1. A

   1. Access to Care:

      How easy it is for a member to receive health care treatments without having to wait too long.

   2. Allowed Amount:

      The maximum amount that the health plan will pay for a treatment, medicine, or service that is covered.

   3. Annual Enrollment Period:

      Every year, the Annual Enrollment Period (AEP) is from Oct. 15 until Dec. 7. During this time anyone with Medicare can change their Medicare health plans and prescription drug coverage. Any changes you make to your coverage during this time will go into effect Jan. 1 of the following year.

   4. Appeal:

      An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare drug plan. You have the right to appeal if Medicare, your Medicare health plan or your Medicare drug plan denies one of these:

      • A request for a healthcare service, supply, item, or prescription drug that you think you should be able to get
      • A request for payment of a healthcare service, supply, item, or prescription drug you already received
      • A request to change the amount you must pay for a healthcare service, supply, item, or prescription drug

      You also can appeal if Medicare or your plan stops providing or paying for all or part of a healthcare service, supply, item, or prescription drug you think you still need.

   5. Approved:

      Your health plan has said yes to paying for a treatment or medicine.

   6. Authorization Number:

      A health plan record number used to track a request.

2. B

   1. Balance Billing:

      If you see a doctor that is not in network with your health plan, they do not have an agreement on how much to charge. If they charge more than what your health plan pays, the doctor might bill you for the rest of the cost.

   2. Beneficiary:

      A person with health insurance through Medicare or Medicaid programs.

   3. Benefit period:

      The way that both our plan and Original Medicare measure your use of skilled nursing facility (SNF) services. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you have not received any skilled care in a SNF for 60 days in a row. If you go into a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods.

   4. Benefits:

      The healthcare items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents.

   5. Billing Statement:

      A document from your doctor showing the total costs for a treatment, service, or medicine that you received. A part of the billing statement that tells you how much you owe for that treatment, service, or medicine after your health plan pays their part.

3. C

   1. Care Coordination:

      The sharing of health care information between you, your doctors, and your health plan to plan your care. 

   2. Centers for Medicare and Medicaid Services (CMS):

      The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance programs as well as federally facilitated marketplace.

   3. Claim:

      A payment request from your doctor to Medicare or your health plan for treatments you received.

   4. Co-insurance:

      A percent of the cost you pay for treatment, medicine, or service after your deductible is met. For example, you pay 20% and your health plan pays 80%.

   5. Copayment and copay:

      An amount you may be required to pay as your share of the cost for a medical service or supply, such as a doctor visit, hospital outpatient visit, or prescription drug. A co-payment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription drug.

   6. Cost Sharing:

      Splitting the cost of medical bill between you and your health plan. Copayments and coinsurance are examples of this.

   7. Coverage determination (Part D): 

      The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:

      • Whether a particular drug is covered
      • Whether you have met all the requirements for getting a requested drug
      • How much you're required to pay for a drug
      • Whether to make an exception to a plan rule when you request it

      The drug plan must give you a prompt decision within 72 hours for standard requests and within 24 hours for expedited requests. If you disagree with the plan's coverage determination, the next step is to file an appeal.

   8. Coverage Determination (non-Part D services): 

      Decision made by your health plan to pay or not pay for a treatment or medicine.

   9. Coverage gap (Medicare prescription drug coverage):

      A period of time in which you pay a greater share of the cost for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap, also called the "donut hole," starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

   10. Covered Service: 

       A treatment or medicine your health plan will pay for as part of your benefits.

   11. Credentialing: 

       The process of making sure a doctor or health professional is trained, licensed, and allowed to give care. All in network providers have been through this process.

4. D

   1. Deductible:

      The amount you must pay out of your own pocket for healthcare or prescriptions before Original Medicare, your prescription drug plan, or your other insurance starts paying.

   2. Denied:

      Your health plan has said no to paying for a treatment or medicine.

   3. Denied Claim:

      A payment request for services you received that your health plan did not approve to pay.

   4. Drug list:

      See Formulary.

   5. Durable medical equipment:

      This refers to certain medical equipment, such as a walker, wheelchair, or hospital bed, that's ordered by the doctor for use in your home.

5. E

   1. Effective Date:

      The date something starts.

   2. Emergency:

      A medical emergency is when you or another have medical symptoms that require immediate medical attention to prevent loss of life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

   3. Emergency Care:

      Covered services that are: 1) provided by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition.

   4. End Stage Renal Disease (ESRD):

      Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

   5. Expedited Appeal:

      A request for a quicker review of your appeal if the usual review time might be dangerous to your health.

   6. Explanation of Benefits (EOB):

      A document that breaks down payment requests for your healthcare and the total paid for by your health plan. It is not a bill.

   7. External Review:

      You have the right to request that another organization that is not your health plan review your appeal.

   8. Extra Help:

      A Medicare program to help people with limited income and resources pay Medicare prescription drug costs, including premiums, deductibles, and co-insurance.
      Learn more about Extra help here 

6. F

   1. Facility Fee:

      An extra cost that a healthcare center charges for giving you care there. 

   2. Final Decision:

      The health plan has made its final decision for the outcome of your appeal.

   3. Formulary:

      A list of prescription drugs covered by a prescription drug plan or another insurance plan that offers prescription drug benefits. A formulary is also called a drug list.

7. G

   1. Grievance:

      A formal complaint from you or your doctor about the way your Medicare health plan or Medicare drug plan is providing care. For example, you may file a grievance if you have a problem calling your health plan or if you're unhappy with the way a staff member at the plan has behaved toward you. If you have a complaint about a plan's refusal to cover a service, supply, or prescription, however, you will need to file an appeal.

8. H

   1. Health Insurance Portability and Accountability Act of 1996 (HIPAA):

      HIPAA's Standards for Privacy of Individually Identifiable Health Information (also called the "privacy rule") assures your health information is properly protected while allowing the flow of health information needed to provide and promote high-quality healthcare and to protect the public's health and well-being.

   2. HEDIS (Health Effectiveness Data and Information Set):

      A tool used to check how well health plans are doing at keeping people healthy and giving good care.

   3. Home health care:

      Healthcare services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.

   4. Hospice:

      A special way of caring for people who are terminally ill. Hospice care involves a team oriented approach that addresses a patient's medical, physical, social, emotional, and spiritual needs. Hospice also provides support to the patient's family or caregiver.

   5. Hospital outpatient setting:

      The part of a hospital where you can receive outpatient services. This includes an emergency department, observation unit, surgery center, or pain clinic.

9. I

   1. In network:

      This refers to doctors, hospitals, pharmacies, and other healthcare providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. With some insurance plans, your care is only covered if you receive it from doctors, hospitals, pharmacies, and other healthcare providers in that health plan's network.

   2. Inpatient care:

      Healthcare you receive when you're admitted to a healthcare facility such as a hospital or skilled nursing facility.

   3. In Review:

      Someone is looking at the request but hasn’t made a decision yet.

10. L

    1. Long-term care:

       Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, such as dressing or bathing. Long-term support and services can be provided at home, in the community, in assisted living facilities, or in nursing homes. Individuals may need long-term support and services at any age. Medicare and most health insurance plans don't pay for long-term care.

    2. Low-income subsidy (LIS):

       See Extra Help.

11. M

    1. Maximum Out-of-Pocket Amount:

       The most that you pay out-of-pocket during the calendar year for in-network covered services. Amounts you pay for your Medicare Part A and Part B premiums, and prescription drugs do not count toward the maximum out-of-pocket amount.

    2. Medicaid:

       A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.

    3. Medically Necessary:

       Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

    4. Medical Necessity:

       A treatment or medicine that you need for your health.

    5. Medical Policy:

       The rules your plan follows when choosing if a treatment, medicine, or service is covered or not. 

    6. Medicare:

       Medicare is a federal health insurance program for people who are age 65 or older, people with disabilities, and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

    7. Medicare Health Maintenance Organization (HMO) Plan:

       A type of Medicare Advantage Plan (Part C) available in some areas of the country. With most HMOs, you can only receive care from doctors, specialists, or hospitals on the plan's list, except in an emergency. Most HMOs also require you to get a referral from your primary care physician.

    8. Member Responsibilities:

       You are responsible for paying your share of your health care and keeping your health plan active. You are also responsible for knowing your benefits as best as possible and asking questions when you have them.

    9. Member Rights: 

       As a member of the health plan, you have the right to privacy, to make choices about your care, and to file a complaint or appeal for treatment that is denied.

12. N

    1. Network:

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

    2. Network Adequacy:

       Making sure we have enough doctors to provide care in all counties where we have members. Member should be able to see a doctor without waiting too much time. 

    3. Network pharmacies:

       Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are covered only if you get them filled at network pharmacies.

    4. Not Covered:

       A treatment or medicine your health plan will not pay for as it is not part of your benefits.

    5. Notice:

       A letter that gives you important information about your health plan or care.

13. O

    1. Occupational therapy:

       Treatment that helps you get back to usual activities such as bathing, preparing meals, and housekeeping after an illness.

    2. Out of network:

       Doctors and healthcare centers that do not have an agreement with your health plan. Services received at an out-of-network location might cost you more than at an in-network location. You might also be balance billed when you go to an out-of-network doctor or location. 

    3. Out-of-pocket costs:

       Health or prescription drug costs that you must pay on your own because they aren't covered by Medicare or other insurance.

    4. Outpatient hospital care:

       Medical or surgical care you get from a hospital when your doctor hasn't written an order to admit you to the hospital for inpatient care. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests, or X-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.

14. P

    1. Partial Payment:

       A payment that covers only a part of the total cost for treatment. 

    2. Penalty (Part D late-enrollment penalty):

       An amount added to your monthly premium for Part B or a Medicare Prescription Drug Plan (Part D) if you don't join when you're first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

    3. Pending:

       The decision is still being worked on by your health plan.

    4. Point-of-service option:

       In a health maintenance organization (HMO), this option lets you use doctors and hospitals outside of the plan's network for an additional cost.

    5. Preferred pharmacy:

       A pharmacy that is part of a Medicare drug plan's network. You pay lower out-of-pocket costs if you get your prescription drugs from a preferred pharmacy instead of a standard pharmacy (non-preferred pharmacy).

    6. Premium:

       The amount you have to pay to Medicare, an insurance company, or a healthcare plan for health or prescription drug coverage.

    7. Preventive services:

       Healthcare to prevent illness or detect illness at an early stage, when treatment is likely to work best. Preventive services include Pap tests, flu shots, and screening mammograms.

    8. Primary Care Provider (PCP):

       The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. Your primary care doctor also may talk with other doctors and healthcare providers about your care and refer you to them.
       Providence Medicare Advantage Plans no longer requires referrals for in-network specialist visits, so you can get the care you need without the extra steps.

    9. Prior authorization:

       The treatment or medicine needs to be approved by your health plan before you get it. Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs.

15. Q

    1. Quality Measures:  

       A way to measure how well health care is delivered. They help health plans, hospitals, and clinics track how well they are doing.

16. R

    1. Recredentialing:

       The credentialing process for network doctors and health professionals needs to be repeated every three years.

    2. Referral:

       A written order from your primary care doctor for you to see a specialist or receive certain medical services.
       Providence Medicare Advantage Plans no longer requires referrals for in-network specialist visits, so you can get the care you need without the extra steps..

17. S

    1. Scope of Practice:

       The kind of care a health professional is allowed to give, based on their training and license.

    2. Service area:

       A geographic area in which a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of its service area.

    3. Skilled nursing care:

       Care, such as intravenous injections, that can only be given by a registered nurse or doctor.

    4. Skilled nursing facility (SNF):

       A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

    5. Specialist: 

       A doctor who focuses on one type of health problem, like heart issues or skin problems. 

    6. Standard Appeal:

       You or your doctor have 180 days to request an appeal. The health plan has 30-60 days from receiving your request to give you an answer.

    7. Standard Pharmacy (Non-preferred pharmacy):

       A pharmacy that's part of a Medicare drug plan network but that isn't a preferred pharmacy. You may pay higher out-of-pocket costs if you get your prescription drugs from a standard pharmacy instead of a preferred pharmacy.

    8. Step therapy:

       A coverage rule used by some Medicare Advantage and Medicare Prescription Drug Plans that requires you to try one or more similar, lower-cost drugs to treat your condition before the plan will cover the more costly drug originally prescribed.

18. T

    1. Tiers:

       A tier refers to drugs grouped by cost. Generally, a drug in a lower tier will cost less than a drug in a higher tier.

    2. TTY:

       A teletypewriter, or TTY for short, is a communication device used by people who are deaf, hard of hearing or severely speech impaired. People who don't have a TTY can communicate with a TTY user through a message relay center, or MRC. An MRC has TTY operators available to send and interpret TTY messages.

19. U

    1. Urgently needed care:

       Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away but isn't life threatening. If it's not safe to wait until you get home to get care from a plan doctor, the health plan must pay for your care.

For more Medicare terms and definitions, visit cms.gov/glossary