Medicare Glossary

Actuarial Equivalent

A term relating to the statistical calculation of risk. A plan sponsor must offer a prescription drug plan this is actuarially the same or better than the Medicare Part D prescription drug plan.

Any Willing Doctor

A doctor, hospital, or other health care provider that agrees to the plan’s terms and conditions as it relates to payment and must meet other requirements for coverage.

Appeal

A special complaint you make if you disagree with decisions made by Original Medicare or your health plan. If Medicare or your health plan denies your request for health care service, supplies, or prescription, you can make an appeal. You also have the right to appeal if you are receiving payment for health care services and payments are stopped. There are specific processes to follow in filing an appeal.

Assignment

You still pay your part of the doctor’s visit; however, in Original Medicare, the doctor or supplier has agreed to accept the Medicare-approved amounts as full payment. It is a cost savings to you if your doctor accepts assignment.

Authorization

MCO approval is different from a referral. Authorization can be verbal or written from the MCO and a referral is a written document that your doctor must receive prior to rendering medical services.

Beneficiary

A name that is given to a person who receives health care insurance through the Medicare or Medicaid program.

Benefit Period

Your “benefit period” begins the day you go to a hospital or skilled nursing facility. Your benefit period ends when you haven’t received any hospital care or skilled nursing facility care for 60 consecutive days. If you go in to a hospital or a skilled nursing facility after one benefit period ends, a new benefit period will begin. There is no limited number of benefit periods; however, you must pay the inpatient hospital deductible for each benefit period.

Carrier

A private company that contracts with Medicare to pay most of your Medicare Part B bills and your doctor.

Catastrophic Coverage

Once you have reached a maximum of $5451.25, you will pay a small coinsurance or copayment for covered drug costs for the remainder of the calendar year.

Certificate of Creditable Coverage

This is a written certificate issued by your group health plan or health insurance issuer, including an HMO. This certificate states the period of time you were covered by your health plan.

Children’s Health Insurance Program

A health plan program for free or low-cost health insurance for uninsured children under age 19. This is for family’s who earn too much to qualify for Medicaid but not enough income to afford private coverage. Information on your state’s program can be found at www.insurekidsnow.gov or your state’s program is accessible through Insure Kids Now at 1-877-KIDSNOW (1-877-543-7669).

CMS Hearing Officer

Designated by CMS, this person conducts the appeals process for a claim dispute.

Coinsurance

This is the amount you may be required to pay for health services after you pay plan deductibles. Original Medicare the percentage is 20% of the Medicare approved amount. The coinsurance amount for the Medicare Prescription Drug plan varies based on how much you have spent.

Comprehensive Outpatient Rehabilitation Facility (CORF)

This is a facility that provides rehabilitation services after an injury or illness. Services can include physicians, physical therapy, outpatient rehabilitation, or social and psychological services.

Coordination of Benefits

The process of determining the respective responsibilities of two or more health plans that have financial responsibility for a medical claim. This may also be referred to as cross-over.

Copayment

Some health care insurance plans have copayments. This is the amount you pay for each medical service. This can applied to a doctor’s visit or prescription drugs. The copayment is normally a small set amount. For example, for a prescription or doctor’s visit you may pay $10 or $20. In Original Medicare, copayments are also used for some hospital outpatient services.

Co-Payment

See copayment.

Cost Sharing

This is the amount you pay for health care and/or prescriptions, which can include copayments, coinsurance, or deductibles.

Covered Employee

A person, who is or was, provided health insurance coverage under a group health plan.

Credible Coverage

Health coverage you have had in the past such as a group health plan, HMO, individual health insurance policy, Medicare, or Medicaid and this coverage had no significant break in coverage. The time period of this coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan. Creditable coverage can be proven by your certificate of credible coverage or other documents, such as a health insurance ID card.

Creditable

Past health coverage that gives an individual certain rights when applying for new coverage.

Creditable Coverage (Medigap)

In order to shorten a pre-existing condition waiting period under a Medigap policy, certain kinds of previous health insurance can be used if it is proven it was creditable coverage.

Creditable Prescription Drug Coverage

This is a prescription drug plan from an employer or union that pays out as much or more than the standard prescription drug coverage provided by Medicare.

Critical Access Hospital

Typically found in rural areas, this is a small facility that provides limited outpatient and inpatient hospital services.

Custodial Care

Custodial care includes nonskilled, personal care such as help with activities of daily living such as bathing, dressing, eating, and mobility. In most cases, Medicare does not pay for custodial care.

Deductible

The amount of money you must pay for prescriptions or health care services before Original Medicare, your other health care insurance, or prescription drug plan begins to pay. Under Original Medicare you pay a new deductible for each benefit period (see benefit period) for Part A and each year for Part B. The deductible amount can change every year.

Drug List

A list of drugs covered by a health care plan. This list may also be called a formulary.

Durable Medical Equipment Regional Carrier (DMERC)

This is a 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. For example: You can “elect” to join or leave.

Electronic Data Interchange (EDI)

This refers to the exchange of business transactions that occur from one computer to another. EDI uses a standard format and communication protocol.

Electronic Funds Transfer (EFT)

The term used for transferring money electronically from one financial institution to another.

End-Stage Renal Disease (ESTD)

Permanent kidney failure that results in a regular course of dialysis or a kidney transplant(s).

Enrollment and Payment System (EPS)

This is a broad term used to cover all the partner company activities involved in the development of the Retiree Drug Subsidy Program (RDS) and the administration of its various aspects such as enrollment, payments, appeals, etc. ERISA — Employee Retirement Income Security Act of 1974 (ERISA).

Excess Charges

In Original Medicare, this is the difference between a doctor’s charge and the Medicare-approved payment amount. This is also applicable to other health are providers. This amount may be limited by Medicare or the state in which you live.)

Expedited Organization Determination

A fast decision from the Medicare + Choice organization as to whether or not it will provide a certain health service. A beneficiary may receive and expedited (within 72 hrs.) decision when life, health or the ability to regain function is in jeopardy.

Extra Help

A Medicare program to assist people with limited income and resources, to pay Medicare prescription drug cost, such as premiums, deductibles, and coinsurance.

Fiscal Intermediary

A private company contracted with Medicare to pay Part A and some Part B health care cost. Also called “intermediary”.

Formulary

A list of drugs approved/covered by a plan. See drug list

Grievance

A complaint about the way your Medicare health plan is giving care. You may file a grievance if you have a problem with customer service from your plan administrators or staff. A grievance is not the correct way to handle a complaint about treatment or services that are not covered. (See Appeal).

Group Health Plan

Employer or employee organization supported health care plan that is provided by the employer to employees, former employees and their families.

Group Health Plan

An employee, or retiree, benefit plan provided by an employer, an employee organization, or church group that provides medical care insurance to employees and their dependents directly or through insurance (including an HMO), reimbursement or otherwise.

Group Health Plan Number

A number that will be assigned to all group plans by CMS division administering the transactions, code sets, security and administrative simplification portions of the Health Insurance Portability And Accountability Act (HIPPA) — General Services Administration.

Guaranteed Issue Rights (also called “Medigap Protections”)

In certain situations, these are rights you have when insurance companies are required, by law, to sell or offer you a Medicap policy. In these situations, insurance companies can’t deny you a policy, or place conditions on a policy for exclusions such as pre-existing conditions. They also can’t charge you more for a policy because of past or present health conditions.

Guaranteed Renewable

This is a right you have that requires your insurance company to automatically renew or continue your Medigap policy. The only reason you can be denied is for making untrue statements to the insurance company, commit fraud, or not pay your premiums.

Health Insurance Portability And Accountability Act (HIPPA) of 1996

A Federal law that allows a person to qualify immediately for comparable health insurance coverage when they change their employment relationship. Title II, Subtitle F, of HIPPA gives the Health and Human Services Department (HHS) the authority to mandate standards for electronic exchange of health care data, specify medical and administrative code sets to 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). The type of measures required to protect the security and privacy of personally identifiable health care information are also included in HIPPA. This is also known as the Kennedy-Kassebaum Bill, K2, or the Public Law 104-191.

Health Maintenance Organization (HMO) (Medicare)

An HMO is a type of Medicare Advantage Plan that is only available in certain parts of the country. HMO plans must cover all Medicare Part A and Part B health care and some HMO’s cover extra benefits. These extra benefits can include extra days in the hospital. Most HMO’s require you to see a doctor, specialist, or hospital on the plan’s list except in an emergency situation. Your costs may be lower than in Original Medicare.

Hemodialysis (HD)

The use of an artificial kidney. This treatment is usually provided at a dialysis facility but can be done from home with the proper training and supplies. HD uses a special filter, called a dialyzer or artificial kidney) to clean your blood. The filter connects to a machine and during the treatment your blood flows through tubes into the filter to filter out impurities and extra fluids. The newly cleansed blood flows into another set of tubes and back into your body.

Home Health Care

This refers to limited part-time or intermittent skilled nursing care and home health aide services; such as, physical therapy, occupational therapy, speech-language pathology, medical social services, medical supplies, and other services. Durable medical equipment is considered items such as; wheelchairs, hospital beds, oxygen, and walkers.

Hospice Care

Health care that involves a special kind of caring for people who are terminally ill. Hospice care involves a team-oriented approach that covers the medical, physical, social, emotional, and spiritual needs of the terminally ill patient. Family and caregiver support is also provided. Hospice care is covered under Medicare Part A (Hospital Insurance).

Inpatient Care

Health care services you are given when admitted to a hospital or skilled nursing facility.

Inpatient Rehabilitation Facility

Intensive rehabilitation program for inpatients of a hospital that is provided in the hospital or a particular section of the hospital.

Institution

A facility that gives short term or long term care. This could be a nursing home, skilled nursing facility, or rehabilitation hospital. Assisted living facilities, group homes, or private homes are not considered institutions for this purpose.

Lifetime Reserve Days

If you are in the hospital more than 90 days during a benefit period, in Original Medicare, Medicare will pay for a total of 60 extra days. These are reserve days. Once these 60 reserve days are used, you will not get more extra days during your lifetime. For each lifetime reserve day, Medicare will pay covered costs except for a daily coinsurance of $456 (in 2005).

Limiting Charge

In Original Medicare, this is the highest amount of money you can be charged for a covered service by doctors and/or other health care suppliers who do not accept assignment. The limiting charge, which is 15% over Medicare’s approved amount, only applies to certain services and doesn’t apply to supplies or equipment.

Long-Term Care

A large variety of services that assist people with the individuals health care or personal needs. These personal needs can include daily living over a period of time and can be provided in the home, community, or various types of facilities, which include nursing homes and assisted living facilities. Most long-term care is considered custodial care and Medicare doesn’st pay for this; if it is the only kind of care you need.

Long-Term Care Hospital

Hospitals that give long-term acute care for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Some services include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

Medicaid

A joint Federal and State program that assist low income or limited resource families with medical cost. Medicaid programs differ from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medical Underwriting

The process an insurance company goes through to decide whether or not to accept your application for insurance. The decision is normally based on medical history. The process of underwriting will also determine if there will be a waiting period for pre-existing condition (if your state law allows this) and how much you will be charged in premiums.

Medically Necessary

Services or supplies needed for a diagnosis or treatment of your medical condition. These services must meet the standards of good medical practice in your local area and can’t be mainly for your convenience or your doctors.

Medicare Advantage Plan

A plan with a private company that is contracted with Medicare to provide 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, your Medicare services are covered through the plans, and are not paid for under Original Medicare.

Medicare Advantage Prescription Drug (MA-PD) Plan

This is a Medicare Advantage plan that also offers Medicare Prescription Drug coverage and Part A and Part B benefits in one plan.

Medicare Coordinated Care Plan

A Medicare Advantage HMO or PPO plan.

Medicare Cost Plans

A Medicare Cost Plan is a type of HMO that contracts as a Medicare Health Plan. Just like other HMOs, the plan only pays for services that are outside its service area when it is an emergency or urgently needed service. However, when you are enrolled in a Medicare Cost Plan, and receive routine services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare. In this scenario, you will be responsible for the Original Medicare deductible and coinsurance.

Medicare Coverage

Two main parts are included in Medicare coverage: Hospital Insurance (Part A) and Medical Insurance (Part B).

Medicare Health Plan

A health care plan offered by a private company that contracts with Medicare to provide you with Medicare Part and/or Part B benefits. Medicare Health Plans include the following; Medicare Advantage Plans (including HMOs, PPOs, or Private Fee-for-Service Plans), Medicare Cost Plans, PACE plans, and special needs plans.

Medicare Managed Care Plan

Only available in some areas of the country, this is a type of Medicare Advantage Plan. In most managed care plans, you can only go to doctors, specialist, or hospitals on the plan’s approved list. Plans must cover all Medicare Part A and Part B. Some managed care plans cover extras, like prescription drugs. The cost of a managed care plan maybe less than Original Medicare.

Medicare Plan

A term used in reference to any other way 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 prescription drug coverage that is available to all people through Medicare. This is provided by insurance companies and other private companies.

Medicare Prescription Drug Plan

A stand-alone drug plan. This is offered by other private companies to beneficiaries who receive their Medicare Part A and/or Part B benefits through Original Medicare; Medicare Private-Fee-for-Service Plans that don’t offer prescription coverage and Medicare Cost Plans offering Medicare prescription drug coverage.

Medicare Select

A Medigap policy that may require you to use hospitals and doctors within a specified network in order to be eligible for full benefits.

Medicare Summary Notice (MSN)

This is a notice you receive after a doctor or provider files a claim for Part A and/or Part B services to Original Medicare. This statement explains what the provider billed you for, the Medicare-approved amount, how much Medicare paid, and the balance you owe.

Medicare - Approved Amount

This is the amount a doctor or health care supplier, that accepts assignment, can be paid by Original Medicare. It includes what Medicare pays and any deductible, coinsurance, or copayment that you are responsible for paying. This amount may be less than the actual amount a doctor or supplier charges.

Medicap Open Enrollment Period

This is a one-time only, six month period, in which you can buy any Medigap policy, offered in your state. Your open enrollment period starts the first month you are covered under Medicare Part B and you are age 65 or older. During this open enrollment you can not be denied coverage or charged more because of past or present health problems.

Medigap Policy

This is a supplement insurance sold by private insurance companies to fill the “gaps” in Original Medicare coverage.

Non-Formulary Drugs

Drugs not on an approved drug list of the plan.

Original Medicare

A fee-for-service health plan that allows you to go to any doctor, hospital, or other health care supplier who accepts Medicare and who is accepting new Medicare patients. You will be responsible for the deductible and Medicare will pay its share of the Medicare-approved amount and you will also pay the coinsurance. In some cases you may be charged more than the Medicare approved-amount. Original Medicare also has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Outpatient Hospital Care

When you receive medical or surgical treatment at a hospital but have not been admitted as an inpatient. The hospital records show you are being registered as an outpatient. In some cases, if your doctor requires you to be placed under observation, this may be considered outpatient although you were under observation overnight.

Penalty

If you do not join Medicare when you are first eligible you will have a penalty added to your premium for Medicare Part B, or for a Medicare Prescription Drug Plan. You will pay this higher premium as long as you have Medicare. Some exceptions do apply.

Physician Services

Health care services provided by an individual licensed under state law to practice medicine or osteopathy. Any physician services given to you while you are in the hospital, and that appear on the hospital bill, are not included.

Plan Administrator

The person responsible for management of the health care plan. A plan administrator is specifically designated by the terms of the plan, if the plan does not make such a designation; the plan sponsor is typically the plan administrator.

Plan Sponsor

This is generally the employer, the employee organization (employee union), or another entity that establishes or maintains an employee benefit plan. This includes a group health plan. See also sponsor.

Point-of-Service (POS) Option

An HMO option that lets you use doctors and hospitals outside the plan at an additional cost.

Pre-Existing Condition

A health condition that existed prior to the effective date of a new insurance policy.

Preferred Provider Organization (PPO) Plan (Medicare)

A type of Medicare Advantage Plan that cost you less if you use doctors, hospitals, or providers that are in the provider’s network. You can use doctors, hospitals, and providers outside the network but it will cost you more.

Premium

The periodic payment to Medicare, your insurance company, or a health care plan for health care coverage or prescription drug coverage.

Preventative Services

Health care services to keep you healthy or prevent illness; such as, Pap tests, pelvic exams, flu shots, and mammogram screenings).

Primary Care Doctor

A doctor that is trained in giving you basic care. Your primary doctor is the one you see first for most health care needs. If your care is not within the bounds of a primary care doctor, he or she may speak with other more specialized doctors and refer you to them. In some HMOs, you are required to see your primary care doctor before you can see any other health care provider.

Private Fee-for-Service Plan

A type of Medicare Advantage Plan that allows you to 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 how much you will pay for the services you receive. You may pay more or less for Medicare-covered benefits. You may have extra benefits Original Medicare doesn’t cover.

Programs of All-Inclusive Care for The Elderly (PACE)

PACE is a program that combines medical, social, and long-term care services for frail individuals in order to help them stay independent and living in their community as long as possible, while receiving the high-quality care they need. PACE is only available in states that offer it under Medicaid. Eligibility includes:

• You must be 55 years old or older,
• You must live in the service area of the PACE program,
• You must be certified as eligible for nursing home care by the appropriate state agency, and
• You must be able to live safely in the community.

Qualified Beneficiary

Normally includes covered employees, their spouses and their dependent children who are covered under the group health plan. In some cases, retired employees, their spouses and dependent children may be considered qualified beneficiaries.

Quality

Quality is based on how well the health plan keeps its members healthy and treats them while they are sick. Good quality health care means doing the right thing at the appropriate time, for the right person, and getting the best possible results.

Quality Improvement Organization

This is a group of practicing doctors and other health care experts who are paid, by the federal government, to review and improve the care given to Medicare patients. This team must review all complains about the quality of care give by inpatient hospitals, hospital outpatient department, 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, home health, hospice care, and skilled nursing facilities for people enrolled in Medicare Health Plans.

Referral

This is a written order from your primary care physician for you to see a specialist or for you to receive certain health care services. Many HMOs will require you to have a referral from your primary health care physician before you can get care from any other doctor. If you don’t acquire this referral first, the plan may not pay for your care.

Regional Home Health Intermediary

This is a private company contracted with Medicare to pay home health and hospice services. They also regulate the quality of home care provided.

Rehabilitation

Services provided by a nurse, physical therapist, occupational therapist, or speech therapist, that are ordered by your doctor to help you recover from an illness or injury. Examples include working with a physical therapist to help you walk or an occupational therapist to help you with getting dressed.

Retiree — For The RDS Program

An individual who has retired and is provided coverage under a group health plan.

Risk Adjustment

A change in payments to a health plan because of a person’s health status.

Second Opinion

When another doctor gives their opinion about your health concern or illness and how the concern or illness should be treated.

Secondary Payer

An insurance policy, plan, or program that pays second on a claim for medical care. This can be Medicare, Medicaid, or insurance depending on your specific situation.

Service Area

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, this is also the area where services are provided. You may loose your enrollment if you move out of the plan’s service area.

Service Area (Private fee-for-Service)

This is the area that a Medicare Private Fee-for-Service plan accepts new members.

Service Category Definition

A very general description of the types of services provided under the service or the characteristics defining the service category.

Side Effect

A problem caused by a treatment. For example, a high blood pressure medicine may make you drowsy. Most treatments do have side effects.

Significant Break In Coverage

Typically a significant break in coverage is a time period of 63 consecutive days in which a person has no creditable coverage. In some states, the period of time is longer, if the individual’s coverage is provided through an insurance policy or HMO. Days you may have in a waiting period during which you had no other health coverage can’t be counted toward determining a significant break in coverage.

Skilled Care

This is a type of care given when you need a rehabilitation staff to manage, observe, and evaluate your care or if you need skilled nursing assistance.

Skilled Nursing Care

A level of care that includes services that can be performed safely and correctly by a licensed nurse. This care must be administered by a registered nurse or a licensed practical nurse.

Skilled Nursing Facility (SNF)

nursing facility with the staff and equipment to give skilled nursing care or skilled rehabilitation services.

Skilled Nursing Facility Care

The level of care that requires daily involvement of a skilled nursing staff of a rehabilitation facility. This is full-time care that can not be provided on an outpatient basis. Examples include; intravenous injections and physical therapy. The need for custodial care can not, by itself, qualify you for Medicare coverage in a skilled nursing facility. Custodial care is defined as daily activities such as bathing and dressing. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover the cost, including assistance with activities of daily living.

Social Health Maintenance Organization (SHMO)

This is a special type of health plan that provides a full range of Medicare benefits that are also provided by standard Medicare HMOs. Other services included are: prescription drug and chromic care benefits, respite care, and short-term nursing care such as homemaker, personal care services, and medical transportation. Eyeglasses, hearing aids, and dental benefits are included.

Special Election Period

A specific set time period a beneficiary can elect to change health plans or return to Original Medicare. Examples include; if you move out of the plan’s service area, your Medicare + Choice organization violates its contract with you, the medical care provider does not renew its contract with CMS, or other exceptional circumstances determined by CMS. Note: the Special Election Period is different from the Special Enrollment Period.

Special Enrollment Period

A specific set time period when you can sign up for Medicare Part B if you didn’t take Medicare Part B during the Initial Enrollment Period due to you or your spouse having a group health plan coverage through your employer or union. You can sign up at anytime you are covered under the group plan based on your current employment status. The last eight months of the Special Enrollment Period starts the month after your employment ends or the group health coverage ends, whichever comes first.

Special Needs Plan

A special type of plan that provides focused health care for specific groups of people. This includes beneficiaries who have both Medicare and Medicaid and who reside in a nursing home, or ones who have certain chronic medical conditions.

Specialist

A doctor who specializes in treating only certain parts of the, particular health problems, or certain age groups of people.

Specified Disease Insurance

A particular kind of insurance that only pays benefits for a single disease; such as cancer, or a group of diseases. Specified Disease Insurance doesn’t fill gaps in your Medicare coverage.

Specified Low-Income Medicare Beneficiaries (SLMB)

A Medicaid program that pays Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

Speech-Language Therapy

Specialized treatment to regain and strengthen speech skills.

Sponsor

An entity that sponsors a health plan. This is normally an employer, union, or some other entity.

State Children’s Health Insurance Program

A health plan program for free or low-cost health insurance for uninsured children under age 19. This is for families who earn too much to qualify for Medicaid but not enough income to afford private coverage. Information on your state’s program can be found at www.insurekidsnow.gov or your state’s program is accessible through Insure Kids Now at 1-877-KIDSNOW (1-877-543-7669).

State Health Insurance Assistance Program (SHIP)

A state program, funded by the federal government, which gives free local health insurance counseling to individuals with Medicare.

State Insurance Department

State agency that is in charge of regulating insurance and provides information about Medigap policies and other private insurance.

State Medical Assistance Office

State agency that is in charge of the state’s Medicaid program and gives information to individuals, with low income, about programs that can help pay medical bills.

State Pharmacy Assistance Program

A state funded program that provides individuals with assistance in paying for drug coverage. This program is based on a person’s financial need, age or medical condition. It is not based on current or former employment status.

State Survey Agency

The agency that is responsible for inspecting dialysis facilities and ensures Medicare standards are met.

Subsidized Senior Housing

A program, available through the Federal Department of Housing and Urban Development and some States, which assist people who have low or moderate incomes pay for housing.

Subsidy

A monetary grant that is paid by the government to a private person or company. This grant is provided to assist in enterprises deemed advantageous to the public.

Supplier

Typically this is any person or agency that gives you a medical item or service.

Telemedicine

Professional services given to a patient from a practitioner at a remote site. This service is performed through an interactive telecommunications system.

Tiers

In order to lower cost, many plans place prescription drugs into different “tiers”. The various tiers cost various amounts. Each plan can form their own tiers in different ways. Here is an example of how a plan may tier prescription drugs:

• Tier 1 - Generic drugs. This tier will cost you the least amount.
• Tier 2 - Preferred brand-name drugs. This tier will cost you more than Tier 1.
• Tier 3 - Non-preferred brand-name drugs. Tier 3 will cost you more than Tier 1 or 2.

Treatment

Something that is done to help you with a health problem. For example surgery or prescribed medicines would be treatments.

Treatment Options

Choices you are given when there is more than one way to treat your health problem.

Tricare for Life (TFL)

This is a health care program for active duty and retired uniformed members of the service and their families.

TTY

This is a communication device called a teletypewriter (TTY). These communication devices are used by individuals who are deaf, hard of hearing, or have a severe speech impairment. A TTY consists of a keyboard, display screen and a modem. Communications are sent via a regular telephone line. Individuals who don’t have a TTY can communicate with a TTY user by going through a message relay center (MRC). An MRC has TTY operators who are available to send and interpret TTY messages.

Unassigned Claim

A claim that is submitted for a service or supply by a provider who does not accept assignment. The claim is considered unassigned.

Urgently Needed Care

This is care you get for a sudden illness or injury that needs medical attention quickly, but is not life threatening. Your primary care doctor generally provides this 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 can’t wait to seek medical attention, the health plan must pay for urgently needed care.

Validation

The process by which integrity and correctness of data is established. The validation process can occur immediately after a data item is collected or after a complete set of data is collected.

Waiting Period

The period of time that must pass before an employee or dependent is eligible to become covered (enrolled) 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 of time before the late or special enrollment is not considered a waiting period. If a plan has a waiting period and 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 the waiting period time frame. Days in a waiting period are also not counted when determining a significant break in coverage.

Workers Compensation

Insurance that employers are required to have that cover employees who get sick or injured on the job.