Actual Charge
The actual dollar amount that a physician, hospital, medical facility, or medical supplier bills for a medical service or equipment.  The approved Medicare dollar amount is typically lower than the Actual Charge.

AEP (see Annual Election Period)

Annual Election Period (also referred to as AEP)
The Annual Election Period occurs between October 15 through December 7 and serves as a period where a Medicare recipient can research and submit paperwork to change from one Medicare Advantage policy to another Medicare Advantage policy or from one Medicare Part D plan to another Medicare Part D plan.  An application or other specific paperwork requesting a plan change is processed during the Annual Election Period, but the effective date for the new, desired plan occurs on January 1.  For example, Jane is unhappy with her Medicare HMO, and she starts to gather information on various Medicare PPO plans available in her county.  Jane starts her research in late November just after Thanksgiving and decides to transfer to a Medicare PPO plan.  Jane submits an application for this PPO plan on December 3.  She is enrolled on the new PPO plan January 1. 

Annual True Out-of-Pocket Cost Amount (also referred to as TROOP)
The Annual True Out-of-Pocket Cost Amount for 2011 is $4550; this amount is the sum of money spent on prescriptions by the Part D subscriber and does NOT include money spent on prescriptions by the insurance company, Medicare, or pharmaceutical companies.  Part D deductibles, copayments, and money spent on drugs during the Part D Coverage Gap Period all accrue toward the Annual True Out-of-Pocket Cost Amount.  Once the Annual True Out-of-Pocket Cost Amount has been met the Part D subscriber then enters the Catastrophic Coverage Period.    

Approved Amount (see Medicare Approved Amount)

Assignment (see Medicare Assignment)

Attained Age Premium
An Attained Age Premium is a Medicare Supplement premium based on the policy holder’s current age.  In short, the premium increases as the subscriber ages and can also be raised due to inflation.  

Authorization
The act of Authorization is limited to HMO (Health Maintenance Organization) insurance plans.  Simply stated, Authorization is permission, granted by your Medical Group or insurance carrier, for you to visit with a specialist or receive medical care. 

Benefit Period
A Benefit Period measures the use of hospital and/or skilled nursing facility services covered by Medicare.  A Benefit Period starts the day a Medicare patient is admitted to the hospital and ends when the patient has been out of the hospital or skilled nursing facility for 60 consecutive days.  If the same patient is, again, admitted to the hospital after the Benefit Period (after being out of the hospital or skilled nursing facility for 60 or more days), the Medicare Part A benefits are renewed, and the patient would be responsible for the Medicare hospital (Part A) deductible.  There is no maximum limit to the number of Benefit Periods that a Medicare recipient can endure.

Brand-Name Drug
A Brand-Name drug has a trade name and is protected by patent.  Therefore, Brand-Name drugs are only manufactured and sold by the pharmaceutical company holding the patent.  Brand-Name drugs are typically more expensive than generic drugs.

Catastrophic Coverage Period
A Part D subscriber enters the Catastrophic Coverage Period when he or she meets the Annual True Out-of-Pocket Cost Amount ($4550 in 2011).  Part D subscribers that enter the Catastrophic Coverage Period will receive prescriptions at a very low rate for the remainder of the calendar year. 

CMS (Centers for Medicare and Medicaid Services)
CMS is the common abbreviation for the Center for Medicare and Medicaid Services.  CMS is the federal agency responsible for administering Medicare and Medicaid.  CMS was formerly known as the Health Care Financing Administration (HCFA).

Coinsurance
Coinsurance refers to the percentage or portion of the Medicare Approved Amount that must be paid by the Medicare recipient.  The term Coinsurance can also refer to the Copayments and Deductibles associated with a private Medicare health plan.

Community Rated Premium
Community Rated Premiums are Medicare Supplement premiums that are identical for all policy holders, regardless of age.  For example, a 65 year old pays the same premium for Medicare Supplement plan F as does an 84 year old with plan F.  Community Rated Premiums will increase with inflation.  

Contracting Hospital
The term Contracting Hospital is limited to HMO (Health Maintenance Organization) and PFFS (Private Fee-For-Service) plans and to some extent PPO (Preferred Provider Organization) insurance plans.  With reference to HMO and PFFS plans, one is restricted to using hospitals that contract with their Medical Group.  PPO plans allow their members to use any hospital, but members will pay more if using a hospital that does not contract with the PPO plan.  Persons enrolled on a Medicare Supplement can utilize ANY hospital that treats Medicare patients.
Copay (see Copayment below)

Copayment (also referred to as Copay)
Copayments are payments made by insurance policy holders to physicians, hospitals, medical facilities, pharmacies, and medical supply companies.  The Copayment amount is established by the private insurance company and is made available for review in the insurance plan Summary of Benefits.  Normally, the Copayment is due at the end of a medical visit or upon receipt of medical equipment or medication.

Covered Services
Covered Services are those medical services specifically mentioned and described in the insurance plan Summary of Benefits.  Any member of a private health plan is entitled to the Covered Services associated with that particular plan.

Creditable Drug Coverage
For a drug benefit to be considered “creditable coverage” the drug benefit must offer equal or greater coverage than Medicare’s standard prescription drug coverage.  Medicare recipients with drug benefits as part of a group plan, old (classic) Medicare Supplement, or a currently offered Medicare plan will receive notification that the drug benefit is considered either “creditable” or “not creditable” by Medicare. 

Custodial Care
Custodial Care is general care provided to meet the personal needs of an individual.  Custodial Care includes help with the following: walking, bathing, dressing, food preparation, feeding, or any other type of care that does not require medical personnel.  Medicare and private health insurance plans do NOT provide Custodial Care, rather, Custodial Care needs are covered by Long Term Care insurance.

Deductible
A Deductible is the amount of money that one must pay before medical services are either covered in part or full.  For example, Original Medicare has its own Deductibles that must be met before Medicare pays 80% of the Medicare Approved Amount.  Further, various private Medicare insurance plans require that the plan member satisfy a Deductible before the actual coverage is to start.  Also, certain Part D prescription plans have a Deductible that must be met before prescriptions can be obtained for a Copayment.

Donut Hole (see Part D Coverage Gap Period)

Drug Formulary (see Formulary)

Durable Medical Equipment (also referred to as DME)
Durable Medical Equipment is medically necessary equipment that can withstand repeated use and is often prescribed by a physician.  Examples of Durable Medical Equipment are as follows: wheelchairs, hospital beds, oxygen equipment, etc.  Medicare provides coverage for Durable Medical Equipment, albeit certain items are not approved/covered by Medicare.
Emergency (also known as Urgently Needed Services)
An Emergency is defined as any sudden, serious or acute illness, injury, or condition that could permanently endanger one’s health or life unless one receives medical treatment immediately.  All Medicare health insurance plans allow plan members to utilize any hospital or urgent care in the case of an Emergency.

Excess Charge
An Excess Charge occurs when the medical bill shows an Actual Charge that exceeds the Medicare Approved Amount.  These Excess Charges are common, as physicians, hospitals, and medical facilities often bill far more than Medicare is willing to pay.  Many private insurance plans pay these Excess Charges.  Should one not have a policy that covers an Excess Charge, one is only responsible for paying a maximum of 15% of the Medicare Approved Amount as an Excess Charge.

Formulary
A drug Formulary is a list of drugs covered by the insurance plan.  Each Formulary should have drugs listed alphabetically at the rear and then by therapeutic class in the main body of the document. 

Generic Drug
A generic drug is a less expensive alternative to more expensive brand-name drugs.  Generic drugs can only be produced when the patent for the associated brand-name drug expires.  Ideally, generic drugs are identical, in terms of content, to their brand name counterpart.  One should sample generic drugs, if available, in order to reduce the cost of prescriptions.   

Guaranteed Issue
Guaranteed Issue (often referred to simply as GI) refers to both Federal and local State laws forcing insurance companies to enroll Medicare recipients in Medicare Supplement plans without underwriting or premium penalties.  Typically, Medicare recipients protected by Guaranteed Issue are not subject to waiting periods before receiving care. 

Guaranteed Renewable
Insurance policies that are Guaranteed Renewable cannot be terminated by the insurance carrier unless the policy holder fails to pay the plan premium or knowingly provided erroneous information in order to obtain the policy.  Health insurance companies cannot terminate an individual policy due to an increase in claim payments or costly health condition.

Health Maintenance Organization (see HMO)

HMO (Health Maintenance Organization)
HMO insurance plans provide comprehensive health care services through contracted Medical Groups and hospitals.  To utilize the HMO plan, the policy holder must, first, see the Primary Care Physician, either for care or to obtain a referral to consult with a specialist or even receive care.  The choice of physicians and hospitals is restricted to the plan network.  We do not offer HMO insurance plans due to wait time associated with the referral process and limited access to doctors and hospitals.  Medicare HMO policies are one type of Medicare Advantage Plan (MAPD).

Home Health Services
Home Health Services are medical visits to the home following a hospital stay; Medicare will provide coverage for up to 100 Home Health Service visits per period of illness.  In order for Home Health Services to be covered by Medicare, the Medicare recipient must be certified by a doctor as homebound and in need of skilled nursing or therapy services.

Hospice
A Hospice is defined as an organization or facility that assists the terminally ill with pain relief and other symptoms.  Hospice facilities are to be certified by Medicare.

IEP (see Initial Enrollment Period)

IPA (Independent Practice Association)
An IPA is a partnership, association, or corporation that contracts with health insurance companies to provide health services. 

In-Network (see Network)

Individual Insurance
Individual Insurance is health care coverage for individuals or families.  In reference to Medicare insurance plans, each Medicare recipient applies as an individual for a Medicare insurance policy.  A Medicare recipient cannot apply for family health insurance as the primary applicant.

Initial Coverage Amount
The Initial Coverage Amount for 2011 is $2840; this amount is the sum of money spent on prescriptions by both the Part D subscriber and the insurance carrier.  The Part D subscriber enters the Part D Coverage Gap Period when the Initial Coverage Amount has been paid.

Initial Enrollment Period (also referred to as IEP)
The Initial Enrollment Period is that period of time when a Medicare beneficiary first receives Medicare benefits and is allowed to enroll in any Medicare health plan or a Part D policy.  The Initial Enrolment Period is a seven month period, comprised of the three months prior to the start of Medicare, the month when Medicare benefits begin, and the three months following the first month of Medicare benefits.  During the Initial Enrollment Period a Medicare beneficiary can enroll in a health or Part D policy but may not change to another Part D policy until the Annual Election Period.
To be clear, we also use the term Initial Enrollment Period when referring to a new Medicare recipient’s enrollment window for Medicare Supplement plans.  To enroll in a Medicare Supplement plan, one can submit an application three months prior to the start of Medicare and up to six months following the Medicare effective date, thus a longer enrollment period than a MAPD or Part D plan.

Inpatient Hospital Care
Inpatient Hospital Care is defined as care given once one has been admitted to the hospital.  Visits to the Emergency Room are NOT part of the Medicare Inpatient Hospital Care benefit. 

Issue Age Premium
An Issue Age Premium is a Medicare Supplement Premium based on one’s age during the time of purchase.  Issue Age Premiums will not increase with age, but the premium can be augmented due to inflation.

Lifetime Reserve Days
Lifetime Reserve Days are an additional 60 reserve days used to extend hospital coverage once a Medicare recipient has been hospitalized for more than 90 days.  On Original Medicare, Medicare pays the entire cost for each reserve day less the daily coinsurance amount.  Medicare Supplement policies provide coverage for an additional 365 Lifetime Reserve Days.

Limiting Charge
The Limiting Charge is the maximum amount a physician may charge a Medicare beneficiary if the physician does not accept Medicare Assignment.  The maximum limit is 15% above the Medicare Approved Amount.  The correct Limiting Charge amount is presented on the Medicare Explanation of Benefits for people who are either on Original Medicare or who have a Medicare Supplemental insurance plan.  Better Medicare Supplemental plans pay any Limiting Charge in full.  Medicare HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) plans do not subject plan subscribers to a Limiting Charge.

Lock-in
Lock-in refers to the Medicare rules governing movement between various Medicare Advantage Plans and Part D prescription plans.  In short, Medicare recipients enrolled on a stand-alone Part D prescription plan can only change to a different Part D plan or to a HMO or PPO plan for an effective date of January 1.  Paperwork for such a change can be collected from October 15 through December 7.  Further, seniors enrolled in a Medicare Advantage Plan can disenroll from the policy during the Medicare Annual Disenrollment Period (MADP) which runs from January 1 through February 15th.  During the Medicare Annual Disenrollment Period, seniors can only move to Original Medicare and enroll in a stand alone Part D policy.  Therefore, there are specific calendar periods where one can change to a different health or prescription plan.  These calendar periods where change is permissible are referred to as Open Enrollment.  In most cases, there are no premium penalties or fees to transfer from one plan to another.  This limited window of opportunity for change means, that, conversely, one cannot change plans for most of the calendar year, that one is Locked-in to his or her plan until Open Enrollment.  Albeit, one can change from one Medicare Supplemental plan to another Supplement plan at any time; Lock-in does not apply to Medicare Supplemental plans.

Long Term Care (also referred to as LTC)
Long Term Care encompasses services intended to assist people with normal daily activities who can no longer perform such activities on their own.  Long Term Care is provided over an extended period of time; care can be provided either at home or in a custodial facility.  Medicare does NOT cover Long Term Care.

LTC (see Long Term Care)

MADP (see Medicare Advantage Disenrollment Period)

MAPD (see Medicare Advantage Plan)

Medicare
Medicare is a federal insurance program for people age 65 and older and, also, certain disabled people.  Medicare is the nation’s largest health insurance program covering over 40 million Americans.

Medicare Advantage Disenrollment Period (also referred to as MADP)
The Medicare Advantage Disenrollment Period begins January 1 and ends February 15th.  During this period, Medicare recipients can disenroll from any Medicare Advantage Plan and move to Original Medicare.  In addition, seniors that disenroll from a Medicare Advantage Plan during this period can also enroll in a Part D policy. 

Medicare Advantage Plan (also referred to as MAPD and, also, Part C)
Medicare Advantage Plans are certain Medicare health insurance plans offered and administered by private health insurance companies, despite being referred to as Part C.  The insurance carrier contracts directly with Medicare to provide all the Medicare Part A and Part B benefits in exchange for a monthly stipend for every person enrolled on the Medicare Advantage Plan.  All Medicare Advantage Plans are approved and heavily monitored by Medicare.  Medicare Advantage Plans include the following: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service Plans (PFFS).  Medicare Advantage Plan members surrender their Medicare to the insurance carrier while enrolled on a Medicare Advantage Plan; thus, Medicare Advantage Plan members cannot use Original Medicare.  Medicare Advantage Plans occur both with and without Part D benefits.  Further, Medicare Advantage Plans are NOT standardized, and, therefore, present unique benefits and costs; Medicare Advantage Plans can and do change premiums, benefits, and copayments every calendar year. 

Medicare Approved Amount (also referred to as Approved Amount)
The Medicare Approved Amount is the actual dollar amount paid by Medicare for Medicare services.  The Medicare Approved Amount is typically less than the Actual Charge.  The Medicare Approved Amount is obtained from a fee schedule set by Medicare. 

Medicare Assignment (sometimes referred to as Assignment)
A physician, hospital, medical facility, or medical supplier that agrees to accept the Medicare Approved Amount as full payment is said to accept Medicare Assignment.   

Medicare Claim Number
A Medicare Claim Number is issued to each Medicare recipient and appears on the Medicare card.  A Medicare Claim number can be either the recipient’s own social security number or the social security number of a living or deceased spouse.  Medicare Claim Numbers always contain a letter before or after the social security number.  Be sure that you include this additional alpha character when providing your Medicare Claim Number.

Medicare Hospital Insurance (also referred to as Part A)
Medicare Hospital Insurance is typically referred to as Part A and pays for inpatient care in a hospital, skilled nursing facility, hospice, and to a lesser extent, home health care.

Medical Group
A Medical Group is a group of physicians organized to provide medical services.  Medical Groups are usually associated with HMO (Health Maintenance Organization) plans.  However, many physicians who contract with a Medical Group also serve patients with PPO (Preferred Provider Organization), PFFS (Private-Fee-For-Service), and Medicare Supplemental plans.  Usually the physicians within a Medical Group share a common office space or building, whereas, physicians belonging to an Independent Practice Association (IPA) are distributed over a wider geographic area and have an independent contract with the IPA.

Medical Savings Account Plan (MSA)
Medical Savings Account Plans consist of a high deductible Medicare Advantage Plan and a managed savings account used to pay all or part of the plan deductible.  Medical Savings Account Plans are not common and have a very high deductible. Medicare dictates the amount to be deposited into the savings account, and this amount is typically far less than the plan deductible.  Medical Savings Account Plans are a type of Medicare Advantage Plan.  Currently, there are no MSA plans available to California residents. 

Medically Necessary
The concept of something being considered Medically Necessary is rather vague.  In brief, one can project that health insurance carriers will consider medical treatment Medically Necessary if the treatment is appropriate and necessary for the symptoms, diagnosis , or treatment of a medical condition. 

Medicare Medical Insurance (also referred to as Part B)
Medicare Medical Insurance is typically referred to as Part B and pays for physician services, out-patient care, and other medical services and supplies not covered by Part A. 

Medicare Prescription Drug Plan (also referred to as Part D)
A Medicare Prescription Drug Plan is either a stand-alone policy providing drug coverage for Medicare recipients or a Medicare approved drug benefit attached to a Medicare Advantage Plan.  Part D policies are NOT purchased or obtained directly from Medicare, rather Part D plans are purchased from a private insurance company and must meet guidelines set by Medicare.   

Medicare Supplement Insurance (also referred to as Medigap)
Medicare Supplement Plans are private health insurance plans that pay the Medicare deductibles and the 20% of all Medicare claims not covered by Medicare.  Medicare Supplement policies also provide more coverage per benefit category that does Original Medicare.  Further, Medicare Supplement plan benefits are standardized so that the plan benefits are identical.  When shopping for a Medicare Supplement Plan, one must consider the plan benefits, premium at the time of purchase, and premium stability.  One needs to have both their Medicare Part A and Part B to enroll in a Medicare Supplement Plan.  Medicare Supplement policies do NOT provide coverage for prescriptions obtained from a pharmacy.  

Medigap (see Medicare Supplement Insurance)

Network (also referred to as In –Network)
Network medical providers are those doctors, hospitals, and medical supply companies that have a contract with an insurance company.  This contract specifies that medical service will be provided for a negotiated amount.

No-Age Rated Premiums (see Community Rated Premiums)

Non-Contracting Provider (also referred to as Out-of-Network)
A Non-Contracting Provider is a medical provider who does not have an agreement with an insurance company specifying payment and covered services.  With a HMO (Health Maintenance Organization) plan one cannot use Non-Contracting Providers.  PPO (Preferred Provider Organization) members can use Non-Contracting Providers, though this usually costs slightly more money.  Finally, folks with a Medicare Supplemental plan can see any physician and use any hospital so long as the providers accept Medicare Assignment.  

Part A (see Medicare Hospital Insurance)

Part B (see Medicare Medical Insurance)

Part C (see Medicare Advantage Plan)

Part D (see Medicare Prescription Drug Plan)

Part D Coverage Gap Period (also referred to as the Donut Hole)
The Part D Coverage Gap Period is the period of Part D coverage where the subscriber pays substantially more for medication than he/she was paying during the Initial Coverage Period (period with fixed copayments).  When in the Part D Coverage Gap Period members pay the appropriate copayment for generic drugs and, in most cases, half the cost for brand-name drugs.  Part D recipients enter the Part D Coverage Gap Period when the total retail cost of drugs reaches $2840 (the 2011 amount).  Part D subscribers leave the Part D Coverage Gap Period when the subscriber pays $4550 (the 2011 amount) toward prescriptions.

Original Medicare
Original Medicare refers to the traditional fee-for-service structure of Medicare, whereby Medicare directly pays hospitals and health care providers.  An individual with Original Medicare either pays the portion of each bill not covered by Original Medicare or has a Medicare Supplement that pays the amount not covered by Medicare. 

Out-of-Network (see Non-Contracting Provider)

Out-of-Pocket Maximum
The Out-of-Pocket Maximum is the total one must pay during a calendar year before the health insurance plan begins paying 100% of additional, covered medical services.  An Out-of-Pocket Maximum is typically associated with PPO (Preferred Provider Organization) and sometimes PFFS (Private-Fee-For-Service) plans.  HMO (Health Maintenance Organization) plans are designed to collect Copayments, often with no dollar maximum.  Conversely, Medicare Supplement plans have no Out-of-Pocket Maximum, as most Medicare Supplemental plans require no payment for medical services. 

PCP (see Primary Care Physician)

Permanent Absence
A Permanent Absence is a continual absence of six months or more from a health insurance plan service area.  If you move or reside outside the insurance plan service area, you must notify your insurance carrier.  Each health insurance plan type has different service areas.  Medicare HMO (Health Maintenance Organization), PPO (Preferred Provider Organization) and PFFS (Private-Fee-For-Service) plans usually have service areas of one or several counties.  Some Medicare PPO plans include the entire state of California as a single service area.  Medicare Supplemental plans have the greatest service area, encompassing the entire United States and its territories.

PFFS (see Private Fee-For-Service)

PPO (also referred to as Preferred Provider Organization)
PPO stands for Preferred Provider Organization and refers to providers who are under contract to provide care at discounted or fixed rates.  Unlike HMO plans, PPO members can utilize any doctor at any time without a referral.  Further, PPO members can see Non-Contracting Providers, but members will have to pay more for seeking care outside the Network.

Preferred Provider Organization (see PPO)

Preexisting Condition
A person has a Preexisting Condition if he or she received medical advice or treatment for any accident, illness, or other medical condition six months prior to the desired effective date of a Medicare insurance plan.  Medicare HMO, PFFS, and PPO plans allow persons with Preexisting Conditions to enroll with NO waiting period for treatment.  The only exception to this is persons with ESRD (End Stage Renal Disease); persons with ESRD will not be enrolled per rules set by the insurance carrier.  Medicare Supplemental plans treat Preexisting Conditions differently.  When a person first acquires Medicare he or she can enroll in any Medicare Supplemental with any Preexisting Condition, except ESRD.  However, once a Medicare recipient has had Medicare for six months or more all Preexisting Conditions are considered during the underwriting process, and health issues, even as far back as five years can prevent one from obtaining a Medicare Supplemental plan.  

Premium
A premium is the payment to maintain membership in a health plan or prescription drug policy.  Medicare Supplement health plan premiums can be either Community Rated, Issue Age Rated, or Attained Age Rated.

Primary Care Physician (also referred to as PCP)
A Primary Care Physician is a HMO member’s first stop to receiving care.  If a visit with the Primary Care Physician cannot treat the problem, then the Primary Care Physician will submit a Referral for the patient to see a specialist or seek more serious treatment.  HMO plans are the only plan types that require a member to work through a Primary Care Physician for access to specialists and more serious care.  Medicare PPO, PFFS, and Medicare Supplemental plans all allow a plan member to see any physician at any time without a referral.

Prior Authorization
Prior Authorization is a process where a medical provider must receive approval from the health insurance company before a plan member can receive care.  A common example occurs with the Medicare Part D drug plans where certain drugs require Prior Authorization before the plan member can purchase the prescription for the copayment amount.  The prescribing doctor actually requests the authorization from the insurance carrier direct, not from a Medical Group.

Private Fee-For-Service (also referred to as PFFS)
Private Fee-For-Service (PFFS) Plans are a type of Medicare Advantage Plan that allow the subscriber to utilize any doctor or hospital so long as the medical provider agrees, in advance, to accept a predesignated payment amount from the insurance carrier.  These PFFS plans afford Medicare recipients the freedom to utilize any medical provider, but the uncertainty of securing providers make this plan type a challenge.   

Referral
A Referral is defined as any request made by the Primary Care Physician to the Medical Group for covered specialty services or hospitalization.  Referrals may require review by the Medical Group.  The Referral process is limited to HMO (Health Maintenance Organization) plans.             

Service Area
A Service Area is a geographic area where one can receive non-emergent care.  When outside the Service Area, the member is only covered for medical emergencies.  Service Areas can be a single county, several counties, or the entire state.  All Medicare HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), and PFFS (Private-Fee-For-Service) plans have a defined Service Area.  Medicare Supplemental policies are unique in that a client can receive non-emergent care anywhere in the United States; Medicare Supplemental policies do not have a defined Service Area.

Skilled Nursing Care
Skilled Nursing Care is any medical service that can only be performed by, or under the supervision of, a licensed nursing professional.  Various forms of therapy and wound care are examples of Skilled Nursing Care.  Feeding and bathing do not require the presence of a nurse and are, therefore, considered Custodial Care.

Skilled Nursing Facility
A Skilled Nursing Facility provides Skilled Nursing Care and keeps medical records for each patient.  Skilled Nursing Facilities are licensed and must be approved by Medicare in order for Medicare beneficiaries to have Medicare pay for the nursing services.

Special Enrollment Period (SEP) (Part D)
The Part D Special Enrollment Period is an enrollment period that occurs outside the scheduled Initial Enrollment Period and Annual Election Period.  Medicare has a set of guidelines explaining the details concerning the unique Special Enrollment Periods.  Common examples of Special Enrollment Period situations are as follows: loss of Part D coverage due to a move outside the plan service area, involuntary loss of creditable drug coverage, permanent move back the United States after living permanently in a foreign country.

Stop Loss
The insurance plan Stop Loss occurs when the subscriber has paid both the plan Deductible and Out-of-Pocket-Maximum in full.  When one reaches the Stop Loss, one no longer pays out of pocket for covered services.  

Summary of Benefits (also referred to as SOB)
The Summary of Benefits is a document that displays policy details, usually organized by benefit category.  Typically, a Summary of Benefits will present copaymants, deductibles, out-of-pocket maximums, premiums, covered benefits, and limitations to coverage.  One should always carefully review the Summary of Benefits before purchasing an insurance policy.

Temporary Absence
A Temporary Absence occurs when a Medicare health insurance plan member spends less than six months outside of the plan Service Area.  A health plan member can travel or reside outside the Service Area for less than six months and still keep the Medicare Insurance policy.  However, if a plan member resides outside the Service Area for six months or more the member is consider to be Permanently Absent and will likely be disenrolled.

TROOP (see Annual True Out-of-Pocket Cost Amount)

Underwriting
Underwriting is the process whereby an insurance company reviews your medical history to determine eligibility.  Underwriting occurs only when a Medicare recipient applies for a Medicare Supplement outside of a Guaranteed Issue scenario.  A physical exam is not required for the underwriting process.  Medicare Advantage Plans never require underwriting.

Urgently Needed Services (see Emergency)

Waiting Period
A Waiting Period is defined as the period of time that a health plan subscriber must wait in order to receive treatment.  Fortunately, there is no Waiting Period with most Medicare Supplement plans and Medicare Advantage Plans.  There are defined Waiting Periods for senior dental policies.  

 

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