Medicare Glossary
At My Silver Benefits, educating our clients is at the core of what we do.
Use this glossary to brush up on important terms related to Medicare.
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In Original Medicare, providers can give an advance beneficiary notice (ABN) before giving an item or service if they think Medicare might not pay. The ABN tells the beneficiary they may have to pay for those items or services.
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A notice from a Medicare Advantage plan, given ahead of time, telling a member whether a specific healthcare service or procedure will be covered under their plan.
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A promise by a doctor, provider, or supplier to take payment directly from Medicare and not bill the patient for anything beyond the Medicare deductible and coinsurance.
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Original Medicare tracks hospital and skilled nursing facility (SNF) use in benefit periods. A benefit period starts the day a person is admitted as an inpatient to a hospital or SNF and ends after 60 straight days with no inpatient care. There’s no limit to how many benefit periods a beneficiary can have.
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A claim is a request to Medicare or another health insurer asking for payment for items or services you received that you think the plan covers.
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A copayment is a set amount you must pay toward a benefit after any deductible is met.
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The plan’s first decision about your Medicare drug benefits. The plan must decide quickly (72 hours for normal requests, 24 hours for urgent ones). If you disagree, you can appeal. These decisions cover:
Whether a drug is covered
Whether you meet the rules to get a drug
How much you must pay
Whether the plan will make an exception to its rules
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Previous health insurance that can shorten the waiting period for a pre-existing condition under a Medigap policy.
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A prescription drug plan that is anticipated to provide coverage comparable to, or greater than, the average benefits offered under Medicare Part D. Acceptable alternative sources of drug coverage may include employer-sponsored or union-sponsored plans, TRICARE, coverage through the Indian Health Service or Department of Veterans Affairs, or individual health insurance policies.
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Deductible is the amount you must pay for medical care or prescriptions before Medicare, a Medicare Advantage plan, a drug plan, or other insurance starts to pay.
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Medical equipment a doctor orders for home use, like walkers, wheelchairs, or hospital beds.
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Balance billing is the difference between a provider’s charge and what Medicare pays. It applies to Original Medicare enrollees.
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Guaranteed issue rights (Medigap protections) require insurers to sell or offer Medicare supplemental plans in specific situations. When these rights apply, companies cannot deny coverage, refuse plans for pre-existing conditions, or raise premiums because of a person’s past or current health.
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Under Original Medicare, you have 60 lifetime reserve days for hospital stays beyond 90 days. Medicare pays covered costs for each reserve day, but you must pay the daily coinsurance.
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In Original Medicare, a limiting charge is the highest fee a doctor or supplier who won’t accept assignment can bill for covered services.
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A notice sent after a doctor, provider, or supplier files a claim for services under Medicare Part A or B. It shows the billed charges, Medicare’s approved amount, what Medicare paid, and what the patient must pay.
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The amount Original Medicare sets for a covered service or item. If a provider accepts assignment, Medicare pays its share and the beneficiary pays the remaining share of that amount.
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A healthcare provider—like a home health agency, hospital, nursing home, or dialysis center—that Medicare has approved. To get approved (often called "certified"), the provider is inspected by the state to make sure it meets required standards. Medicare only pays for care from certified providers.
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A one-time six-month window starting the first month you have Medicare Part B at age 65 or older, when you can choose any Medigap plan sold in your state of residence. During this time, insurers can't deny coverage or raise premiums because of your health or medical history.
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A regular payment paid to Medicare, an insurer, or a health plan for medical or drug coverage.
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Prior authorization means a Medicare Part D drug plan must approve a prescription before it will fill and pay for it. Some drugs need this review so the plan can decide if the medicine is medically necessary before covering it.
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Supplemental Security Income (SSI) is a monthly payment from the Social Security Administration for people with low income and few resources who are 65 or older, blind, or disabled. Unlike Social Security retirement or disability benefits, SSI is based on financial need.
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Medicare plans must pay for emergency care outside their area for sudden, non-life-threatening illnesses or injuries that need immediate attention. If it's unsafe to wait until you’re home to see an in-network provider, the plan must cover the care.
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