The world of health care can be confusing, especially for people who are on a limited income or near retirement. It may seem like they’re speaking another language when people talk about claims, appeals, and deductibles. However, learning the language of health care isn’t so hard and can empower you to make decisions about your health.
Appeal: An appeal is an action you can take if you disagree with the decision made by Medicare or another type of health plan. An appeal is allowed if your plan denies a claim for a service, item, or medication that you believe that you need or have already received.
Claim: The request for payment that a beneficiary submits to (Medicare) when a drug, item, or service is expected to be covered is a claim. Claims can be submitted electronically or by mail and are often submitted by a medical provider.
Drug List: This is also called a formulary. A drug list is the full list of prescription drugs covered by a health care plan. The list can change, so you must continue to check if your prescription brands are covered.
Health Care Provider: A person, organization, or facility with a license to provide health care services is a health care provider. This may be an individual doctor, a group of nurses, or a hospital. Providers often submit claims to Medicare and are the most familiar with your conditions and needs, so finding a trusted provider is important.
Hospice: Hospice care is an approach to caring for and supporting terminally ill patients. It is unique in that it focuses on a mixture of medical treatment, palliative care, and emotional health. This is normally done in a team-based approach that takes the patient’s comfort into account above all. They also provide support to the patient’s family and caregiver. Hospice care is covered under Medicare Part A.
In-Network: The network is the group of doctors, facilities, pharmacies, and other health care providers that participate in an insurance plan. They have agreed with the plan to offer discounted rates to their patients. Some insurance plans only cover in-network services and providers, while others offer a discount for receiving medical care in-network.
Long-Term Care: Long-term care includes both medical and non-medical services provided to a patient to assist in the basic activities of daily life. This may be administered in a home environment, a community, an assisted living facility, or a nursing home. Long-term care can be given to people of any age who struggle with tasks such as dressing, eating, or taking care of their home.
Medicaid: Medicaid is a joint federal and state program designed to help with medical costs for patients with limited income or resources. What is covered is different in each state. Medicare can be combined with Medicaid. If you qualify for both Medicare and Medicaid, most of your health costs will be covered by one or the other.
Medicare: Medicare is a federal health insurance program. You qualify for Medicare if you are 65 or older, disabled, or have end-stage renal disease.
Medicare-Certified Provider: A Medicare-certified provider is a health care provider that has been approved for use by Medicare. This includes facilities, hospitals, nursing homes, and doctors. The providers must pass an inspection administered by a state government agency. Medicare only covers care given by certified providers.
Medicare Supplement: A Medicare supplemental policy is designed to fill the gaps in the coverage from Medicare. These are offered by private insurance companies and have separate rules than Medicare.
Out-of-Pocket: Out-of-pocket costs must be paid by the policy owner. They are not covered by insurance, including Medicare. These can be copays, deductibles, or coinsurance.
Premium: A premium is a periodic payment to an insurance company or Medicare. This is often paid on a monthly basis.
Preventive Services: Preventive care helps to detect illnesses at an early stage and prevent them before they happen. This is when treatment is likely to work best, and preventive care is a vital part of staying healthy.
Supplemental Security Income: SSI is a monthly benefit from Social Security for people who are disabled, blind, or 65 or older. They must also have low income or limited assets. This is not the same as Social Security disability or retirement benefits.
- What Is the Difference Between Medicaid and Medicare?
- Troubleshooting When Your Provider Refuses to File a Claim
- Formulary Guidance
- What Is Hospice?
- What Does In-Network Mean?
- What Is Long-Term Care?
- How to Find Medicare Providers
- What Is a Certified Senior Care Center?
- Understanding Medicare’s Parts
- Medicare Supplemental Policies
- Differences Between Your Health Insurance Copay and Coinsurance
- Ten Factors That Affect Your Health Insurance Premium Costs
- Preventive Services Covered
- Understanding Supplemental Security Income