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Health Insurance Glossary of Terms

Learning about health insurance can be challenging because it comes with complicated jargon. We know it’s difficult to keep up with all the terms you need to know, so we put together a glossary to help you better understand your insurance options before enrolling in a plan.

A

Activities of Daily Living (ADL)

Activities of daily living are self-care tasks you do every day. The six daily living activities are eating, bathing, dressing, toileting, continence and transferring.

Acute Illness

An acute illness is a disease or condition that comes on rapidly and severely, but that can—with proper treatment—be cured, such as pneumonia or a broken bone.

Advance Beneficiary Notice (ABN)

An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice health care providers and suppliers are required to give a person with Original Medicare when they believe that Medicare will not cover their services or items and the person has no reason to know that Medicare will not cover these services or items.

Advance Coverage Decision

An advance coverage decision is a Private Fee-For-Service (PFFS) plan’s determination about whether or not it will pay for a certain service. Note: This is completely unrelated to an Advance Beneficiary Notice (ABN), which only applies to people with Original Medicare.

Advance Directive

An advance directive is a legal document that outlines how you want medical and financial decisions made if you can no longer communicate your wishes. An advance directive may include a health care proxy, living will, and a healthcare power of attorney.

Advanced Illness

An advanced illness is a serious disease or condition that has progressed too far to be cured, such as cancer that has spread throughout the body.

Advanced Premium Tax Credit

Advanced Premium Tax Credits are tax breaks designed to lower the monthly premium payment you make to your health insurance company. Households with an income within 100-400% of the Federal Poverty Level may qualify. Premium Tax Credits are also called "tax subsidies."

Affordable Care Act (ACA)

The Affordable Care Act (ACA) is healthcare reform to reduce the number of uninsured Americans by making coverage more affordable. Also known as The Patient Protection and Affordable Care Act, the ACA also requires insurance companies to cover preventive care and other essential health benefits. Also known as "Obamacare."

Allowed Amount

The allowed amount is the maximum amount your health insurance provider will cover for care. You may have to pay the difference if your healthcare provider charges more than your plan's allowed amount.

ALS (Amyotrophic Lateral Sclerosis)/Lou Gehrig’s Disease

ALS (Amyotrophic Lateral Sclerosis) is a disease that affects the motor nerve cells of the spinal cord and causes their degeneration. Patients with this disease can qualify for Medicare coverage regardless of age.

Annual Enrollment Period

The Annual Enrollment Period (AEP), also known as the Medicare Open Enrollment Period, allows you can enroll, change or drop Medicare coverage. The period takes place from October 15 through December 7 each year; changes take effect January 1.

Annual Notice of Change (ANOC)

The Annual Notice of Change (ANOC) is the notice you receive from your Medicare Advantage or Part D plan in late September. This notice gives a summary of any changes in the plan’s cost and coverage that will take effect January 1 of the next year.

Annual Wellness Visit

The Annual Wellness Visit is a once-a-year visit covered by Medicare in which you can meet with your doctor to develop a prevention plan based on your needs.

Appeal

An appeal is a formal request for review of an official decision made by a Medicare Advantage plan, a Medicare private drug plan (Part D), or Original Medicare regarding payment for or coverage of healthcare.

Approved Amount

The approved amount, also known as the Medicare-approved amount, is the fee that a health insurance plan sets as the amount a provider or supplier should be paid for a particular service or item. Original Medicare calls this "assignment."

Area Agency on Aging

Area Agencies on Aging are state and local agencies that coordinate and offer services such as Meals on Wheels, homemaker assistance and similar programs that help older adults remain independent in their home and community.

Assignment

If your doctor or healthcare provider accepts an assignment, it means they agree to receive the Medicare-approved amount as the full amount for any services provided. Your healthcare provider will submit the claim to Medicare, and your out-of-pocket costs are usually less if your doctor accepts Medicare assignments.

Assisted Living Facility

Assisted living facilities, also known as group homes, are facilities designed to assist people with activities of daily living who can otherwise take care of themselves. Assisted living facilities are different than nursing homes.

B

Beneficiary

A beneficiary is a person who enrolls in a health insurance plan and receives benefits.

Benefit Period

The benefit period is the amount of time you are covered by Medicare Part A, beginning the day you're admitted as an inpatient and ending once you haven't gotten any inpatient care for 60 days in a row.

Brand Name Drugs

Brand name drugs are prescription drugs sold under a specific name or trademark. They have the same active ingredients as generic drugs but usually cost more.

C

Care Manager

A care manager is a nurse or specially trained educator or doctor who will assess your needs and advise you on how to best manage your health conditions.

Caregiver

A caregiver is anyone who provides help and support to someone who is either temporarily or permanently unable to function optimally.

Catastrophic Coverage

Insurance designed to protect you from having to pay very high out-of-pocket costs. Catastrophic coverage usually begins after you have spent a pre-determined amount on your healthcare.

Catastrophic Limit

The catastrophic limit, also known as the out-of-pocket limit, is the highest amount of money you have to pay out-of-pocket during a given period of time for certain services. After you have reached the catastrophic limit of your insurance plan, a higher level of coverage begins.

Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), is the United States government agency responsible for administering Medicare, Medicaid and several other health-related programs.

Certificate of Medical Necessity (CMN)

A certificate of medical necessity (CMN) is documentation from a doctor that Medicare requires before it will cover certain durable medical equipment (DME).

Children's Health Insurance Program (CHIP)

The Children's Health Insurance Program (CHIP) provides healthcare for children in low-income households. CHIP recipients usually earn too much to qualify for Medicaid but not enough to purchase private coverage.

Chronic Illness

A chronic illness is a disease or condition, such as diabetes or asthma, that lasts for a long period of time or is marked by frequent recurrence.

Claim

A claim is a request for payment to your health insurance company. A claim is usually handled by your doctor or provider, though some plans will make you file your claim if you visit an out-of-network doctor.

Coinsurance

Coinsurance is the percentage of your medical costs that you pay after you meet your deductible. Your insurance company pays the remaining amount.

For example:
If you have a $1,000 medical bill and your coinsurance is 20%, you'll pay $200. Your insurance company will cover the final $800.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a law that allows you to continue receiving your job-based health insurance after you've lost your job, whether it's voluntary or involuntary. If you have COBRA, your former employer isn't required to pay any portion of your monthly premium.

Continuous Open Enrollment

Continuous open enrollment is a consumer’s right to buy private insurance at any time, regardless of age or health status.

Coordination of Benefits

Coordination of benefits is the sharing of costs by two or more health plans, based on their respective financial responsibilities for medical claims. Your primary insurance and secondary insurance must coordinate benefits in order to pay claims.

Copayment

A copayment is the fixed amount you pay directly to your provider for medical services or prescription drugs covered in your plan.

For example:
If your plan includes a copayment of $20 for office visits, you'll pay $20 to your doctor whenever you have an appointment.

Cost Plan

A cost plan is a private health plan sponsored by a Health Maintenance Organization (HMO), through which you can get your Medicare benefits. A cost plan is not a Medicare Advantage Plan. It allows you to go out of network to get care.

Cost Sharing Reduction (CSR)

A Cost Sharing Reduction (CSR) is a discount applied to your out-of-pocket costs such as deductibles, copayments and coinsurance. Your income must be within 100-250% of the Federal Poverty Level to qualify.

Coverage Gap

The coverage gap, also known as the donut hole, is a gap in Medicare prescription drug coverage (Part D).

Creditable Coverage

Creditable coverage is prescription drug coverage that is considered to be as good as or better than the Medicare prescription drug benefit (Part D) in monetary value.

Curative Care

Curative care is the treatment of a patient with the intent of curing the patient’s disease or condition. For example, chemotherapy treatments to cure breast cancer.

Custodial Care

Custodial care helps you with daily life activities, including eating, dressing, bathing, moving around, continence, and going to the bathroom. Medicare usually doesn't cover custodial care.

D

Deductible

A deductible is an amount you pay out of pocket before your insurance company covers its portion of your medical bills.

For example:
If your deductible is $1,000, your insurance company will not cover any costs until you pay the first $1,000 yourself.

Denial of Coverage

A denial of coverage is a refusal by Original Medicare, a Medicare Advantage Plan or a Medicare drug plan (Part D) to pay for medical services.

Department of Veterans Affairs (VA)

The Department of Veterans Affairs (VA) is a government agency that provides federal benefits to veterans and their families.

Dependent

A dependent is a child, spouse or domestic partner covered by another person's health insurance plan.

Diagnosis

A diagnosis identifies a medical condition or disease from signs, symptoms and diagnostic testing.

Diagnostic Tests

Doctors or specialists order diagnostic tests to determine if the patient has a medical condition or disease. For example, doctors may request X-rays, ultrasounds and other services to make a diagnosis.

Dialysis

Dialysis is the technique used to artificially cleanse your blood of toxins when your kidneys no longer work.

Disability

A disability is a restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being. The Social Security Administration judges disability — and whether you qualify for financial assistance — based on whether you can work.

Discharge

Discharge is the end to your stay as an inpatient in a medical institution such as a hospital or skilled nursing facility (SNF).

Disenrollment

Disenrollment is leaving a private health plan or Medicare private drug plan.

Drug Class

A drug class is a group of drugs that treat the same symptoms or have similar effects on the body.

Drug Tiers

Drug tiers are the categories health insurance companies use to categorize all the prescription drugs they cover. Drug tiers typically range from One to Five; Tier One is the lowest and usually includes the least expensive generic drugs. Tier Five includes specialty drugs that are usually very expensive. Some carriers have a Sixth Tier.

Dual Eligible

Dual eligible individuals qualify for both Medicare and Medicaid.

Durable Medical Equipment (DME)

Durable medical equipment (DME) is equipment that primarily serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home.

E

Effective Date

The effective date is when your health plan coverage starts.

Eligibility

Some health plans require you to meet minimum requirements before you can enroll.

Emergency Care

Emergency care is the treatment for life-threatening medical problems that need attention right away. Death or severe health problems can occur if you don't immediately get care.

Employer Group Health Plan

A employer group health plan is a welfare benefit plan maintained by an employer or by an employee organization (such as a union) that provides medical care for participants or their dependents.

End-Stage Renal Disease (ESRD)

End-stage renal disease (ESRD) is permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Enrollment Period

The enrollment period is the time in which you can sign up for a new health insurance plan.

Essential Health Benefits

Essential Health Benefits are 10 benefits every health insurance policy must include under the Affordable Care Act. They are: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health, prescription drugs, rehabilitative and habilitative care, laboratory services, preventive care, and pediatric services.

Evidence of Coverage (EOC)

An Evidence of Coverage (EOC) document is sent by your Medicare administrator each year that gives you details about what the plan covers, how much you pay and more.

Exception Request

You can request an exception with your Medicare Part D plan if you need a prescription drug that is not on your plan's formulary. You can also request an exception to move a drug from a more expensive tier to a less expensive tier that's already on your plan's formulary.

Excess Charges

An excess charge is a difference between your healthcare provider's actual cost and the payment amount Medicare approves.

Exchange

An exchange is a virtual space where you can shop for and enroll in health insurance. You can reach the exchange through the internet, phone, or in-person. Also known as The Health Insurance Marketplace.

Exclusions

Exclusions are services that your health plan doesn't offer. Your policy should have a list of exclusions in your plan documents.

Expedited Appeal

An expedited appeal is a fast appeal that you have the right to when Medicare makes a decision related to your coverage (i.e. the length of coverage for a hospital stay).

Explanation of Benefits (EOB)

After you visit a provider, you may receive an Explanation of Benefits (EOB) from your insurer that explains the total charges for your visit and how much you and your health plan will have to pay. An EOB is not a bill.

Extra Help

Extra Help is a financial assistance program that helps people with low incomes pay for Medicare Part D coverage.

Extra Savings

Extra Savings is a discount applied to your out-of-pocket costs such as deductibles, copayments and coinsurance. Your income must be within 100-250% of the Federal Poverty Level to qualify. Also known as a "Cost Sharing Reduction (CSR)".

F

Federal Poverty Level (FPL)

The Federal Poverty Level (FPL) is a measure of income issued every year by the Department of Health and Human Services that is used to determine your eligibility for certain programs and benefits.

Fee

An amount you pay when you receive a service from a doctor or other healthcare provider.

Flexible Spending Account (FSA)

A Flexible Spending Account (FSA) is a savings account that you can use for healthcare expenses. FSAs are usually provided by employers and included in a job's benefits package.

Formulary

A formulary is a list of prescription drugs covered by a specific prescription drug plan.

G

General Enrollment Period (GEP)

The General Enrollment Period (GEP) runs from January 1 to March 31 each year and is your opportunity to enroll in Medicare Part B if you missed your Initial Enrollment Period.

Generic Drugs

A generic drug is an approved prescription drug that has the same active-ingredient formula as a brand name drug and is usually offered at a lower cost.

Grandfathered Health Plans

A grandfathered health plan is a policy purchased before March 23, 2010. Grandfathered plans may not include some of the rights and protections established by the Affordable Care Act.

Grievance

A grievance is a complaint about the way your Medicare coverage or Medicare drug plan is giving care. It's different than an appeal, which questions a specific decision made by Medicare.

Group Health Plan

A group health plan is a type of insurance policy that an employer generally offers. The plan usually offers health, dental, life insurance, disability coverage and more.

Guaranteed Issue Rights

If you have guaranteed issue rights, insurance companies are required to sell you a Medigap (Medicare Supplement) policy without any additional conditions.

H

Health Insurance

Health insurance is a contract that requires your insurer to pay some or all of your healthcare costs in exchange for a premium.

Health Insurance Marketplace

The Health Insurance Marketplace is a virtual space where you can shop and enroll in health insurance. Marketplaces can be run by the government, your state or private companies. Marketplaces can be accessed online, by phone, or in-person.

Health Maintenance Organization (HMO)

A Health Maintenance Organization (HMO) is a type of plan that uses a network of doctors, hospitals, and other providers to treat an insurance company's customers.

Health Savings Account (HSA)

A Health Savings Account (HSA) can pay for healthcare expenses. Your pre-tax income is deposited into your HSA to pay for medical expenses.

Healthcare

Healthcare is the industry dedicated to maintaining or improving health and well-being.

Healthcare Power of Attorney

A healthcare power of attorney is a person you trust given legal authority to make health decisions if you can’t. It's sometimes called a durable power of attorney.

Healthcare Provider

A healthcare provider is a person or organization that is licensed to give healthcare (i.e. a doctor or a hospital).

High Deductible Health Plan (HDHP)

A High Deductible Health Plan (HDHP) may lower your monthly premium payments but have higher-than-normal deductibles.

HIPAA

HIPAA is short for the Health Insurance Portability and Accountability Act of 1996, a federal law that sets national standards protecting sensitive patient health information from being disclosed without consent.

Home Health Agency

A home health agency is an organization that provides home healthcare.

Hospice Care

Hospice care is for people who are terminally ill. The care includes pain management, counseling, respite care as well as inpatient and outpatient care. Hospice care is covered by Medicare Part A.

Hospital Insurance

Hospital insurance is a term commonly used to describe Medicare Part A.

I

In-network

In-network refers to the doctors, hospitals and other providers that are inside of your provider network. A provider network is a group of providers that have agreed with your health insurance company to treat its customers.

Income-Related Monthly Adjustment (IRMAA)

Income-Related Monthly Adjustments determine the premium costs for Medicare Part B and Part D based on your income.

Individual Health Insurance

You can purchase individual health insurance to cover you and your family's medical needs. This type of insurance is offered and sold by private companies.

Initial Coverage Election Period

The Initial Coverage Election Period is the period you have when you first enroll in Parts A and B of Original Medicare that allows you to switch to a Medicare Advantage plan.

Initial Enrollment Period (IEP)

The Initial Enrollment Period (IEP) is the seven-month period around your 65th birthday when most people are eligible for the first time to enroll in Medicare.

Inpatient

Inpatient refers to medical care that requires admission to the hospital, usually overnight.

L

Lifetime Reserve Days

Lifetime reserve days are additional days that Medicare Part A will cover when you're in a hospital for more than 90 days. You have a total of 60 reserve days that can be used over different benefit periods.

Limitations

Limitations are restrictions on your health insurance coverage. Either your plan won't cover a service, or there may be cost limits on the coverage.

Living Will

A living will is a legal document, also called a "medical directive" or "advance directive," that contains your wishes for medical treatment if you become incapable of speaking for yourself.

Long-Term Care

Long-term care coverage is insurance that helps pay for medical services and care you receive due to a chronic illness or disability. Long-term care often refers to "custodial care" or personal care needs.

Low-Income Subsidy (LIS)

Also know as "Extra Help," LIS is a program that helps pay prescription drug costs for people with limited income and resources.

M

Major Medical Insurance

Major medical insurance is health insurance that covers the Ten Essential Health Benefits. In the past, this term referred to the most comprehensive plans. The Affordable Care Act made it mandatory for insurance companies to provide many of these comprehensive benefits to all customers.

Managed Care

Managed care is a form of healthcare that focuses on improving and maintaining good health with preventive care. This helps control costs and improve the quality of care you receive.

Managed Care Plans

Managed care is a type of health plan that encourages beneficiaries to stay in-network. Insurance companies sign agreements with healthcare providers to offer lower costs. If you go out-of-network, healthcare costs are often higher.

Medicaid

Medicaid is a state-based health insurance program for individuals that qualify. Unlike Medicare, Medicaid does not have age restrictions for members.

Medicaid Spend-Down

Medicaid spend-down is the process by which someone who normally wouldn't qualify for Medicaid may qualify for a limited time if their medical expenses are more than their available income.

Medical Underwriting

When you apply for a plan, health insurance companies use medical underwriting to determine your health status and whether they will cover you. The process may include interviews, medical exams, tests, and more.

Medically Necessary

Healthcare services that are necessary for the diagnosis or treatment of an illness, injury, condition, disease or symptoms.

Medicare Advantage Open Enrollment Period

The annual period, from January 1 to March 31, when individuals enrolled in Medicare Advantage can make changes to their coverage.

Medicare Advantage Plan (Part C)

Medicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D).

Medicare Card

A Medicare card is the recognizable red, white and blue card that indicates enrollment in Medicare and features personal details required by healthcare providers for Medicare coverage.

Medicare Part A

Medicare Part A, also called "hospital insurance," covers the care you receive while admitted to the hospital, skilled nursing facility or other inpatient services. Medicare Part A is part of Original Medicare.

Medicare Part A Premium

Medicare Part A premiums are monthly fees paid in exchange for coverage of hospital visits, skilled nursing stays, some home health services and more. Part A premiums are based on how long you or your spouse paid income taxes. Most individuals won't pay a Part A premium.

Medicare Part B

Medicare Part B is the portion of Medicare that covers your medical expenses. Sometimes called "medical insurance," Part B helps pay for the Medicare-approved services you receive.

Medicare Part B Premium

Medicare Part B premiums are monthly fees paid in exchange for coverage of doctor services, inpatient therapies, durable medical equipment and more. You may have to pay more than the standard Part B premium if you are high-income.

Medicare Part D

Medicare Part D is prescription drug coverage for people enrolled in Medicare. Part D is optional and is offered by private insurance companies.

Medicare Part D Catastrophic Coverage

The Medicare Part D catastrophic coverage reduces the amount of copays and coinsurance after the coverage gap. For example, in 2021, the coverage gap amount is $6,500.

Medicare Part D Coverage Gap (Donut Hole)

The Medicare Part D coverage gap, also known as the donut hole, is the payment stage between the initial coverage limit and catastrophic coverage. The portion you pay for prescriptions is usually higher in this phase until you enter the catastrophic level.

Medicare Part D Initial Coverage

Medicare Part D initial coverage is the payment stage where you pay either Part D copays or coinsurance for prescription drugs after you've met the deductible (if your plan has one) but before you enter the coverage gap.

Medicare Part D Late Enrollment Penalty

The Medicare Part D late enrollment penalty is a fee added onto your Part D premium if you go 63 consecutive days after your Initial Enrollment Period ends without creditable prescription drug coverage. The penalty generally applies for the lifetime of your Part D plan.

Medicare Savings Account (MSA)

A Medicare Savings Account (MSA) is a type of Medicare Advantage plan that provides you with a set amount of money to help cover some medical expenses in exchange for a high deductible for which you are responsible.

Medicare Savings Program

Medicare Savings Programs help those with low incomes pay premiums and sometimes coinsurance for Medicare expenses.

Medicare Savings Programs (MSP)

Medicare Savings Programs (MSP) are administered by state-level Medicaid programs to help people with limited income and resources pay some or all of their Medicare expenses.

Medicare SELECT

Medicare SELECT is a type of Medigap plan that requires you to use in-network healthcare providers in order to receive full coverage.

Medicare Summary Notice (MSN)

Medicare's equivalent of an Explanation of Benefits, a Medicare Summary Notice (MSN) is a written document that details Medicare charges over a three-month period. An MSN is not a bill.

Medicare Supplement Insurance (Medigap)

Medicare Supplement Insurance (Medigap) is designed to provide coverage that Original Medicare (Parts A and B) does not. Medigap policies are purchased in addition to Original Medicare and have their own monthly premiums you'll need to pay.

Mental Health Services

Mental health services help your emotional and psychological health. Coverage generally includes behavioral health treatment (psychotherapy and counseling), mental and behavioral health inpatient services and substance abuse.

N

Network

A network is the group of facilities, providers and suppliers you usually must use to receive the full benefits of your plan.

Non-Participating Provider

If you have Original Medicare, a non-participating provider is a healthcare provider that doesn't accept assignment from Medicare, meaning you could owe more out of pocket.

Non-Preferred Provider

If you have Medicare Advantage or a Part D drug plan, a non-preferred provider is a healthcare provider that isn't "preferred" by your insurance company, meaning you could owe more out of pocket.

Notice of Medicare Non-Coverage

A Notice of Medicare Non-Coverage (NOMNC) is a letter to a Medicare beneficiary stating that their coverage is ending.

Nursing Home

A nursing home provides medical and long-term care to older adults in a residential setting.

O

Obamacare

Also known as The Patient Protection and Affordable Care Act (ACA), Obamacare requires insurance companies to cover preventive care and other essential health benefits.

Observation Stay

An observation stay features short-term tests and assessments used to gauge whether a patient needs to be admitted to a hospital or discharged.

Occupational Therapy

Occupational therapy builds, maintains or improves the skills needed to carry out everyday tasks, including balance and motor skills.

Open Enrollment

The Medicare Open Enrollment Period (OEP), also known as the Annual Enrollment Period, runs from October 15 to December 7 each year and allows you to make multiple Medicare-related changes. In addition, Affordable Care Act Open Enrollment allows changes to non-Medicare coverage from November 1 to December 15.

Original Medicare (Parts A and B)

Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance).

Out-of-network

Out-of-network refers to doctors, hospitals and other providers that do not have an agreement to treat your health insurance company's clients. Visiting an out-of-network provider typically means more out-of-pocket costs and less coverage.

Out-of-Pocket Maximum

The maximum amount of money an individual will pay towards out of pocket expenses like deductibles, copayments, and coinsurance.

Outpatient

Outpatient refers to services that don't require an overnight hospital stay.

Over-the-Counter Drug

Over-the-counter drugs are medications that can be purchased without a prescription.

P

Palliative Care

Palliative care focuses on easing pain and increasing quality of life for patients with serious illnesses.

Participating Provider

Participating providers have agreed to accept Medicare assignment as payment in full.

Physical Therapy

Physical therapy is treatment designed to restore, improve or maintain your body's physical functions by using massage, exercise and other physical methods.

Point of Service (POS)

Point of Service (POS) plans are health insurance policies that feature provider networks and primary care physicians. POS customers are also allowed to see out-of-network providers for a higher cost.

Pre-Existing Condition

A pre-existing condition is an illness, injury or other medical condition you had before you enrolled in your health insurance policy.

Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is a health insurance plan that doesn't require you to get a referral from a primary care physician to see other doctors. Most PPOs allow you to see any doctors or providers in their network.

Premium

A premium is a fee you pay to your insurance company for health plan coverage. This is usually a monthly cost.

Preventive Care

Preventive care is medical care that aims to prevent serious diseases and injuries. These include immunizations, physicals, screenings, and more.

Primary Care Physician

A Primary Care Physician is a doctor that oversees and monitors your medical care under some plan types. PCPs also may be responsible for referrals to specialists.

Primary Insurance

Primary insurance is the policy that pays first when you have more than one plan.

Prior Authorization

Prior authorization is the decision your health insurer makes on whether the service, prescription or durable medical equipment you're requesting is medically necessary.

Private Fee-For-Service (PFFS)

Private Fee-for-Service (PFFS) plans are Medicare Advantage plans that pay your provider for each service you receive, but have negotiated different cost-sharing and reimbursement than Original Medicare.

Program of All-Inclusive Care for the Elderly (PACE)

Program of All-Inclusive Care for the Elderly (PACE) is a health insurance program specialized for older adults that need nursing home care but can still live in their communities. Your care is handled by an interdisciplinary team of providers.

Provider

A doctor or medical facility that is licensed to treat an illness or injury and other conditions.

Provider Network

A provider network is a group of doctors, hospitals and other specialists who agree with an insurance company to treat its clients. It's usually less expensive for you to see a doctor within your provider network.

Q

Qualifying Life Event (QLE)

Qualifying Life Events (QLE) are life changes that allow you to enroll in a new health insurance plan during a Special Enrollment Period. These include having or adopting a child, losing other coverage, marriage, a change of income and moving.

Quantity Limit

Medicare Part D plans may have quantity limits on certain prescription drugs. For example: you may only be allowed 30 pills per month. You can file an exception request if you and your healthcare provider believe this could affect your health.

R

Railroad Retirement Board (RRB)

The Railroad Retirement Board (RRB) is an independent federal program that administers health insurance and retirement benefits to railroad workers.

Redetermination

A redetermination is a review of a Medicare claim that was initially turned down. If you request a redetermination through an appeal, a new Medicare Administrative Contractor will review your case.

Referral

A referral is a written order from your doctor to see another provider or to receive medical equipment. A referral generally is written by your primary care physician (PCP) and may be required for you to receive benefits.

Rehabilitation Services

Rehabilitation improves your skills for daily activities after an injury or illness. The services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation in both inpatient and outpatient settings.

Respite Care

Respite care is temporary assistance designed to give a patient's caregiver some time off.

S

Secondary Insurance

Secondary insurance is the policy that pays after primary insurance when you have more than one plan.

Skilled Nursing Facility Care

Skilled nursing facilities provide in-patient extended care with trained medical professionals to recover from injury or illness and activities of daily living. These facilities provide physical and occupational therapists, speech pathologists and medical professionals assist with medications, tube feedings and wound care. Skilled nursing stays are usually covered under Medicare Part A.

Social Security Administration (SSA)

The Social Security Administration (SSA) is the federal agency that administers older Americans' retirement benefits, including Medicare.

Social Security Disability Insurance (SSDI)

Social Security Disability Insurance (SSDI) is a federal program designed to provide monthly benefits to Americans who can't work because of disability. These benefits are funded through payroll taxes.

Special Enrollment Period

A Special Enrollment Period is an opportunity outside of a standard enrollment period in which your specific circumstances allow you an opportunity to make changes to your Medicare-related coverage.

Special Needs Plan (SNP)

Special Needs Plans (SNP) are Medicare Advantage plans for beneficiaries living with certain health conditions or financial needs. These plans tailor their provider and drug offerings to meet the groups' specific needs.

Specialist

A specialist is a medical doctor or clinician that has undergone advanced training in order to focus on a specific area of care.

Speech Therapy

Speech therapy is a medical service that assesses your speech and language skills and implements treatments to regain or improve these skills.

State Health Insurance Assistance Program (SHIP)

The State Health Insurance Assistance Program (SHIP) receives funding from the federal government to provide free non-medical services to Medicare beneficiaries.

Step Therapy

Step therapy is used with Medicare Part D plans. Your health plan may require you to take a less expensive medication before approving a more expensive drug. You can request an exception if you and your healthcare provider think it could affect your health.

Subsidies

Subsidies are tax breaks meant to lower the monthly premium payment you make to your health insurance company. Households with an income within 100-400% of the Federal Poverty Level may qualify. Also known as "Premium Tax Credits".

Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC) is a comprehensive list of all the benefits included in your health insurance policy.

T

Terminal Illness

A terminal illness is a condition that can't be cured and is expected to end in death.

TRICARE

TRICARE is health insurance for active-duty and retired American service personnel.

TRICARE for Life

TRICARE for Life is secondary health insurance for service members who are enrolled in Medicare Parts A and B. TRICARE for Life pays medical costs that Parts A and B do not.

V

Veterans Administration (VA) Benefits

VA benefits are services exclusively for active-duty and retired military service personnel. VA benefits include healthcare, housing assistance, disability and more.

W

Waiting Period

A waiting period is the amount of time you have to wait between enrolling in a health plan and when your coverage starts.

Waiver of Liability

A waiver of liability is a form signed by a provider that states they will not seek payment from the patient for services that were denied by Medicare.

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.

If you’re looking for the government’s Medicare site, please navigate to www.medicare.gov.