal information will be listed on the MSN.
You can also read Your Medicare Rights and Protections online or call 1-800-MEDICARE to have a copy mailed to you.
Medicare supplement insurance plans – sold by private insurance companies – offer supplemental benefits to fill gaps in Original Medicare coverage. The plans – also known as Medigap – offer combinations of benefits, covering expenses ranging from copayments and deductibles to foreign travel emergency expenses and preventive care.
Medigap plans – sold by private insurance companies – offer supplemental benefits to fill gaps in Original Medicare coverage. The plans – also known as Medicare supplement insurance – offer combinations of benefits, covering expenses ranging from copayments and deductibles to foreign travel emergency expenses and preventive care.
You are eligible to enroll in a Medigap policy – without the possibility of being denied coverage – during the six months beginning the first month you turn 65 and you receive coverage under Medicare Part B. If you do not enroll during that initial window of opportunity, insurers have the right to deny you coverage.
Medigap protections – also known as “guaranteed issue rights” – require insurance carriers by law to offer you a Medigap policy, prohibiting the carrier from denying you coverage or charging you more for coverage based on reasons that include pre-existing conditions – as long as you enroll during your initial enrollment period or during limited special enrollment periods that are triggered by certain qualifying events.