Common Medicare Terms Annual Election Period (AEP) During the AEP, Medicare Advantage-eligible individuals may enroll in or disenroll from an MA plan. The last enrollment request made, determined by the application date, will be the enrollment request that takes effect. AEP occurs from [October 15 through December 7] of every year. The AEP is also referred to as the “Fall Open Enrollment” season in Medicare beneficiary publications and other tools. BENEFICIARY A person who has health care insurance through the Medicare or Medicaid program. BENEFIT PERIOD A “benefit period” begins the day you go into a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods. CARRIER A private insurance company that has a contract with Medicare to pay your physician and most other Medicare Part B bills. CATASTROPHIC COVERAGE Once your total drug costs reach the $4700 maximum, you pay a small coinsurance (like 5%) or a small copayment for covered drug costs until the end of the calendar year. CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) The US federal agency that administers Medicare, Medicaid and the State Children’s Health Insurance Program. CERTIFICATE OF CREDITABLE COVERAGE A written certificate issued by a group health plan or health insurance issuer (including an HMO), that states the period of time you were covered by your health plan. COINSURANCE The amount you may be required to pay for services after you pay any plan deductibles. In Original Medicare, this is a percentage (like 20%) of the Medicare approved amount. You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent. COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF) A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physician’s services, physical therapy, social or psychological services, and outpatient rehabilitation. COORDINATION OF BENEFITS Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim; also referred to as “cross-over.” COPAYMENT In some Medicare health and prescription drug plans, the amount you pay for each medical service, such as a doctor’s visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor’s visit or prescription. Copayments are also used for some hospital outpatient services in Original Medicare. COST SHARING The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and/or deductibles. Coverage Gap Also known as the “donut hole,” this is a gap in coverage that occurs when someone with Medicare goes beyond the initial prescription drug coverage limit. When this happens, the person is responsible for more of the cost of prescription drugs until their expenses reach the catastrophic coverage threshold. CREDITABLE COVERAGE Health coverage you have had in the past, such as group health plan (including COBRA continuation coverage), an HMO, an individual health insurance policy, Medicare or Medicaid, and this prior coverage was not interrupted by a significant break in coverage. The time period of this prior coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan. Creditable coverage may be proven by a certificate of creditable coverage or by other documents showing an individual had health coverage, such as a health insurance ID card. See also Certificate of Creditable Coverage. CREDITABLE COVERAGE (MEDIGAP) Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy; see “Pre-Existing Conditions.” CREDITABLE PRESCRIPTION DRUG COVERAGE Prescription drug coverage (for example, from an employer or union), that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage. CRITICAL ACCESS HOSPITAL A small facility that provides limited outpatient and inpatient hospital services to people living in rural areas. CUSTODIAL CARE Non-skilled personal care to help with activities of daily living, such as bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care. DEDUCTIBLE (MEDICARE) The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or other insurance begins to pay. For example, in Original Medicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year. DONUT HOLE Most Medicare drug plans have a coverage gap, referred to as a “donut hole.” This means that after you and your plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your drugs (up to a limit). DRUG LIST A list of drugs covered by a plan. This list is also called a formulary. DURABLE MEDICAL EQUIPMENT (DME) Certain medical equipment ordered by a doctor for use in the home; for example, walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services. DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER (DMERC) A private company that contracts with Medicare to pay bills for durable medical equipment. ELECTION Your decision to join or leave Original Medicare or a Medicare+Choice plan. END STAGE RENAL DISEASE ( ESRD) ESRD is permanent kidney failure requiring dialysis or a kidney transplant. EPO EPO (Exclusive Provider Organization): Similar to an HMO, with an EPO you must use network providers – doctors, hospitals and other health care providers – that participate in the plan. The only exception is for emergency care. Unlike an HMO, you do not need to select a Primary Care Physician, nor do you need to contact your PCP for referrals to specialists. However, because you are responsible for choosing specialists and hospitals, it is especially important to check with the plan by phone or their website to be sure the provider is in the network. EXCESS CHARGES If you are in Original Medicare, this is the difference between a doctor’s or other health care provider’s actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount. EXPEDITED ORGANIZATION DETERMINATION A fast decision from the Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized. EXTRA HELP A Medicare program to help people with limited income and resources pay Medicare prescription drug costs, such as premiums, deductibles, and coinsurance. FEDERAL EMPLOYEE HEALTH BENEFITS PLAN (FEHP) The FEHB Program offers health coverage for current and retired federal employees. If you are covered under a FEHB plan, you will get information during the open season about your prescription drug coverage and whether it is creditable prescription drug coverage. Read this information carefully. Contact your FEHB insurer before making any changes. It will almost always be to your advantage to keep your current coverage without any changes. For most people, unless you qualify for extra help, it is not cost effective to join a Medicare drug plan. Caution: You cannot drop FEHB drug coverage without also dropping FEHB plan coverage for hospital and medical services, which may mean higher costs for these services. Fee-for-service A program where doctors and other health care providers receive payment for each service provided. Payments are issued after the services are provided. FORMULARY A list of prescription drugs covered by a health plan. GENERIC DRUG According to the FDA, a generic prescription drug is the same as a brand-name prescription drug in safety, strength, quality, the way it works, how it’s taken, and the way it should be used. Generic prescription drugs use the same active ingredients as brand-name prescription drugs and work the same way. Generic prescription drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. GROUP HEALTH PLAN A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization. GUARANTEED ISSUE RIGHTS (ALSO CALLED “MEDIGAP PROTECTIONS”) Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company cannot deny you a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and cannot charge you more for a policy because of past or present health problems. GUARANTEED RENEWABLE A right you have that requires your insurance company to automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud or do not pay your premiums. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA ) OF 1996: A Federal law that allows individuals to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191. HEALTH MAINTENANCE ORGANIZATION (HMO) (MEDICARE) A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to a specific network of doctors, specialists, or hospitals on the plan’s list except in an emergency. In most cases, you will need to choose a primary care doctor, who you will need to get a referral from before seeing a specialist. Health Maintenance Organization (HMO) Plan In most HMO Plans, you can only go to doctors, other health care providers, or hospitals on the plan’s list except in an emergency. You may also need to get a referral from your primary care doctor. In HMO Plans, you can’t get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option. HOME HEALTH CARE Limited, part-time, or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services. HOSPICE CARE A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver as well. Hospice care is covered under Medicare Part A (Hospital Insurance). INPATIENT CARE Health care that you receive when you are admitted to a hospital or skilled nursing facility. INPATIENT REHABILITATION FACILITY A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients. INSTITUTION A facility that provides short-term or long-term care, such as a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences, such as an assisted living facility, or group home are not considered institutions for this purpose. LIFETIME RESERVE DAYS In Original Medicare, a total of 60 extra days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, you do not get any more extra days during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance. LIMITING CHARGE In Original Medicare, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who do not accept assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment. LONG-TERM CARE A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare does not pay for this type of care if this is the only kind of care you need. LONG-TERM CARE HOSPITAL Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management MEDICAID A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. MEDICAL SAVINGS ACCOUNT (MSA) Medicare MSA Plans have two parts: a high deductible health plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account. The amount deposited is less than your deductible amount, so you will have to pay out of pocket before your coverage begins. Part A and Part B services count toward your plan’s deductible. After you reach your out of pocket limit, your plan will cover your Medicare covered services in full. Any money left in your account at the end of the year remains in your account along with the deposit for next year. Note: In 2010, Medicare MSA Plans are only available in Pennsylvania. MEDICAL UNDERWRITING The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance. MEDICALLY NECESSARY Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of you or your doctor. MEDICARE Medicare is the Federal health insurance program designed for people who are age 65 or older, people under age 65 with certain disabilities, and people of any age with End Stage Renal Disease (ESRD, permanent kidney failure requiring dialysis or a kidney transplant). Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, and skilled nursing facilities, hospice, and home health care. Medicare Part B (Medical Insurance) helps cover doctors’ services, outpatient care, and home health care, some preventive services to help maintain your health and to keep certain illnesses from getting worse. MEDICARE ADVANTAGE PLAN A plan offered by a private insurance company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare. MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) PLAN A Medicare Advantage plan that offers Medicare Prescription Drug coverage and Part A and Part B benefits in one plan. MEDICARE AND MEDICAID TOGETHER Some people qualify for both Medicare and Medicaid (these people are also called “dual eligibles”). If you have Medicare and full Medicaid coverage, most of your health care costs are covered. You have the option of Original Medicare or a Medicare Advantage Plan (like an HMO or PPO). MEDICARE APPROVED AMOUNT In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges. MEDICARE COORDINATED CARE PLAN A Medicare Advantage HMO or PPO Plan. MEDICARE COST PLANS Medicare cost plans are a type of HMO that contracts as a Medicare Health Plan. As with other HMOs, the plan only pays for services outside its service area when they are emergency or urgently needed services. However, when you are enrolled in a Medicare Cost Plan, if you get routine services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare, and you will be responsible for the Original Medicare deductibles and coinsurance. MEDICARE COVERAGE Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).) MEDICARE HEALTH PLAN A plan offered by a private insurance company that contracts with Medicare to provide you with your Medicare Part A and/or Part B benefits. Medicare health plans include Medicare Advantage plans (including HMO, PPO, or Private Fee-for-Service Plans); Medicare Cost Plans; PACE plans; and Special Needs Plans. MEDICARE MANAGED CARE PLAN A type of Medicare Advantage Plan that is available in some areas of the country. In most managed care plans, you can only go to doctors, specialists, or hospitals on the plan’s list. Plans must cover all Medicare Part A and Part B health care. Some managed care plans cover extras, such as prescription drugs. Your costs may be lower than in Original Medicare. MEDICARE PART A Medicare Part A is hospital insurance. It helps cover inpatient care in hospitals, skilled nursing facilities, hospice, and home health care. MEDICARE PART B Medicare Part B is medical insurance. It helps cover doctors’ services, outpatient care, home health care, and some preventive services to help maintain your health and to keep certain illnesses from getting worse. There is always a premium for Part B, and deductibles and copays may add up quickly. MEDICARE PART C (MEDICARE ADVANTAGE PLANS) A health coverage option offered by private insurance companies approved by and under contract with Medicare. It includes Part A, Part B, and usually other coverage, such as prescription drugs. MEDICARE PART D (PRESCRIPTION DRUG PLAN) Medicare Part D is prescription drug coverage offered by private insurance companies approved by and under contract with Medicare. It helps cover the cost of prescription drugs, and may help lower your prescription drug costs and help protect against higher costs in the future. There are 2 types of Part D plans: Integrated Medicare Advantage-Part D Plans and Standalone Prescription Drug Plans (Part D). MEDICARE PLAN Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug Plans. MEDICARE PRESCRIPTION DRUG COVERAGE Optional coverage available to all people with Medicare through insurance companies and other private companies. MEDICARE PRESCRIPTION DRUG PLAN (PART D) A stand-alone drug plan, offered by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or Part B benefits through Original Medicare; Medicare Private Fee-for-Service Plans that don’t offer prescription drug coverage; and Medicare Cost Plans offering Medicare prescription drug coverage. MEDICARE SELECT A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits. MEDICARE SUMMARY NOTICE (MSN) A notice you get after the doctor or provider files a claim for Part A and Part B services in Original Medicare. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. MEDIGAP (MEDICARE SUPPLEMENT PLANS) Medicare Supplement coverage sold by private insurance companies to fill “gaps” in Original Medicare coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are 12 standardized plans labeled Plan A through Plan L. Medigap policies only work with Original Medicare. NON-FORMULARY DRUGS Brand name or generic prescription drugs not included on a health plan’s list of approved prescription drugs. ORIGINAL MEDICARE A fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). OUT-OF-NETWORK PROVIDER A doctor, dentist, hospital or other practitioner who is not contracted with that particular health plan. OUT-OF-POCKET MAXIMUM The maximum dollar amount, including deductibles and copayments, that you pay in any calendar year toward the cost of covered medical care. Your out-of-pocket costs in a Medicare Advantage Plan depend on whether the plan charges a monthly premium in addition to your Part B premium; whether the plan pays any of the monthly Part B premium; whether the plan has a yearly deductible or any additional deductibles; how much you pay for each visit or service (copayments); the type of health care services you need and how often you get them; whether you follow the plan’s rules, like using network providers; whether you need extra coverage and what the plan charges for it; whether the plan has a yearly limit on your out-of-pocket costs for all medical services. OUTPATIENT HOSPITAL CARE Medical or surgical care furnished by a hospital to you if you have not been admitted as an inpatient but are registered on hospital records as an outpatient. If a doctor orders that you must be placed under observation, it may be considered outpatient care, even if you stay under observation overnight. Outpatient Medical Services and Supplies Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services. PENALTY An amount added to your monthly premium for Medicare Part B, or for a Medicare Prescription Drug Plan, if you don’t join when you’re first able to. You pay this higher amount as long as you have Medicare. There are some exceptions. PHYSICIAN SERVICES Services provided by an individual licensed under state law to practice medicine or osteopathy. Physician services given while in the hospital that appear on the hospital bill are not included. PLAN ADMINISTRATOR The person who is responsible for the management of the plan. The plan administrator is a person specifically designated by the terms of the plan. If the plan does not make such a designation, then the plan sponsor is generally the plan administrator. PLAN SPONSOR Generally, the employer, the employee organization, (such as a union), or other entity that establishes or maintains an employee benefit plan, including a group health plan; see also, “Sponsor.” POINT-OF-SERVICE (POS) OPTION An HMO option that allows you to use doctors and hospitals outside the plan for an additional cost. PRE-EXISTING CONDITION A health problem you had before the date that a new insurance policy starts. PREFERRED PROVIDER ORGANIZATION (PPO) PLAN A type of Medicare Advantage Plan in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for covered services at an additional cost. Referrals are not required for you to visit a specialist. Preferred Provider Organization (PPO) Plans A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network . You pay more if you use doctors, hospitals, and providers outside of the network. In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more. PREMIUM The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage. PREVENTIVE SERVICES Health care to keep you healthy or to prevent illness; for example, Pap tests, pelvic exams, flu shots, and screening mammograms. PRIMARY CARE DOCTOR A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she may talk with other doctors and health care providers about your care and refer you to them. In many HMOs, you must see your primary care doctor before you can see any other health care provider or specialist. PRIVATE FEE-FOR-SERVICE PLAN (PFFS) A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits Original Medicare does not cover. PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PACE combines medical, social, and long-term care services for frail people to help people stay independent and living in their community as long as possible, while getting the high-quality care they need. PACE is available only in states that have chosen to offer it under Medicaid. To be eligible, you must be 55 years old or older, live in the service area of the PACE program, be certified as eligible for nursing home care by the appropriate state agency, and be able to live safely in the community. QUALIFIED BENEFICIARY Generally, qualified beneficiaries include covered employees, their spouses and their dependent children who are covered under the group health plan. In certain cases, retired employees, their spouses and dependent children may be qualified beneficiaries. QUALITY IMPROVEMENT ORGANIZATION Groups of practicing doctors and other health care experts. They are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for-Service Plans, and ambulatory surgical centers. These doctors also review fast-track termination decisions in comprehensive outpatient rehabilitation facilities, skilled nursing facilities, and home health and hospice settings for people in Medicare health plans. REFERRAL A written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you do not get a referral first, the plan may not pay for your care. REGIONAL HOME HEALTH INTERMEDIARY (RHHI) A private company that contracts with Medicare to pay home health and hospice bills under Original Medicare and check on the quality of home health care. REHABILITATION Rehabilitation services are ordered by your doctor to help you recover from an illness or injury. These services are provided by nurses, and physical, occupational, and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed. RETIREE – FOR THE RDS PROGRAM An individual who is provided coverage under a group health plan after that individual has retired. RISK ADJUSTMENT The way that payments to health plans are changed to take into account a person’s health status. SECOND OPINION A “second opinion” refers to an additional doctor giving his or her view about what you have and how it should be treated. SECONDARY PAYER An insurance policy, plan or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation. SERVICE AREA The area in which a health plan accepts members; for plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan’s service area. SERVICE AREA (PRIVATE FEE-FOR-SERVICE) The area in which a Medicare Private Fee-for-Service plan accepts members. SIGNIFICANT BREAK IN COVERAGE Generally, a significant break in coverage is a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual’s coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage. SKILLED CARE A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. SKILLED NURSING CARE A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse). SKILLED NURSING FACILITY (SNF) A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services. SKILLED NURSING FACILITY CARE This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, cannot be provided on an outpatient basis. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living SPECIAL ELECTION PERIOD A set time that a beneficiary can change health plans or return to Original Medicare, such as: you move outside the service area, your Medicare+Choice organization violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP). (See Election Periods; Enrollment; Special Enrollment Period (SEP).) SPECIAL ENROLLMENT PERIOD A set period of time when you can sign up for a Medicare Advantage Program (Medicare Part B) if you did not take Medicare Part B during the Initial Enrollment Period. This Special Enrollment Period allows those individuals with special circumstances to enroll in a Medicare Advantage Plan. These circumstances include, but are not limited to, loss of job, change in qualifications to Medicaid, entrance or exit from long- term care facility, a move outside of a plan’s service area, or termination of plan contract. SPECIAL NEEDS PLAN (SNP) A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions. The Special Needs Plan will provide a primary physician or care coordinator to manage your care, and services are provided within the plan’s network. Prescription drug coverage is included. SPECIALIST A doctor who treats only certain parts of the body, certain health problems, or certain age groups. SPECIFIED DISEASE INSURANCE This kind of insurance pays benefits for only a single disease, such as cancer, or for a group of diseases. Specified Disease Insurance does not fill gaps in your Medicare coverage. SPONSOR An entity that sponsors a health plan; this can be an employer, a union, or some other entity. TIERS To have lower costs, many plans place prescription drugs into different “tiers,” which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers. For example: Tier 1 – Generic drugs (Tier 1 drugs will cost you the least amount); Tier 2 – Preferred brand-name drugs (Tier 2 drugs will cost you more than Tier 1 drugs); Tier 3 – Non-preferred brand-name drugs (Tier 3 drugs will cost you more than Tier 1 and Tier 2 drugs). TREATMENT Something done to help with a health problem; for example, medicine and surgery are treatments. TRICARE A health care program for active duty and retired uniformed services members and their families. TRICARE FOR LIFE (TFL) Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses. TTY A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who do not have a TTY can communicate with a TTY user through a Message Relay Center (MRC). An MRC has TTY operators available to send and interpret TTY messages. URGENTLY NEEDED CARE Care that you receive for a sudden illness or injury that needs medical care right away, but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than Original Medicare. If you are out of your plan’s service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care. VETERANS ADMINISTRATION (VA) MEDICAL BENEFITS Health coverage for veterans and individuals who have served in the U.S. military. You may be able to get prescription drug coverage through the U.S. Department of Veterans Affairs (VA) program. You may join a Medicare drug plan, but if you do, you cannot use both types of coverage for the same prescription. For more information, call the VA at 1-800-827-1000, or visit www.va.gov. TTY users should call 1-800-829-4833. WAITING PERIOD The period that must pass before an employee or dependent is eligible to enroll (becomes covered) under the terms of the group health plan. If the employee or dependent enrolls as a late enrollee or on a special enrollment date, any period before the late or special enrollment is not a waiting period. If a plan has a waiting period and a pre-existing condition exclusion, the pre-existing condition exclusion period begins when the waiting period begins. Days in a waiting period are not counted toward creditable coverage unless there is other creditable coverage during that time. Days in a waiting period are not counted when determining a significant break in coverage.